Management of massive hemothorax due to internal mammary pseudoaneurysm treated with angioembolization post-cesarean section involving traumatic fetal extraction: A case report.

Introduction: Pseudoaneurysm, or false aneurysm, is a clinical entity caused by rupture of the arterial wall, leading to blood leakage that is confined by sorroundig tissue. Massive hemothorax constitutes a life-threatening condition demanding timely and accurate medical response. Case report: A puerperal presented with a massive hemothorax precipitated by a traumatic cesarean section due to hemorrhage from a pseudoaneurysm of the left internal thoracic artery. Initial treatment involved a sternotomy, followed by a conclusive therapy via angioembolization. Conclusion: Precise assessment, including the measurement and localization of the ITA pseudoaneurysm is crucial to formulate an appropriate therapeutic strategy. Current medial practice favors endovascular embolization as a reliable and minimally invasive alternative to open surgery, establishing ir as the treatment of choice.

Pulmonary arteriovenous malformations in Rendu-Osler-Weber syndrome.

Rendu-Osler-Weber syndrome, also known as hereditary hemorrhagic telangiectasia, is an autosomal dominant hereditary disorder. It is characterized by presence of multiple arteriovenous malformations (AVMs) and telangiectasias. This article reports two cases of patients with Rendu-Osler-Weber syndrome who had pulmonary AVMs and underwent successful endovascular treatment. A brief review of the literature shows that up to 50% of patients with the syndrome have pulmonary AVMs and there is usually a positive family history in these patients. These pulmonary AVMs are multiple in 30% of cases and are associated with the most severe disease complications. Most patients are asymptomatic, even in the presence of AVMs with right-left shunts. When these shunts exceed 25% of the total blood volume, dyspnea, cyanosis, digital clubbing, and extracardiac murmurs may occur. Endovascular treatment is safe and offers control of complications from hereditary hemorrhagic telangiectasia and is currently the treatment of choice for these lesions.

Use of surgical videos available on social media among retina surgeons: results of a vitreoretinal specialist survey / Uso de vídeos cirúrgicos nas mídias sociais entre cirurgiões de retina: resultados de uma pesquisa com especialista em retina

ABSTRACT Purpose: This study aimed to assess and interpret how vitreoretinal surgeons use surgical videos available on social media as complementary learning tools to improve, review, or update their abilities, considering their different levels of expertise. Methods: In this cross-sectional survey, an online survey was sent to vitreoretinal specialists and fellows. Results: This survey included 258 participants, of whom 53.88% had been in practice for >10 years (senior surgeons), 29.07% between 4 and 10 years (young surgeons), and 17.05% for <3 years (surgeons in training). Retinal surgical videos available on social media were used by 98.84% of the participants (95% confidence interval, 97.52%-100%). YouTube (91%) was the most common source of videos, and surgeons in training watched more videos on YouTube than senior surgeons. Regarding the preferred method when preparing for a procedure, 49.80% of the participants watched surgical videos available on social media, 26.27% preferred to "consult colleagues", and 18.82% preferred to seek information in scientific articles. Participants valued the most the "image quality" (88%) and presence of "surgical tips and tricks" (85%). Conclusion: Surgical videos can provide benefits in acquiring strategic skills, such as decision-making, surgical planning, and situational awareness. Retina surgeons used them as teaching aids regardless of their level of expertise, despite being relatively more valuable to surgeons in training or young surgeons.

RESUMO Objetivo: Avaliar e interpretar como os cirurgiões vitreorretinianos utilizam os vídeos cirúrgicos disponíveis nas mídias sociais como ferramentas complementares de aprendizagem para melhorar, revisar ou atualizar suas habilidades, considerando seus diferentes níveis de especialização. Métodos: Nesta pesquisa transversal, um survey online foi enviado à especialistas e aprendizes na área vítreo-retiniana. Resultados: Esta pesquisa incluiu 258 participantes, dos quais 53,88% atuavam há mais de 10 anos (cirurgiões seniores), 29,07% entre 4 e 10 anos (cirurgiões jovens) e 17,05% há menos de 3 anos (cirurgiões em treinamento). Vídeos cirúrgicos de retina nas mídias sociais foram usados por 98,84% dos participantes (intervalo de confiança de 95%, 97,52%-100%). A fonte mais comum de acesso aos vídeos foi o YouTube (91%), e o grupo de cirurgiões com menos de 3 anos de experiência assistiu mais vídeos no YouTube em comparação aos cirurgiões seniores. Assistir a vídeos cirúrgicos nas redes sociais foi o método preferido na preparação para um procedimento para 49,80% dos participantes versus 26,27% que preferiram "consultar colegas" e 18,82% que preferiram buscar informações em artigos científicos. A "qualidade de imagem" (88%) e a presença de "dicas e truques cirúrgicos" (85%) foram as características dos vídeos mais valorizadas pelos participantes. Conclusão: O uso de vídeos cirúrgicos pode trazer benefícios na aquisição de habilidades estratégicas, como tomada de decisão, planejamento cirúrgico e consciência situacional. Sua aplicação como auxiliar de ensino foi utilizada por cirurgiões de retina independentemente de seu nível de especialização, apesar de ser relativamente mais valioso para cirurgiões em formação ou com menos de 10 anos de experiência.

Telementoring versus face-to-face mentoring in the training of scleral fixation surgery of intraocular lenses.

PURPOSE: To assess telementoring as a complementary tool for surgical training of a scleral fixation technique. DESIGN: Randomized, controlled, two-arm, blinded clinical trial. METHODS: Using a 3D visualization system, 132 participants were randomized in order of enrollment into traditional face-to-face mentoring (n = 66) and telementoring (n = 66). A single surgeon mentored all participants in the 2 groups. The procedure was performed in a model suitable for training in intraocular lens fixation SimulEYE® (INSEYET, WESTLAKE VILLAGE, CA, USA). In the telementoring group, the images captured on a local computer were sent to a second computer located in another room through a teleconferencing platform in real-time. Nine steps of the recorded procedure were evaluated and scored by two masked independent surgeons experienced in the technique. MAIN OUTCOMES MEASURES: The primary outcomes evaluated were the global score (the sum of each score on the rubric), surgical failure, and surgical time (in seconds). RESULTS: Surgical success was achieved in 98.5% in the face-to-face group and in 95.5% in the telementoring group (p-value = 0.619). Minimal technical problems were reported in 8 procedures in the telementoring group (12%), without interfering with the surgical result, and completion of the procedure. CONCLUSIONS: Telementoring is an encouraging educational tool that can overcome geographical barriers to ease the transfer of abilities and knowledge. We lack evidence in terms of group differences for superiority comparing face-to-face and telementoring, in addition to presenting comparable results regarding surgical success and failure. More studies are needed to explore the impact of telementoring in other ophthalmological surgeries. TRIAL REGISTRATION: The Federal University of São Paulo institution's Research Ethics Committee reviewed and approved this study protocol (approval number, 5.383.484).

The Nervous System Development Regulator Neuropilin-1 as a Potential Prognostic Marker and Therapeutic Target in Brain Cancer.

Neuropilins are transmembrane glycoproteins that regulate developmental processes in the nervous system and other tissues. Overexpression of neuropilin-1 (NRP1) occurs in many solid tumor types and, in several instances, may predict patient outcome in terms of overall survival. Experimental inhibition of NRP1 activity can display antitumor effects in different cancer models. Here, we review NRP1 expression and function in adult and pediatric brain cancers, particularly glioblastomas (GBMs) and medulloblastomas, and present analyses of NRP1 transcript levels and their association with patient survival in GBMs. The case of NRP1 highlights the potential of regulators of neurodevelopment as biomarkers and therapeutic targets in brain cancer.

Is the computed tomography exam important for planning mini-implant installation?

Background: Mini-implants are devices used to provide absolute and temporary anchorage for tooth movement. Objectives: The present study was carried out to compare the use of periapical radiographs and computed tomography (CT) for planning mini-implants performed by orthodontists. Material and Methods: Five radiographs and five CT scans of premolars and molars regions. These were analyzed by ten Orthodontists. Initially (T1), the evaluators indicated the preferred location for the insertion of a mini-implant, as well as the diameter and length of the device, using only a periapical radiograph. After 30 days (T2), the same evaluation was performed. Sixty days later (T3), the orthodontists reassessed the radiographs in association with the CT scans. Finally, after 90 days (T4), the evaluation was performed with the same exams. The comparison of the chosen diameter and length of the mini-implants was performed using the Student's t-test. The evaluation of the chosen insertion sites was analyzed by the Wilcoxon test. For both tests, the level of significance was 5%. The kappa concordance test was also performed for the intra- and inter-examiner evaluations. Results: The results of the study showed substantial or perfect intra-examiner and reasonable to perfect inter-examiner agreement. Considering the length and diameter of the mini-implants, no statistical difference was found between the groups. Regarding the insertion site, more than 20% of the treatment plans were changed when the CT scan was associated. Conclusions: The results showed that the association of a CT scan with radiography frequently leads the professional to change the insertion point for the installation of mini-implants. Key words:Orthodontic anchorage procedures. Mini Dental Implants. Bone Screws. Cone-beam computed tomography. Periapical radiography.

Use of surgical videos available on social media among retina surgeons: results of a vitreoretinal specialist survey.

PURPOSE: This study aimed to assess and interpret how vitreoretinal surgeons use surgical videos available on social media as complementary learning tools to improve, review, or update their abilities, considering their different levels of expertise. METHODS: In this cross-sectional survey, an online survey was sent to vitreoretinal specialists and fellows. RESULTS: This survey included 258 participants, of whom 53.88% had been in practice for >10 years (senior surgeons), 29.07% between 4 and 10 years (young surgeons), and 17.05% for <3 years (surgeons in training). Retinal surgical videos available on social media were used by 98.84% of the participants (95% confidence interval, 97.52%-100%). YouTube (91%) was the most common source of videos, and surgeons in training watched more videos on YouTube than senior surgeons. Regarding the preferred method when preparing for a procedure, 49.80% of the participants watched surgical videos available on social media, 26.27% preferred to "consult colleagues", and 18.82% preferred to seek information in scientific articles. Participants valued the most the "image quality" (88%) and presence of "surgical tips and tricks" (85%). CONCLUSION: Surgical videos can provide benefits in acquiring strategic skills, such as decision-making, surgical planning, and situational awareness. Retina surgeons used them as teaching aids regardless of their level of expertise, despite being relatively more valuable to surgeons in training or young surgeons.

Recurrent Transient Ischemic Attacks and Stroke Due to Carotid Dissection During Air Travel: A Case Report.

Carotid artery dissection causes 2.5% of ischemic acute strokes and is more common in younger rather than older patients. Extracranial lesions often manifest as transient and reversible neurological deficits until a stroke occurs. In this case, we describe a 60-year-old male patient with no known cardiovascular risk factors who experienced three transient ischemic attacks (TIAs) in four days while traveling in Portugal. At the emergency department, he was treated for an occipital headache associated with nausea and two episodes of decreased left upper-limb muscle strength lasting two to three minutes with spontaneous recovery. He requested discharge against medical advice so that he could travel home. During the return flight, he had a severe right parietal headache followed by decreased muscle strength in the left arm. After an emergency landing in Lisbon, he was referred to the local emergency department, where his neurological examination revealed preferential gaze to the right exceeding the midline, left homonymous hemianopsia, minor left central facial paresis, and spastic left brachial paresis. On the National Institutes of Health Stroke Scale, he scored 7. A head CT was performed, showing no acute vascular lesions (i.e., Alberta Stroke Program Early CT Score of 10). However, an image compatible with dissection was identified on CT angiography of the head and neck and confirmed by digital subtraction angiography. The patient underwent balloon angioplasty and placement of three stents in the right internal carotid artery with vascular permeabilization. This case highlights how prolonged and incorrect cervical posture and microtrauma secondary to aircraft turbulence may be associated with carotid artery dissection in predisposed individuals. The Aerospace Medical Association guidelines advocate that patients with a recent acute neurological event should avoid air travel until clinical stability is assured. As TIA is considered a harbinger of stroke, patients should be properly evaluated and avoid air travel for at least two days after the event.

Comparative complete scheme and booster effectiveness of COVID-19 vaccines in preventing SARS-CoV-2 infections with SARS-CoV-2 Omicron (BA.1) and Delta (B.1.617.2) variants: A case-case study based on electronic health records.

Background: Information on vaccine effectiveness in a context of novel variants of concern (VOC) emergence is of key importance to inform public health policies. This study aimed to estimate a measure of comparative vaccine effectiveness between Omicron (BA.1) and Delta (B.1.617.2 and sub-lineages) VOC according to vaccination exposure (primary or booster). Methods: We developed a case-case study using data on RT-PCR SARS-CoV-2-positive cases notified in Portugal during Weeks 49-51, 2021. To obtain measure of comparative vaccine effectiveness, we compared the odds of vaccination in Omicron cases versus Delta using logistic regression adjusted for age group, sex, region, week of diagnosis, and laboratory of origin. Results: Higher odds of vaccination were observed in cases infected by Omicron VOC compared with Delta VOC cases for both complete primary vaccination (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.8 to 2.4) and booster dose (OR = 5.2; 95% CI: 3.1 to 8.8), equivalent to reduction of vaccine effectiveness from 44.7% and 92.8%, observed against infection with Delta, to -6.0% (95% CI: 29.2% to 12.7%) and 62.7% (95% CI: 35.7% to 77.9%), observed against infection with Omicron, for complete primary vaccination and booster dose, respectively. Conclusion: Consistent reduction in vaccine-induced protection against infection with Omicron was observed. Complete primary vaccination may not be protective against SARS-CoV-2 infection in regions where Omicron variant is dominant.

How can public open spaces contribute to physical activity promotion? / Como os espaços públicos abertos podem contribuir para a promoção da atividade física?

Public open spaces (POSs) are means to ensure one's right to recreation and health. The objective of this essay is to present reflections and evidence on how these spaces contribute to promoting physi-cal activity (PA). Understanding how to access (proximity/distance), quantity and diversity, and the surrounding and internal conditions of places (quality, structure, aesthetics, safety) can affect the use of POSs is imperative for public management actions. Thinking of POS use beyond PA by recog-nizing its social, economic, and cultural benefits can be fundamental to reduce inequalities regarding access to these places. POS-related actions and demands are intersectoral, multiprofessional, and interdisciplinary, thus requiring political, academic, and community involvement and commitment for PA promotion

Espaços públicos abertos (EPA) são equipamentos que promovem o direito à recreação e à saúde. O objetivo deste ensaio é apresentar reflexões e evidências sobre como esses espaços contribuem para a promoção da atividade física (AF). Compreender como o acesso (proximidade/distância), a quantidade e diversidade, as condições do entorno e internas dos locais (qualidade, estrutura, estética, segurança), podem afetar o uso dos EPA é fundamental para ações da gestão pública. Pensar o uso do EPA para além da prática de AF, reconhecendo seus benefícios sociais, econômicos e culturais pode ser fundamental para diminuir as iniquidades de acesso a esses locais. Ações e demandas relacionadas aos EPA são intersetoriais, multiprofissionais e interdisciplinares, necessitando com isso envolvimento e comprometimento político, acadêmico e comunitário, a fim de promover AF

Three-Dimensional Performance Evaluation of Hemispherical Coriolis Vibratory Gyroscopes.

In this paper, the oscillation patterns and characteristics of gyroscopic reaction to rotation-induced Coriolis force and phase relations are reviewed by examining the main principles of operation of Coriolis vibratory gyroscopes based on the dynamic relations and proposed improvements in performance using parameter changes. Coriolis vibratory gyroscopes (CVGs) are among the most modern applicable gyroscopes in position detection that have replaced traditional gyroscopes due to some great features of the design of vibrating proof mass and elastic suspension. Given the key characteristics of capacitive versus piezoelectric excitation technologies for determining the vibration type in sensors, their operating principles and equations have completely changed. Therefore, two-dimensional finite element analysis is required to evaluate their optimal performance. Since the sensor space is constantly vibrating, a general equation is presented in this paper to explain the impact of parameters on the frequency of different operating modes. The main purposes of building vibrating gyroscopes are replacing the constant spinning of the rotor with a vibrating structure and utilizing the Coriolis effect, based on which the secondary motion of the sensitive object is generated according to the external angular velocity.

Evaluating Adherence to Diabetic Retinopathy Care in an Urban Ophthalmology Clinic Utilizing the Compliance With Annual Diabetic Eye Exams Survey.

Introduction The objective of this study was to identify barriers that affect adherence to the management of diabetic retinopathy (DR) in an urban ophthalmology clinic. Patient beliefs regarding diabetic eye care, transportation to the eye clinic, the COVID-19 pandemic, and treatment with panretinal photocoagulation (PRP) or anti-vascular endothelial growth factor (anti-VEGF) injections were investigated. Materials and methods The original Compliance with Annual Diabetic Eye Exams Survey (CADEES) included 44 statements designed with a 5-point Likert scale to assess patients' beliefs and understanding of their eye health and the importance of diabetic eye examinations. This survey was modified to include additional statements regarding the COVID-19 pandemic and free-response questions about transportation barriers and patients' subjective experiences with PRP or anti-VEGF injections. A total of 365 patients with a diagnosis of any stage of DR from SLUCare Ophthalmology were identified as potential participants to complete the telephone survey. Patients were classified as non-adherent if they did not have a dilated eye examination within the past year, missed a scheduled follow-up appointment for DR care within the past year, or missed an appointment for anti-VEGF injections or PRP. The mean Likert scores for each CADEES statement were compared between the adherent and non-adherent groups using independent samples t-tests. Demographics and clinical indicators were also reported and compared between the two groups. Results Out of 365 patients, 68 completed the modified CADEES. Twenty-nine patients were adherent, and 39 patients were non-adherent. Results from six of the 54 CADEES statements were significantly different between the adherent and non-adherent groups. These statements addressed patients' perception of their eye health, self-confidence in making an eye appointment, knowing someone with diabetic eye complications, self-confidence in controlling blood sugar, ability to use public transportation during the COVID-19 pandemic, and prioritizing eye health during the pandemic. There were no significant differences in clinical indicators or demographics between the adherent and non-adherent groups. Of the participants, 39.7% offered reasons for why transportation to the eye clinic was difficult. Patients suggested three novel reasons for missing eye appointments that were not specifically addressed in the CADEES. Fourteen unique barriers were reported for non-adherence with PRP or anti-VEGF injections. Conclusions The CADEES is a thorough tool for evaluating social barriers impacting adherence with DR appointments in an urban ophthalmology clinic. The survey did not identify any clinical or demographic risk factors for non-adherence in this patient population. Decreased patient self-efficacy may lead to non-adherence with the management of DR. The COVID-19 pandemic impacted the adherence of a small percentage of patients.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group.

BACKGROUND: The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making. METHODS: We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups. RESULTS: Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases. CONCLUSIONS: The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400-550 µm) and X-Large (550-800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Outcomes of Pars Plana Vitrectomy and 4-Point Sutured Scleral Fixation of Akreos AO60 Intraocular Lens in Clinical Settings: A Case Series.

PURPOSE: To determine the long-term anatomic outcomes and surgical complications of pars plana vitrectomy (PPV) and 4-point Gore-Tex-sutured Akreos AO60 intraocular lens (IOL) scleral fixation. DESIGN: Retrospective, multicenter, multisurgeon case series. PARTICIPANTS: Ninety-seven patients in tertiary eye care centers. METHODS: The patients underwent PPV and intraocular fixation of the Akreos AO60 IOL using Gore-Tex CV-8 sutures between January 2015 and April 2020. The inclusion criteria were aphakia, no capsular support, and a minimal 1 year of follow-up. MAIN OUTCOME MEASURES: Uncorrected visual acuity (VA), complication rates or types, and refraction. RESULTS: Data from 101 eyes of the 97 patients were analyzed (mean follow-up duration, 33.4 months; range, 12-62 months). The mean ± standard deviation uncorrected logarithm of the minimum angle of resolution VA improved from 1.04 ± 0.73 (20/200 Snellen equivalent) before surgery to 0.66 ± 0.65 (20/80) at 6 months after surgery (P < 0.001). The most prevalent complications included hypotony (12.9%), ocular hypertension (12.9%), corneal edema (8.9%), cystoid macular edema (6.9%), and vitreous hemorrhage (5.9%). Refraction was measured between 3 and 6 months after surgery, and 61.8% of the patients had spherical equivalent of ± 2.0 diopters. Most complications occurred in the first postoperative month and resolved spontaneously or with medical treatment. CONCLUSIONS: The results demonstrated that this surgical technique is well tolerated by the eyes, with a low complication rate in the long term. The rates of IOL opacification were infrequent for up to 62 months of follow-up.

Brittle Bone Disease: A Case Report.

Osteogenesis imperfecta (OI) is a rare genetic disorder. Due to considerable phenotypic variability, a classification was developed for OI subtypes based on clinical features and disease severity. A seven-day-old female was born at 40+1 weeks of gestation whose mother received routine antenatal care and had an uneventful pregnancy. In delivery, the newborn suffered bilateral collarbone fractures. After a week, she returned to an unscheduled appointment at the healthcare family unit due to an inconsolable cry and pain during mobilization of the left lower limb with three days of evolution, which were noticed by her parents. On examination, she presented edema in the right coxofemoral joint, asymmetry in the folds, and inconsolable crying during the mobilization of both hip joints. She was sent to the emergency department, where a pelvis X-ray was performed revealing a bilateral fracture of the femurs. During hospitalization, a genetic study revealed pathogenic variants of the WNT1 gene, which causes OI type XV. When a newborn presents with fractures, the main differential diagnosis is physical abuse. However, this was ruled out as we knew her mother and family, leaving no other possible evidence of abuse. OI was a highly probable diagnostic hypothesis due to the presence of two other cases of this type of OI in the same region of origin, even though her parents were not consanguineous and there was no history of fractures in their families. Although OI is a rare condition, the diagnosis was immediately suspected because there were two confirmed cases of this type in the same geographic area as our patient. Additionally, she had bilateral clavicle fractures at birth with no obvious signs or risk factors for abuse. As family doctors, it is our aim to support this family throughout their journey and provide the child with the best care possible.

Superficial femoral vein transposition as a solution for hemodialysis vascular access.

The significant growth in the number of individuals dependent on hemodialysis for renal replacement therapy and unrestricted use of short and long-term catheters have challenged vascular surgeons in search of solutions for patients whose options for access via the upper limbs have been exhausted and for the increasing rates of central venous stenosis in these patients. When access via the upper limbs is impossible, exceptional techniques can be used and the lower limbs offer feasible alternative vascular access sites for hemodialysis. This article reports a case of superficial femoral vein transposition to make a loop arteriovenous fistula in a patient with no possibility of access via the upper limbs and presents a literature review on this technique that remains little used.

Impact of a Hemoglobin Trigger Communication Tool on Perioperative Transfusion in Cardiac Surgery.

OBJECTIVES: Blood transfusion represents an important and potentially modifiable risk in the daily practice of cardiac surgery. The risk profile and increasing cost of transfusion led us to study the effect of different maneuvers, interventions, or surgical techniques to minimize transfusion while maintaining patient safety. This study compares postoperative outcomes before and after incorporating a verbal hemoglobin (Hb) trigger during the surgical timeout in which the surgeon and anesthesiologist preemptively agree on a threshold for packed red blood cell (PRBC) administration in the perioperative period. METHODS: The authors performed a chart review of patients who underwent cardiac surgery from July 2013 through June 2014 at our institution. Patients who underwent surgery from July 2013 through December 2013 served as the pre-Hb trigger group, and patients who underwent surgery from January 2014 through June 2014 served as the post-Hb trigger group. Information collected included patient demographics, type of cardiac surgery, preoperative Hb, Hb trigger, and intraoperative and postoperative variables. The primary outcome was the incidence of PRBC transfusions. Secondary outcomes included the incidence of frozen plasma (FP) transfusion, mechanical ventilation beyond postoperative day 1, and 30-day mortality. RESULTS: The study included 191 patients, with 84 in the pre-Hb trigger group and 107 in the post-Hb trigger group. Intraoperative PRBC transfusions did not decrease in the posttrigger group compared with the pretrigger group (pretrigger 51.4% vs posttrigger 52.4%, P = 1.0); however, intraoperative FP administration was lower in the posttrigger group (65.4% vs 50.0%, P = 0.038). Postoperative mechanical ventilation beyond postoperative day 1 also was significantly lower in the posttrigger group compared with the pretrigger group (27.1% vs 14.3%, P = 0.035). CONCLUSIONS: Implementation of a verbal Hb trigger during the surgical timeout was associated with a reduction in FP administration and duration of mechanical ventilation, but not a decrease in PRBC transfusion and mortality.

Analysis of Pre-Driver and Last-Stage Power-Ground-Induced Jitter at Different PVT Corners.

This paper presents the study of power/ground (P/G) supply-induced jitter (PGSIJ) on a cascaded inverter output buffer. The PGSIJ analysis covers the IO buffer transient simulation under P/G supply voltage variation at three process, voltage, and temperature (PVT) corners defined at different working temperatures and distinct P/G DC supply voltages at the pre-driver (i.e., VDD/VSS) and last stage (i.e., VDDQ/VSSQ). Firstly, the induced jitter contributions by the pre-driver, as well as the last, stage are compared and studied. Secondly, the shared and decoupled P/G supply topologies are investigated. The outcomes of these simulation analyses with respect to worst case jitter corners are determined, while highlighting the importance of modeling the pre-driver circuit behavior to include the induced jitter in the input-output buffer information specification (IBIS)-like model. Accordingly, the measured PGSIJ depends on the corners to be analyzed and, therefore, the designer needs to explore the worst-case corner for the driver's technology node and the most supply voltage noise affecting the jitter output for signal and power integrity (SiPI) simulations. Finally, the jitter transfer function sensitivity to the amplitude and frequency/phase variations of the separate and combined impacts of the pre-driver and last stage are explored, while discussing the superposition of the power supply induced jitter (PSIJ) induced by both the driver's IO stages under small signal and large signal supply voltage variations. The linear superposition of the separate PSIJ effects by the pre-driver and last stage depends on the amplitude of the variation of the supply voltage that can drive the transistor to their nonlinear working regions.

Anatomy of the optic radiations from the white matter fiber dissection perspective: A literature review applied to practical anatomical dissection.

Background: Knowledge of the anatomical course of the optic radiations and its relationship to medial temporal lobe structures is of great relevance in preoperative planning for surgery involving the temporal lobe to prevent damage that may result in postsurgical visual field deficits. Methods: In this anatomical study, we reviewed the literature on this topic and applied the information to practical anatomical dissection. The three-dimensional relationship between the course of the optic radiations and structures accessed in the main microneurosurgical approaches to the medial temporal lobe was examined by applying Klingler's white matter fiber dissection technique to five formalin-fixed human brains. The dissections were performed with an operating microscope at magnifications of ×3-×40. High-resolution images were acquired during dissection for identification of the anatomical structures, focusing on the characterization of the course of the optic radiations in relation to medial temporal lobe structures. Results: In all five dissected brains, we could expose and clearly define the relationship between the optic radiations and medial temporal lobe structures, improving our understanding of these complex structures. Conclusion: The knowledge gained by studying these relationships will help neurosurgeons to develop risk-adjusted approaches to prevent damage to the optic radiations in the medial temporal region, which may result in a disabling visual field deficit.