Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases.

PURPOSE: Robotic radical cystectomy (RRC) has become a commonly utilised alternative to open radical cystectomy (ORC). We performed a systematic review and meta-analysis of RRC vs ORC focusing on perioperative outcomes and safety. METHODS: Medline, EMBASE and CENTRAL were searched from January 2000 to April 2020 following the Preferred Reporting Items for Systematic Review and Meta-analysis Statement for study selection. RESULTS: In total, 47 studies (5 randomised controlled trials, 42 non-randomised comparative studies) comprising 12,640 patients (6572 ORC, 6068 RRC) were included. There was no difference in baseline demographics between the groups apart from males were more likely to undergo ORC (OR 0.77, 95% CI 0.69-0.85). Those with muscle-invasive disease were more likely to undergo RRC (OR 1.21, 95% CI 1.09-1.34), and those with high-risk non-muscle-invasive bladder cancer were more likely to undergo ORC (OR 0.80, 95% CI 0.72-0.89). RRC had a significantly longer operating time, less blood loss and lower transfusion rate. There was no difference in lymph node yield, rate of positive surgical margins, or Clavien-Dindo Grade I-II complications between the two groups. However, the RRC group were less likely to experience Clavien-Dindo Grade III-IV (OR 1.56, 95% CI 1.30-1.89) and overall complications (OR 1.45, 95% CI 1.26-1.68) than the ORC group. The mortality rate was higher in ORC although this did not reach statistical significance (OR 1.52, 95% CI 0.99-2.35). CONCLUSION: RRC has significantly lower blood loss, transfusion rate and is associated with fewer high grade and overall complications compared to ORC.

Likelihood of Distal Ureteric Calculi to Pass Spontaneously: Systematic Review and Cumulative Analysis of the Placebo Arm of Randomized-Controlled Trials.

INTRODUCTION: Distal ureteric calculi remain a widely debated topic without clear consensus on expectant management. This systematic review aims to assess the placebo arms of RCTs to extrapolate data on the natural history of distal ureteral stones and ascertain the success rate of expectant management. METHODS: A literature search was performed, and 3 reviewers used a predefined inclusion criterion to independently select articles for inclusion. A cumulative analysis was undertaken, and risk of bias assessed using the Cochrane tool. RESULTS: Stone expulsion was recorded in 1,823/2,447 (74.5%) patients overall. The expulsion rate of study participants receiving placebo varied widely from 35.2 to 88.9%. The overall expulsion rate of stones ≤5 mm was 486/561 (87%) as opposed to 814/1,093 (75%) in stones >5 mm in size. Time to stone expulsion varied from 8.54 to 24.5 days. A re rate of 2% was reported. CONCLUSIONS: Spontaneous passage of distal ureteric calculi is dependent on stone size and location within the ureter. Provided a patient does not portray symptoms of uncontrollable pain, infection, obstruction, or declining renal function, it is reasonable to trial a period of expectant management. Follow-up should be arranged to ensure symptom resolution, and alternative treatment can be offered if required.

Observational Study of Grand Canyon Rim-to-Rim Day Hikers: Determining Behavior Patterns to Aid in Preventive Search and Rescue Efforts.

INTRODUCTION: Grand Canyon National Park has seen an increase in visitors traversing the canyon from rim to rim (R2R) in a single day. R2R hikers travel over 33.8 km (21 mi) over 3300 m (11,000 ft) of elevation change and endure large temperature changes. Grand Canyon emergency medical service providers provide emergency medical services to over 1100 visitors annually. Direct guidance by Preventive Search and Rescue rangers has improved safety. The objective of this study was to examine visitors attempting an R2R traverse and to enhance PSAR rangers' anticipatory guidance. METHODS: We conducted an observational study of R2R hikers in the spring and fall of 2015. Hikers consented to study inclusion and were interviewed at the starting trailhead, canyon bottom, and exit trailhead. We performed a survey and collected biometric data. RESULTS: We enrolled 617 visitors with a median age of 43 y (interquartile range [IQR] 33-53); 65% were male and 46% had hiked the R2R a median number of 3 times previously (IQR 2-7). Hydration strategies included water bottle only (20%), hydration bladder only (31%), and both water bottle and hydration bladder (48%). R2R crossers had an average start time of 0530 (SD 1.3 h) and median crossing time of 11.9 h (IQR 10.7-13.3). Crossing time and self-reported fatigue were negatively correlated with prior R2R experience (P=0.02). CONCLUSIONS: Crossing R2R in a day is hazardous and associated with risk of injury and illness. The results of this study can be used by Preventive Search and Rescue to reduce these risks by educating hikers.

Pain relief for women undergoing oocyte retrieval for assisted reproduction.

BACKGROUND: Various methods of conscious sedation and analgesia (CSA) have been used during oocyte retrieval for assisted reproduction. The choice of agent has been influenced by the quality of sedation and analgesia and by concerns about possible detrimental effects on reproductive outcomes. OBJECTIVES: To assess the effectiveness and safety of different methods of conscious sedation and analgesia for pain relief and pregnancy outcomes in women undergoing transvaginal oocyte retrieval. SEARCH METHODS: We searched; the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL, and trials registers in November 2017. We also checked references, and contacted study authors for additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing different methods and administrative protocols for conscious sedation and analgesia during oocyte retrieval. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcomes were intraoperative and postoperative pain. Secondary outcomes included clinical pregnancy, patient satisfaction, analgesic side effects, and postoperative complications. MAIN RESULTS: We included 24 RCTs (3160 women) in five comparisons. We report the main comparisons below. Evidence quality was generally low or very low, mainly owing to poor reporting and imprecision.1. CSA versus other active interventions.All evidence for this comparison was of very low quality.CSA versus CSA plus acupuncture or electroacupunctureData show more effective intraoperative pain relief on a 0 to 10 visual analogue scale (VAS) with CSA plus acupuncture (mean difference (MD) 1.00, 95% confidence interval (CI) 0.18 to 1.82, 62 women) or electroacupuncture (MD 3.00, 95% CI 2.23 to 3.77, 62 women).Data also show more effective postoperative pain relief (0 to 10 VAS) with CSA plus acupuncture (MD 0.60, 95% CI -0.10 to 1.30, 61 women) or electroacupuncture (MD 2.10, 95% CI 1.40 to 2.80, 61 women).Evidence was insufficient to show whether clinical pregnancy rates were different between CSA and CSA plus acupuncture (odds ratio (OR) 0.61, 95% CI 0.20 to 1.86, 61 women). CSA alone may be associated with fewer pregnancies than CSA plus electroacupuncture (OR 0.22, 95% CI 0.07 to 0.66, 61 women).Evidence was insufficient to show whether rates of vomiting were different between CSA and CSA plus acupuncture (OR 1.64, 95% CI 0.46 to 5.88, 62 women) or electroacupuncture (OR 1.09, 95% CI 0.33 to 3.58, 62 women).Trialists provided no usable data for other outcomes of interest.CSA versus general anaesthesia Postoperative pain relief was greater in the CSA group (0 to 3 Likert: mean difference (MD) 1.9, 95% CI 2.24 to 1.56, one RCT, 50 women).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 1.00, 95% CI 0.43 to 2.35, two RCTs, 108 women, I2 = 0%).Evidence was insufficient to show whether groups differed in rates of vomiting (OR 0.46, 95% CI 0.08 to 2.75, one RCT, 50 women) or airway obstruction (OR 0.14, 95% CI 0.02 to 1.22, one RCT, 58 women). Fewer women needed mask ventilation in the CSA group (OR 0.05, 95% CI 0.01 to 0.20, one RCT, 58 women).Evidence was also insufficient to show whether groups differed in satisfaction rates (OR 0.66, 95% CI 0.11 to 4.04, two RCTs, 108 women, I2 = 34%; very low-quality evidence).Trialists provided no usable data for outcomes of interest.2. CSA + paracervical block (PCB) versus other interventions.CSA + PCB versus electroacupuncture + PCB Intraoperative pain scores were lower in the CSA + PCB group (0 to 10 VAS: MD -0.66, 95% CI -0.93 to -0.39, 781 women, I2 = 76%; low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.96, 95% CI 0.72 to 1.29, 783 women, I2 = 9%; low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus general anaesthesiaEvidence was insufficient to show whether groups differed in postoperative pain scores (0 to 10 VAS: MD 0.49, 95% CI -0.13 to 1.11, 50 women; very low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.70, 95% CI 0.22 to 2.26, 51 women; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus spinal anaesthesiaPostoperative pain scores were higher in the CSA + PCB group (0 to 10 VAS: MD 1.02, 95% CI 0.48 to 1.56, 36 women; very low-quality evidence).Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.24 to 3.65, 38 women; very low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus PCBEvidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.93, 95% CI 0.44 to 1.96, 150 women; low-quality evidence) or satisfaction (OR 1.63, 95% CI 0.68 to 3.89, 150 women, low-quality evidence).Trialists provided no usable data for other outcomes of interest.CSA + PCB versus CSA only Evidence was insufficient to show whether groups differed in clinical pregnancy rates (OR 0.62, 95% CI 0.28 to 1.36, one RCT, 100 women; very low-quality evidence). Rates of postoperative nausea and vomiting were lower in the CS + PCB group (OR 0.42, 95% CI 0.18 to 0.97, two RCTs, 140 women, I2 = 40%; very low-quality evidence).Trialists provided no usable data for other outcomes of interest. AUTHORS' CONCLUSIONS: The evidence does not support one particular method or technique over another in providing effective conscious sedation and analgesia for pain relief during and after oocyte retrieval. Simultaneous use of sedation combined with analgesia such as the opiates, further enhanced by paracervical block or acupuncture techniques, resulted in better pain relief than occurred with one modality alone. Evidence was insufficient to show conclusively whether any of the interventions influenced pregnancy rates. All techniques reviewed were associated with a high degree of patient satisfaction. Women's preferences and resource availability for choice of pain relief merit consideration in practice.

Multi-Patient Rabies Exposure on a Colorado River Rafting Expedition: Urgent vs. Emergent Transport Decision Making in an Austere Setting.

We present a case of rabies exposure on a private river rafting trip on Grand Canyon National Park's Colorado River. Five individuals were exposed to an erratically acting bat; one of the individuals sustained a direct bite to the upper lip while sleeping. This case illustrates the challenges of austere medical care and evacuation in remote conditions while highlighting the importance of risk mitigation considerations in all austere situations.

Healing of canine skin incisions made with monopolar electrosurgery versus scalpel blade.

OBJECTIVE: To determine the influence of monopolar electrosurgery in cutting mode set at 10, 20, or 30 W on surgery time, hemostasis, and healing of cutaneous wounds compared to scalpel incisions. STUDY DESIGN: Randomized blinded control trial. ANIMALS: Dogs (n = 15). METHODS: Four skin incisions were created on either side of the dorsal midline with a scalpel, or monopolar electrosurgery at 10, 20, and 30 W. Surgical time and incisional bleeding were measured. Each incision was assessed daily for edema, erythema and discharge, and complications. Healing was evaluated via histology at 7 days. Results were analyzed for significance at P ≤ .05. RESULTS: Surgical time and hemostasis were improved in all electrosurgery groups. Erythema was reduced in all electrosurgical incisions for days 1-4, but was greater in wounds created via electrosurgery at 20 W than those made with a scalpel blade by day 7. No difference was noted in the degree of edema or presence of wound discharge. All histologic variables of tissue healing were lower in electrosurgical incisions than scalpel incisions (P < .001). Ten incisional complications occurred, all associated with electrosurgery. CONCLUSIONS: The use of monopolar electrosurgery at 10, 20, and 30 W in a cutting waveform improved hemostasis and surgical time when incising canine skin, but delayed healing and increased complications within the first 7 days compared to scalpel incisions.

Three cases of severe hyponatremia during a river run in Grand Canyon National Park.

We present 3 cases of severe hyponatremia occurring on a commercially guided river rafting trip on the Colorado River in Grand Canyon National Park. All 3 women appeared to have been overhydrating because of concern about dehydration and required evacuation within 24 hours of each other after the staggered onset of symptoms, which included fatigue and emesis progressing to disorientation or seizure. Each was initially transferred to the nearest hospital and ultimately required intensive care. Imaging and laboratory data indicated all 3 patients had hypervolemic hyponatremia. Unlike the well-documented exercise-associated hyponatremia cases commonly occurring in prolonged endurance athletic events, these 3 unique cases of acute hyponatremia were not associated with significant exercise. The cases illustrate the diagnostic and treatment challenges related to acute hyponatremia in an austere setting, and underscore the importance of preventive measures focused on avoidance of overhydration out of concern for dehydration.

Nonurgent commercial air travel after acute coronary syndrome: a review of 288 patient events.

OBJECTIVES: We studied a population of individuals who experienced an acute coronary syndrome (ACS) event while traveling abroad and required nonurgent commercial air travel to the home region. METHODS: This retrospective study gathered data from 288 patients enrolled in a travel-based medical assistance program. Interventions, complications, and travel home were assessed for trends. Descriptive and comparison statistical analyses were performed. RESULTS: Two hundred eighty-eight patients were identified and entered into the review. Of the patients in this study, 77.1% were male with an average age of 67.7 years. One hundred sixteen (40.3%) patients were diagnosed with unstable angina pectoris (USAP), whereas the remaining 172 (59.7%) patients experienced acute myocardial infarction (AMI). Regarding inpatient complications during the initial admission, 121 (42.0%) patients experienced 1 or more adverse event. The average number of days after an ACS event that a patient began to travel home was 10.5 days for the entire patient population (USAP patients = 8.8 days, AMI patients = 11.8 days). Two hundred twenty (76.4%) patients traveled with a medical escort, and 48 (16.7%) patients received supplemental oxygen during air travel. Four (1.4%) in-flight adverse events occurred in the following ACS diagnostic groups: 2 in the complicated AMI group, 1 in the uncomplicated USAP group, and 1 in the uncomplicated AMI group. No in-flight deaths occurred. Nine (3.1%) deaths were noted within 2 weeks after returning to the home region. The deaths after returning to the home region occurred in the following ACS diagnostic groups: 2 in the complicated USAP group, 1 in the uncomplicated USAP group, and 6 in the complicated AMI group. None of the patients who experienced in-flight events died after returning to their home region. CONCLUSIONS: Upon discharge, the vast majority of ACS patients who travel to their home region via commercial air do not experience adverse events in-flight; when such adverse events occur in-flight, these events do not result in a poor outcome. No in-flight deaths occurred; death occurred in a minority of patients after returning to their home region, particularly in the complicated USAP and AMI groups, who were planned readmissions to the hospital.

The Use of Social Media to Express and Manage Medical Uncertainty in Dyskeratosis Congenita: Content Analysis.

BACKGROUND: Social media has the potential to provide social support for rare disease communities; however, little is known about the use of social media for the expression of medical uncertainty, a common feature of rare diseases. OBJECTIVE: This study aims to evaluate the expression of medical uncertainty on social media in the context of dyskeratosis congenita, a rare cancer-prone inherited bone marrow failure and telomere biology disorder (TBD). METHODS: We performed a content analysis of uncertainty-related posts on Facebook and Twitter managed by Team Telomere, a patient advocacy group for this rare disease. We assessed the frequency of uncertainty-related posts, uncertainty sources, issues, and management and associations between uncertainty and social support. RESULTS: Across all TBD social media platforms, 45.98% (1269/2760) of posts were uncertainty related. Uncertainty-related posts authored by Team Telomere on Twitter focused on scientific (306/434, 70.5%) or personal (230/434, 53%) issues and reflected uncertainty arising from probability, ambiguity, or complexity. Uncertainty-related posts in conversations among patients and caregivers in the Facebook community group focused on scientific (429/511, 84%), personal (157/511, 30.7%), and practical (114/511, 22.3%) issues, many of which were related to prognostic unknowns. Both platforms suggested uncertainty management strategies that focused on information sharing and community building. Posts reflecting response-focused uncertainty management strategies (eg, emotional regulation) were more frequent on Twitter compared with the Facebook community group (χ21=3.9; P=.05), whereas posts reflecting uncertainty-focused management strategies (eg, ordering information) were more frequent in the Facebook community group compared with Twitter (χ21=55.1; P<.001). In the Facebook community group, only 36% (184/511) of members created posts during the study period, and those who created posts did so with a low frequency (median 3, IQR 1-7 posts). Analysis of post creator characteristics suggested that most users of TBD social media are White, female, and parents of patients with dyskeratosis congenita. CONCLUSIONS: Although uncertainty is a pervasive and multifactorial issue in TBDs, our findings suggest that the discussion of medical uncertainty on TBD social media is largely limited to brief exchanges about scientific, personal, or practical issues rather than ongoing supportive conversation. The nature of uncertainty-related conversations also varied by user group: patients and caregivers used social media primarily to discuss scientific uncertainties (eg, regarding prognosis), form social connections, or exchange advice on accessing and organizing medical care, whereas Team Telomere used social media to express scientific and personal issues of uncertainty and to address the emotional impact of uncertainty. The higher involvement of female parents on TBD social media suggests a potentially greater burden of uncertainty management among mothers compared with other groups. Further research is needed to understand the dynamics of social media engagement to manage medical uncertainty in the TBD community.

Review of self-reported physical activity assessments for pregnancy: summary of the evidence for validity and reliability.

BACKGROUND: Epidemiological studies and surveillance systems of pregnant women often rely on collection of physical activity through self-report. This systematic review identified and summarised self-reported physical activity assessments with evidence for validity and reliability among pregnant women. METHODS: Peer-reviewed articles published through 2011 were included if they assessed validity and/or reliability of an interviewer- or self-administered physical activity questionnaire or diary among pregnant women. RESULTS: We identified 15 studies, including 12 studies that assessed questionnaires and 4 studies that assessed diaries, conducted in Australia, Finland, Norway, the U.K., the U.S. and Vietnam. For questionnaires, 92% (11/12) assessed mode, all assessed frequency and/or duration and 58% (7/12) collected information on perceived intensity. All but one study (92%) assessed validity of the questionnaires. Questionnaires compared with objective measures (accelerometers, pedometers) ranged from slight to fair agreement, while comparison with other self-reported measures ranged from substantial to almost perfect agreement. Five studies (42%) assessed test-retest reliability of the questionnaires, ranging from substantial to almost perfect agreement. The four studies on diaries were all assessed for validity against objective measures, ranging from slight to substantial agreement. CONCLUSIONS: Selection of valid and reliable physical activity measures that collect information on dose (type, frequency, duration, intensity) is recommended to increase precision and accuracy in detecting associations of physical activity with maternal and fetal outcomes.

Telomere length and epigenetic clocks as markers of cellular aging: a comparative study.

Telomere length (TL) and DNA methylation-based epigenetic clocks are markers of biological age, but the relationship between the two is not fully understood. Here, we used multivariable regression models to evaluate the relationships between leukocyte TL (LTL; measured by qPCR [n = 635] or flow FISH [n = 144]) and five epigenetic clocks (Hannum, DNAmAge pan-tissue, PhenoAge, SkinBlood, or GrimAge clocks), or their epigenetic age acceleration measures in healthy adults (age 19-61 years). LTL showed statistically significant negative correlations with all clocks (qPCR: r = - 0.26 to - 0.32; flow FISH: r = - 0.34 to - 0.49; p < 0.001 for all). Yet, models adjusted for age, sex, and race revealed significant associations between three of five clocks (PhenoAge, GrimAge, and Hannum clocks) and LTL by flow FISH (p < 0.01 for all) or qPCR (p < 0.001 for all). Significant associations between age acceleration measures for the same three clocks and qPCR or flow FISH TL were also found (p < 0.01 for all). Additionally, LTL (by qPCR or flow FISH) showed significant associations with extrinsic epigenetic age acceleration (EEAA: p < 0.0001 for both), but not intrinsic epigenetic age acceleration (IEAA; p > 0.05 for both). In conclusion, the relationships between LTL and epigenetic clocks were limited to clocks reflecting phenotypic age. The observed association between LTL and EEAA reflects the ability of both measures to detect immunosenescence. The observed modest correlations between LTL and epigenetic clocks highlight a possible benefit from incorporating both measures in understanding disease etiology and prognosis.

DNA-methylation-based telomere length estimator: comparisons with measurements from flow FISH and qPCR.

Telomere length (TL) is a marker of biological aging associated with several health outcomes. High throughput reproducible TL measurements are needed for large epidemiological studies. We compared the novel DNA methylation-based estimator (DNAmTL) with the high-throughput quantitative PCR (qPCR) and the highly accurate flow cytometry with fluorescent in situ hybridization (flow FISH) methods using blood samples from healthy adults. We used Pearson's correlation coefficient, Bland Altman plots and linear regression models for statistical analysis. Shorter DNAmTL was associated with older age, male sex, white race, and cytomegalovirus seropositivity (p<0.01 for all). DNAmTL was moderately correlated with qPCR TL (N=635, r=0.41, p < 0.0001) and flow FISH total lymphocyte TL (N=144, r=0.56, p < 0.0001). The agreements between flow FISH TL and DNAmTL or qPCR were acceptable but with wide limits of agreement. DNAmTL correctly classified >70% of TL categorized above or below the median, but the accuracy dropped with increasing TL categories. The ability of DNAmTL to detect associations with age and other TL-related factors in the absence of strong correlation with measured TL may indicate its capture of aspects of telomere maintenance mechanisms and not necessarily TL. The inaccuracy of DNAmTL prediction should be considered during data interpretation and across-study comparisons.

Aerosol generation with various approaches to oxygenation in healthy volunteers in the emergency department.

OBJECTIVES: Health care workers experience an uncertain risk of aerosol exposure during patient oxygenation. To improve our understanding of these risks, we sought to measure aerosol production during various approaches to oxygenation in healthy volunteers in an emergency department. METHODS: This was a prospective study conducted in an empty patient room in an academic ED. The room was 10 ft. long x 10 ft. wide x 9 ft. tall (total volume 900 ft3) with positive pressure airflow (1 complete turnover of air every 10 minutes). Five oxygenation conditions were used: humidified high-flow nasal cannula (HFNC) at 3 flow rates [15, 30, and 60 liters per minute (LPM)], non-rebreather mask (NRB) at 1 flow rate (15 LPM), and closed-circuit continuous positive airway pressure (CPAP) using the ED ventilator; in all cases a simple procedural mask was used. The NRB and HFNC at 30 LPM maneuvers were also repeated without the procedural mask, and CPAP was applied both with and without a filter. Each subject then sequentially underwent 8 total oxygenation conditions, always in the same order. Each oxygenation condition was performed with the participant on a standard ED bed. Particles were measured by laser aerosol spectrometer, with the detector sampling port positioned directly over the center of the bed, 0.35 meters away and at a 45-degree angle from the subject's mouth. Each approach to oxygenation was performed for 10 minutes, followed by a 20-minute room washout (≈ 2 complete room air turnovers). Particle counts were summated for 2 size ranges (150-300 nm and 0.5-2.0 µm) and compared before, during, and after each of the 8 oxygenation conditions. RESULTS: Eight adult subjects were enrolled (mean age 42 years, body mass index 25). All subjects completed 8 oxygenation procedures (64 total). Mean particle counts per minute across all oxygenation procedures was 379 ± 112 (mean ± SD) for smaller aerosols (150-300 nm) and 9.3 ± 4.6 for larger aerosols (0.5-2.0 µm). HFNC exhibited a flow-dependent increase in particulate matter (PM) generation-at 60 LPM, HFNC had a substantial generation of small (55% increase) and large particles (70% increase) compared to 15 LPM. CPAP was associated with lowered small and large particle generation (≈ 10-15% below baseline for both sizes of PM). A patient mask limited particle generation with the NRB, where it was associated with a reduction in small and large particulates (average 40% and 20% lower, respectively). CONCLUSION: Among 3 standard oxygenation procedures, higher flow rates generally were associated with greater production of both small and large aerosols. A patient mask lowered aerosol counts in the NRB only. Protocol development for oxygenation application should consider these factors to increase health care worker safety.

Tracheal Squamous Cell Carcinoma Treated with Tracheal Resection and Anastomosis in a Cat.

A 10-year-old male castrated domestic shorthair cat presented for a suspected tracheal mass. Radiographs confirmed an intraluminal tracheal mass. Tracheal resection and anastomosis of 5 tracheal rings was performed with minimal, mild intraoperative complications and no postoperative complications. Histopathology of the tracheal mass revealed a diagnosis of squamous cell carcinoma (SCC) with incomplete margins both cranially and caudally. Further treatment, including surgical revision, radiation therapy, or chemotherapy, was recommended. At the time of publication, no further treatment has been initiated, and a scheduled consultation with the oncologist has been canceled. The cat is doing well at home with no reported signs of recurrence 120 days postoperatively. This is the first report of a cat with a tracheal SCC to be treated with a tracheal resection and anastomosis and only the third feline tracheal SCC to be treated in the veterinary literature.

Cardiac Rehabilitation Programs for Cancer Survivors: A Scoping Review.

PURPOSE OF REVIEW: Participation in cardiac rehabilitation is associated with improved quality of life and physical functioning and may be an effective strategy to assist in the recovery from cancer. We conducted a scoping review to identify studies that enrolled cancer survivors into cardiac rehabilitation programs. RECENT FINDINGS: We identified nine studies that included 662 cancer survivors. Five studies integrated cancer survivors and cardiac patients into the same sessions, three studies developed cancer-only rehabilitation sessions, and one study did not report details on the rehabilitation sessions. On average, more than 60% of enrolled cancer survivors completed the rehabilitation programs and many health and psychosocial outcomes improved after rehabilitation. SUMMARY: Cardiac rehabilitation appears to be acceptable and favorably impacts many health and psychosocial outcomes among cancer survivors. Future research should consider randomized controlled trial study designs, enrolling diverse survivor populations, and using a set of core physical function and psychosocial outcomes.

A systematic review of pediatric adherence to antiretroviral therapy in low- and middle-income countries.

BACKGROUND: Sustaining antiretroviral therapy (ART) adherence requires accurate, consistent monitoring, a particular challenge for low-income countries. The optimal strategy to measure pediatric adherence remains unclear. OBJECTIVE: To conduct a systematic review of pediatric ART adherence measurement techniques, adherence estimates, and clinical correlates in low- and middle-income countries to inform ART adherence monitoring. METHODS: We searched online bibliographic databases, including MEDLINE and EMBASE, using systematic criteria. Two reviewers selected all descriptive or interventional studies involving nonpregnant, HIV-positive individuals < or =18 years old that measured ART adherence in low- or middle-income countries as defined by World Bank criteria. Data were extracted regarding sample characteristics, study setting, measurement strategy, adherence estimate, and adherence correlates. RESULTS: The search yielded 1566 titles, of which 17 met selection criteria. Adherence measurement strategies included self- or proxy-report measures (14 studies), pill counts (4 studies), pharmacy records, drug levels, clinic adherence, and directly observed therapy (1 study each). The self- or proxy-report measures were heterogeneous, and few employed validation strategies. Caregiver-reported adherence was generally higher than self-report estimates. Pill counts revealed lower adherence estimates. Estimates of ART adherence ranged from 49% to 100%, with 76% of articles reporting >75% adherence. Factors related to family structure, socioeconomic status, disclosure, and medication regimen were all significantly associated with ART adherence. CONCLUSIONS: Pediatric HIV care programs in low- and middle-income countries use heterogeneous methods to measure ART adherence. Adherence estimates vary substantially, but most studies from low- and middle-income countries report >75% adherence, whereas most studies from high-income countries report <75% adherence.

Evaluation of the Physical Activity and Public Health Course for Practitioners.

PURPOSE: From 1996 to 2013, a 6-day Physical Activity and Public Health Course for Practitioners has been offered yearly in the United States. An evaluation was conducted to assess the impact of the course on building public health capacity for physical activity and on shaping the physical activity and public health careers of fellows since taking the courses. METHOD: An evaluation quantified time that fellows spent in different course offerings and surveyed fellows. RESULTS: From 1996 to 2012, 410 fellows attended the course, and in 2013, 186 participated in the Web-based survey (56% response rate). The number of fellows attending the course ranged from 15 to 33 yearly. From 1996 to 2012, the course averaged 38 hr of instructional time that included topics on interventions and environment/policy work to increase physical activity, program evaluation, public health research, and health disparities. The course included consultations, collaborative work, and field-based experiences. Fellows who participated in the survey agreed that the course had a positive impact on the physical activity research or practice work they did (98%), met their expectations (96%), helped them with research/practice collaborations with other physical activity professionals (96%), assisted them in conducting higher-quality interventions/programs (95%), helped increase their professional networking in the field (93%), and had a positive impact on other work they did (91%). Following the course, 66% and 56% had further contact with faculty and other fellows, respectively. CONCLUSION: The Physical Activity and Public Health Course for Practitioners made important contributions toward building the capacity of physical activity and public health practitioners.

Strategies to Promote Physical Activity During Pregnancy: A Systematic Review of Intervention Evidence.

Physical activity during pregnancy has been associated with significant health benefits, however most women in the United States do not meet current guidelines. This systematic review evaluates evidence for interventions to improve physical activity during pregnancy in order to identify best practices and inform future research. Electronic databases (PubMed, CINAHL, SportDISCUS, Embase, ERIC, Psych Info and ISI Web of Science) were searched in July 2011 for peer-reviewed journal articles. Studies were included if they were English-language randomized control trials that measured the efficacy of an intervention targeted to pregnant women and designed to change physical activity as a primary or secondary outcome. Out of 777 studies identified through the systematic search, nine interventions were identified for inclusion by multiple reviewers. Data was abstracted using an abstraction form modeled after the "Guide to Community Preventive Services." Of the nine interventions included in the review, three reported statistically significant positive results for physical activity. While interventions included a variety of strategies and techniques, none were uniquely associated with positive outcomes. Overall this review suggests that little is known about the efficacy of interventions for physical activity during pregnancy. We provide several recommendations for future research and intervention design.

A systematic review of clinical diagnostic systems used in the diagnosis of tuberculosis in children.

Background. Tuberculosis (TB) is difficult to diagnose in children due to lack of a gold standard, especially in resource-limited settings. Scoring systems and diagnostic criteria are often used to assist in diagnosis; however their validity, especially in areas with high HIV prevalence, remains unclear. Methods. We searched online bibliographic databases, including MEDLINE and EMBASE. We selected all studies involving scoring systems or diagnostic criteria used to aid in the diagnosis of tuberculosis in children and extracted data from these studies. Results. The search yielded 2261 titles, of which 40 met selection criteria. Eighteen studies used point-based scoring systems. Eighteen studies used diagnostic criteria. Validation of these scoring systems yielded varying sensitivities as gold standards used ranged widely. Four studies evaluated and compared multiple scoring criteria. Ten studies selected for pulmonary tuberculosis. Five studies specifically evaluated the use of scoring systems in HIV-positive children, generally finding the specificity to be lower. Conclusions. Though scoring systems and diagnostic criteria remain widely used in the diagnosis of tuberculosis in children, validation has been difficult due to lack of an established and accessible gold standard. Estimates of sensitivity and specificity vary widely, especially in populations with high HIV co-infection.

Usefulness of cardiovascular magnetic resonance imaging of the superficial femoral artery for screening patients with diabetes mellitus for atherosclerosis.

Cardiovascular magnetic resonance (CMR) of the superficial femoral artery (SFA) allows direct and noninvasive visualization of atherosclerotic plaque burden. We examined atherosclerosis in 3 groups of patients without history or symptoms of peripheral arterial disease with varying expected burdens: those with diabetes mellitus (DM) and known coronary artery disease (CAD) (n = 24), those with DM and a high prevalence of CAD risk factors (n = 20), and controls of similar age without DM or CAD and few CAD risk factors (n = 15). We also assessed the diagnostic accuracy of this technique to differentiate among these 3 groups. T1-weighted spin-echocardiographic images were used to measure mean wall thickness (WT) and total wall volume indexed to total vessel volume. Diagnostic accuracy was assessed by area under receiver operating characteristics curve analysis. Patients with DM plus risk factors and DM plus CAD had higher mean WT (1.28 and 1.37 mm) and mean indexed wall volume (0.53 and 0.56) compared to controls (mean WT 1.16 mm and mean indexed wall volume 0.45; p <0.010 for all comparisons). Mean WT and indexed wall volume showed good diagnostic accuracy in discriminating controls from those with DM plus CAD (areas under curve 0.85 and 0.87, respectively, p <0.001), whereas only indexed wall volume discriminated DM plus risk factors from controls (area under curve 0.82, p <0.001). Neither could discriminate between DM plus risk factors and DM plus CAD. In conclusion, patients with DM plus risk factors and DM plus CAD had significantly greater atherosclerotic burden in the SFA on CMR imaging than controls of similar age, with good diagnostic accuracy in differentiating these groups. The high reproducibility and reliability of CMR of the SFA may facilitate improved assessment of atherosclerosis prevalence and progression/regression in studies of novel therapies.