Prevention and management of foot and lower limb health complications in adults undergoing dialysis: a scoping review.

BACKGROUND: Foot and lower limb health complications are common among patients undergoing dialysis; but a summary of prevention and management evidence is not available. The aim of this scoping review was to summarise study characteristics and the nature of results regarding strategies to prevent and manage peripheral arterial disease (PAD), foot ulceration, amputation, associated infection and associated hospital admission in adults undergoing dialysis. METHODS: MEDLINE, Embase, CINAHL and AMED databases were searched for longitudinal experimental and observational studies. Eligible studies included adults undergoing dialysis (≥10 dialysis patients, with separate results or ≥ 75% of the cohort). Any interventions relating to PAD, foot ulceration, amputation, associated infection, and associated hospital admission were included. RESULTS: The review included 212 studies, of which 199 were observational (94%) and 13 were experimental (6%). Sixteen studies (8%) addressed the prevention of foot and lower limb health complications, 43 (20%) addressed management, and 153 (72%) addressed both. The main intervention type in each study was surgery (n = 159, 75%), care from one or more health professionals (n = 13, 6%), screening by a health professional (n = 10, 5%), medication (n = 9, 4%) and rehabilitation (n = 5, 2%). No studies were identified where exercise, offloading or education were the main intervention. Results for PAD were reported in 137 (65%) studies, foot ulceration in 54 (25%), amputation in 171 (81%), infection in 7 (3%), and admission in 26 studies (12%). Results for more than one foot or lower limb outcome were reported in 141 studies (67%), with each study reporting on average two outcomes. Results varied and spanned positive, negative, and neutral outcomes following intervention. CONCLUSIONS: Identified studies frequently aimed to both prevent and manage foot and lower limb health complications. A variety of interventions were identified and studies often reported results for more than one foot or lower limb health outcome. Findings from this review can be used to guide future research, with a goal to support improved patient outcomes.

Do green bonds offer a diversification opportunity during COVID-19?-an empirical evidence from energy, crypto, and carbon markets.

The present study is a novel attempt to unravel the connectedness of the green bond with energy, crypto, and carbon markets using the S&P green bond index (RSPGB). We consider MAC global solar energy index (RMGS) and ISE global wind energy index (RIGW) as proxies of the energy market and use bitcoin and the European energy exchange carbon index (REEX) for the cryptocurrency and carbon market. Employing the Diebold and Yilmaz (2012), Baruník and Krehlík (2018), and wavelet coherence econometric techniques, we find that the energy market (RMGS) has the highest connectedness derived from other asset classes, and bitcoin (RBTC) has the least connectedness. Concurrently, we find that the risk transmission is heterogeneous in different scales as the short period has less connectedness than the medium and long run. We conclude that the overall diversification opportunity among green bonds, energy stock, bitcoin, and the carbon market is more in the short-run than in the medium and long-run. In summary, our findings on the green bond market will provide investors, portfolio managers, and policymakers with critical insight into ensuring a sustainable financial market.

Vulnerability of financial markets in India: The contagious effect of COVID-19.

This study aims to examine the impact of COVID-19 on financial markets, using emerging market data. Specifically, panel data regression is applied on 3200 observations for daily market returns during lockdown in India. The event study methodology is adopted to show abnormal returns registered in the lockdown period. A contrasting breakdown effect of COVID-19 on various Indian industries has been observed through sectoral analysis. The study also provides empirical evidence for lockdown measures taken by the government on stock market returns and post lockdown impact of COVID-19 on daily market returns for over 6550 observations.

Postpartum Magnesium Sulfate Overdose: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation with a nurse educator maintained the quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and labor and delivery nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets in a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency, beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for "Was an effective use of my educational time" and "Will influence/enhance my future practice." In this scenario, participants must evaluate and treat a postpartum preeclamptic woman who is being treated with magnesium sulfate for the purpose of seizure prophylaxis. The patient experiences magnesium sulfate toxicity and subsequent respiratory arrest. Any mannequin that can display vital signs can be used for this scenario. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Umbilical Cord Prolapse in a Labouring Patient: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (OB/GYN) and anesthesiology. Consultation from a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train OB/GYN and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations, and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow OB/GYN and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluative data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 with comments, such as "Was an effective use of my educational time" and "Will influence/enhance my future practice". In this scenario, participants must recognize and manage fetal distress resulting from umbilical cord prolapse in a labouring patient and respond with urgent operative delivery. This scenario requires adult and fetal mannequins with presenting umbilical cord for pelvic examination as well as equipment for fetal monitoring, general anesthetic, and emergency cesarean section. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

The effect of simulator fidelity on acquiring non-technical skills: a randomized non-inferiority trial.

INTRODUCTION: As simulator fidelity (i.e., realism) increases from low to high, the simulator more closely resembles the real environment, but it also becomes more expensive. It is generally assumed that the use of high-fidelity simulators results in better learning; however, the effect of fidelity on learning non-technical skills (NTS) is unknown. This was a non-inferiority trial comparing the efficacy of high- vs low-fidelity simulators on learning NTS. METHODS: Thirty-six postgraduate medical trainees were recruited for the trial. During the pre-test phase, the trainees were randomly assigned to manage a scenario using either a high-fidelity simulator (HFS) or a low-fidelity simulator (LFS), followed by expert debriefing. All trainees then underwent a video recorded post-test scenario on a HFS, and the NTS were assessed between the two groups. The primary outcome was the overall post-test Ottawa Global Rating Scale (OGRS), while controlling for overall pre-test OGRS scores. Non-inferiority between the LFS and HFS was based on a non-inferiority margin of greater than 1. RESULTS: For our primary outcome, the mean (SD) post-test overall OGRS score was not significantly different between the HFS and LFS groups after controlling for pre-test overall OGRS scores [3.8 (0.9) vs 4.0 (0.9), respectively; mean difference, 0.2; 95% confidence interval, -0.4 to 0.8; P = 0.48]. For our secondary outcomes, the post-test total OGRS score was not significantly different between the HFS and LFS groups after controlling for pre-test total OGRS scores (P = 0.33). There were significant improvements in mean overall (P = 0.01) and total (P = 0.003) OGRS scores from pre-test to post-test. There were no significant associations between postgraduate year (P = 0.82) and specialty (P = 0.67) on overall OGRS performance. CONCLUSION: This study suggests that low-fidelity simulators are non-inferior to the more costly high-fidelity simulators for teaching NTS to postgraduate medical trainees.

Autonomic Dysreflexia in the Peripartum Patient: A Multidisciplinary and Interprofessional Simulation Scenario.

This case is one of an eight-case multidisciplinary curriculum designed and implemented at the University of Ottawa by simulation educators with specialty training in obstetrics and gynecology (ob/gyn) and anesthesiology. Consultation with a nurse educator maintained quality and relevance of objectives for nursing participants. The curriculum was prepared to train ob/gyn and anesthesiology residents and nurses to hone crisis resource management skills and to recognize and manage rare/critical medical events in an obstetrical setting. Obstetricians, anesthesiologists, and nurses often work together in acute, high-stakes situations and this curriculum provides a safe environment to practice team-based management of such emergencies. Over an eight-year period, this curriculum has been executed in scenario couplets on a four-year cycle to allow ob/gyn and anesthesiology residents exposure to all scenarios during a five-year residency beginning in their second year. Prospective evaluation data has been positive. For example, over 90% of participants rated these simulations to be 5 out of 5 for "Was an effective use of my educational time" and "Will influence/enhance my future practice". In this scenario, participants must recognize and manage a parturient with spinal cord injury in active labour who develops autonomic dysreflexia. The fetal heart tracing becomes abnormal and the team must respond with urgent delivery. This scenario requires a mannequin for a pelvic exam and a pregnant abdomen. This simulation case includes a case template, critical actions checklist, debriefing guide, summary of key medical content, and an evaluation form for learners to provide feedback.

Correlation between serum ferritin and bone marrow iron stores.

Bone marrow aspirate examination is a gold standard to assess bone marrow iron stores. The correlation between serum ferritin and bone marrow iron has not been established in detail, as the cutoff value for iron stores have not been uniformly established. Ours was a cross-sectional study. Perl's Prussian blue stain was used to stain bone marrow, assessed by Gale's grading. Receiver operating characteristic curve analysis and Spearman's correlation coefficient calculated. Gale's grading revealed iron store deficiency in 26 and sufficiency in 13. Spearman's correlation coefficient of 0.90 showed a significant relation between serum ferritin and bone marrow iron stores. A serum ferritin of 228 pmol/L had high sensitivity and specificity for iron deficiency; our study suggests that this level be taken as the cutoff value to predict iron store deficiency in bone marrow.

Volume Conductivity and Scatter Parameters as an Indicator of Acute Bacterial Infections by the Automated Haematology Analyser.

INTRODUCTION: Complete blood picture is the first and foremost investigation ordered for evaluation of acute infectious processes which require early and prompt intervention. With the advent of automated Coulter (®) Haematology analysers, the Volume, Conductivity & Scatter parameters of the leucocytes could be analysed for the early detection of the infections. AIM: To evaluate the clinical usefulness of Volume, Conductivity & Scatter parameters of neutrophils & monocytes in predicting the onset of acute bacterial infections. MATERIALS AND METHODS: Peripheral blood samples from 94 patients with infections (systemic infections n=36 & localised infections n=58) and 46 control subjects were studied using the Volume, Conductivity & Scatter parameters by the Coulter Haematology analyser. RESULTS: We observed a significant increase in the mean channel of neutrophil volume & mean channel of monocyte volume from patients with infections (both systemic & localised) as compared with control subjects (Mean Neutrophil Volume: 158.3 ± 13.7 vs 137.2 ± 4.3; p<0.001) & (Mean Monocyte Volume: 177.8± 16 vs 161.7 ± 6.04; p <0.001). However, there was no significant difference in the Mean Neutrophil Volume of patients with systemic infection & localised infections (160.5±17.5 vs 156.8±10.5, p>0.05). CONCLUSION: The Volume, Conductivity & Scatter parameters like Mean Neutrophil Volume & Mean Monocyte Volume are more sensitive parameters and could prove to be a quick diagnostic indicator of acute bacterial infections.

Evidence for genetic linkage between a polymorphism in the GNAS gene and malaria in South Indian population.

The complex imprinted GNAS locus which encodes G-alpha subunit (Gαs) is involved in a number of G-protein coupled signaling pathways in eukaryotic cells. Erythrocyte invasion by Plasmodium falciparum parasites is significantly regulated by protein of GNAS gene. This study was designed to evaluate the association between single nucleotide polymorphisms (SNPs) present in GNAS locus and susceptibility to malaria. In this case control study, individuals affected by P. falciparum malaria (n=230), Plasmodium vivax malaria (n=230) and normal controls (n=230) were tested for the association of eighteen (18) known SNPs to evaluate their role in the onset of the disease. There was no significant difference in genotype frequencies of all the SNPs tested between P. falciparum and P. vivax affected individuals. However, when Bonferroni correction for multiple comparisons were performed as a control, our results demonstrated alleles and genotypes of rs7121: C>T (NC_000020.10:g.57478807C>T), a silent polymorphism situated in the exon 5, were significantly (p<0.05) associated with susceptibility to malaria in the South Indians participants. Our results demonstrate that population specific polymorphisms that exist in GNAS gene may alter the risk of occurrence of malaria.

Epithelioid sarcoma: a diagnostic challenge.

Epithelioid sarcoma is an uncommon slow-growing soft tissue malignancy, associated with a high incidence of local recurrence and metastasis. We report a 26-year-old male with epithelioid sarcoma on the right palm with a long history of over seven years, which was initially misdiagnosed as cutaneous tuberculosis and epithelioid hemangioendothelioma, as a result of which the treatment was delayed. No metastasis was found in our patient. The patient was referred to the oncology centre where he underwent wide excision of the lesion followed by radiotherapy. The review of the literature including clinical and histological differential diagnosis is presented as it mimics inflammatory, benign tumors as well as other malignant conditions.

Synchronous vulvar intraepithelial neoplasia (VIN) of warty type and cervical intraepithelial neoplasia (CIN): case report.

Vulvar intraepithelial neoplasia is a precancerous lesion of the vulva, which has been referred to in the past with varied terminology. It can be associated with multicentricity of other neoplastic squamous lesions in the cervix and vagina. We report a case of vaginal intraepithelial neoplasia and concomitant cervical intraepithelial neoplasia in a 30 year old female. An attempt is made to put forth the recent terminology of vulvar intraepithelial neoplasia.