The Impact of Antithrombotic Medications on Postoperative Bleeding Events Following Hemorrhoidectomy.

BACKGROUND: Bleeding complications are a risk associated with hemorrhoid procedures. Despite the prevalence of anticoagulant and antiplatelet therapies, including newer direct oral anticoagulants (DOACs) in the aging patient population there is a paucity of data regarding the impact of the use of antithrombotic therapy (AT) especially DOACs, on bleeding complications of hemorrhoid procedures. METHODS: We retrospectively reviewed charts of patients who had undergone a total of 1152 procedures, including hemorrhoid excision and ligation, at a single institution in the years 2016-2018. We noted whether they were prescribed AT, the indication for therapy, perioperative medication management, whether a PBE occurred, and how the PBE was managed. RESULTS: PBE's were noted in 5.92% of patients on ATs, as opposed to 2.66% of patients not on ATs (P = .014.) The odds ratio of having a PBE when on ATs vs not on ATs is 2.3 (95% CI 1.21 to 4.38, P = .011). Seven out of 40 (17.5%) total PBE's required hospital admission or repeat procedure, and this was not associated with AT use. Surprisingly, although males represented most of the patients on ATs, females were statistically more likely to have a PBE following a hemorrhoidectomy if on ATs. DISCUSSION: Patients on AT have an elevated risk of PBE compared to patients not on AT. No significant difference was found between the two groups when considering only those PBE's severe enough to require hospital admission or repeat procedure. Further research is required to establish clear guidelines regarding the perioperative management of AT for hemorrhoid procedures.

Impact of COVID-19 public health restrictions on hospital admissions for young infants in Victoria, Australia.

AIM: Strict public health measures during the COVID-19 pandemic led to less support for infants and their parents. We aimed to characterise the frequency and nature of infant admissions to the Royal Children's Hospital (RCH), Melbourne in 2020, compared to the previous year. METHODS: A retrospective review of medical records identified infants ≤3 months admitted to the general medicine unit, RCH from March to September in 2019 and 2020. Diagnoses potentially related to the impact of public health measures and reduced family and community supports were identified and compared to all infant diagnoses across both years. Clinical characteristics and need for referral for additional supports or mental health services were also ascertained. RESULTS: There were fewer admissions for infants ≤3 months in 2020 (n = 411) compared to 2019 (n = 678), with a threefold increase in admissions with a primary or secondary diagnosis of feeding difficulties, growth disturbance, infant irritability or maternal mental health concerns (191/411; 46% vs. 97/678; 14%). There were more infants of first-time parents (112/191; 59% vs. 44/97; 45%) and a reduction in the number of admissions due to infection (145/411; 35%; vs. 467/678; 69%). CONCLUSION: During the COVID-19 pandemic, there was a threefold increase in admissions for infants ≤3 months due to poor growth, feeding difficulties, irritability and maternal mental health concerns in 2020 compared to 2019. These findings may inform future pandemic planning and policy development to ensure maintenance of community supports such as maternal child health nurse (MCHN) service delivery for young infants.

End-Stage Tibiotalar Osteoarthritis and Chronic Strontium Toxicity.

Metal toxicity due to environmental sources or orthopedic implants has been a primary focus in recent literature. Specifically, in orthopedics, total joint arthroplasty regarding metal-on-metal articulation with cobalt-chromium articulation has adverse local and systemic effects. In particular, strontium toxicity is less known metal toxicity that can cause many systemic effects such as severe osteoporosis. This is the first reported case of strontium toxicity and end-stage tibiotalar osteoarthritis. We present a case of a 68-year-old female with bilateral ankle pain and deformity that were refractory to conservative measures, including physical therapy and anti-inflammatory medications. She was diagnosed with bilateral osteoarthritis and osteoporosis secondary to strontium toxicity by exclusion after extensive workup with a multi-disciplinary approach. The patient pursued conservative measures with ankle-foot orthosis, physical therapy, and anti-inflammatory medications. After the failure of conservative measures with over two years of follow-up, we recommended operative intervention to improve function and pain with staged bilateral tibiotalocalcaneal fusions utilizing an intramedullary device. Since she is moving out of state, she chose to pursue operative intervention at a different institution in order to establish long-term follow-up. The patient was placed on teriparatide for her osteoporosis secondary to strontium toxicity. Clinicians should be aware of strontium toxicity and its systemic effects and take a multi-disciplinary approach to treatment for optimal management.

Efficacy of Distance-Based EMS Education in a Low-Resource Country.

INTRODUCTION: Road traffic collisions are a major cause of morbidity and mortality in low-resource countries. Compounding this issue is a lack of advanced medical training in these regions and a paucity of developed emergency medical services (EMS). To help address this need, a distance-based EMS educational module was developed with the goal of advancing medical training in resource-poor areas. DESIGN: This prospective study evaluated the knowledge acquisition and technical effectiveness of a live online, distance-based EMS lecture provided to medical providers at Karl Heusner Memorial Hospital in Belize City, Belize. Participants were given a pretest consisting of 15 questions regarding ambulance and emergency vehicle safety, followed by a posttest of the same questions. One month later, a third test with the same questions was administered to assess knowledge retention. Technological effectiveness was evaluated as well. RESULTS: Nine participants completed all aspects of the study. Improvement was noted between the average scores of the pretest compared to the posttest (32.5% vs 74.1%) and was maintained from the pretest through the delayed posttest (32.5% vs 57.0%). Overall, participants approved of the technical aspects of the project. CONCLUSIONS: This synchronously presented distance-based EMS educational program showed gains in both immediate and delayed knowledge acquisition among a small sample size. These results show promise that online, distance-based education is a viable option for continuing graduate medical education in low-resource countries.

The Central-Splitting Approach for Achilles Insertional Tendinopathy and Haglund Deformity.

Insertional Achilles tendinopathy causes posterior heel pain at the insertion of the Achilles tendon, often in combination with a calcaneal exostosis, or Haglund deformity. Insertional Achilles tendinopathy often presents with a posterior osseous prominence and leads to calcification of the Achilles tendon1. Nonoperative treatment of these conditions includes activity modification, nonsteroidal anti-inflammatory agents, heel lifts, shoe modification, physical therapy focused on eccentric strengthening exercises, iontophoresis, and shock wave therapy. Nonoperative treatment will fail in approximately 50% of these cases, and such patients become candidates for surgical intervention2,3. Multiple surgical approaches have been described, including the medial J-shaped, lateral, Cincinnati transverse, double incision, and central-splitting approaches4. Currently, there is no consensus regarding the ideal approach. Recent literature has suggested that the central-splitting approach allows for adequate exposure of both the most commonly diseased area of the tendon and the calcaneal exostosis, with excellent postoperative pain and functional results5-13. DESCRIPTION: Place the patient in the prone position with the feet at the edge of the operating table. Make a full-thickness, 5 to 7-cm longitudinal incision centered over the Achilles tendon and the posterior aspect of the calcaneus. Make a central incision through the Achilles tendon. Sharply mobilize the medial and lateral slips and excise the diseased portion of the Achilles tendon. Expose the calcaneal exostosis and perform the calcaneal exostectomy with a microsagittal saw. Repair the remaining healthy-appearing Achilles tendon to the calcaneus with 2 suture anchors. An additional suture anchor or, alternatively, the double-row technique for the Achilles tendon repair may be used. Repair the central split in the Achilles tendon with absorbable suture. Close the soft tissue and skin in layers. ALTERNATIVES: Alternative approaches include the medial, lateral, or Cincinnati transverse incisions. The central-splitting approach is favored because of the excellent exposure of both the diseased tendon and the calcaneal exostosis. Additional augmentations to this procedure include a flexor hallucis longus transfer and a gastrocnemius recession. RATIONALE: This technique provides adequate exposure to the diseased Achilles tendon, calcific deposits, and calcaneal exostosis. Recent studies have demonstrated it to be a safe and effective technique with high patient-satisfaction scores5-13.

Providing palliative care closer to home: a retrospective analysis from a remote Australian hospital.

BACKGROUND: Rural and remote patients have reduced access to palliative care, often resulting in inter-hospital transfers and death a long way from home and family. Katherine Hospital (KH), a 50-bed hospital services a population with high Aboriginality who experience this issue. AIMS: To characterise trends in mortality and transfers at a remote hospital in reference to increasing capacity to provide palliative care. METHODS: Retrospective analysis of deaths in patients over 18 years of age, admitted between 2008 and 2018 at KH, Northern Territory. Outcome measures include number of deaths, aeromedical transfers to tertiary facility, palliative care episodes, demographics including Aboriginality, admission data and comorbidity. Statistical analysis included unpaired t-test, chi-square test and regression analysis. RESULTS: The number of deaths in KH increased from 23 (0.88% of inpatient admissions) in 2011 to 52 in 2018 (1.7%). During the same period, the proportion of all deaths classified as palliative increased from 51.4 to 66.0% (P = 0.001), with fewer deaths occurring in the emergency department (17.2-1.4% for the last 3 years, R = 0.75, P = 0.008). The number of aeromedical transfers of patients from KH to tertiary centres decreased from 769 (10.4% of all admissions) in 2011 to 434 (3.4%) in 2018 (P = 0.006). CONCLUSIONS: Increasing the capacity of a remote hospital to provide palliative care allowed more patients to die closer to home and decreased inappropriate aeromedical retrievals. An increased in-hospital mortality rate should not be misinterpreted as reflecting suboptimal care if palliative intent, patients' wishes and non-clinical risk factors have not been ascertained.

Beaming in Charcot Arthropathy-Intramedullary Fixation for Complicated Reconstructions: A Cadaveric Study.

In the modern treatment of Charcot neuroarthropathy, beam screw fixation is an alternative to plate and screw fixation. Exposure is minimized for implantation, and this technique supports the longitudinal columns of the foot as a rigid load-sharing construct. A published data review identified a paucity of data regarding metatarsal intramedullary canal morphology relevant to beam screw fixation. The purpose of the present study was to describe metatarsal diaphyseal morphology qualitatively and quantitatively in an effort to provide data that can be used by surgeons when selecting axially based intramedullary fixation. Twenty fresh-frozen cadaveric below-the-knee specimens were obtained. The metatarsals were exposed, cleaned of soft tissue, and axially transected at the point of the narrowest external diameter. Next, a digital caliper was used to measure the size and shape of the diaphysis of the first through fourth metatarsals. The diaphyseal canal shape was categorized as round, oval, triangular, or pear. The widest distance between the endosteal cortical surfaces was measured. Triangular endosteal canals were only found in the first metatarsal, and the remainder of the metatarsal canals were largely round or oval. These data help to approximate the size of fixation needed to achieve maximal screw-endosteal purchase.

Accurate tissue characterization in low-dose CT imaging with pure iterative reconstruction.

INTRODUCTION: We assess the ability of low-dose hybrid iterative reconstruction (IR) and 'pure' model-based IR (MBIR) images to maintain accurate Hounsfield unit (HU)-determined tissue characterization. METHODS: Standard-protocol (SP) and low-dose modified-protocol (MP) CTs were contemporaneously acquired in 34 Crohn's disease patients referred for CT. SP image reconstruction was via the manufacturer's recommendations (60% FBP, filtered back projection; 40% ASiR, Adaptive Statistical iterative Reconstruction; SP-ASiR40). MP data sets underwent four reconstructions (100% FBP; 40% ASiR; 70% ASiR; MBIR). Three observers measured tissue volumes using HU thresholds for fat, soft tissue and bone/contrast on each data set. Analysis was via SPSS. RESULTS: Inter-observer agreement was strong for 1530 datapoints (rs > 0.9). MP-MBIR tissue volume measurement was superior to other MP reconstructions and closely correlated with the reference SP-ASiR40 images for all tissue types. MP-MBIR superiority was most marked for fat volume calculation - close SP-ASiR40 and MP-MBIR Bland-Altman plot correlation was seen with the lowest average difference (336 cm3 ) when compared with other MP reconstructions. CONCLUSIONS: Hounsfield unit-determined tissue volume calculations from MP-MBIR images resulted in values comparable to SP-ASiR40 calculations and values that are superior to MP-ASiR images. Accuracy of estimation of volume of tissues (e.g. fat) using segmentation software on low-dose CT images appears optimal when reconstructed with pure IR.

Polyhydroxyalkanoate synthesis by mixed microbial consortia cultured on fermented dairy manure: Effect of aeration on process rates/yields and the associated microbial ecology.

Polyhydroxyalkanoates (PHAs) are biodegradable polymers that can substitute for petroleum-based plastics in a variety of applications. One avenue to commercial PHA production involves coupling waste-based synthesis with the use of mixed microbial consortia (MMC). In this regard, production requires maximizing the enrichment of a MMC capable of feast-famine PHA synthesis, with the metabolic response induced through imposition of aerobic-dynamic feeding (ADF) conditions. However, the concept of PHA production in complex matrices remains unrefined; process operational improvements are needed, along with an enhanced understanding of the MMC. Research presented herein investigated the effect of aeration on feast-famine PHA synthesis, with four independent aeration state systems studied; MMC were fed volatile fatty acid (VFA)-rich fermented dairy manure. Regardless of the aeration state, all MMC exhibited a feast-famine response based on observed carbon cycling. Moreover, there was no statistical difference in PHA synthesis rates, with qPHA ranging from 0.10 to 0.19 CmmolPHA gVSS-1 min-1; VFA uptake rates exhibited similar statistical indifferences. PHA production assessments on the enriched MMC resulted in maximum intracellular concentrations ranging from 22.5 to 90.7% (mgPHA mgVSS-1); at maximum concentration, the mean hydroxyvalerate mol content was 73 ± 0.6%. While a typical feast-famine dissolved oxygen (DO) pattern was observed at maximum aeration, less resolution was observed at decreasing aeration rates, suggesting that DO may not be an optimal process monitoring parameter. At lower aeration states, nitrogen cycling patterns, supported by molecular investigations targeting AOBs and NOBs, indicate that NO2 and NO3 sustained feast-famine PHA synthesis. Next-generation sequencing analysis of the respective MMC revealed numerous and diverse genera exhibiting the potential to achieve PHA synthesis, suggesting functional redundancy embedded in the diverse MMC. Ultimately, results demonstrate that aeration can be controlled in waste-based ADF systems to sustain PHA production potential, while enriching for a diverse MMC that exhibits potential functional redundancy. Reduced aeration could also enhance cost competitiveness of waste-based PHA production, with potential further benefits associated with nitrogen treatment.

Reinforcing Visual Grouping Cues to Communicate Complex Informational Structure.

In his book Multimedia Learning [7], Richard Mayer asserts that viewers learn best from imagery that provides them with cues to help them organize new information into the correct knowledge structures. Designers have long been exploiting the Gestalt laws of visual grouping to deliver viewers those cues using visual hierarchy, often communicating structures much more complex than the simple organizations studied in psychological research. Unfortunately, designers are largely practical in their work, and have not paused to build a complex theory of structural communication. If we are to build a tool to help novices create effective and well structured visuals, we need a better understanding of how to create them. Our work takes a first step toward addressing this lack, studying how five of the many grouping cues (proximity, color similarity, common region, connectivity, and alignment) can be effectively combined to communicate structured text and imagery from real world examples. To measure the effectiveness of this structural communication, we applied a digital version of card sorting, a method widely used in anthropology and cognitive science to extract cognitive structures. We then used tree edit distance to measure the difference between perceived and communicated structures. Our most significant findings are: 1) with careful design, complex structure can be communicated clearly; 2) communicating complex structure is best done with multiple reinforcing grouping cues; 3) common region (use of containers such as boxes) is particularly effective at communicating structure; and 4) alignment is a weak structural communicator.

Improving adaptive display with temporally adaptive rendering.

Making computer imagery more responsive and realistic is one of the most basic goals of graphics researchers, and adaptive display is one of the primary means for achieving it. While previous displays have achieved a spatial adaptivity, our research focuses on achieving temporal adaptivity--sampling some regions not only more densely, but also more often. We use closed loop feedback to guide sampling to image regions that change significantly over space or time. Adaptive reconstruction emphasizes older samples in static settings, resulting in sharper images; and new samples in dynamic settings, resulting in images that may be blurry but are up-to-date. In terms of peak signal-to-noise ratio, this prototype produces much better image streams than nonadaptive renderers with the same simulated sampling rates. This new display also offers new opportunities for adapting to user state, allowing adaptive response both where and when it is needed. Our prototype system already responds interactively to changes in the user's viewpoint, it might also respond to any of a number of other indications of user state, including eye tracking, repeatedly manipulated objects, and biometrics.