Neonatal intubation: what are we doing?

How and when the forces are applied during neonatal intubation are currently unknown. This study investigated the pattern of the applied forces by using sensorized laryngoscopes during the intubation process in a neonatal manikin. Nine users of direct laryngoscope and nine users of straight-blade video laryngoscope were included in a neonatal manikin study. During each procedure, relevant forces were measured using a force epiglottis sensor that was placed on the distal surface of the blade. The pattern of the applied forces could be divided into three sections. With the direct laryngoscope, the first section showed either a quick rise of the force or a discontinuous rise with several peaks; after reaching the maximum force, there was a sort of plateau followed by a quick drop of the applied forces. With the video laryngoscope, the first section showed a quick rise of the force; after reaching the maximum force, there was an irregular and heterogeneous plateau, followed by heterogeneous decreases of the applied forces. Moreover, less forces were recorded when using the video laryngoscope.    Conclusions: This neonatal manikin study identified three sections in the diagram of the forces applied during intubation, which likely mirrored the three main phases of intubation. Overall, the pattern of each section showed some differences in relation to the laryngoscope (direct or video) that was used during the procedure. These findings may provide useful insights for improving the understanding of the procedure. What is Known: • Neonatal intubation is a life-saving procedure that requires a skilled operator and may cause direct trauma to the tissues and precipitate adverse reactions. • Intubation with a videolaryngoscope requires less force than with a direct laryngoscope, but how and when the forces are applied during the whole neonatal intubation procedure are currently unknown. What is New: • Forces applied to the epiglottis during intubation can be divided into three sections: (i) an initial increase, (ii) a sort of plateau, and (iii) a decrease. • The pattern of each section shows some differences in relation to the laryngoscope (direct or videolaryngoscope) that is used during the procedure.

Assessing the resilience of HIV healthcare services provided to adolescents and young adults after the COVID-19 pandemic in the city of Beira (Mozambique): an interrupted time series analysis.

BACKGROUND: The COVID-19 pandemic has put the provision of health services globally at risk. In Sub-Saharan Africa, it had a major impact on HIV services. However, there is a lack of data on the post-pandemic period. This study aims to evaluate the resumption of HIV services and retention in care for adolescents and young people in the period following the COVID-19 pandemic. METHODS: A retrospective cohort study was conducted using interrupted time series analysis. Three periods were considered: pre-pandemic (form June 2019 to March 2020), pandemic (form April 2020 to March 2022) post-pandemic (from April 2022 to March 2023). Six outcome measures were considered: number of outpatient visits, HIV tests, HIV positivity ratio, the antiretroviral treatment (ART) non-adherence ratio, recall ratio, and the return ratio for adolescent and young adults on ART. RESULTS: During the study period, 447,515 outpatient visits and 126,096 HIV tests were recorded. After a reduction at the beginning of the pandemic period, both visits and tests increased during the pandemic (p < 0.05) and decreased in the post-pandemic (p < 0.05), recovering the pre-pandemic trends. The HIV positivity ratio slightly decreased from 3.3% to 1.7% during the study period (p < 0.05). The ART non-adherence ratio decreased from 23.4% to 2.4% throughout the study period (p < 0.05), with a drop at the beginning of the post-pandemic period (p < 0.05). The recall ratio increased during the study period (p < 0.05) with a drop at the beginning of the pandemic and post-pandemic periods (p < 0.05). The return ratio decreased at the beginning of the pandemic (p < 0.05) but returned to the pre-pandemic ratio in the post-pandemic period. CONCLUSIONS: The post-pandemic values of the investigated outcomes were comparable to pre-pandemic period, or even improved. Differently from other services, such as the community activities, that have been severely affected by COVID-19 pandemic, the HIV service system has shown resilience following emergency situation.

A multicentre neonatal manikin study showed a large heterogeneity in tactile stimulation for apnoea of prematurity.

AIM: Apnoea of prematurity requires prompt intervention to prevent long-term adverse outcomes, but specific recommendations about the stimulation approach are lacking. Our study investigated the modalities of tactile stimulation for apnoea of prematurity in different settings. METHODS: In this multi-country observational prospective study, nurses and physicians of the neonatal intensive care units were asked to perform a tactile stimulation on a preterm neonatal manikin simulating an apnoea. Features of the stimulation (body location and hand movements) and source of learning (training course or clinical practice) were collected. RESULTS: Overall, 112 healthcare providers from five hospitals participated in the study. During the stimulation, the most frequent location were feet (72%) and back (61%), while the most frequent techniques were rubbing (64%) and massaging (43%). Stimulation modalities different among participants according to their hospitals and their source of learning of the stimulation procedures. CONCLUSION: There was a large heterogeneity in stimulation approaches adopted by healthcare providers to counteract apnoea in a simulated preterm infant. This finding may be partially explained by the lack of specific guidelines and was influenced by the source of learning for tactile stimulation.

A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation.

BACKGROUND: Face-mask ventilation is the most common resuscitation method for birth asphyxia. Ventilation with a cuffless laryngeal mask airway (LMA) has potential advantages over face-mask ventilation during neonatal resuscitation in low-income countries, but whether the use of an LMA reduces mortality and morbidity among neonates with asphyxia is unknown. METHODS: In this phase 3, open-label, superiority trial in Uganda, we randomly assigned neonates who required positive-pressure ventilation to be treated by a midwife with an LMA or with face-mask ventilation. All the neonates had an estimated gestational age of at least 34 weeks, an estimated birth weight of at least 2000 g, or both. The primary outcome was a composite of death within 7 days or admission to the neonatal intensive care unit (NICU) with moderate-to-severe hypoxic-ischemic encephalopathy at day 1 to 5 during hospitalization. RESULTS: Complete follow-up data were available for 99.2% of the neonates. A primary outcome event occurred in 154 of 563 neonates (27.4%) in the LMA group and 144 of 591 (24.4%) in the face-mask group (adjusted relative risk, 1.16; 95% confidence interval [CI], 0.90 to 1.51; P = 0.26). Death within 7 days occurred in 21.7% of the neonates in the LMA group and 18.4% of those in the face-mask group (adjusted relative risk, 1.21; 95% CI, 0.90 to 1.63), and admission to the NICU with moderate-to-severe hypoxic-ischemic encephalopathy at day 1 to 5 during hospitalization occurred in 11.2% and 10.1%, respectively (adjusted relative risk, 1.27; 95% CI, 0.84 to 1.93). Findings were materially unchanged in a sensitivity analysis in which neonates with missing data were counted as having had a primary outcome event in the LMA group and as not having had such an event in the face-mask group. The frequency of predefined intervention-related adverse events was similar in the two groups. CONCLUSIONS: In neonates with asphyxia, the LMA was safe in the hands of midwives but was not superior to face-mask ventilation with respect to early neonatal death and moderate-to-severe hypoxic-ischemic encephalopathy. (Funded by the Research Council of Norway and the Center for Intervention Science in Maternal and Child Health; NeoSupra ClinicalTrials.gov number, NCT03133572.).

Simple rules, O-RADS, ADNEX and SRR model: Single oncologic center validation of diagnostic predictive models alone and combined (two-step strategy) to estimate the risk of malignancy in adnexal masses and ovarian tumors.

OBJECTIVE: To compare performance of Assessment of Different NEoplasias in the adneXa (ADNEX model), Ovarian-Adnexal Reporting and Data System (O-RADS), Simple Rules Risk (SRR) assessment and the two-step strategy based on the application of Simple Rules (SR) followed by SRR and SR followed by ADNEX in the pre-operative discrimination between benign and malignant adnexal masses (AMs). METHODS: We conducted a retrospective study from January-2018 to December-2021 in which consecutive patients with at AMs were recruited. Accuracy metrics included sensitivity (SE) and specificity (SP) with their 95% confidence intervals (CI) were calculated for ADNEX, O-RADS and SRR. When SR was inconclusive a "two-step strategy" was adopted applying SR + ADNEX model and SR + SRR assessment. RESULTS: A total of 514 women were included, 400 (77.8%) had a benign ovarian tumor and 114 (22.2%) had a malignant tumor. At a threshold malignancy risk of >10%, the SE and SP of ADNEX model, O-RADS and SRR were: 0.92 (95% CI, 0.86-0.96) and 0.88 (95% CI, 0.85-0.91); 0.93 (95% CI, 0.87-0.97) and 0.89 (95% CI, 0.96-0.92); 0.88 (95% CI, 0.80-0.93) and 0.84 (95% CI, 0.80-0.87), respectively. When we applied SR, 109 (21.2%) cases resulted inconclusive. The SE and SP of two-step strategy SR + SRR assessment and SR + ADNEX model were 0.88 (95% CI, 0.80-0.93) and 0.92 (95% CI, 0.89-0.94), SR + ADNEX model 0.90 (95% CI, 0.83-0.95) and 0.93 (95% CI, 0.90-0.96), respectively. CONCLUSIONS: O-RADS presented the highest SE, similar to ADNEX model and SR + ADNEX model. However, the SR + ADNEX model presented the higher performance accuracy with the higher SP and PPV. This two-step strategy, SR and ADNEX model applicated to inconclusive SR, is convenient for clinical evaluation.

Association between thyroid function and regorafenib efficacy in patients with relapsed wild-type IDH glioblastoma: a large multicenter study.

PURPOSE: Regorafenib demonstrated encouraging results in recurrent glioblastoma patients. Some studies showed that changes in circulating thyroid hormones (fT3, fT4, fT3/fT4 ratio) can be considered as prognostic factors in patients with various types of tumors. We designed this study to investigate the relationship between baseline thyroid variables and outcome in IDH-wild type GBM patients who were treated with regorafenib. METHODS: This multicenter retrospective study included recurrent IDH-wild-type glioblastoma patients treated with regorafenib. Only patients with baseline thyroid function values (TSH, fT3, fT4, fT3/fT4 ratio) available were evaluated. RANO criteria were used to analyze neuroradiological response. Survival curves were estimated using the Kaplan-Meier method. The relationships between baseline thyroid variables (TSH, fT3, fT4, fT3/fT4) and survival (PFS, OS) were investigated with Cox regression models. RESULTS: From November 2015 to April 2022, 134 recurrent IDH-wildtype GBM patients were treated with regorafenib and 128 of these had information on baseline thyroid function value. Median follow-up was 8 months (IQR 4.7-14.0). Objective Response Rate was 9% and Disease Control Rate was 40.9%. Median PFS was 2.7 months (95%CI 2.2-3.6) and median OS was 10.0 months (95%CI 7.0-13.0). Lower baseline TSH value in the blood was correlated with a higher rate of disease progression to regorafenib (p = 0.04). Multivariable analyses suggested a non-linear relationship between PFS (p = 0.01) and OS (p = 0.03) with baseline fT3/fT4 ratio. CONCLUSION: In recurrent wild-type IDH glioblastoma patients, baseline fT3/fT4 ratio showed a non-linear relationship with survival, with different impacts across the spectrum of fT3/fT4 ratio. Moreover, baseline TSH may be a predictor of regorafenib activity.

Venous outflow obstruction in pediatric left lateral segment split liver transplantation.

BACKGROUND: Venous outflow obstruction (VOO) is a known cause of graft and patient loss after pediatric liver transplantation (LT). We analyzed the incidence, risk factors, diagnosis, management, and outcome of VOO in a large, consecutive series of left lateral segment (LLS) split LT with end-to-side triangular venous anastomosis. METHODS: We evaluated data collected in our prospective databases relative to all consecutive pediatric liver transplants performed from January 2006 to December 2021. We included in this study children undergoing LLS split liver transplant with end-to-side triangular anastomosis. Diagnosis of VOO was based on clinical suspicion and radiological confirmation. RESULTS: VOO occurred in 24/279 transplants (8.6%), and it was associated with lower graft weight (p = .04), re-transplantation (p = .008), and presence of two hepatic veins (p < .0001). In presence of two segmental veins' orifices, the type of reconstruction (single anastomosis after venoplasty or double anastomosis) was not significantly related to VOO (p = .87). Multivariable analysis indicated VOO as a risk factor for graft lost (hazard ratio 3.21, 95% confidence interval 1.22-8.46; p = .01). Percutaneous Transluminal Angioplasty (PTA) was effective in 17/22 (77%) transplants. Surgical anastomosis was redone in one case. Overall six grafts (25%) were lost. CONCLUSION: VOO after LLS split LT with end-to-side triangular anastomosis is an unusual but critical complication leading to graft loss in a quarter of cases. The occurrence of VOO was associated with lower graft weight, re-transplantation, and presence of two hepatic veins. PTA was safe and effective to restore proper venous outflow in most cases.

Laryngeal mask airway in neonatal stabilization and transport: a retrospective study.

Laryngeal mask airway (LMA) may be considered by health caregivers of level I-II hospitals for neonatal resuscitation and stabilization before and during interhospital care, but literature provides little information on this aspect. This study reviewed the use of LMA during stabilization and transport in a large series of neonates. This is a retrospective study evaluating the use of LMA in infants who underwent emergency transport by the Eastern Veneto Neonatal Emergency Transport Service between January 2003 and December 2021. All data were obtained from transport registry, transport forms, and hospital charts. In total, 64/3252 transferred neonates (2%) received positive pressure ventilation with an LMA, with increasing trend over time (p = 0.001). Most of these neonates were transferred after birth (97%), due to a respiratory or neurologic disease (95%). LMA was used before the transport (n = 60), during the transport (n = 1), or both (n = 3). No device-related adverse effects were recorded. Sixty-one neonates (95%) survived and were discharged/transferred from the receiving center. CONCLUSION: In a large series of transferred neonates, LMA use during stabilization and transport was rare but increasing over time, and showed some heterogeneity among referring centers. In our series, LMA was safe and lifesaving in "cannot intubate, cannot oxygenate" situations. Future prospective, multicenter research may provide detailed insights on LMA use in neonates needing postnatal transport. WHAT IS KNOWN: • A supraglottic airway device may be used as an alternative to face mask and endotracheal tube during neonatal resuscitation. • The laryngeal mask may be considered by health caregivers of low-level hospitals with limited exposure on airway management, but literature provides little information on this aspect. WHAT IS NEW: • In a large series of transferred neonates, laryngeal mask use was rare but increasing over time, and showed some heterogeneity among referring centers. • The laryngeal mask was safe and lifesaving in "cannot intubate, cannot oxygenate" situations.

Preoperative Prognostic Nutritional Index was not predictive of short-term complications after laparoscopic resection for rectal cancer.

BACKGROUND AND AIM: Prognostic Nutritional Index (PNI) is a useful tool to predict short-term results in patients undergoing surgery for gastrointestinal cancer. Few studies have addressed this issue in colorectal cancer or specifically in rectal cancer. We evaluated the prognostic relevance of preoperative PNI on morbidity of patients undergoing laparoscopic curative resection for rectal cancer (LCRRC). METHODS: PNI data and clinico-pathological characteristics of LCRRC patients (June 2005-December 2020) were evaluated. Patients with metastatic disease were excluded. Postoperative complications were evaluated using the Clavien-Dindo classification. RESULTS: A total of 182 patients were included in the analysis. Median preoperative PNI was 36.5 (IQR 32.8-41.2). Lower PNI was associated with females (p=0.02), older patients (p=0.0002), comorbidity status (p<0.0001), and those who did not receive neoadjuvant treatment (p=0.01). Post-operative complications occurred in 53 patients (29.1%), by the Clavien-Dindo classification: 40 grades I-II and 13 grades III-V. Median preoperative PNI was 35.0 (31.8-40.0) in complicated patients and 37.0 (33.0-41.5) in uncomplicated patients (p=0.09). PNI showed poor discriminative performance regarding postoperative morbidity (AUC 0.57) and was not associated with postoperative morbidity (OR 0.97) at multivariable analysis. CONCLUSIONS: Preoperative PNI was not associated with postoperative morbidity after LCRRC. Further research should focus on different nutritional indicators or hematological/immunological biomarkers.

"Diagnostic ability in oral pathology among different population clusters".

OBJECTIVES: To assess the diagnostic ability in detecting oral lesions among dentists, dental hygienists, dentistry students, oral hygiene students, and non-healthcare subjects. MATERIALS AND METHODS: Participants were invited to classify 30 images of oral lesions in "benign" or "suspected malignant" only based on the visual appearance of the lesion. Diagnostic accuracy was assessed by calculating sensitivity and specificity with 95% confidence intervals and stratified by population group and image features (color, shape, and size of the lesions). RESULTS: A total of 16,590 examinations by 553 subjects were analyzed. Overall sensitivity and specificity were 57% (95% confidence interval 56%-58%) and 64% (95% confidence interval 63%-65%). Diagnostic accuracy varied among population groups, with experienced dentists showing the lowest sensitivity (52%) and the highest specificity (71%). Red lesions, flat lesions, and large lesions had the lowest sensitivity (42%, 36%, 57%) but the highest specificity (70%, 75%, 76%). CONCLUSIONS: We found worrying low ability to detect suspected malignant oral lesions by both healthcare workers and non-healthcare subjects. Lesion-specific characteristics may lead to differences in recognition. Specific courses and more adequate teaching methods should be proposed to increase identification of oral lesions.

Applied forces with direct versus indirect laryngoscopy in neonatal intubation: a randomized crossover mannequin study.

PURPOSE: In adult mannequins, videolaryngoscopy improves glottic visualization with lower force applied to upper airway tissues and reduced task workload compared with direct laryngoscopy. This trial compared oropharyngeal applied forces and subjective workload during direct vs indirect (video) laryngoscopy in a neonatal mannequin. METHODS: We conducted a randomized crossover trial of intubation with direct laryngoscopy, straight blade videolaryngoscopy, and hyperangulated videolaryngoscopy in a neonatal mannequin. Thirty neonatal/pediatric/anesthesiology consultants and residents participated. The primary outcome measure was the maximum peak force applied during intubation. Secondary outcome measures included the average peak force applied during intubation, time needed to intubate, and subjective workload. RESULTS: Direct laryngoscopy median forces on the epiglottis were 8.2 N maximum peak and 6.8 N average peak. Straight blade videolaryngoscopy median forces were 4.7 N maximum peak and 3.6 N average peak. Hyperangulated videolaryngoscopy median forces were 2.8 N maximum peak and 2.1 N average peak. The differences were significant between direct laryngoscopy and straight blade videolaryngoscopy, and between direct laryngoscopy and hyperangulated videolaryngoscopy. Significant differences were also found in the top 10th percentile forces on the epiglottis and palate, but not in the median forces on the palate. Time to intubation and subjective workload were comparable with videolaryngoscopy vs direct laryngoscopy. CONCLUSIONS: The lower force applied during videolaryngoscopy in a neonatal mannequin model suggests a possible benefit in reducing potential patient harm during intubation, but the clinical implications require assessment in future studies. REGISTRATION: ClinicalTrials.gov (NCT05197868); registered 20 January 2022.

RéSUMé: OBJECTIF: Sur les mannequins adultes, la vidéolaryngoscopie améliore la visualisation glottique avec une force plus faible appliquée aux tissus des voies aériennes supérieures et une charge de travail réduite par rapport à la laryngoscopie directe. Cette étude a comparé les forces appliquées sur la zone oropharyngée et la charge de travail subjective au cours d'une laryngoscopie directe vs indirecte (vidéolaryngoscopie) sur un mannequin néonatal. MéTHODE: Nous avons réalisé une étude randomisée croisée d'intubation par laryngoscopie directe, vidéolaryngoscopie à lame droite et vidéolaryngoscopie avec lame hyperangulée sur un mannequin néonatal. Trente spécialistes diplômés et résidents en néonatologie, en pédiatrie et en anesthésiologie y ont participé. Le critère d'évaluation principal était le pic de force maximal obtenu pendant l'intubation. Les critères d'évaluation secondaires comprenaient la force maximale moyenne appliquée pendant l'intubation, le temps nécessaire pour intuber et la charge de travail subjective. RéSULTATS: Les forces médianes appliquées sur l'épiglotte lors de la laryngoscopie directe étaient de 8,2 N pour le pic maximum et de 6,8 N pour le pic moyen. Les forces médianes appliquées lors de la vidéolaryngoscopie à lame droite étaient de 4,7 N pour le pic maximum et de 3,6 N pour le pic moyen. Les forces médianes appliquées lors de la vidéolaryngoscopie avec lame hyperangulée étaient de 2,8 N pour le pic maximum et de 2,1 N pour le pic moyen. Les différences étaient significatives entre la laryngoscopie directe et la vidéolaryngoscopie à lame droite, et entre la laryngoscopie directe et la vidéolaryngoscopie avec lame hyperangulée. Des différences significatives ont également été observées dans le 10e percentile supérieur des forces sur l'épiglotte et le palais, mais pas dans les forces médianes sur le palais. Le délai d'intubation et la charge de travail subjective étaient comparables entre la vidéolaryngoscopie et la laryngoscopie directe. CONCLUSION: La force plus faible appliquée lors de la vidéolaryngoscopie dans un modèle de mannequin néonatal suggère un avantage possible de réduction des lésions potentielles pour le patient pendant l'intubation, mais les implications cliniques doivent être évaluées dans des études futures. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT05197868); enregistré le 20 janvier 2022.

Marked versus unmarked tip catheter for less invasive surfactant administration: A crossover randomised controlled manikin trial.

AIM: Less invasive surfactant administration is becoming increasingly popular, but health-care providers may experience some difficulties in achieving the correct positioning of the catheter in the trachea. We compared catheters with marked versus unmarked tips in terms of correct depth positioning in the trachea, total time, number of attempts and participant's opinion on using the device in a manikin model. METHODS: A randomised controlled crossover trial of surfactant administration with less invasive surfactant administration catheters with marked versus unmarked tip in a preterm infant manikin. Fifty tertiary hospital consultants and paediatric residents with previous experience in surfactant administration participated. The primary outcome measure was the positioning of the device at the correct depth in the trachea. The secondary outcome measures were the total time and the number of attempts for positioning the device in the trachea, and participant's opinion on using the device. RESULTS: Correct depth in the trachea was achieved by 38 (76%) and 28 (56%) participants using the catheters with marked and unmarked tip, respectively (P = 0.04). Median time of device positioning (P = 0.08) and number of attempts (P = 0.13) were not statistically different between the two catheters. Participants found the catheter with the marked tip easier to use (P = 0.007), especially concerning the insertion in the trachea (P = 0.04) and the positioning at the correct depth (P = 0.004). CONCLUSIONS: In a preterm manikin model, the marked tip catheter offered a higher chance of achieving the correct depth of the device in the trachea and was favoured by the participants.

Single session of laser photobiomodulation for symptom management of oral lichen planus: a retrospective study.

This study aimed to evaluate the effectiveness of a single session of laser photobiomodulation (PBM) with flat top handpiece in reducing painful symptoms in patients with Oral Lichen Planus (OLP). The clinical charts of 20 patients of the Dental Clinic of University of Padua (Italy) who underwent a single laser PBM to manage OLP symptomatology were retrospectively analyzed. A 980 nm diode laser and a flat top handpiece with a 1-cm2 spot area were employed to perform the PBM with a single session protocol. VAS pain scores were assessed before and after the laser PBM, the day after, and on the 7th and 30th days after the treatment. No adverse effects occurred within 30 days after treatment. The mean VAS-pain score was 3.8 (SD 2.3) before PBM; 2.6 (SD 2.0) after PBM; 1.9 (SD 2.2) on day 1; 2.0 (SD 2.3) on day 7; and 1.5 (SD 2.2) on day 30. VAS pain decreased significantly over time (p < 0.0001). A single session of laser PBM may be safe and effective in reducing pain for symptomatic OLP patients. Further investigations are required to include placebo or topical corticosteroids as comparators.

Chemoradiation vs. local excision in the management of early squamous cell carcinoma of the anus: a systematic review.

PURPOSE: Squamous cell carcinoma of the anus (SCCA) suffers a constant increase each year in the last decades. Recent studies suggested the possibility of local excision (LE) as an option for early-stage SCAC patients. This systematic review aims to summarize the available evidence on the comparison of LE vs. chemoradiotherapy (CRT) in the treatment of early SCCA patients. METHODS: We conducted a literature review including MEDLINE/PubMed, EMBASE, SCOPUS, clinicaltrials.gov, and the Cochrane Database of Systematic Reviews through June 2022. MOOSE guidelines were followed. We used the methodological index for non-randomized studies (MINORS) tool to assess quality. Data on survival and procedure-associated costs were extracted. RESULTS: Four retrospective studies including 3323 patients were included. They were all comparative retrospective cohort studies (three were registry-based studies, either NCDB or SEER) with a MINORS score of 16-19 points. Overall survival (OS) was comparable between LE and CRT patients in three studies, with a 5-year OS of 85.3-100% in LE patients and 85-91.6% in CRT patients. One study investigated cancer-specific survival (CSS) and reported similar 5-year CSS in LE (98%) and CRT patients (96%). One investigated progression-free survival (PFS) and did not report any statistically significant difference in 5-year PFS between LE (91%) and CRT patients (83%). Only one study considered the mean costs associated with the two approaches (29,210 USD with LE and 46,350 USD with CRT). CONCLUSIONS: LE may potentially be considered a valid alternative to CRT for patients with early-stage SCAA. Results of prospective randomized long-term trials comparing LE with CRT are warranted to draw definitive conclusions and consider LE as a true cost-effective strategy for T1N0 SCCA with similar oncologic results offered by CRT, which-to date-remains the "gold standard." PROSPERO REGISTRATION: CRD42022338750.

Per- and polyfluoroalkyl substances (PFAS) exposure in melanoma patients: a retrospective study on prognosis and histological features.

Per- and polyfluoroalkyl substances (PFAS) are endocrine disrupting chemicals which could be associated with cancer development, such as kidney and testicular cancers, pancreatic and hepatocellular carcinoma and thyroid tumor. Available scientific literature offers no information on the role of PFAS in melanoma development/progression. Since 1965, a massive environmental contamination by PFAS has occurred in northeastern Italy. This study compared histopathology and prognosis between melanoma patients exposed (n = 194) and unexposed (n = 488) to PFAS. All patients were diagnosed and/or treated for melanoma at the Veneto Oncological Institute and the University Hospital of Padua (Italy) in 1998-2014. Patients were categorized in exposed or unexposed groups according to their home address and the geographical classification of municipalities affected by PFAS contamination as provided by Veneto Government in 2018. Presence of mitoses was found in 70.5% of exposed patients and 58.7% of unexposed patients (p = 0.005). Median follow-up was 90 months (IQR 59-136). 5-year overall survival was 83.7% in exposed patients and 88.0% in unexposed patients (p = 0.20); 5-year disease-specific survival was 88.0% in exposed patients and 90.9% in unexposed patients (p = 0.50); 5-year disease-free survival was 83.8% in exposed patients and 87.3% in unexposed patients (p = 0.20). Adjusting for imbalanced characteristics at baseline (presence of mitoses), survival was not statistically different between exposed and unexposed patients (overall survival: HR 1.10, 95% CI 0.77 to 1.58, p = 0.57; disease-specific survival: HR 0.99, 95% CI 0.62 to 1.59, p = 0.99; disease-free survival: HR 1.10, 95% CI 0.74 to 1.64, p = 0.62). Although the magnitude of PFAS exposure was not quantifiable, our findings suggested that exposure to PFAS was associated with higher level of mitosis in melanoma patients, but this did not translate into a survival difference. Further studies are required to investigate this relationship and all effects of PFAS on prognosis.

Comparison of alternative gestational age assessment methods in a low resource setting: a retrospective study.

BACKGROUND: Accurate gestational age (GA) determination allows correct management of high-risk, complicated or post-date pregnancies and prevention or anticipation of prematurity related complications. Ultrasound measurement in the first trimester is the gold standard for GA determination. In low- and middle-income countries elevated costs, lack of skills and poor maternal access to health service limit the availability of prenatal ultrasonography, making it necessary to use alternative methods. This study compared three methods of GA determination: Last Normal Menstrual Period recall (LNMP), New Ballard Score (NBS) and New Ballard Score corrected for Birth Weight (NBS + BW) with the locally available standard (Ultrasound measurement in the third trimester) in a low-resource setting (Tosamaganga Council Designated Hospital, Iringa, Tanzania). METHODS: All data were retrospectively collected from hospital charts. Comparisons were performed using Bland Altman method. RESULTS: The analysis included 70 mother-newborn pairs. Median gestational age was 38 weeks (IQR 37-39) according to US. The mean difference between LNMP vs. US was 2.1 weeks (95% agreement limits - 3.5 to 7.7 weeks); NBS vs. US was 0.2 weeks (95% agreement limits - 3.7 to 4.1 weeks); NBS + BW vs. US was 1.2 weeks (95% agreement limits - 1.8 to 4.2 weeks). CONCLUSIONS: In our setting, NBS + BW was the least biased method for GA determination as compared with the locally available standard. However, wide agreement bands suggested low accuracy for all three alternative methods. New evidence in the use of second/third trimester ultrasound suggests concentrating efforts and resources in further validating and implementing the use of late pregnancy biometry for gestational age dating in low and middle-income countries.

Prognostic role of TOPS in ambulance-transferred neonates in a low-resource setting: a retrospective observational study.

BACKGROUND: Assessing the severity of transferred neonates at admission can improve resource allocation. This study evaluated the role of TOPS (illness severity score including temperature, oxygen saturation, skin perfusion and blood sugar) in predicting mortality in neonates transferred by ambulance in a low-resource setting. METHODS: The study was conducted at Beira Central Hospital (Mozambique). Infants who were transferred by ambulance to the Neonatal Intensive Care Unit between 16th June and 16th October 2021 were included. The association between TOPS and mortality was investigated with a logistic regression model. Receiver-operating characteristics (ROC) curve was derived for TOPS; area under the ROC curve, sensitivity and specificity were calculated. RESULTS: In-transport mortality was 2/198 (1.0%) and in-hospital mortality was 75/196 (38.3%). Median gestational age and birthweight were 38 weeks and 2600 g. Main causes of admission were asphyxia (29.3%), prematurity (25.3%) and sepsis (22.7%). Hypothermia and oxygen desaturation at admission were 75.8% and 32.3%. TOPS ≥ 1 was associated with increased mortality risk (odds ratio 7.06. 95% confidence interval 1.90 to 45.82), with 0.97 sensitivity and 0.26 specificity. CONCLUSIONS: The high mortality rate calls for interventions and quality initiative studies to improve the transfer process and the conditions at admission. TOPS can be used to identify neonates at risk of mortality and concentrate efforts of health care providers. Interventions preventing hypothermia and oxygen desaturation should be implemented in pre-transport stabilization and care during transport.

Crohn's Disease-Related Stoma Complications and Their Impact on Postsurgical Course.

INTRODUCTION: Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract. The diversion through a colostomy or an ileostomy is sometimes required for disease control. In these patients, common stoma-related complications sum up with CD-related complications and often require revisional surgery. METHODS: The aim of the study was to assess stoma morbidity after surgery for CD and to identify the burden of CD-related or CD-associated complications. Thus, details of past medical history, surgery, and follow-up of 54 consecutive patients operated on for CD with any sort of stoma were retrieved from the stoma therapist prospectively maintained database. RESULTS: In our series, 23 patients had a colostomy, and 31 patients had an ileostomy. Complications occurred after stoma creation in 38 patients (70%) at a median of 1.3 months (interquartile range 0.6-7.2). CD-related complications arose in 8 patients (including pyoderma gangrenosum in 3 patients, peristomal fistulae in 2, granulomas in 2, and peristomal abscess in 1). Patients with CD-related complications tended to have a shorter disease duration (p = 0.07) and higher occurrence of CD-related complications was associated with end-stoma (p = 0.006). In this cohort, 11 cases had to be surgically treated for peristomal fistulae or abscess, parastomal hernia, prolapse, pyoderma gangrenosum, and recurrent CD. DISCUSSION/CONCLUSIONS: In patients with CD, stoma creation is burdened by a high rate of postoperative complication and a relevant rate is specifically related to CD. Often these patients are required to be reoperated on to redo the stoma. Moreover, end-stoma configuration and aggressive CD phenotype are associated to a higher rate of complications.

Influence of a quality improvement intervention on rehabilitation outcomes of children (6-24 months) with acute malnutrition: a retrospective study in rural Angola.

BACKGROUND: Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. METHODS: Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6-24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. RESULTS: The intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil. CONCLUSIONS: The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.

Training on the Silverman and Andersen score improved how special care unit nurses assessed neonatal respiratory distress in a low-resource setting.

AIM: Identifying the severity of neonatal respiratory distress (RD) is essential, so that resources can be appropriately allocated. We assessed the ability of nurses to grade neonatal RD in a low-resource setting before and after they were trained to use a dedicated scoring tool. METHODS: The study was conducted in the Special Care Unit of St Luke Wolisso Hospital, Ethiopia. Ten nurses reviewed nine local video recordings and graded neonatal RD without a standardised method, which was current practice, and then after they were trained to use the Silverman and Andersen score. The data were analysed using the McNemar test and Cohen's kappa. RESULTS: Training increased the identification of mild RD from 63% to 93% (p = 0.008) and moderate RD from 40% to 73% (p = 0.03). Severe RD was 93% before and 90% after training (p = 0.99). Overall, the agreement improved from kappa 0.59 to 0.84, mainly by reducing the overestimation of milder degrees of RD. CONCLUSION: Being trained on how to use the Silverman and Andersen score improved the ability of nurses to identify mild and moderate neonatal RD. This improvement has the potential to optimise the use of equipment, staff and time.