RAWS4all project: validation of a new silicone model for robotic TAPP inguinal hernia repair.

BACKGROUND: Trans-abdominal pre-peritoneal (TAPP) hernia repair is a complex procedure that presents several challenges. Even though, due to the high prevalence of inguinal hernia, TAPP technique is increasing in frequency and robotic Abdominal Wall Surgery (rAWS) is emerging as a valuable tool in this regard. Although inguinal TAPP procedure principles have been published and simulation is needed, the availability of validated models remains scarce. METHODS: A new low-cost model was developed to simulate inguinal rTAPP repair. For validity assessment, a new TAPP-specific fidelity questionnaire and assessment scale were developed to compare the performance of novices and experts in the simulated procedure. The models used were assessed at 60 min for execution and quality score. RESULTS: Twenty-five residents and specialists from all over the country participated in this study. Execution, quality, and global performance was higher in the seniors group compared to juniors (8.91 vs 6.36, p = 0.02; 8.09 vs 5.14, p < .001; and 17 vs. 11,5, p < .001, respectively). Overall fidelity was assessed as being very high [4.41 (3.5-5.0), α = .918] as well as face [4.31 (3.0-5.0), α = .867] and content validity [4.44 (3.2-5.0), α = .803]. Participants strongly agreed that the model is adequate to be used with the DaVinci® Robot [4.52 (3.5-5.0), α = .758]. CONCLUSION: This study shows face, content, and construct validity of the model for inguinal TAPP simulation, including for robotic surgery. Therefore, the model can be a valuable tool for learning, understanding, practicing, and mastering the TAPP technique prior to participating in the operating room.

Atrial fibrillation as a new prognosis factor in chronic patients after hospitalization: the CHRONIBERIA index.

A collaborative project in different areas of Spain and Portugal was designed to find out the variables that influence the mortality after discharge and develop a prognostic model adapted to the current healthcare needs of chronic patients in an internal medicine ward. Inclusion criteria were being admitted to an Internal Medicine department and at least one chronic disease. Patients' physical dependence was measured through Barthel index (BI). Pfeiffer test (PT) was used to establish cognitive status. We conducted logistic regression and Cox proportional hazard models to analyze the influence of those variables on one-year mortality. We also developed an external validation once decided the variables included in the index. We enrolled 1406 patients. Mean age was 79.5 (SD = 11.5) and females were 56.5%. After the follow-up period, 514 patients (36.6%) died. Five variables were identified as significantly associated with 1 year mortality: age, being male, lower BI punctuation, neoplasia and atrial fibrillation. A model with such variables was created to estimate one-year mortality risk, leading to the CHRONIBERIA. A ROC curve was made to determine the reliability of this index when applied to the global sample. An AUC of 0.72 (0.7-0.75) was obtained. The external validation of the index was successful and showed an AUC of 0.73 (0.67-0.79). Atrial fibrillation along with an advanced age, being male, low BI score, or an active neoplasia in chronic patients could be critical to identify high risk multiple chronic conditions patients. Together, these variables constitute the new CHRONIBERIA index.

The Caloric Necessities of Critical Care Patients During the First Week of Admission.

INTRODUCTION:  The nutritional needs of critically ill patients have been the subject of intense controversy. In accordance with international guidelines, it is advocated to optimize a nutritional intake based on the following recommendation: 25-30 kcal/kg body weight per day. However, there still are authors who recommend permissive underfeeding in the first week of hospitalization. Nevertheless, energy expenditure (EE) and necessity are influenced by the catabolic phase of critical illness, which may vary over time on a patient and from patient to patient. OBJECTIVE: The objective of this study is to assess if the energy needs of critically ill patients admitted in our intensive care unit (ICU) in the first week of hospitalization are in line with those recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) international guidelines. METHODS: A prospective cross-sectional study was carried out from September to December 2019. The energy needs were evaluated by indirect calorimetry and by the Harris-Benedict equation. Stress variables were evaluated, namely, the type of pathology, hemodynamic support, sedation, temperature, sequential organ failure assessment (SOFA) score, and state at discharge. RESULTS: Forty-six patients were included in this study, with an average energy expenditure by indirect calorimetry of 19.22 ± 4.67 kcal/kg/day. The energy expenditure was less than 20 kcal/kg/day in 63% of the measurements. The concordance rate did not show the relationship between the Harris-Benedict equation and the values of indirect calorimetry. Stress variables were analyzed, with the SOFA score as the only variable with values close to statistical significance. CONCLUSION: In our ICU, the energy needs of critically ill patients in the first week of hospitalization are lower than the intake recommended by the guidelines.

An atomistic explanation of the ethanol-water azeotrope.

Ethanol and water form an azeotropic mixture at an ethanol molecular percentage of ∼91% (∼96% by volume), which prohibits ethanol from being further purified via distillation. Aqueous solutions at different concentrations in ethanol have been studied both experimentally and theoretically. We performed cylindrical micro-jet photoelectron spectroscopy, excited by synchrotron radiation, 70 eV above C1s ionization threshold, providing optimal atomic-scale surface-probing. Large model systems have been employed to simulate, by molecular dynamics, slabs of the aqueous solutions and obtain an atomistic description of both bulk and surface regions. We show how the azeotropic behaviour results from an unexpected concentration-dependence of the surface composition. While ethanol strongly dominates the surface and water is almost completely depleted from the surface for most mixing ratios, the different intermolecular bonding patterns of the two components cause water to penetrate to the surface region at high ethanol concentrations. The addition of surface water increases its relative vapour pressure, giving rise to the azeotropic behaviour.

Correction: The molecular structure of the surface of water-ethanol mixtures.

Correction for 'The molecular structure of the surface of water-ethanol mixtures' by Johannes Kirschner et al., Phys. Chem. Chem. Phys., 2021, 23, 11568-11578, DOI: 10.1039/D0CP06387H.

Progestin-Primed Ovarian Stimulation is a non-inferior alternative to the GnRH Antagonist Protocol in patients undergoing assisted reproductive techniques: a retrospective study.

OBJECTIVE: To demonstrate the non-inferiority of Clinical Pregnancy Rates from Progestin-Primed Ovarian Stimulation compared to the GnRH Antagonist Protocol when the freeze-all and blastocyst transfer strategy is applied. METHODS: A retrospective study included all IVF cycles performed at Pró-Criar Reproductive Medicine Center, Belo Horizonte, Minas Gerais, Brazil, between May 2018 and May 2019 using a GnRH antagonist analogue or oral progestins to block the LH peak in IVF/intra-cytoplasmic sperm injection (ICSI) cycles for infertility treatment. RESULTS: The primary outcome of our study was Clinical Pregnancy Rate at the first ET (Blastocyst), which were 58.4% in the progestin group and 54.9% in the antagonist group (p=0.735), a finding consistent with most studies published to date using different progestins. The mean number of retrieved oocytes was 11 in the antagonist group and 9 oocytes in the progestin group (p=0.009). The fertilization rate was 80% for both groups (p=0.935). The rate of blastocyst formation per cycle was 50% in the antagonist group and 55.6% in the progestin group (p=0.106). The stimulation lasted a mean of 10 days in the two groups (p=0.403) and did not vary with patient age in either group. The gonadotropin dose used was higher in the antagonist group (2025 IU) than in the progestin group (1950 IU) (p=0.057). In addition, the blockade was effective: there was only one case of spontaneous ovulation, which corresponded to less than 1% of the cycles. CONCLUSIONS: Progestin-Primed Ovarian Stimulation is a non-inferior alternative to the GnRH Antagonist Protocol in patients undergoing assisted reproductive techniques. An incidence compatible with the 0.34 to 8% risk described in the literature for failure to control the premature LH surge in antagonist protocol cycles.

Prevalence of Nutritional Risk at Admission in Internal Medicine Wards in Portugal: The Multicentre Cross-Sectional ANUMEDI Study.

INTRODUCTION: Disease-related undernutrition is highly prevalent and requires timely intervention. However, identifying undernutrition often relies on physician judgment. As Internal Medicine wards are the backbone of the hospital setting, insight into the prevalence of nutritional risk in this population is essential. We aimed to determine the prevalence of nutritional risk in Internal Medicine wards, to identify its correlates, and to assess the agreement between the physicians' impression of nutritional risk and evaluation by Nutritional Risk Screening 2002. MATERIAL AND METHODS: A cross-sectional multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Data on demographics, previous hospital admissions, primary diagnosis, and Charlson comorbidity index score were collected. Nutritional risk at admission was assessed using Nutritional Risk Screening 2002. Agreement between physicians' impression of nutritional risk and Nutritional Risk Screening 2002 was tested by Cohen's kappa. RESULTS: The study included 729 participants (mean age 74 ± 14.6 years, 51% male). The main reason for admission was respiratory disease. Mean Charlson comorbidity index score was 5.8 ± 2.8. Prevalence of nutritional risk was 51%. Nutritional risk was associated with admission during the previous year (odds ratio = 1.65, 95% confidence interval: 1.22 - 2.24), solid tumour with metastasis (odds ratio = 4.73, 95% confidence interval: 2.06 - 10.87), any tumour without metastasis (odds ratio = 2.04, 95% confidence interval:1.24 - 3.34), kidney disease (odds ratio = 1.83, 95% confidence interval: 1.21 - 2.75), peptic ulcer (odds ratio = 2.17, 95% confidence interval: 1.10 - 4.25), heart failure (odds ratio = 1.51, 95% confidence interval: 1.11 - 2.04), dementia (odds ratio = 3.02, 95% confidence interval: 1.96 - 4.64), and cerebrovascular disease (odds ratio = 1.62, 95% confidence interval: 1.12 - 2.35). Agreement between physicians' evaluation of nutritional status and Nutritional Risk Screening 2002 was weak (Cohen's kappa = 0.415, p < 0.001). DISCUSSION: Prevalence of nutritional risk in the Internal Medicine population is very high. Admission during the previous year and multiple comorbidities increase the odds of being at-risk. Subjective physician evaluation is not appropriate for nutritional screening. CONCLUSION: The high prevalence of at-risk patients and poor subjective physician evaluation suggest the need to implement mandatory nutritional screening.

Introdução: A subnutrição associada à doença apresenta grande morbimortalidade e necessita de intervenção precoce. Contudo, a sua identificação assenta frequentemente no julgamento médico. Adicionalmente, sendo a enfermaria de Medicina Interna o pilar do hospital, é essencial maior conhecimento sobre o estado nutricional desta população. Os objetivos consistiram em determinar a prevalência de risco nutricional na enfermaria de Medicina Interna, identificar fatores relacionados e avaliar a concordância entre a avaliação do risco nutricional baseada no julgamento médico e no Nutritional Risk Screening 2002. Material e Métodos: Estudo transversal multicêntrico realizado nas enfermarias de Medicina Interna de 24 hospitais portugueses durante 2017. Foram avaliadas características demográficas, internamentos prévios, diagnósticos principais, índice de comorbilidades de Charlson e habilitações literárias. O risco nutricional à admissão foi avaliado usando o Nutritional Risk Screening 2002. A concordância entre o julgamento médico e o Nutritional Risk Screening 2002 foi testado usando o teste kappa de Cohen (k). Resultados: Foram incluídos 729 participantes (idade média 74 ± 14,6 anos, 51% do sexo masculino). A principal causa de admissão foi doença respiratória. O índice de comorbilidades de Charlson médio foi 5,8 ± 2,8. A prevalência de risco nutricional foi 51%. O risco nutricional associou-se a internamento recente (odds ratio = 1,65, 95% intervalo de confiança: 1,22 - 2,24), neoplasia sólida metastizada (odds ratio = 4,73, 95% intervalo de confiança: 2,06 - 10,87), neoplasia não metastizada (odds ratio = 2,04, 95% intervalo de confiança: 1,24 - 3,34), doença renal (odds ratio = 1,83, 95% intervalo de confiança: 1,21 - 2,75), úlcera péptica (odds ratio = 2,17, 95% intervalo de confiança: 1,10 - 4,25), insuficiência cardíaca (odds ratio = 1,51, 95% intervalo de confiança: 1,11 - 2,04), demência (odds ratio = 3,02, 95% intervalo de confiança: 1,96 - 4,64) e doença cerebrovascular (odds ratio = 1,62, 95% intervalo de confiança: 1,12 - 2,35). A concordância entre julgamento médico e Nutritional Risk Screening 2002 foi fraca (kappa de Cohen = 0,415, p < 0,001). Discussão: A prevalência de risco nutricional na enfermaria de Medicina Interna é muito elevada. Admissão recente e múltiplas comorbilidades aumentam a probabilidade de risco nutricional. A avaliação subjetiva do médico não é apropriada para o rastreio nutricional. Conclusão: A elevada prevalência de doentes em risco e baixa precisão da avaliação subjetiva médica sugerem a necessidade de implementar rastreio nutricional obrigatório a nível nacional.

Double-valence photoionization of SUVA134a molecule (CFH2 CF3 ).

RATIONALE: In this work we investigate the single-photon double ionization of the SUVA 134a (1,1,1,2-tetrafluoroethane) molecule in the energy range from 21.21 to 320 eV. Our experimental data are supported by Thomas' and Samson's models. It is shown that the double photoionization of the SUVA 134a can be expressed as a sum of the so-called shake-off (SO) and the knockout (KO) processes. METHODS: The experiments were executed at the TGM beamline at Laboratório Nacional de Luz Síncrotron in Campinas, Brazil. The source of EUV and X-ray radiation was a bending magnet that enabled us to work in the photon energy range of 21.21 to 320 eV. The spectrometer was devised to collect 100% of the ions with kinetic energies up to 30 eV. The photoelectron-photoion (PEPICO) and photoelectron-photoion-photoion (PE2PICO) coincidence techniques were used in the present work. RESULTS: The ratio of double-to-total photoionization as a function of the photon energy for the SUVA molecule exhibits remarkably similar behavior with other atomic and molecular systems. SO depends on large excess energy above the ionization threshold, enabling the photoelectron to leave the interaction region rather speedily to yield a sudden change in the Coulomb field that the shaken electron feels. The measured asymptotic SO probability is PSO (∞) = 0.09. CONCLUSIONS: The present analysis shows that the separation of SO and KO processes relies on the experimental evidence that there is no significant interference between SO and KO. The analysis also shows that the separate formulation of KO and SO presents a factual portrayal of double photoionization. Despite having 50 electrons, SUVA has lower double-to-total photoionization fraction (9%) in comparison, for instance, to argon atoms (~20%), which has 18 electrons. This lower e-e correlation could be attributed to its larger volume, that is, lower electron density.

The molecular structure of the surface of water-ethanol mixtures.

Mixtures of water and alcohol exhibit an excess surface concentration of alcohol as a result of the amphiphilic nature of the alcohol molecule, which has important consequences for the physico-chemical properties of water-alcohol mixtures. Here we use a combination of intensity vibrational sum-frequency generation (VSFG) spectroscopy, heterodyne-detected VSFG (HD-VSFG), and core-level photoelectron spectroscopy (PES) to investigate the molecular properties of water-ethanol mixtures at the air-liquid interface. We find that increasing the ethanol concentration up to a molar fraction (MF) of 0.1 leads to a steep increase of the surface density of the ethanol molecules, and an increased ordering of the ethanol molecules at the surface. When the ethanol concentration is further increased, the surface density of ethanol remains more or less constant, while the orientation of the ethanol molecules becomes increasingly disordered. The used techniques of PES and VSFG provide complementary information on the density and orientation of ethanol molecules at the surface of water, thus providing new information on the molecular-scale properties of the surface of water-alcohol mixtures over a wide range of compositions. This information is invaluable in understanding the chemical and physical properties of water-alcohol mixtures.

Survey of Third-Party Parenting Options Associated With Fertility Preservation Available to Patients With Cancer Around the Globe.

Purpose: In the accompanying article, "Survey of Fertility Preservation Options Available to Patients With Cancer Around the Globe," we showed that specific fertility preservation services may not be offered at various sites around the world because of cultural and legal barriers. We assessed global and regional experiences as well as the legal status of third-party reproduction and adoption to serve as a comprehensive international data set and resource for groups that wish to begin oncofertility interventions. Methods: We provide data on the legalities of third-party assisted reproductive technologies and other family-building options in the 28 oncofertility-practicing countries surveyed. Results: We found regional and country differences that will be important in the development of tailored resources for physicians and for patient brochures that are sensitive to these local restrictions and cultural norms. Conclusion: Because many patients first consult Web-based materials, the formal assessment of the availability of these options provides members of the global oncofertility community with data to which they might otherwise not have ready access to better serve their patients.

Survey of Fertility Preservation Options Available to Patients With Cancer Around the Globe.

Purpose: Oncofertility focuses on providing fertility and endocrine-sparing options to patients who undergo life-preserving but gonadotoxic cancer treatment. The resources needed to meet patient demand often are fragmented along disciplinary lines. We quantify assets and gaps in oncofertility care on a global scale. Methods: Survey-based questionnaires were provided to 191 members of the Oncofertility Consortium Global Partners Network, a National Institutes of Health-funded organization. Responses were analyzed to measure trends and regional subtleties about patient oncofertility experiences and to analyze barriers to care at sites that provide oncofertility services. Results: Sixty-three responses were received (response rate, 25%), and 40 were analyzed from oncofertility centers in 28 countries. Thirty of 40 survey results (75%) showed that formal referral processes and psychological care are provided to patients at the majority of sites. Fourteen of 23 respondents (61%) stated that some fertility preservation services are not offered because of cultural and legal barriers. The growth of oncofertility and its capacity to improve the lives of cancer survivors around the globe relies on concentrated efforts to increase awareness, promote collaboration, share best practices, and advocate for research funding. Conclusion: This survey reveals global and regional successes and challenges and provides insight into what is needed to advance the field and make the discussion of fertility preservation and endocrine health a standard component of the cancer treatment plan. As the field of oncofertility continues to develop around the globe, regular assessment of both international and regional barriers to quality care must continue to guide process improvements.

Research priorities in infertility and assisted reproductive technology treatments - a James Lind Alliance priority setting partnership with brazilian patients.

OBJECTIVE: To identify the main research interests of Brazilian patients in the field of infertility and assisted reproductive technology (ART) treatments. METHODS: This prospective multicenter cross-sectional study was carried out in Brazil. Patients attending five fertility centers from the Huntington Group between October and December 2018 were invited to join the study, which consisted of answering an anonymous survey online. Two hundred and twenty-seven patients signed the informed consent form and were emailed the survey link. The survey was designed based on the James Lind Alliance Priority Setting Partnership protocol. In the area of infertility, patients were probed on issues such as somatic and psychological effects of treatment, prevention, assisted reproductive technology (medications and procedures), success rates, risks, and emotional aspects. RESULTS: The response rate (RR) was 47.58% (108 patients; 88 women - RR 51.46% and 20 men - RR 35.71%). Patient mean age was 36.5 years (SD 4.6). The top ten research priorities listed were 1) short- and long-term side effects of treatment; 2) how to cope with infertility; 3) risks associated with ART; 4) success rates in ART; 5) impact of diet on ART and fertility; 6) healthy habits; 7) alternative therapies; 8) impact of exercise on fertility and ART success; 9) oocyte quality and ovarian reserve; and 10) genetic or inherited causes of infertility. CONCLUSION: To better cater to the needs of patients and develop patient-centered care in the field of infertility and ART treatment, clinicians, healthcare providers, and the scientific community must identify patient concerns and priorities and make efforts to address them.

High prevalence of malnutrition in Internal Medicine wards - a multicentre ANUMEDI study.

BACKGROUND: Disease-related malnutrition is a significant problem in hospitalized patients, with high prevalence rates depending on the studied population. Internal Medicine wards are the backbone of the hospital setting. However, prevalence and determinants of malnutrition in these patients remain unclear. We aimed to determine the prevalence of malnutrition in Internal Medicine wards and to identify and characterize malnourished patients. METHODS: A cross-sectional observational multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Demographics, hospital admissions during the previous year, type of admission, primary diagnosis, Charlson comorbidity index, and education level were registered. Malnutrition at admission was assessed using Patient-Generated Subjective Global Assessment (PG-SGA). Demographic characteristics were compared between well-nourished and malnourished patients. Logistic regression analysis was used to identify determinants of malnutrition. RESULTS: 729 participants were included (mean age 74 years, 51% male). Main reason for admission was respiratory disease (32%). Mean Charlson comorbidity index was 5.8 ±â€¯2.8. Prevalence of malnutrition was 73% (56% moderate/suspected malnutrition and 17% severe malnutrition), and 54% had a critical need for multidisciplinary intervention (PG-SGA score ≥9). No education (odds ratio [OR] 1.88, 95% confidence interval [CI]: 1.16-3.04), hospital admissions during previous year (OR 1.53, 95%CI: 1.05-2.26), and multiple comorbidities (OR 1.22, 95%CI: 1.14-1.32) significantly increased the odds of being malnourished. CONCLUSIONS: Prevalence of malnutrition in the Internal Medicine population is very high, with the majority of patients having critical need for multidisciplinary intervention. Low education level, admissions during previous year, and multiple comorbidities increase the odds of being malnourished.

A critical analysis of the impact of endocrine disruptors as a possible etiology of primary ovarian insufficiency.

Primary ovarian insufficiency is a cause of infertility that affects about 1% of women under 40 years old, and is considered as idiopathic in 75% of cases. This review aims to carry out a critical synthesis of the knowledge of the chemical agents likely to affect follicular stock in humans and / or animals, by direct toxicity to follicles, or by increasing their recruitments. For the majority of toxic agents, only experimental data are currently available. We propose a strategy to encourage progress in identifying occupational factors responsible for premature ovarian failure.

Donor-derived fatal hyperinfection strongyloidiasis in renal transplant recipient.

Strongyloides stercoralis is a nematode, endemic in tropical and subtropical areas. Strongyloidiasis has been reported in recipients of hematopoietic stem cells, kidney, liver, heart, intestine, and pancreas, eventually presenting as disseminated strongyloidiasis and hyperinfection syndrome (SHS) which is associated with high mortality. We report one case of a recent renal transplant recipient, who presented with gastrointestinal and respiratory symptoms, evolving into shock. The identification of Strongyloides stercoralis in the bronchoalveolar lavage (BAL) lead us to the diagnosis of SHS. Treatment with subcutaneous ivermectin was started, however the patient did not survive. Retrospective serum donor analysis allowed us to identify the donor as the source of infection.

Identification of research priorities in infertility and assisted reproduction: an international, multicentre study.

RESEARCH QUESTION: What are the main research interests among patients of assisted reproductive technologies (ART)? DESIGN: Cross-sectional study consisting of an anonymous online survey sent to 2112 patients from eight centres in four countries in 2018. Patients were asked to identify research questions relevant to them in the field of infertility and ART. Answers were categorized into topics and ranked by frequency. A long list of the top 30 research topics was extracted from the aggregate results, from which a short list of the top 10 research topics was created. Ten research questions were finally formulated. RESULTS: A total of 945 responses were analysed. Main interests were side-effects, success rates, infertility prevention and emotional support. The 10 research questions were: 1. What are the side-effects of drugs used in ART treatments? (51.6%). 2. What are the most effective methods to cope with infertility from the psychological point of view? (35.7%). 3. What effects could diet have on fertility? (25.9%). 4. What are ART success rates per clinical profile? (24.8%). 5. Are there some habits and lifestyle factors that could prevent infertility? (20.0%). 6. What are the long-term risks associated with ART in mother and child? (18.5%). 7. Are alternative therapies such as acupuncture, yoga and meditation effective to treat/prevent infertility? (18.5%). 8. What is the impact of exercise on fertility? (15.4%). 9. How does oocyte quantity and quality affect fertility? (9.5%). 10. What are the genetic patterns or hereditary conditions causing/related to infertility? (9.5%). CONCLUSIONS: Researchers and clinicians should keep in mind that, in addition to success rates and safety, patients greatly value research into causes, prevention and emotional aspects of infertility.

Creating a Global Community of Practice for Oncofertility.

Fertility preservation in the cancer setting, known as oncofertility, is a field that requires cross-disciplinary interaction between physicians, basic scientists, clinical researchers, ethicists, lawyers, educators, and religious leaders. Funded by the National Institutes of Health, the Oncofertility Consortium (OC) was formed to be a scientifically grounded, transparent, and altruistic resource, both intellectual and monetary, for building this new field of practice capable of addressing the unique needs of young patients with cancer. The OC has expanded its attention to include other nonmalignant conditions that can threaten fertility, and the work of the OC now extends around the globe, involving partners who together have created a community of shared effort, resources, and practices. The OC creates materials that are translated, disseminated, and amended by all participants in the field, and local programs of excellence have developed worldwide to accelerate the pace and improve the quality of oncofertility research and practice. Here we review the global oncofertility programs and the capacity building activities that strengthen these research and clinical programs, ultimately improving patient care.

Alteplase for Massive Pulmonary Embolism after Complicated Pericardiocentesis.

BACKGROUND: The occurrence of a high-risk pulmonary embolism (PE) within 48 hours of a complicated pericardiocentesis to remove a haemorrhagic pericardial effusion, is an uncommon clinical challenge. CASE SUMMARY: The authors report the case of a 75-year-old woman who presented with signs of imminent cardiac tamponade due to recurring idiopathic pericardial effusion. The patient underwent pericardiocentesis that was complicated by the loss of 1.5 litres of blood. Within 48 hours, the patient had collapsed with clear signs of obstructive shock. This was a life-threating situation so alteplase was administered after cardiac tamponade and hypertensive pneumothorax had been excluded. CT chest angiography later confirmed bilateral PE. The patient achieved haemodynamic stability less than an hour after receiving the alteplase. However, due to the high risk of bleeding, the medical team suspended the thrombolysis protocol and switched to unfractionated heparin within the hour. The cause of the PE was not identified despite extensive study, but after 1 year of follow-up the patient remained asymptomatic. DISCUSSION: Despite the presence of a contraindication, the use of thrombolytic therapy in obstructive shock after exclusion of hypertensive pneumothorax can be life-saving, and low-dose thrombolytic therapy may be a valid option in such cases. LEARNING POINTS: A quick and systematic approach to a collapsed patient with signs of shock is mandatory; understanding the type of shock may help narrow the differential diagnosis and help in therapeutic decisions.After exclusion of cardiac tamponade and hypertensive pneumothorax, life-saving thrombolytic therapy can be administered in obstructive shock due to probable massive pulmonary embolism.Contraindications for thrombolytic therapy originated as exclusion criteria for clinical trials but should not prevent the use of this therapy in life-threatening situations.

The Development of an International Oncofertility Competency Framework: A Model to Increase Oncofertility Implementation.

BACKGROUND: Despite international evidence about fertility preservation (FP), several barriers still prevent the implementation of equitable FP practice. Currently, oncofertility competencies do not exist. The aim of this study was to develop an oncofertility competency framework that defines the key components of oncofertility care, develops a model for prioritizing service development, and defines the roles that health care professionals (HCPs) play. MATERIALS AND METHOD: A quantitative modified Delphi methodology was used to conduct two rounds of an electronic survey, querying and synthesizing opinions about statements regarding oncofertility care with HCPs and patient and family advocacy groups (PFAs) from 16 countries (12 high and 4 middle income). Statements included the roles of HCPs and priorities for service development care across ten domains (communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, oncofertility training, reproductive survivorship care and fertility-related psychosocial support, supportive care, and ethical frameworks) that represent 33 different elements of care. RESULTS: The first questionnaire was completed by 457 participants (332 HCPs and 125 PFAs). One hundred and thirty-eight participants completed the second questionnaire (122 HCPs and 16 PFAs). Consensus was agreed on 108 oncofertility competencies and the roles HCPs should play in oncofertility care. A three-tier service development model is proposed, with gradual implementation of different components of care. A total of 92.8% of the 108 agreed competencies also had agreement between high and middle income participants. CONCLUSION: FP guidelines establish best practice but do not consider the skills and requirements to implement these guidelines. The competency framework gives HCPs and services a structure for the training of HCPs and implementation of care, as well as defining a model for prioritizing oncofertility service development. IMPLICATIONS FOR PRACTICE: Despite international evidence about fertility preservation (FP), several barriers still prevent the implementation of equitable FP practice. The competency framework gives 108 competencies that will allow health care professionals (HCPs) and services a structure for the development of oncofertility care, as well as define the role HCPs play to provide care and support. The framework also proposes a three-tier oncofertility service development model which prioritizes the development of components of oncofertility care into essential, enhanced, and expert services, giving clear recommendations for service development. The competency framework will enhance the implementation of FP guidelines, improving the equitable access to medical and psychological oncofertility care.