Dynamic Fixation versus Static Screw Fixation for Syndesmosis Injuries in Pronation External Rotation Ankle Fractures: A Retrospective Case Control Study.

Introduction: The current standard treatment for ankle syndesmosis injury is static screw fixation. Dynamic fixation was developed to restore the dynamic function of the syndesmosis. The purpose of this study was to determine that which of static screw fixation and dynamic fixation is better for treatment of ankle syndesmosis injury in pronation-external rotation fractures. Materials and methods: Thirty patients were treated with dynamic fixation (DF group) and 28 patients with static screw fixation (SF group). The primary outcome was Olerud-Molander Ankle Outcome Score. The secondary outcome were Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score, radiographic outcomes, complications and cost effectiveness. To evaluate the radiographic outcome, the tibiofibular clear space, tibiofibular overlap, and medial clear space were compared using the pre-operative and last follow-up plain radiographs. To evaluate the cost effectiveness, the total hospital cost was compared between the two groups. Results: There was no significant difference in primary outcome. Moreover, there were no significant difference in secondary outcome including Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score and radiographic outcome. Two cases of reduction loss and four cases of screw breakage were observed in the SF group. No complication in the DF group was observed. Dynamic fixation was more cost effective than static screw fixation with respect to the total hospital cost. Conclusion: Although dynamic fixation provided similar clinical and radiologic outcome, dynamic fixation is more cost effective with fewer complications than static screw fixation in ankle syndesmosis injury of pronation-external rotation fractures.

Uninsured immigrants in the United States significantly delayed the initiation of prenatal care after the changes to the Public Charge Rule.

OBJECTIVE: We estimated the impact of the changes made to the Public Charge Rule on the initiation of prenatal care among uninsured immigrants in the United States. STUDY DESIGN: We used a difference-in-differences approach to analyse the impact of the changes made to the Public Charge Rule (first difference) on initiation of prenatal care between uninsured and privately insured immigrants (second difference). METHODS: We used the natality data by the National Center for Health Statistics as the main data source, which includes all singleton births in a hospital to an immigrant birthing person aged from 15 to 44. The study covers three phases: (1) the period prior to the leaked draft Executive Orders concerning changes made to the public charge policy-from January 2014 to December 2016; (2) the period after the draft Executive Orders were leaked until the proposal of the Public Charge Rule-from January 2017 to September 2018; and (3) post proposal of the Public Charge Rule -from October 2018 to December 2019. RESULTS: After the proposal of the Public Charge Rule in 2018, the odds of initiating prenatal care in the first trimester decreased among uninsured immigrants by 12% (odds ratio [OR]: 0.880; 95% confidence interval [CI]: 0.832, 0.931) compared to privately insured immigrants. The odds of second trimester initiation of prenatal care was also negatively associated with the leak of the draft Executive Orders (OR: 0.942; 95% CI: 0.905, 0.981). CONCLUSION: The results of this study suggest that uninsured immigrants in the United States significantly delayed prenatal care after the changes were made to the Public Charge Rule.

Internal evaluation of risk stratification tool using serial procalcitonin and clinical risk factors in pediatric febrile neutropenia: The non-interventional, single institution experience prior to clinical implementation.

Risk stratification of pediatric febrile neutropenia (FN) is an established concept, yet clinical risk tools misclassify nearly 5% of clinical standard-risk episodes with severe outcomes. The internal evaluation of a clinical risk tool before implementation has not been well-described. In this noninterventional cohort study, we evaluated a study decision rules (SDR) tool; a clinical risk tool with serial procalcitonin. The study standard-risk (SSR) group met clinical standard-risk criteria with two serial procalcitonin <0.4 ng/mL. The study high-risk (SHR) group met clinical high-risk criteria or clinical standard-risk with a procalcitonin ≥0.4 ng/mL. Descriptive and bivariate statistics compared the groups and outcomes. Clinical criteria alone identified 39.1% (238/608) standard-risk episodes; 5.9% (14/238) had severe events. Prospectively using the SDR, the SHR group encompassed 76.6% (92/120) of episodes; severe events occurred in 20% (3/15) of standard-risk episodes included due to elevated procalcitonin ≥0.4 ng/mL. The SHR group had more blood stream infections [21.7% (20/92) vs. 0% (0/28); P = 0.007] and intensive care admissions [13% (12/92) vs. 3.6% (1/28); P = 0.158]. In conclusion, the SDR with serial procalcitonin aided in identifying severe events in clinical standard-risk episodes, but analysis was limited. Institutions may consider similar internal evaluation methodology before FN episode risk stratification.

Precise Measurement of Differential Cross Sections of the Σ

The differential cross sections of the Σ^{-}p→Λn reaction were measured accurately for the Σ^{-} momentum (p_{Σ}) ranging from 470 to 650 MeV/c at the J-PARC Hadron Experimental Facility. Precise angular information about the Σ^{-}p→Λn reaction was obtained for the first time by detecting approximately 100 reaction events at each angular step of Δcosθ=0.1. The obtained differential cross sections show a slightly forward-peaking structure in the measured momentum regions. The cross sections integrated for -0.7≤cosθ≤1.0 were obtained as 22.5±0.68 [statistical error(stat.)] ±0.65 [systematic error(syst.)] mb and 15.8±0.83(stat)±0.52(syst) mb for 470

Characterization and clinicopathological significance of circulating tumour cells in patients with oral squamous cell carcinoma.

Circulating tumour cells (CTCs) are cancer cells released by cancer into the peripheral circulation. Haematogenous tumour spread is a hallmark of metastatic malignancy and a key factor in cancer recurrence and prognosis. CTCs have diagnostic and prognostic significance for a number of adenocarcinomas and melanoma. A review of the published peer-reviewed literature was performed to determine the clinical relevance of CTCs as a biomarker in the management of oral squamous cell carcinoma (OSCC). Fourteen studies met the eligibility criteria. With regard to patients with OSCC, this review found the following: (1) CTCs have been detected using multiple techniques; (2) the presence of CTCs does not appear to be related to tumour differentiation or size; (3) CTCs may be detected without lymph node involvement; (4) the detection of CTCs may be prognostic for both disease-free survival and overall survival; (5) quantification of CTCs may reflect the efficacy of therapy; (6) CTCs may be of value for ongoing patient monitoring. Preliminary evidence suggests that CTCs have diagnostic and prognostic potential as a biomarker for oral cancer management and warrant further investigation to determine their appropriate place in the management of OSCC patients.

PROsetta: An R Package for Linking Patient-Reported Outcome Measures.

A common problem when using a variety of patient-reported outcomes (PROs) for diverse populations and subgroups is establishing a harmonized scale for the incommensurate outcomes. The lack of comparability in metrics (e.g., raw summed scores vs. scaled scores) among different PROs poses practical challenges in studies comparing effects across studies and samples. Linking has long been used for practical benefit in educational testing. Applying various linking techniques to PRO data has a relatively short history; however, in recent years, there has been a surge of published studies on linking PROs and other health outcomes, owing in part to concerted efforts such as the Patient-Reported Outcomes Measurement Information System (PROMIS®) project and the PRO Rosetta Stone (PROsetta Stone®) project (www.prosettastone.org). Many R packages have been developed for linking in educational settings; however, they are not tailored for linking PROs where harmonization of data across clinical studies or settings serves as the main objective. We created the PROsetta package to fill this gap and disseminate a protocol that has been established as a standard practice for linking PROs.

Seasonal variation of patulous Eustachian tube diagnoses using climatic and national health insurance data.

OBJECTIVES: This study aimed to analyse if there were any associations between patulous Eustachian tube occurrence and climatic factors and seasonality. METHODS: The correlation between the monthly average number of patients diagnosed with patulous Eustachian tube and climatic factors in Seoul, Korea, from January 2010 to December 2016, was statistically analysed using national data sets. RESULTS: The relative risk for patulous Eustachian tube occurrence according to season was significantly higher in summer and autumn, and lower in winter than in spring (relative risk (95 per cent confidence interval): 1.334 (1.267-1.404), 1.219 (1.157-1.285) and 0.889 (0.840-0.941) for summer, autumn and winter, respectively). Temperature, atmospheric pressure and relative humidity had a moderate positive (r = 0.648), negative (r = -0.601) and positive (r = 0.492) correlation with the number of patulous Eustachian tube cases, respectively. CONCLUSION: The number of patulous Eustachian tube cases was highest in summer and increased in proportion to changes in temperature and humidity, which could be due to physiological changes caused by climatic factors or diet trends.

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care.

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.

Comparison of patulous Eustachian tube patients with and without a concave defect in the anterolateral wall of the tubal valve.

OBJECTIVE: Patulous Eustachian tube appears to be caused by a concave defect in the anterolateral wall of the tubal valve of the Eustachian tube. This study aimed to compare the clinical features of patulous Eustachian tube patients with or without a defect in the anterolateral wall of the tubal valve. METHODS: Sixty-six patients with a patulous Eustachian tube completed a questionnaire, which was evaluated alongside endoscopic findings of the tympanic membrane, nasal cavity and Eustachian tube orifice. RESULTS: Females were more frequently diagnosed with a patulous Eustachian tube, but the valve defect was more common in males (p = 0.007). The ratio of patulous Eustachian tube patients with or without defects in the anterolateral wall of the tubal valve was 1.6:1. Weight loss in the previous six months and being refractory to conservative management were significantly associated with the defect (p = 0.035 and 0.037, respectively). Symptom severity was significantly higher in patients with the defect. CONCLUSION: Patulous Eustachian tube patients without a defect in the anterolateral wall of the tubal valve can be non-surgically treated more often than those with the defect. Identification of the defect could assist in making treatment decisions for patulous Eustachian tube patients.

Complications related to peri-operative transoesophageal echocardiography - a one-year prospective national audit by the Association of Cardiothoracic Anaesthesia and Critical Care.

Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro-oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05-0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01-0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.

Familial Influences on Neuroticism and Education in the UK Biobank.

Genome-wide studies often exclude family members, even though they are a valuable source of information. We identified parent-offspring pairs, siblings and couples in the UK Biobank and implemented a family-based DNA-derived heritability method to capture additional genetic effects and multiple sources of environmental influence on neuroticism and years of education. Compared to estimates from unrelated individuals, total heritability increased from 10 to 27% and from 17 to 56% for neuroticism and education respectively by including family-based genetic effects. We detected no family environmental influences on neuroticism. The couple similarity variance component explained 35% of the variation in years of education, probably reflecting assortative mating. Overall, our genetic and environmental estimates closely replicate previous findings from an independent sample. However, more research is required to dissect contributions to the additional heritability by rare and structural genetic effects, assortative mating, and residual environmental confounding. The latter is especially relevant for years of education, a highly socially contingent variable, for which our heritability estimate is at the upper end of twin estimates in the literature. Family-based genetic effects could be harnessed to improve polygenic prediction.

The effect of sleep deprivation and disruption on DNA damage and health of doctors.

Observational studies have highlighted the detrimental health effects of shift work. The mechanisms through which acute sleep deprivation may lead to chronic disease have not been elucidated, but it is thought that increased DNA damage or decreased repair can lead to disease. The objective of this study was to examine the effects of acute sleep deprivation on DNA damage. This was a cross-sectional observational study on 49 healthy, full-time doctors. Baseline blood was sampled from each participant after three consecutive days of adequate sleep. Participants (n = 24) who were required to work overnight on-site had additional blood sampled on a morning after acute sleep deprivation. DNA damage and expression of DNA repair genes were quantified. Information on health, working patterns and sleep diaries were collected. Independent t-tests were used to compare differences between groups and standardised mean differences expressed as Cohen's d. Overnight on-site call participants had lower baseline DNA repair gene expression and more DNA breaks than participants who did not work overnight (d = 1.47, p = 0.0001; and 1.48, p = 0.0001, respectively). In overnight on-site call participants, after acute sleep deprivation, DNA repair gene expression was decreased (d = 0.90, p = 0.0001) and DNA breaks were increased (d = 0.87, p = 0.0018). Sleep deprivation in shift workers is associated with adverse health consequences. Increased DNA damage has been linked to the development of chronic disease. This study demonstrates that disrupted sleep is associated with DNA damage. Furthermore, larger prospective studies looking at relationships between DNA damage and chronic disease development are warranted, and methods to relieve, or repair, DNA damage linked to sleep deprivation should be investigated.

Upper limb disorders in anaesthetists - a survey of Association of Anaesthetists members.

Upper limb disorders (affecting the hand, arm and neck) are common. The nature of anaesthetists' work poses a potential extra risk from poor posture that may contribute to the development of upper limb disorders in this professional group. However, to date, the problem has received scant attention in the literature. Following a 2 to 3-month period of publicity via newsletter, email and social media, all 10,231 electronically accessible members of the Association of Anaesthetists were invited by email to complete an online survey that was administered by a third-party company. A total of 3884 usable responses were received (38%). Analysis of possible risk factors found a significant association between upper limb disorders and years since starting anaesthetic training, having children (irrespective of respondents' sex or the number of children) and right-handedness. Years of practice and having children are less modifiable identified risk factors. However, right-handedness may be linked to the ergonomic design of the environment/equipment used within this specialty and may thus be a potentially modifiable risk factor worthy of further investigation.

Nonlinear association between bone mineral density and all-cause mortality: the Dong-gu study.

There was a U-shaped association between hip BMD and all-cause mortality, with the lowest mortality in the 90th percentile in males. However, there was an inverse linear relationship in females. In contrast, the association between lumbar spine BMD and mortality was less evident in males, with no association in females. INTRODUCTION: Bone mineral density (BMD) is reported inversely associated with mortality. Although some previous studies provided evidence for nonlinear associations, these were not adequately assessed in most previous works. METHODS: We evaluated the nonlinear relationship between BMD and mortality in Asians. Our study involved 8629 participants in the Dong-gu study from 2007 to 2010. Cox proportional hazard regression was used to calculate hazard ratios (HRs) according to BMD categories after adjusting for potential confounders. During a follow-up of 6.7 ± 1.4 years, 712 participants died. RESULTS: There was a U-shaped association between hip BMD and all-cause mortality, with the lowest mortality in the 90th percentile in males. However, there was an inverse linear relationship in females. In males, compared with the 75th to 95th percentile group, the < 2.5th percentile group had a 3.89 (95% CI 2.41-6.28)-fold higher risk and the 2.5th to 5th percentile group had a 2.51 (95% CI 1.25-5.04)-fold higher risk. The HR was 2.51 (95% CI 1.25, 5.04) in the > 97.5th percentile group. In females, compared with that in the 75th to 95th percentile group, the HR was 2.33 (95% CI 1.24, 4.39) in the < 2.5th percentile group. In contrast, the association between lumbar spine BMD and mortality was less evident in males, with no association in females. CONCLUSION: In conclusion, this study shows that the association between BMD and mortality varies by gender and that high and low BMD are predictors of all-cause mortality in males.

A comparison of two techniques for induction of anaesthesia with target-controlled infusion of propofol.

Induction of anaesthesia with target-controlled infusion of propofol may be achieved by stepwise increases in effect-site concentration until the patient loses consciousness (titration method), or by setting a high effect-site concentration target and observing the calculated effect-site concentration at loss of consciousness (standard method). When the estimated effect-site concentration at loss of consciousness is accurate, the difference between effect-site concentration at loss of consciousness and at recovery of consciousness should be small. This prospective, randomised, controlled trial was designed to compare this difference (effect-site concentration at loss of consciousness - effect-site concentration at recovery of consciousness) associated with the two techniques. Sixty-seven healthy patients undergoing elective hemithyroidectomy were recruited. Induction of anaesthesia was achieved using effect-site target-controlled infusion with the modified Marsh model and ke0 of 1.2 min-1 . The median (IQR [range]) difference between effect-site concentration at loss of consciousness and recovery of consciousness was significantly lower in patients in the titration group at 1.2 (0.8-1.5 [0.1-2.9]) µg.ml-1 compared with the standard group 2.1 (1.9-2.6 [0.2-3.6] µg.ml-1 ; p < 0.0001). There was a positive correlation between effect-site concentration at loss of, and recovery of, consciousness (R = 0.41, p = 0.016) in the titration group, which was not seen in the standard group (R = -0.15, p = 0.44). In conclusion, using the modified Marsh pharmacokinetic model, the titration method for target-controlled infusion propofol at induction of anaesthesia allows closer matching of propofol concentration to depth of anaesthesia than the standard method.

An international survey evaluating factors influencing the use of total intravenous anaesthesia.

The purpose of this study was to evaluate factors influencing the use of propofol-based total intravenous anaesthesia (TIVA)since despite TIVA being a well-established technique, it is used far less frequently than volatile anaesthesia. Questions were formulated after reviewing the literature for perceived disadvantages of TIVA and meeting with a focus group consisting of both senior and junior anaesthestists from our department. Once the survey had been formulated, specialist anaesthetists from professional colleges and societies from several countries were invited to complete the survey on an electronic web-based platform to allow evaluation of the respondent's rating of the importance of a range of factors in their decision not to use TIVA for a particular case. Basic descriptive statistics were determined using SPSS statistical software, while graphical depictions of data were handled using R for statistical analysis. A total of 763 survey responses were included in the final analysis and stratified according to the frequency of TIVA use. Among the infrequent users, issues such as additional effort, institutional preference, lack of real-time monitoring of propofol concentration, risk of missing drug delivery failure and increased turnaround time were among the top reasons mentioned. Interestingly, these issues were considered far less important among the frequent users when not choosing TIVA. We concluded that frequent and infrequent users respond quite differently to similar technical TIVA-related factors. Non-technical factors may play an important role in the infrequent user's decision not to use TIVA for a particular case.