CASEMIX study: Assessment of patient factors influencing the subprocedure duration of trauma/orthopaedic surgeries.

INTRODUCTION: The social and financial burdens of the operative environment remains to be a major problem in modern society. We analyse the impact of the introduction and application of a perioperative cloud system that cross-analyzes the pre-/intraoperative risks to minimize surgical time and maximize operation theater efficiency through improved planning. METHODS: TCC-CASEMIX© was introduced to our Department of Trauma Surgery of the University of Szeged to objectively measure intraoperative time durations according to each essential subprocedure. The study is largely divided into pre-operative assessments and intraoperative measurements. Patient data (age, sex, and ethnicity etc.) was registered preoperatively, and the expected time per each essential intraoperative step (skin incision, reduction, fixation etc.) was entered. The steps were then timed intraoperatively by surveyors, and postoperative cross analysis was performed. Our study was divided into two phases; phase 1, the surveying of general trauma / orthopedic cases, and phase two; the examination of high volume surgeries. RESULTS: Acute cases of Open Reductions and Internal Fixation (ORIF) procedures depended heavily on the presentation of the fracture, and no clear correlations in the risk factors were found. Arthroscopies were a short, high-volume procedure, but there was a large difference between the surgeon's estimates and the operation duration. In high volume surgeries, although individual factors only slightly influenced surgical duration, patient cohort stratification led to a better understanding of factors that impact surgeries, namely the combination of BMI and surgeon years of experience. While the average (Intraoperative Duration) seemed to increase with BMI, younger surgeons were more influenced by the patients BMI. CONCLUSION: A data filtering algorithm-assisted cloud system can be a reliable way to facilitate the planning of operating theater schedules. Patient stratification according to BMI and surgeon years of experience seems to affect intraoperative duration significantly, and the understanding of the risks and intraoperative steps has the potential to forecast surgeries with high precision.

Evaluating police drug diversion in England: protocol for a realist evaluation.

There is increasing international interest in the use of police drug diversion schemes that offer people suspected of minor drug-related offences an educative or therapeutic intervention as an alternative to criminalisation. While there have been randomised trials of some such schemes for their effects on reducing offending, with generally positive results, less is known about the health outcomes, and what works, for whom, in what circumstances and why. This protocol reports on a realist evaluation of police drug diversion in England that has been coproduced by a team of academic, policing, health, and service user partners. The overall study design combines a qualitative assessment of the implementation, contexts, mechanisms, moderators and outcomes of schemes in Durham, Thames Valley and the West Midlands with a quantitative, quasi-experimental analysis of administrative data on the effects of being exposed to the presence of police drug diversion on reoffending and health outcomes. These will be supplemented with analysis of the cost-consequences of the evaluated schemes, an analysis of the equity of their implementation and effects, and a realist synthesis of the various findings from these different methods.

Regionalization or Access to Care? A Joint Pediatric Heart Care Program That Achieves Both: One Program-Two Sites.

Background: Regionalization of care for children with congenital heart disease has been proposed as a method to improve outcomes. This has raised concerns about limiting access to care. We present the details of a joint pediatric heart care program (JPHCP) which utilized regionalization and actually improved access to care. Methods: In 2017, Kentucky Children's Hospital (KCH) launched the JPHCP with Cincinnati Children's Hospital Medical Center (CCHMC). This unique satellite model was the product of several years of planning, leading to a comprehensive strategy with shared personnel, conferences, and a robust transfer system; "one program-two sites." Results: Between March 2017 and the end of June 2022, 355 operations were performed at KCH under the auspices of the JPHCP. As of the most recent published Society of Thoracic Surgeons (STS) outcome report (through the end of June 2021), for all STAT categories, the JPHCP at KCH outperformed the STS overall in postoperative length of stay, and the mortality rate was lower than expected for the case mix. Of the 355 operations, there were 131 STAT 1, 148 STAT 2, 40 STAT 3, and 36 STAT 4 operations, with two operative mortalities: an adult undergoing surgery for Ebstein anomaly, and a premature infant who died from severe lung disease many months after aortopexy. Conclusions: With a select case mix, and by affiliating with a large volume congenital heart center, the creation of the JPHCP at KCH was able to achieve excellent congenital heart surgery results. Importantly, access to care was improved for those children at the more remote location utilizing this one program-two sites model.

Chloride Channel-3 (ClC-3) Modifies the Trafficking of Leucine-Rich Repeat-Containing 8A (LRRC8A) Anion Channels.

Chloride channel-3 (ClC-3) Cl-/H+ antiporters and leucine-rich repeat-containing 8 (LRRC8) family anion channels have both been associated with volume-regulated anion currents (VRACs). VRACs are often altered in ClC-3 null cells but are absent in LRRC8A null cells. To explore the relationship between ClC-3, LRRC8A, and VRAC we localized tagged proteins in human epithelial kidney (HEK293) cells using multimodal microscopy. Expression of ClC-3-GFP induced large multivesicular bodies (MVBs) with ClC-3 in the delimiting membrane. LRRC8A-RFP localized to the plasma membrane and to small cytoplasmic vesicles. Co-expression demonstrated co-localization in small, highly mobile cytoplasmic vesicles that associated with the early endosomal marker Rab5A. However, most of the small LRRC8A-positive vesicles were constrained within large MVBs with abundant ClC-3 in the delimiting membrane. Dominant negative (S34A) Rab5A prevented ClC-3 overexpression from creating enlarged MVBs, while constitutively active (Q79L) Rab5A enhanced this phenotype. Thus, ClC-3 and LRRC8A are endocytosed together but independently sorted in Rab5A MVBs. Subsequently, LRRC8A-labeled vesicles were sorted to MVBs labeled by Rab27A and B exosomal compartment markers, but not to Rab11 recycling endosomes. VRAC currents were significantly larger in ClC-3 null HEK293 cells. This work demonstrates dependence of LRRC8A trafficking on ClC-3 which may explain the association between ClC-3 and VRACs.

Case series of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy during extracorporeal life support.

Therapeutic hypothermia initiated within 6 hours of birth is currently the standard of care for the management of neonates with hypoxic-ischemic encephalopathy. Neonates undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy are also at risk for severe respiratory failure and need for extracorporeal life support. The risks and benefits of therapeutic hypothermia for hypoxic-ischemic encephalopathy during extracorporeal life support are still not well defined. We report our experience of a case series of six neonates who underwent therapeutic hypothermia for hypoxic-ischemic encephalopathy during extracorporeal life support. We also report long-term neurodevelopmental follow-up from 6 to 24 months and add to the current body of evidence regarding feasibility, clinical experience, and short-term complications.

Profound Iron Deficiency Anemia and Irreversible Dilated Cardiomyopathy in a Child.

Iron deficiency anemia has been associated with a secondary and potentially reversible cardiomyopathy. The pathophysiologic paradigm has been that the hematologic disease begets cardiac dysfunction. There may be, however, a point at which myocardial injury is irreversible in susceptible individuals. We present the case of a 4-year-old, developmentally normal, child who presented with iron deficiency anemia and a dilated cardiomyopathy with congestive heart failure. Despite appropriate correction of the anemia, the patient developed decompensated heart failure requiring milrinone therapy and eventual heart transplantation. This report will alert clinicians to the potential for irreversible adverse cardiac remodeling and the importance of close pediatric cardiology consultation and serial assessment in order to implement appropriate heart failure therapy.

Extracorporeal Membrane Oxygenation (ECMO) Support in Special Patient Populations-The Bidirectional Glenn and Fontan Circulations.

Extracorporeal membrane oxygenation (ECMO) is a support modality used within the pediatric cardiac ICU population as a bridge to recovery or decision in the setting of acute myocardial decompensation, support for combined cardiopulmonary failure or in the setting of refractory cardiopulmonary arrest. Patients with univentricular physiology are at particular risk for decompensation requiring ECMO support. This review will focus upon current evidence and techniques for ECMO support of single ventricle patients who have undergone a stage II bidirectional Glenn procedure or the stage III Fontan procedure.

Hollow Fiber Oxygenator Composition Has a Significant Impact on Failure Rates in Neonates on Extracorporeal Membrane Oxygenation: A Retrospective Analysis.

In extracorporeal life support (ECLS), there are two main types of oxygenators in clinical use for neonates: polymethylpentene (PMP) hollow fiber and polypropylene (PP) hollow fiber. A retrospective study was performed on neonates ( n = 44) who had undergone ECLS for noncardiac indications from 2009 to 2015. Between the two groups (PMP n = 21, PP n = 23), the PP oxygenators failed 91% of the time, whereas the PMP oxygenators failed 43% of the time ( p < 0.05). Analysis suggests PMP oxygenators are less prone to failure than PP oxygenators, and they require fewer number of oxygenator changes during a neonatal ECLS.

The contractual governance of drug users in treatment.

One of the challenges for drug treatment services is how to engage drug users effectively. This commentary examines one particular strategy for enhancing engagement that appears to have spread quite rapidly in recent years: the use of contract-like written agreements between treatment service providers and users. The development of the contractual governance of drug users in treatment is located in the wider context of emerging social control strategies and practices. In particular, insights are drawn from the socio-legal literature which has begun to examine these new control practices in diverse domains. The commentary also reports on the findings of a national survey of all 149 local authority areas in England that was designed to provide a preliminary mapping of the extent of contractual governance in treatment settings (response rate=62%). In spite of the fact that the use of contracts between drug services and service users does not feature in the national drug policy framework, our survey strongly indicates that it is a widespread practice. Although these agreements can take on many different forms, typically they set out the responsibilities and requirements placed on users and, somewhat less frequently, what the service commits to providing for them. This novel practice of contractual governance may be viewed as having considerable potential but it also raises important issues concerning justice and rights. We conclude by arguing that this is an important area of emerging practice which raises significant theoretical and policy questions and the need for further research.

A novel family of peptides with potent activity against influenza A viruses.

The emergence of drug-resistant strains of influenza virus has catalysed a search for new antiviral agents to supplement or replace existing drugs. Following the success of the human immunodeficiency virus entry blocker Enfuvirtide, there has been a resurgence of interest in peptide-based antivirals. In this paper, we report on the discovery of a novel family of peptides (FluPep, FP) that function as inhibitors of influenza A virus infection. The prototype peptide (FP1, also known as Tkip) interacts with haemagglutinin and inhibits the binding of the virus to cell membranes. Using a plaque-reduction assay, we have demonstrated that a variety of influenza A virus subtypes (including H1N1, H3N2 and H5N1) are inhibited by FluPep and its derivatives at nanomolar concentrations. By truncating FluPep we have identified a minimal sequence of 6 aa that binds to haemagglutinin and inhibits infection. Using a mouse model of intranasal influenza virus infection, we observed potent inhibition of virus infection when peptide is given at the time of virus administration. These data indicate that FluPep is a highly effective anti-influenza agent with the potential to translate to the clinic.

Strategies for the preparation of synthetic transfection vectors.

In the late 1980s independent work by Felgner and Behr pioneered the use of cationic materials to complex and deliver nucleic acids into eukaryotic cells. Since this time, a vast number of synthetic transfection vectors, which are typically divided into two main "transfectors", have been developed namely: (1) cationic lipids and (2) polycationic polymers. In this chapter the main synthetic approaches used for the synthesis of these compounds will be reviewed with particular attention paid to: cationic lipids and dendrimers. This review is aimed primarily at the younger audience of doctoral students and non-specialist readers.