Virtual urgent care is here to stay: driving toward safe, equitable, and sustainable integration within emergency medicine.

BACKGROUND: Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine. METHODS: We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement. RESULTS: The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada. CONCLUSION: Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada.

RéSUMé: CONTEXTE: Les soins virtuels au Canada ont rapidement pris de l'ampleur pendant la pandémie de COVID-19 dans un environnement où les règles sont peu strictes, en réponse aux besoins urgents d'accès continu aux soins dans un contexte de restrictions en santé publique. Les spécialistes de la médecine d'urgence sont maintenant confrontés au défi de conseiller sur les services de soins d'urgence virtuels qui devraient rester dans le cadre des soins d'urgence complets. Il faut tenir compte des soins sécuritaires, de qualité et appropriés, ainsi que des questions d'accès équitable, de la demande publique et de la durabilité (financière et autre). L'objectif de ce projet était de résumer la littérature actuelle et l'opinion d'experts et de formuler des recommandations sur la voie à suivre pour les soins virtuels en médecine d'urgence. MéTHODES: Nous avons formé un groupe de travail composé de médecins urgentistes de partout au Canada qui travaillent dans divers milieux de pratique. Le groupe de travail sur les soins virtuels a effectué un examen de la portée de la documentation et s'est réuni chaque mois pour discuter des thèmes et formuler des recommandations. Les recommandations finales ont été distribuées aux intervenants pour obtenir leurs commentaires, puis présentées au symposium universitaire 2023 de l'Association canadienne des médecins d'urgence (ACMU) pour discussion, rétroaction et perfectionnement. RéSULTATS: Le groupe de travail a élaboré et atteint l'unanimité sur neuf recommandations portant sur les thèmes de la conception du système, de l'équité et de l'accessibilité, de la qualité et de la sécurité des patients, de l'éducation et des programmes, des modèles financiers et de la viabilité des services virtuels de soins d'urgence au Canada. CONCLUSION : Les soins d'urgence virtuels sont devenus un service établi dans le système de santé canadien. Les spécialistes en médecine d'urgence sont particulièrement bien placés pour fournir un leadership et des conseils sur la prestation optimale de ces services afin d'améliorer et de compléter les soins d'urgence au Canada.

Pediatric emergency department physicians' perceptions of virtual mental health assessments for urgent needs.

PURPOSE: Pressures related to the COVID-19 pandemic have created the need to develop innovative ways to deliver mental health care, especially for urgent needs. After the launch of a pediatric Emergency Department (ED) Virtual Care service, we aimed to evaluate pediatric ED physicians' experiences with the use of ED virtual care for mental health assessments. METHODS: This mixed-methods study was conducted at a pediatric academic health center in Ontario, Canada. Pediatric ED physicians who conducted ED virtual mental health assessments from May to December 2020 were eligible. Participants completed a 22-question novel survey and were invited to participate in a focus group. Descriptive and thematic analyses were used to analyze the data. RESULTS: Twenty-nine physicians provided mental health services through the ED virtual care platform. Twenty-five physicians (86% response rate) completed the survey and 3 (10%) participated in a focus group. While many agreed that virtual care benefits patients (67%), key barriers identified included time constraints, lack of mental health clinician support, and uncertainty around the pediatric ED physicians' role in these types of assessments. Despite these barriers, physicians recognized the potential benefit of the ED virtual care service for mental health assessments and were largely amenable to improving this process should mental health support be available. CONCLUSIONS: While many physicians agreed that there is a potential benefit of the ED virtual care platform for urgent mental health assessments, time constraints and lack of confidence in providing satisfactory virtual mental health care with minimal mental health support limited its acceptability. These findings can inform the future implementation of mental health services using an innovative virtual ED platform.

RéSUMé: OBJECTIF: Les pressions liées à la pandémie de COVID-19 ont créé le besoin de développer des moyens innovants pour fournir des soins de santé mentale, en particulier pour les besoins urgents. Après le lancement d'un service de soins virtuels aux urgences pédiatriques, nous avons cherché à évaluer les expériences des médecins des urgences pédiatriques avec l'utilisation des soins virtuels aux urgences pour les évaluations de la santé mentale. MéTHODOLOGIE: Cette étude à méthodes mixtes a été menée dans un centre universitaire de santé pédiatrique en Ontario, au Canada. Les médecins pédiatriques qui ont effectué des évaluations virtuelles de la santé mentale aux urgences de mai à décembre 2020 étaient admissibles. Les participants ont rempli une enquête inédite de 22 questions et ont été invités à participer à un groupe de discussion. Des analyses descriptives et thématiques ont été utilisées pour analyser les données. RéSULTATS: Vingt-neuf médecins ont fourni des services de santé mentale par le biais de la plateforme de soins virtuels des urgences. Vingt-cinq médecins (taux de réponse de 86 %) ont répondu au sondage et trois (10 %) ont participé à un groupe de discussion. Si beaucoup s'accordent à dire que les soins virtuels sont bénéfiques pour les patients (67 %), les principaux obstacles identifiés sont les contraintes de temps, le manque de soutien des cliniciens en santé mentale et l'incertitude quant au rôle des urgentistes pédiatriques dans ces types d'évaluations. Malgré ces obstacles, les médecins ont reconnu l'avantage potentiel du service de soins virtuels de l'urgence pour les évaluations de la santé mentale et étaient largement disposés à améliorer ce processus si un soutien en santé mentale était disponible. CONCLUSIONS: Bien que de nombreux médecins s'accordent à dire que la plateforme de soins virtuels des urgences présente un avantage potentiel pour les évaluations urgentes de la santé mentale, les contraintes de temps et le manque de confiance dans la prestation de soins de santé mentale virtuels satisfaisants avec un soutien minimal en matière de santé mentale ont limité son acceptabilité. Ces résultats peuvent éclairer la mise en œuvre future des services de santé mentale à l'aide d'une plateforme virtuelle d'urgence innovante.

Effects of primary granulocyte-colony stimulating factor prophylaxis on neutropenic toxicity and chemotherapy dose delivery in Chinese patients with breast cancer who received adjuvant docetaxel plus cyclophosphamide chemotherapy: a retrospective cohort study.

INTRODUCTION: This study was performed to examine the effects of primary granulocyte-colony stimulating factor (G-CSF) prophylaxis on neutropenic toxicity, chemotherapy delivery, and hospitalisation among Chinese patients with breast cancer in Hong Kong. METHODS: This retrospective study included patients with breast cancer who received adjuvant docetaxel plus cyclophosphamide chemotherapy from November 2007 to October 2013 at Princess Margaret Hospital. Data were collected regarding the usage of G-CSF prophylaxis; incidences of grade 3 or 4 neutropenia, febrile neutropenia, non-neutropenic fever, and infection; hospital admissions, and chemotherapy dose delivery. Patients who began to receive G-CSF prophylaxis during the first cycle of chemotherapy and continued such prophylaxis in subsequent cycles were regarded as the primary G-CSF prophylaxis group. RESULTS: In total, 231 female Chinese patients with breast cancer were included in the analysis. Overall, 193 (83.5%) patients received primary G-CSF prophylaxis. The demographics and tumour characteristics were comparable between patients with and without primary G-CSF prophylaxis. Primary G-CSF prophylaxis significantly reduced febrile neutropenia incidence from 31.6% to 14.5% (relative risk=0.45, 95% confidence interval=0.25-0.81). Primary G-CSF prophylaxis also significantly reduced the incidence of grade 3 or 4 neutropenia from 57.9% to 24.7% (relative risk=0.43, 95% confidence interval=0.30-0.62) and the incidence of febrile neutropenia-related hospital admission from 31.6% to 12.4% (P=0.025). Finally, it enabled more patients to receive adequate chemotherapy dose delivery. CONCLUSION: Primary G-CSF prophylaxis effectively reduced the incidences of grade 3 or 4 neutropenia and febrile neutropenia, while enabling adequate chemotherapy dose delivery and reducing hospital admissions among Chinese patients with breast cancer who received adjuvant docetaxel plus cyclophosphamide chemotherapy.

Cognitive Stimulation for Persons with Dementia: a Systematic Review and Meta-Analysis.

OBJECTIVE: We aim to provide an up-to-date systematic review and meta-analysis of the effects of cognitive stimulation (CS) on cognition, depressive symptoms, and quality of life in persons with dementia. Factors affecting the treatment effect were examined. METHODS: A literature search was performed on databases of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, and Cochrane Library up to 7 March 2019. Only randomised controlled trials investigating the effects of CS in persons with dementia were included. The outcome measures were cognitive function, depressive symptoms, and quality of life. RESULTS: 20 randomised controlled trials with a total of 1251 participants (intervention group: 674; control group: 577) were included for meta-analysis. Most participants had mild to moderate dementia. CS had a significant positive small-to-moderate effect on cognition (Hedges's g = 0.313, p < 0.001). Heterogeneity of CS was low to moderate (Q=30.5854, df=19, p < 0.05, I2 = 37.877%). Inconclusive results were found for depressive symptoms and quality of life. CONCLUSION: CS has a significant positive effect on cognitive function, but its effect on depressive symptoms and quality of life was inconclusive. Future studies with more robust methodology establishing evidence of its efficacy are required.

Effect of immunosuppressive therapies on survival of systemic lupus erythematosus: a propensity score analysis of a longitudinal cohort.

Objectives The aim of this study was to study the relationship between immunosuppressive drug treatment and survival in patients with systemic lupus erythematosus (SLE). Methods Patients who fulfilled four or more American College of Rheumatology criteria for SLE were followed longitudinally. Clinical characteristics, use of immunosuppressive agents and mortality were reviewed. Cox regression was used to study the relationship between immunosuppressive treatment and survival, adjusted for age, sex, vascular risk factors, organ damage, the anti-phospholipid antibodies and a propensity score for the indication of individual immunosuppressive agent derived from separate regression models. Results A total of 803 SLE patients were studied (92% women; age of SLE onset 33.2±14 years; follow-up time 10.8±7.7 years). The frequencies of ever use of immunosuppressive agents were: high-dose prednisolone (≥0.6 mg/kg/day for ≥4 weeks) (85%), azathioprine (63%), cyclophosphamide (25%), mycophenolate mofetil (27%), the calcineurin inhibitors (23%) and hydroxychloroquine (69%). Ninety-seven patients (12%) died and 56 (7%) patients were lost to follow-up. The causes of death were infection (44%), cerebrovascular events (12%), cardiovascular events (10%) and malignancy (8.2%). Cox regression revealed that the ever use of high-dose prednisolone, mycophenolate mofetil, calcineurin inhibitors or cyclophosphamide was not significantly associated with improved survival. However, the ever use of hydroxychloroquine (hazard ratio 0.59 (0.37-0.93); P=0.02) and azathioprine (hazard ratio 0.46 (0.28-0.75); P=0.002) was significantly associated with reduced mortality (41% and 54%, respectively) after adjustment for the propensity score and other confounding factors. A similar beneficial effect of hydroxychloroquine and azathioprine on survival was also observed in patients with lupus nephritis. Conclusions In this longitudinal cohort of Chinese SLE patients, the ever use of hydroxychloroquine and azathioprine was significantly associated with a probability of better survival. Treatment with high-dose prednisolone, cyclophosphamide, mycophenolate mofetil or the calcineurin inhibitors was not associated with long-term survival benefit.

A genetic factor associated with low final bone mineral density in children after a long-term glucocorticoids treatment.

Treatment with glucocorticoids is associated with lower bone mineral density (BMD). We performed a genome-wide association study to analyze interactive effects between genotypes and cumulative dose of prednisone (PD) over 4.3 years of follow-up period on the final BMD Z-scores in 461 white children from the Childhood Asthma Management Program. No variants met the conventional criteria for genome-wide significance, and thus we looked for evidence of replication. The top 100-ranked single-nucleotide polymorphisms (SNPs) were then carried forward replication in 59 children with acute lymphoblastic leukemia (ALL) exposed to large fixed doses of PD as part of their chemotherapeutic regimen. Among them, rs6461639 (interaction P=1.88 × 10-5 in the CAMP population) showed a significant association with the final BMD Z-scores in the ALL population (P=0.016). The association of the ALL population was only present after correction for the anti-metabolite treatment arm (high vs low dose). We have identified a novel SNP, rs6461639, showing a significant effect on the final BMD Z-scores in two independent pediatric populations after long-term high-dose PD treatment.

Health-related behaviours and mental health in Hong Kong employees.

BACKGROUND: Poor physical and mental health in employees can result in a serious loss of productivity. Early detection and management of unhealthy behaviours and mental health symptoms can prevent productivity loss and foster healthy workplaces. AIMS: To examine health-related behaviours, mental health status and help-seeking patterns in employees, across different industries in Hong Kong. METHODS: Participants were telephone-interviewed and assessed using the Case-finding and Help Assessment Tool (CHAT) with employee lifestyle risk factors, mental health issues and help-seeking intentions screened across eight industries. Subsequent data analysis involved descriptive statistics and chi-square tests. RESULTS: There were 1031 participants. Key stressors were work (30%), family (19%), money (14%) and interpersonal issues (5%). Approximately 18, 9 and 9% of participants were smokers, drinkers and gamblers, respectively, and only 51% exercised regularly. Depressive and anxiety symptoms were reported by 24 and 31% of employees, respectively. Issues for which they wanted immediate help were interpersonal abuse (16%), anxiety (15%), anger control (14%) and depression (14%). Employees with higher educational attainment were less likely to smoke, drink and gamble than those with lower attainment. Lifestyle and mental health status were not associated with income. Employees in construction and hotel industries smoked more and those in manufacturing drank more than those in other industries. CONCLUSIONS: Physical and mental health of Hong Kong employees are concerning. Although employee assistance programmes are common among large companies, initiation of proactive engagement approaches, reaching out to those employees in need and unlikely to seek help for mental health issues, may be useful.

Pathway to mental health recovery: a qualitative and quantitative study on the needs of Chinese psychiatric inpatients.

BACKGROUND: Exploration of the information and participation needs of psychiatric inpatients is an important step for the implementation of recovery-oriented mental health service. The objective of this study was to explore the information and participation needs of Chinese psychiatric inpatients in the largest psychiatric hospital in Hong Kong. METHODS: The study was divided into two parts. In the first part, eight focus groups with patients, patients' relatives and healthcare professionals were held to identify 22 items of information needs and 16 items of participation needs of Chinese psychiatric inpatients. Basing on the items identified in the first part of the study, a questionnaire was developed to survey on the importance of the different information and participation needs in the second part of the study. Participants were asked to rate in rank order their perceived importance of the items in the questionnaire survey. RESULTS: A hundred and eighty three Chinese psychiatric inpatients completed the questionnaire and the majority of them suffered from schizophrenia (68.3 %). For information needs, the top three needs rated by patients as the most important in descending order were: "Information on the classifications of mental illnesses, signs and symptoms and factors contributing to relapse", "Information on the criteria and arrangements for discharge", and "Information on the importance of psychiatric drug taking and its side effects". For participation needs, the top three needs rated by patients as the most important in descending order were: "Enquiring about personal needs and arrangements", "Keeping in touch with the outside world", and "Learning and practising self-management". CONCLUSIONS: This study reveals that Chinese psychiatric inpatients are concerned about information on their mental illness and its treatments as well as the criteria for discharge. On the other hand, patients are concerned about their personal needs, their self-management, as well as their keeping in touch with the outside world during their hospitalisation. Moreover, patients with different socio-demographic and clinical characteristics have different information and participation needs. The results of the present study serve as a reference for designing guidelines, strategies, and programmes to meet the information needs and participation needs of psychiatric inpatients in Hong Kong.

A survey on the prevalence and utilization characteristics of gua sha in the Hong Kong community.

OBJECTIVE: To conduct a community-based survey to describe the demographics, experience, and utilization variables among the users of gua sha living in Hong Kong. METHOD: A total of 3209 adult respondents were surveyed by using a short Chinese questionnaire. RESULTS: Gua sha was found to have a one-year prevalence of 22.7% and four-week prevalence of 6.6%. The users were seen to be old of age and less educated. The majority believed that gua sha is beneficial to health, practiced in non-regular basis, and mainly employed for treating illnesses. For both male and female, the top two common illnesses to be treated were the respiratory and pain problems, which accounting for 74% of all users. Other illnesses included nervousness, heat stroke, fever, infection, dizziness, diarrhoea and vomiting, oedema, and constipation. As practiced by most respondents, unidirectional pressured stroking was applied repeatedly on the lubricated skin surface at the back region using various smooth-edged tools typically spoons. Almost all users reported the occurrence of skin blemishing and subsequently faded within 7 days after the gua sha treatment. CONCLUSION: The general population of Hong Kong was found to have high prevalence of gua sha usage. The utilization characteristics as reported by the users were generally aligned with the current scientific knowledge, in particular the treatment procedures and response.

ST13 polymorphisms and their effect on exacerbations in steroid-treated asthmatic children and young adults.

BACKGROUND: The clinical response to inhaled corticosteroids (ICS) is associated with single nucleotide polymorphisms (SNPs) in various genes. This study aimed to relate variations in genes in the steroid pathway and asthma susceptibility genes to exacerbations in children and young adults treated with ICS. METHODS: We performed a meta-analysis of three cohort studies: Pharmacogenetics of Asthma Medication in Children: Medication with Anti-Inflammatory effects (n = 357, age: 4-12 years, the Netherlands), BREATHE (n = 820, age: 3-22 years, UK) and Paediatric Asthma Gene Environment Study (n = 391, age: 2-16 years, UK). Seventeen genes were selected based on a role in the glucocorticoid signalling pathway or a reported association with asthma. Two outcome parameters were used to reflect exacerbations: hospital visits and oral corticosteroid (OCS) use in the previous year. The most significant associations were tested in three independent validation cohorts; the Childhood Asthma Management Programme (clinical trial, n = 172, age: 5-12 years, USA), the Genes- environment and Mixture in Latino Americans II- study (n = 745, age: 8-21, USA) and the Pharmacogenetics of adrenal suppression cohort (n = 391, age: 5-18, UK) to test the robustness of the findings. Finally, all results were meta-analysed. RESULTS: Two SNPs in ST13 (rs138335 and rs138337), but not in the other genes, were associated at a nominal level with an increased risk of exacerbations in asthmatics using ICS in the three cohorts studied. In a meta-analysis of all six studies, ST13 rs138335 remained associated with an increased risk of asthma-related hospital visits and OCS use in the previous year; OR = 1.22 (P = 0.013) and OR = 1.22 (P = 0.0017), respectively. CONCLUSION AND CLINICAL RELEVANCE: A novel susceptibility gene, ST13, coding for a cochaperone of the glucocorticoid receptor, is associated with exacerbations in asthmatic children and young adults despite their ICS use. Genetic variation in the glucocorticoid signalling pathway may contribute to the interindividual variability in clinical response to ICS treatment in children and young adults.

What will it take for recovery to flourish in Hong Kong?

The notion of mental health "recovery" is beginning to stimulate important changes in the mental health care provided to persons with serious mental illnesses in Hong Kong. However, the Chinese culture poses many challenges to implementing the types of recovery-oriented practices developed over the last 2 decades in the West. This article considers some of the challenges that policy makers, system leaders, practitioners, family members, and persons with mental illnesses themselves may face in attempting to transform care in Hong Kong. In addition to shifting from an individualistic to a more collectivist culture that emphasises the importance of family involvement, the primarily linear notion of mental stability that currently guides practice may need to be reconsidered in the face of evidence which suggests that recovery is a non-linear path that involves hard work both on the part of the individual as well as the family.

Expected possible selves and coping skills among young and middle-aged adults with bipolar disorder.

OBJECTIVES: This qualitative study explored expected possible selves and coping skills among young and middle-aged adults with bipolar disorder in Hong Kong. Disruptive or positive experiences associated with bipolar disorder can shape the development of the sense of possible selves. METHODS: Guided by narrative inquiry methodology, 14 Chinese participants (8 women; age range, 22-65 years), recruited from community mental health services and the public, were interviewed. RESULTS: Young participants (18-40 years) elaborated on their expected possible selves as they related to health, work, and family, whereas middle-aged participants (41-65 years) talked about independent possible selves. The participants used problem-focused, emotion-focused, and cultural coping methods to deal with their bipolar disorder and achieve their expected possible selves. Furthermore, the young participants expressed ambivalence towards self-help strategies to manage high mood episodes. CONCLUSIONS: This study not only improves our understanding of possible selves among young and middle-aged adults with bipolar disorder, but also provides information for designing self-help interventions. Limitations of the study along with directions for future research are discussed.

Long-term outcome of anti-tumor necrosis factor alpha blockade in the treatment of juvenile spondyloarthritis.

OBJECTIVES: A significant proportion of patients with juvenile spondyloarthritis (JSpA) are refractory to treatment with established medications. The objective of this study was to assess long-term efficacy of treatment with anti-TNF agents in patients with JSpA. METHODS: An observational study of 16 patients with JSpA from 3 centres treated with infliximab (n=10) and etanercept (n=6) was performed, with a median follow-up period of 7.2 years. Prospective data was collected according to a standardized protocol. Outcomes examined were TEC, TAJC, markers of inflammation (ESR, CRP), functional assessments (C-HAQ, BASDAI, BASFI), and ongoing requirement for anti-TNF treatment. RESULTS: 13/16 patients (83%) had achieved clinical remission 6 months into the treatment. Improvement was sustained over time, with a median TAJC and TEC of 0 at any time point after 6 weeks. 6/16 patients (38%) showed a flare of arthritis after a median of 3.5 years. Two patients with hip disease prior to treatment required an arthroplasty 3 and 8 years post anti-TNF initiation. Patients showed progression of sacroiliitis with median modified New York score of 1 (range 0-3) at time of diagnosis and 3 (range 0-4) at last follow-up (p=0.002). Median BASDAI at last follow up was 1.6, median BASFI 3.1. Two patients developed transient reactions (one generalised, one local); no patient developed other adverse effects during the study. CONCLUSIONS: Anti-TNF treatment in JSpA refractory to standard treatment results in good long-term disease control except for pre-existing hip disease. However, radiographic evidence suggests inferior efficacy for control of sacroiliac joint disease.

Scrotal antegradesclerotherapy demonstrates anatomical variations on venous drainage in paediatric, adolescent and young adult varicoceles.

AIM OF THE STUDY: Anatomical variations on venous drainage in varicoceles are under-reported. We report our experience in scrotal antegrade sclerotherapy (SAS) for adolescent varicoceles. METHODS: Since 2011, 15 consecutive boys with left varicoceles were recruited. Under general anaesthesia, a 5-mm transverse incision was made at scrotal neck, testicular vein was cannulated at pampiniform plexus with venogram performed. Foam sclerosant by mixing sodium tetradecyl sulphate (STS), Lipiodol(®) and air was slowly injected under fluoroscopy. Postoperatively the patients were followed-up for varicocele grading, testicular size, and complications. MAIN RESULTS: Median age at operation was 14 (10-19) years. 80 % had grade three varicoceles, 33.3 % had smaller left testis before operation. Intra-operative venogram showed three different anatomical variations. Group I: eleven patients (73.3 %) had single distinct internal spermatic vein; Group II: two patients demonstrated duplication of internal spermatic vein draining into left renal vein; Group III: two patients had pampiniform plexus draining to iliac and/or paraspinal veins. SAS was performed in Group I and II patients. Sclerosant volume injected ranged from 1.5 to 4.5 ml. In Group III patients, surgical ligation of testicular veins was performed rather than SAS to avoid uncontrolled systemic sclerosant spillage. Mean length of stay was 1.13 day. One patient with scrotal haematoma and one other with minor wound dehiscence were managed conservatively. Mean follow-up period was 10.9 (1-22) months. Thirteen patients (86.7 %) achieved varicocele grading ≤ 1. There was no postoperative testicular atrophy, hydrocele and epididymo-orchitis. CONCLUSION: Scrotal antegrade sclerotherapy using STS foam is a safe and effective treatment for adolescent varicoceles. Anatomical variations on venous drainage in varicoceles are common.

Unique transcriptional profile of liver-resident memory CD8+ T cells induced by immunization with malaria sporozoites.

Sterile immunity against live Plasmodium infection can be achieved by immunization with radiation-attenuated sporozoites. This protection is known to be mediated in part by antigen-specific memory CD8(+) T cells, presumably those residing in the liver. We characterized and compared the transcriptional profile of parasite-specific memory CD8(+) T cells residing in the liver and spleen after immunization of mice with irradiated sporozoites. Microarray-based expression analysis of these memory CD8(+) T cells indicated that liver-resident memory cells display a distinct gene expression profile. We found major differences in the expression of immune function genes as well as genes involved in the cell cycle, cell trafficking, transcription and intracellular signaling. Importantly, the malaria parasite-induced liver-resident CD8(+) T cells display a transcriptional profile different to that described for CD8(+) T cells following other microbial challenges.

Effect of haptic feedback in laparoscopic surgery skill acquisition.

BACKGROUND: The benefits of haptic feedback in laparoscopic surgery training simulators is a topic of debate in the literature. It is hypothesized that novice surgeons may not benefit from the haptic information, especially during the initial phase of learning a new task. Therefore, provision of haptic feedback to novice trainees in the early stage of training may be distracting and detrimental to learning. A controlled experiment was conducted to examine the effect of haptic feedback on the learning curve of a complex laparoscopic suturing and knot-tying task. METHODS: The ProMIS and the MIST-VR surgical simulators were used to represent conditions with and without haptic feedback, respectively. A total of 20 novice subjects (10 per simulator) were trained to perform suturing and knot-tying and practiced the tasks in 18 sessions of 1 h each. RESULTS: At the end of the 3-week training period, the subjects performed equally fast but more consistently with haptics (ProMIS) than without haptics (MIST-VR). The subjects showed a slightly higher learning rate and reached the first plateau of the learning curve earlier with haptic feedback. CONCLUSION: In general, learning with haptic feedback was significantly better than learning without it for a laparoscopic suturing and knot-tying task, but only during the first 5 h of training. Haptic feedback may not be warranted in laparoscopic surgical trainers. The benefits of a shorter time to the first performance plateau and more consistent initial performance should be balanced with the cost of implementing haptic feedback in surgical simulators.

The pharmacogenetics and pharmacogenomics of asthma therapy.

Despite the availability of several classes of asthma medications and their overall effectiveness, a significant portion of patients fail to respond to these therapeutic agents. Evidence suggests that genetic factors may partly mediate the heterogeneity in asthma treatment response. This review discusses important findings in asthma pharmacogenetic and pharmacogenomic studies conducted to date, examines limitations of these studies and, finally, proposes future research directions in this field. The focus will be on the three major classes of asthma medications: ß-adrenergic receptor agonists, inhaled corticosteroids and leukotriene modifiers. Although many studies are limited by small sample sizes and replication of the findings is needed, several candidate genes have been identified. High-throughput technologies are also allowing for large-scale genetic investigations. Thus, the future is promising for a personalized treatment of asthma, which will improve therapeutic outcomes, minimize side effects and lead to a more cost-effective care.