Successful surgical management of a combined abdominal and thoracic penetrating injury: a case report.

Penetrating rebar injuries are extremely rare occurrences, but they are very life-threatening, particularly when involving the thoracic and abdominal cavities. The surgical approach to these traumatic injuries depends upon the length and diameter of the rebar as well as the path of penetration into the abdominal and thoracic regions. Due to the highly uncommon occurrence of penetrating rebar injuries, there is very limited information and studies pertaining to this topic in the literature. In this case report, we present a 43-year-old male patient sustaining a rebar penetrating injury, with the entry site being the left flank and the exit site being the anterior left chest. Upon arrival, the patient was emergently taken to the operating room and underwent simultaneous exploratory laparotomy and a left thoracotomy. The operation was successful in removing the rebar and the patient survived.

Delayed Presentation of Nail Gun-Associated Traumatic Pneumothorax with a Retained Foreign Body: A Case Report.

BACKGROUND Pneumatic nail guns were first introduced in the 1950's, which revolutionized the construction industry. Since that time, nail gun injuries have been reported predominantly in the extremities with rare cases of thoracic and head injuries. A nail gun can easily propel nails through human tissue with velocities varying based on propellant and object. There are limited case reports on the appropriate management of thoracic nail gun injuries. CASE REPORT A 30-year-old man presented to the Emergency Department with right-sided chest pain seven and a half hours after getting struck in the right lateral thorax with a pneumatic nail gun. The patient was hemodynamically stable and without respiratory distress. A chest X-ray was taken and showed a right pneumothorax with a retained radio-opaque object at the right lung hilum. A CT angiogram subsequently showed the object abutting the right middle lobe branch of the pulmonary artery. Cardiothoracic surgery was called and the patient was taken urgently to the operating room for right thoracotomy, finding the nail deep in the right fissure at the hilum with the nail head in contact but not puncturing the right middle lobe branch of the pulmonary artery. The patient was extubated and recovered well postoperatively. CONCLUSIONS This case demonstrates the critical nature of nail gun injuries and can better inform the trauma protocols used to treat these injuries. Even in a delayed presentation, there should be a high suspicion of traumatic lung and cardiac injuries due to the velocities obtained with pneumatic nail guns.

The effect of different service models on quality of care in the assessment of autism spectrum disorder in children: study protocol for a multi-centre randomised controlled trial.

BACKGROUND: There is significant variability in clinical pathways available in the diagnostic assessment of ASD, including the order and timing of allied health assessments in relation to paediatrician consultations. Allied health professionals in first-contact models are increasingly used to improve the timeliness of healthcare access, whilst complementing medical specialty workforce shortages. Anecdotally, the implementation of allied health first-contact models in paediatrics has improved waitlists and timely access to healthcare. However, no rigorous studies have been conducted to evaluate the outcomes of these models. This study aims to determine the impacts of an allied health first-contact model on health service use and costs and patient quality of life and satisfaction. METHODS: An open, semi-blinded, multi-centre randomised controlled trial in paediatric outpatient clinics at two Australian metropolitan public hospitals. 56 children (0-16 years) fulfilling the inclusion criteria will be randomised to one of two clinical pathways for assessment of ASD: (1) allied health first-contact or (2) medical first-contact model. Cost outcomes will be collected from both health service and family perspectives. Caregiver-reported outcome measures include: Pediatric Quality of Life Inventory (PedsQL), the EuroQOL Five Dimension Youth Version (EQ-5D-Y), the Autism Family Experience Questionnaire (AFEQ) and Measure of Processes of Care. DISCUSSION: Evidence of improvements in service and consumer centric outcomes will help inform the development and implementation of high-value, evidenced based models of care for the assessment of ASD in children. The findings from this study are expected to contribute to the evidence base around the costs and consequences of allied health first contact models for the assessment of children with ASD in the Australian setting. Findings of this study may help to inform the allocation of health care resources while maintaining, or potentially improving, patient and family quality of life and experience of care. These findings may be useful in informing the wider adoption of these models in Australia and internationally, particularly in healthcare settings where medical specialist shortages exist. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR) ACTRN12621001433897 . Registered: 25th October, 2021.

NHS Scotland's community GP fellowship - a qualitative study of the first year.

NHS Scotland faces the challenges of an ageing population and a GP recruitment problem. Research has shown that hospital admissions can be reduced if community services can offer enhanced support, in keeping with the Scottish Government's 2020 Vision for healthcare. This study presents the findings of an evaluation of the first year of a three-year community GP fellowship which included working in primary care and secondary care and an educational programme. A grounded theory approach was adopted with data collected from GP fellows and key stakeholders using focus groups and individual interviews. A total of 12 fellows were interviewed at various times in the first year and 22 key stakeholders were interviewed once. The main themes were: aspirations for the fellowship, career choices of recently-qualified GPs, perceptions of primary care and secondary care components, planning and preparation of educational events, the creation of community hubs and identity and status of fellows. The fellowship showed potential for a change in practice and was a good foundation for further collaboration between health care sectors. Physical hubs need to be constructed and resourced to allow fellows to demonstrate a reduction in hospital admissions. More research is needed throughout the lifetime of the fellowship.

Complications after use of elastomeric pressure-indicating media at 24-hour follow-up visit for immediate maxillary complete removable dental prosthesis: A clinical report.

Various pressure-indicating media are available to assess the adaptation of the intaglio surface of a removable dental prosthesis at the insertion and follow-up appointments. This clinical report describes the use of an elastomer that entered the maxillary sinus through an undetected oroantral communication at the 24-hour follow-up for an immediate maxillary complete removable dental prosthesis. A Caldwell-Luc sinusotomy procedure was required to remove the material, and the patient required over 1 year of healing time before his reported symptoms resolved.

Systematic review: Health care transition practice service models.

BACKGROUND: Nearly 750,000 adolescents and emerging adults with special health care needs (AEA-SHCN) enter into adulthood annually. The linkages to ensure the seamless transfer of care from pediatric to adult care and transition to adulthood for AEA-SHCN have yet to be realized. PURPOSE: The purpose of this systematic review was to investigate the state of the science of health care transition (HCT) service models as described in quantitative investigations. METHODS: A four-tier screening approach was used to obtain reviewed articles published from 2004 to 2013. A total of 17 articles were included in this review. DISCUSSION: Transfer of care was the most prominent intervention feature. Overall, using the Effective Public Health Practice Project criteria, the studies were rated as weak. Limitations included lack of control groups, rigorous designs and methodology, and incomplete intervention descriptions. CONCLUSION: As the findings indicate, HCT is an emerging field of practice that is largely in the exploratory stage of model development.

Marginal and internal adaptation of milled cobalt-chromium copings.

STATEMENT OF PROBLEM: The application of computer-aided design and computer-aided manufacturing (CAD/CAM) systems to produce complete coverage restorations with different materials continues to increase. To date, insufficient information is available regarding the adaptation of recently introduced milled cobalt-chromium (Co-Cr) copings for metal ceramic restorations. PURPOSE: The purpose of this in vitro study was to evaluate the marginal and internal fit of milled Co-Cr copings produced by CAD/CAM with 2 different marginal preparation designs. MATERIAL AND METHODS: Four master dies were developed from 2 ivorine central incisors and 2 ivorine maxillary molars, 1 of each prepared with a 0.8-mm chamfer and a 1.2-mm rounded shoulder. These 4 groups of teeth were replicated with polyvinyl siloxane and used as templates to fabricate epoxy dies (n=10) for each of the 4 groups; a total of 40 epoxy resin dies. Cobalt-chromium copings of standard thickness (0.4 mm) were fabricated for each die with CAD/CAM technology. Next, the working dies were scanned with a 5-axis laser scanner to produce a 3-dimensional model. A thin layer of low-viscosity polyvinyl siloxane material was placed inside each coping and seated on the die until the material set. Copings were removed from the dies, leaving the polyvinyl siloxane intact, and these silicone-coated dies were scanned. The software superimposed the 2 scans, and the marginal openings and internal fit were measured at multiple locations. The marginal opening was determined at 4 locations: mid-buccal (mB), mid-lingual (mL), mid-mesial (mM), and mid-distal (mD), and the mean of these 4 measurement locations was referred to as the group variable "edge." The internal occlusal adaptation was measured at the midpoint from buccal to lingual and mesial to distal locations and referred to as mid-occlusal (mO). Means and standard deviations for edge (marginal adaptation) and mO were calculated for each of the 4 groups. A 2-sample t test was performed to detect differences among groups. A regression analysis was done to evaluate the interaction between the variables mO and edge (α=.05). RESULTS: Significantly smaller mean marginal openings (P=.017) were observed overall for the chamfer marginal design (anterior chamfer: 61 ±41 µm; posterior chamfer: 52 ±27 µm) compared with the shoulder design (anterior shoulder 103 ±49 µm, posterior shoulder 113 ±110 µm). The anterior chamfer had a statistically significant (P=.055) smaller mean marginal opening (61 ±41 µm) than the anterior shoulder (103 ±49 µm). No statistically significant differences (P=.119) were found between the posterior chamfer and posterior shoulder. The internal adaptation at the mO location was not significantly different among all 4 groups (P>.05). However, a regression analysis demonstrated a strong correlation (R=.842; P<.001) between the occlusal seat (mO) and marginal opening, with the smaller mean marginal opening of the chamfer design coinciding with the smaller occlusal seat values (61µm; mO: 182 µm) anterior chamfer; (52 µm; mO: 172 µm) posterior chamfer versus (103 µm; mO: 235 µm) anterior shoulder; (113 µm; mO: 242 µm) posterior shoulder. CONCLUSIONS: The milled Co-Cr copings produced with a CAD/CAM system in this study demonstrated clinically acceptable marginal fit in the range of 52 to 113 µm before ceramic application.

Within the boundary fence: an investigation into the perceptions of men's experience of depression in rural and remote areas of Australia.

This is a study exploring perceptions of men's experience of depression in rural and remote areas of Australia. The purpose of this investigation was to generate 'new' information that can inform models of diagnosis and primary care for the treatment of depression in men in rural and remote areas. Men and women were recruited from two North Queensland sites to participate in semistructured interviews in both an individual and focus group format and completing a series of questionnaires. A combination of grounded theory and content analysis was adopted to analyse the qualitative data, and develop theory around men's experience of depression in rural and remote areas. The findings of this study suggest that men's experience of depression within a rural context is defined by a process of 'internal compound' whereupon emotional distress can represent itself in avoidant and dulling behaviours along with self-reliant attempts to 'fix' the situation. From this study a language has been provided to give explanation to the experience of depression in men in rural and remote areas. The findings of this study have implications for, and provide opportunity for reform in, how we approach the recognition, diagnosis and treatment of depression for men in rural and remote areas.

Misperception of aspect ratio in binocularly viewed surfaces.

The horizontal-vertical illusion, in which the vertical dimension is overestimated relative to the horizontal direction, has been explained in terms of the statistical relationship between the lengths of lines in the world, and the lengths of their projections onto the retina (Howe & Purves, 2002). The current study shows that this illusion affects the apparent aspect ratio of shapes, and investigates how it interacts with binocular cues to surface slant. One way in which statistical information could give rise to the horizontal-vertical illusion would be through prior assumptions about the distribution of slant. This prior would then be expected to interact with retinal cues to slant. We determined the aspect ratio of stereoscopically viewed ellipses that appeared circular. We show that observers' judgements of aspect ratio were affected by surface slant, but that the largest image vertical:horizontal aspect ratio that was considered to be a surface with a circular profile was always found for surfaces close to fronto-parallel. This is not consistent with a Bayesian model in which the horizontal-vertical illusion arises from a non-uniform prior probability distribution for slant. Rather, we suggest that assumptions about the slant of surfaces affect apparent aspect ratio in a manner that is more heuristic, and partially dissociated from apparent slant.

Normal muscular activity during swallowing as measured by surface electromyography.

OBJECTIVES: Speech-language pathologists use surface electromyography biofeedback as a tool to facilitate swallowing treatment, particularly to improve swallowing strength and coordination. The present study sought to establish normative data of swallowing muscular activity as measured by surface electrodes in order to compare the performance of patients with dysphagia to normal swallow performance. METHODS: Thirty normal young (18 to 25 years of age) and elderly (60 or more years of age) subjects swallowed 3 bolus volumes (5, 10, and 20 mL) in 2 conditions: swallow-to-command and swallow-when-ready. Swallow muscular activity was measured in microvolts with a portable biofeedback unit. RESULTS: There were significant differences between the 2 swallowing conditions in both age groups. Neither age nor bolus volume had a significant effect on the findings. CONCLUSIONS: In using surface electromyography biofeedback as an adjunct to swallowing rehabilitation, it may be more beneficial to use swallow-to-command techniques if one is interested in measuring maximum effort, regardless of patient age or volume selected.

Prevención de la hemorragia posparto / Post partum hemorrhage prevention

OBJETIVO: evaluar los cambios en la pérdida estimada de sangre y tasas de Hemorragia Posparto [HPP] derivados del entrenamiento en el Manejo Activo de la Tercera Etapa del Parto [MATED] en cinco Clínicas Materno Infantiles del departamento de Yoro, Honduras. METODOLOGÍA: durante nueve meses, el equipo de investigación enseña las habilidades sobre la pérdida estimada de sangre, establece una tasa base para la HPP y enseña el manejo activo de la tercera etapa del parto. En cada nacimiento se registran la pérdida estimada de sangre, los resultados para la madre y el neonato, así como el uso calculado de Oxitocina en el periodo posnatal. Los datos obtenidos se analizan estadísticamente con SPSS descriptivo, prueba-T y Chi-cuadrado. RESULTADOS: el periodo de estudio previo al entrenamiento en MATEP incluye 178 casos, el periodo posterior al entrenamiento incluye 392 casos. La pérdida estimada de sangre durante el periodo previo es de 109 ml en promedio, comparado con 81 ml en promedio que se obtiene durante el periodo posterior al entrenamiento (p=.004). En la fase previa y posterior a/ entrenamiento, el uso de Oxitocina en el periodo posparto es de 99.5%, aunque en el 17% de los casos reportados la administración de Oxitocina se realiza después de la expulsión de la placenta. Después del entrenamiento en MATER la tasa de hemorragia posparto disminuye del 7.3% al 3.8%, dato que no es estadísticamente significativo.

AIM: evaluate the changes in estimated blood loss and Post Partum Hemorrhage [PPH] rates with dissemination of Active Management of Third Stage of Labor [AMTSL] training to five Clinicas Materno Infantiles in the state of Yoro, Honduras. METHODS: over a nine month period, the research team utilized a two part training module to first teach the skills of estimated blood loss to establish a baseline rate for PPH and then in the second phase teach skills of active management of third stage labor. Estimated blood loss, outcomes for mother and neonate as well as the use and timing of Oxytocin in the postpartum period were recorded for each birth for the research team. The collected data were analyzed with SPSS for descriptive, t-test and chi-square statistics. RESULTS: pre-AMTSL training period N= 178, post AMTSL training N=392. Estimated blood loss pre-AMTSL training was a mean of 109 ml compared with post-training period of 81ml (p=.004). The use of Oxytocin in the postpartum period was 99.5% in both pre and post AMTSL training, though 17% of the cases reported Oxytocin administration after delivery of the placenta. The postpartum hemorrhage rate decreased from 7.3% to 3.8% after the AMTSL training, but was not statistically significant. CONCLUSION: AMTSL training reduced estimated blood loss though did not significantly change PPH rates in this study. Use of Oxytocin postpartum has become a regular component of care provided.

Oropharyngeal dysphagia in patients with chronic obstructive pulmonary disease: a systematic review / Disfagia orofaríngea em pacientes com doença pulmonar obstrutiva crônica: revisão sistemática

BACKGROUND: oropharyngeal dysphagia in patients with chronic obstructive pulmonary disease. PURPOSE: patients with Chronic Obstructive Pulmonary Disease (COPD) can be vulnerable to respiratory incompetence that may lead to swallowing impairment. A systematic review was conducted to investigate the relationship between Chronic Obstructive Pulmonary Disease and oropharyngeal dysphagia. Forty-seven articles were retrieved relating to Chronic Obstructive Pulmonary Disease and dysphagia. Each article was graded using evidence-based methodology. Only 7 articles out of the 47 addressed oropharyngeal swallowing disorders in patients with Chronic Obstructive Pulmonary Disease. This review found few studies that documented the relationship between oropharyngeal swallowing disorders and Chronic Obstructive Pulmonary Disease. There were no randomized control trials. CONCLUSION: although the evidence is not strong, it appears that patients with Chronic Obstructive Pulmonary Disease are prone to oropharyngeal dysphagia during exacerbations. Future studies are needed to document the prevalence of oropharyngeal dysphagia in homogeneous groups of patients with Chronic Obstructive Pulmonary Disease, and to assess the relationship between respiration and swallowing using simultaneous measures of swallowing biomechanics and respiratory function. These investigations will lead to a better understanding of the characteristics and risk factors of developing oropharyngeal dypshagia in patients with Chronic Obstructive Pulmonary Disease.

TEMA: disfagia orofaríngea em pacientes com doença pulmonar obstrutiva crônica. OBJETIVO: pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC) podem ser vulneráveis à insuficiência respiratória que pode levar ao distúrbio de deglutição. Uma análise sistemática foi conduzida para investigar a relação entre a doença pulmonar obstrutiva crônica e a disfagia orofaríngea. Quarenta e sete artigos foram encontrados relativos à doença pulmonar obstrutiva crônica e disfagia. Cada artigo foi classificado utilizando metodologia baseada em evidências. Apenas 07 artigos dos 47 abordaram distúrbios de deglutição orofaríngea em pacientes com doença pulmonar obstrutiva crônica. Esta revisão encontrou poucos estudos que documentaram a relação entre os transtornos de deglutição orofaríngea e a doença pulmonar obstrutiva crônica. Não foram realizadas triagens de controle randomizadas. CONCLUSÃO: embora a prova não seja conclusiva, parece que os pacientes com doença pulmonar obstrutiva crônica são propensas à disfagia orofaríngea durante exacerbações. Futuros estudos são necessários para documentar a prevalência de disfagia orofaríngea em grupos homogêneos de pacientes com doença pulmonar obstrutiva crônica, e para avaliar a relação entre respiração e deglutição, utilizando medidas simultâneas de biomecânica de deglutição e função respiratória. Estas investigações conduzirão a uma melhor compreensão das características e fatores de risco do desenvolvimento de disfagia orofaríngea em pacientes com doença pulmonar obstrutiva crônica.

Vertical disparity affects shape and size judgments across surfaces separated in depth.

Vertical binocular disparity provides a useful source of information allowing three-dimensional (3-D) shape to be recovered from horizontal binocular disparity. In order to influence metric shape judgments, a large field of view is required, suggesting that vertical disparity may play a limited role in the perception of objects projecting small retinal images. This limitation could be overcome if vertical disparity information could be pooled over wide areas of 3-D space. This was investigated by assessing the effect of vertical disparity scaling of a large surround surface on the perceived size and 3-D shape of a small, central object. Observers adjusted the size and shape of a virtual, binocularly defined ellipsoid to match those of a real, hand-held tennis ball. The virtual ball was presented at three distances (200, 325, and 450 mm). Vertical disparities in a large surround surface were manipulated to be consistent with a distance of 160 mm or infinity. Both shape and size settings were influenced by this manipulation. This effect did not depend on presenting the surround and target objects at the same distance. These results suggest that the influence of vertical disparity on the perceived distance to a surface also affects the estimated distance of other visible surfaces. Vertical disparities are therefore important in the perception of metric depth, even for objects that in themselves subtend only small retinal images.