Impacto del síndrome de iris flácido intraoperatorio (IFIS) en cirugía de cataratas mediante facoemulsificación: análisis de 622 casos / Impact of intraoperative floppy IRIS syndrome in cataract surger by phacoemulsification: Analysis of 622 cases

Introducción Los síndromes de pupila estrecha, incluido el síndrome de iris flácido intraoperatorio (IFIS), aumentan el riesgo de complicaciones durante la cirugía de cataratas si no se realiza una correcta planificación quirúrgica. La tamsulosina se asocia a un incremento muy significativo del riesgo de IFIS, debido a la inactivación prolongada de los receptores alfa-1 adrenérgicos en la fibra muscular lisa del iris. Material y métodos Estudio prospectivo observacional unicéntrico, llevado a cabo en el Hospital de l’Esperança - Parc de Salut Mar.ResultadosSe incluyeron 622 ojos de 502 pacientes, de los cuales 337 (62%) eran mujeres. La media de edad de la muestra era de 74,8 años. Se observaron 61 casos de IFIS (11%), de los cuales 13 recibían tratamiento con tamsulosina y uno con doxazosina. Se observaron 23 casos de IFIS en pacientes mujeres. La ratio mujer:hombre fue de aproximadamente 1:3. Se observaron 19 casos (3%) de IFIS severo, de los cuales 6 recibían tratamiento con alfa-antagonistas, sin correlación estadísticamente significativa.La media del tiempo quirúrgico fue de 13,80min (desviación estándar [DE]: 4,01min) en pacientes sin IFIS y de 16,93min (DE: 4,32min) en pacientes con IFIS. La relación entre la duración del procedimiento quirúrgico en minutos y la presencia de IFIS fue estadísticamente significativa, aplicando un test t-Student «a dos colas» o bilateral con un p valor de 0,01. Conclusión Independientemente del grado de severidad, el diagnóstico de IFIS alarga el tiempo quirúrgico en cirugía de cataratas. Esto supone otra evidencia más que apoya la utilización de tratamientos antagonistas adrenérgicos menos alfa-1 selectivos que la tamsulosina o la realización de la cirugía de cataratas antes de iniciar dichos tratamientos. (AU)

Background Small pupil syndromes, including intraoperative-floppy iris syndrome (IFIS), increase the risk of complications during cataract surgery if proper surgical planning is not performed. Tamsulosin is associated with a very significant increase in the risk of IFIS, due to the prolonged inactivation of alpha-1 adrenergic receptors in the smooth muscle fiber of the iris. Material and methods Single-center prospective observational study, carried out at the Hospital de l’Esperança – Parc de Salut Mar.ResultsSix hundred and twenty-two eyes of 502 patients were included, of which 337 (62%) were women. The mean age of the sample is 74.8 years. Sixty-one cases of IFIS (11%) were observed, of which 13 received treatment with Tamsulosin and 1 with Doxazosin. Twenty-three cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. Nineteen cases (3%) of severe IFIS were observed, of which 6 received treatment with alpha-antagonists, with no statistically significant correlation.The mean surgical time was 13.80min (standard deviation – SD: 4.01min) in patients without IFIS and 16.93min (SD: 4.32min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a ‘two-tailed’ or bilateral t-Student test with a p value of 0.01. Conclusion Regardless of the degree of severity, the diagnosis of IFIS lengthens the surgical time in cataract surgery. This represents yet another piece of evidence that supports the use of less selective alpha-1 adrenergic antagonist treatments than tamsulosin or the performance of cataract surgery before starting these treatments. (AU)

Incentivising public transport use for physical activity gain: process evaluation of the COVID-19 disrupted trips4health randomised controlled trial.

BACKGROUND: Partnering with a public transport (PT) provider, state government, and local government, the single-blinded randomised controlled trial, trips4health, investigated the impact of PT use incentives on transport-related physical activity (PA) in Tasmania, Australia. The intervention involved 16-weeks of incentives (bus trip credits) for achieving weekly PT use targets, supported by weekly text messages. This study objective was to conduct a process evaluation of the COVID-19 disrupted trips4health study. METHODS: The Medical Research Council UK's framework for complex public health interventions guided the process evaluation. Participant reach, acceptability, fidelity and feasibility were evaluated. Administrative and post-intervention survey data were analysed descriptively. Semi-structured interviews with intervention participants (n = 7) and PT provider staff (n = 4) were analysed thematically. RESULTS: Due to COVID-19, trips4health was placed on hold (March 2020) then stopped (May 2020) as social restrictions impacted PT use. At study cessation, 116 participants (approximately one third of target sample) had completed baseline measures, 110 were randomised, and 64 (n = 29 in the intervention group; n = 35 in the control group) completed post-intervention measures. Participants were 18 - 80 years (average 44.5 years) with females (69%) and those with tertiary education (55%) over-represented. The intervention was delivered with high fidelity with 96% of bus trip credits and 99% of behavioural text messages sent as intended. Interviewed PT staff said implementation was highly feasible. Intervention participant acceptability was high with 90% reporting bus trip incentives were helpful and 59% reporting the incentives motivated them to use PT more. From a total of 666 possible bus trip targets, 56% were met with 38% of intervention participants agreeing and 41% disagreeing that 'Meeting the bus trip targets was easy'. Interviews and open-ended survey responses from intervention participants revealed incentives motivated bus use but social (e.g., household member commitments) and systemic (e.g., bus availability) factors made meeting bus trip targets challenging. CONCLUSIONS: trips4health demonstrated good acceptability and strong fidelity and feasibility. Future intervention studies incentivising PT use will need to ensure a broader demographic is reached and include more supports to meet PT targets. TRIAL REGISTRATION: ACTRN12619001136190 .

Impact of intraoperative floppy IRIS syndrome in cataract surgery by phacoemulsification: Analysis of 622 cases.

BACKGROUND: Small pupil syndromes, including IFIS, increase the risk of complications during cataract surgery if proper surgical planning is not performed. Tamsulosin is associated with a very significant increase in the risk of IFIS, due to the prolonged inactivation of alpha-1 adrenergic receptors in the smooth muscle fiber of the iris. MATERIAL AND METHODS: Single-center prospective observational study, carried out at the Hospital de l'Esperança - Parc de Salut Mar. RESULTS: 622 eyes of 502 patients were included, of which 337 (62%) were women. The mean age of the sample is 74.8 years. 61 cases of IFIS (11%) were observed, of which 13 received treatment with Tamsulosin and 1 with Doxazosin. 23 cases of IFIS were observed in female patients. The female:male ratio was approximately 1:3. 19 cases (3%) of severe IFIS were observed, of which 6 received treatment with alpha-antagonists, with no statistically significant correlation. The mean surgical time was 13.80 min (Standard Deviation - SD: 4.01 min) in patients without IFIS and 16.93 min (SD: 4.32 min) in patients with IFIS. The relationship between the duration of the surgical procedure in minutes and the presence of IFIS was statistically significant, applying a 'two-tailed' or bilateral t-Student test with a p value of 0.01. CONCLUSION: Regardless of the degree of severity, the diagnosis of IFIS lengthens the surgical time in cataract surgery. This represents yet another piece of evidence that supports the use of less selective alpha-1 adrenergic antagonist treatments than Tamsulosin or the performance of cataract surgery before starting these treatments.

Burden of osteoarthritis in India and its states, 1990-2019: findings from the Global Burden of disease study 2019.

OBJECTIVE: To describe the burden of osteoarthritis (OA) in India from 1990 to 2019. DESIGN: Data from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used. The burden of OA -knee OA, hip OA, hand OA, and other OA- was estimated for India and its states from 1990 to 2019 through a systematic analysis of prevalence, incidence, years lived with disability (YLD), and disability-adjusted life years (DALY) using methods reported in GBD 2019 study. RESULT: Around 23.46 million individuals in India had OA in 1990; this increased to 62.35 million in 2019. The age-standardised prevalence of OA increased from 4,895 (95% uncertainty interval (UI):4,420-5,447) in 1990-5313 (95%UI:4,799-5,898) in 2019, per 100,000 persons. Similarly, DALYs due to OA increased from 0.79 million (95%UI:0.40-1.55) to 2.12 million (95%UI:1.07-4.23); while age-standardised DALYs increased from 164 (95%UI:83-325) to 180 (95%UI:91-361) per 100,000 persons from 1990 to 2019. OA was the 20th most common cause of YLDs in India in 2019, accounting for 1.48% (95%UI:0.88-2.78) of all YLDs; increasing from 23rd most common cause in 1990 (1.25%(95%UI:0.74-2.34)). Knee OA was the most common form of OA, followed by hand OA. The prevalence, incidence, and DALYs for OA and knee OA were consistently higher in females than males. CONCLUSION: The burden and impact of OA in India are substantial and is increasing. Adopting suitable control and preventive community measures to reduce modifiable risk factors (obesity, injuries, occupational stress) are needed to reduce the current and future burden of OA in India.

Carrier-Envelope Phase-Dependent Strong-Field Excitation.

We present a joint experimental-theoretical study on the effect of the carrier-envelope phase (CEP) of a few-cycle pulse on the atomic excitation process. We focus on the excitation rates of argon at intensities in the transition between the multiphoton and tunneling regimes. Through numerical simulations, we show that the resulting bound-state population is highly sensitive to both the intensity and the CEP. The experimental data clearly agree with the theoretical prediction, and the results encourage the use of precisely tailored laser fields to coherently control the strong-field excitation process. We find a markedly different behavior for the CEP-dependent bound-state population at low and high intensities with a clear boundary, which we attribute to the transition from the multiphoton to the tunneling regime.

Long-term cost-effectiveness of Dexcom G6 real-time continuous glucose monitoring system in people with type 1 diabetes in Australia.

INTRODUCTION: Real-time continuous glucose monitoring (rt-CGM) allows patients with diabetes to adjust insulin dosing, potentially improving glucose control. This study aimed to compare the long-term cost-effectiveness of the Dexcom G6 rt-CGM device versus self-monitoring of blood glucose (SMBG) and flash glucose monitoring (FGM) in Australia in people with type 1 diabetes (T1D). METHODS: Long-term costs and clinical outcomes were estimated using the CORE Diabetes Model. Clinical input data for the analysis of rt-CGM versus SMBG and FGM were sourced from the DIAMOND study and a network meta-analysis, respectively. Rt-CGM and FGM were associated with quality of life (QoL) benefits due to reduced fear of hypoglycaemia (FoH) and fingerstick testing. Analyses were performed over a lifetime time horizon from an Australian healthcare payer perspective, including direct costs from published data. Future costs and clinical outcomes were discounted at 5% per annum. RESULTS: Rt-CGM was associated with an increased quality-adjusted life expectancy of 1.199 quality-adjusted life years (QALYs), increased mean total lifetime costs of AUD 21,596 and an incremental cost-effectiveness ratio (ICER) of AUD 18,020 per QALY gained compared with SMBG. Compared with FGM, rt-CGM was associated with an increased quality-adjusted life expectancy of 0.569 QALYs, increased mean total lifetime costs of AUD 11,064 and an ICER of AUD 19,455 per QALY gained. Key drivers of outcomes included HbA1c benefits and QoL benefits associated with reduced FoH and fingerstick testing. CONCLUSIONS: Due to improved clinical outcomes and QoL gains rt-CGM is highly cost-effective compared with SMBG and FGM in people with T1D in Australia.

Macular optical coherence tomography for screening of pathology prior to cataract surgery: An approach based on tele-evaluation.

BACKGROUND: To assess the benefit of macular spectral-domain optical coherence tomography (SD-OCT) as a part of the routinary preoperative study of patients undergoing cataract surgery. METHODS: A prospective single-center study study was performed. Consecutive patients with normal biomicroscopic funduscopy, moderate cataract and no history of ophthalmological pathologies were enrolled. All patients underwent macular SD-OCT. The obtained images were analysed by a general ophthalmologist and two retina specialists. Incidence of macular pathology and its relation to age and comorbidities were assessed. RESULTS: Eight-hundred and thirty-six eyes of 419 patients were enrolled in this study. All images were analysed telematically by a general ophthalmologist. Forty-nine eyes were excluded due to insufficient quality of the obtained images. Abnormal images were observed in 156 eyes (18.6%), including age-related macular degeneration in 68 (8.2%), epiretinal membrane (ERM) in 67 (8.0%), cystoid macular edema in 3 eyes (0.4%), among others. Diagnostics with severe impact on patient visual prognosis were observed in 16 eyes (3.82%) from 12 patients. The relationship between incidence of macular pathologies and age or comorbidities was not statistically significant. To assess accuracy of the first observer, images were subsequently analysed by two retinologists. The kappa index of concordance was 0.80 and 0.85. CONCLUSIONS: Implementing a systematic macular SD-OCT as a preoperative test prior to cataract surgery would improve quality of postoperative visual prognosis information. A general ophthalmologist would be suitable to screen for pathology through macular OCT images.

Evaluation of delay discounting as a transdiagnostic research domain criteria indicator in 1388 general community adults.

BACKGROUND: The Research Domain Criteria (RDoC) approach proposes a novel psychiatric nosology using transdiagnostic dimensional mechanistic constructs. One candidate RDoC indicator is delay discounting (DD), a behavioral economic measure of impulsivity, based predominantly on studies examining DD and individual conditions. The current study sought to evaluate the transdiagnostic significance of DD in relation to several psychiatric conditions concurrently. METHODS: Participants were 1388 community adults (18-65) who completed an in-person assessment, including measures of DD, substance use, depression, anxiety, posttraumatic stress disorder, and attention-deficit hyperactivity disorder (ADHD). Relations between DD and psychopathology were examined with three strategies: first, examining differences by individual condition using clinical cut-offs; second, examining DD in relation to latent psychopathology variables via principal components analysis (PCA); and third, examining DD and all psychopathology simultaneously via structural equation modeling (SEM). RESULTS: Individual analyses revealed elevations in DD were present in participants screening positive for multiple substance use disorders (tobacco, cannabis, and drug use disorder), ADHD, major depressive disorder (MDD), and an anxiety disorder (ps < 0.05-0.001). The PCA produced two latent components (substance involvement v. the other mental health indicators) and DD was significantly associated with both (ps < 0.001). In the SEM, unique significant positive associations were observed between the DD latent variable and tobacco, cannabis, and MDD (ps < 0.05-0.001). CONCLUSIONS: These results provide some support for DD as a transdiagnostic indicator, but also suggest that studies of individual syndromes may include confounding via comorbidities. Further systematic investigation of DD as an RDoC indicator is warranted.

Development and validation of the risk engine for an Australian Health Economics Model of Osteoporosis.

The Australian Health Economics Model of Osteoporosis (AusHEMO) has shown good face, internal and cross validities, and can be used to assist healthcare decision-making in Australia. PURPOSE: This study aimed to document and validate the risk engine of the Australian Health Economics Model of Osteoporosis (AusHEMO). METHODS: AusHEMO is a state-transition microsimulation model. The fracture risks were simulated using fracture incidence rates from the Dubbo Osteoporosis Epidemiology Study. The AusHEMO was validated regarding its face, internal and cross validities. Goodness-of-fit analysis was conducted and Lin's coefficient of agreement and mean absolute difference with 95% limits of agreement were reported. RESULTS: The development of AusHEMO followed general and osteoporosis-specific health economics guidelines. AusHEMO showed good face validity regarding the model's structure, evidence, problem formulation and results. In addition, the model has been proven good internal and cross validities in goodness-of-fit test. Lin's coefficient was 0.99, 1 and 0.94 for validation against the fracture incidence rates, Australian life expectancies and residual lifetime fracture risks, respectively. CONCLUSIONS: In summary, the development of the risk engine of AusHEMO followed the best practice for osteoporosis disease modelling and the model has been shown to have good face, internal and cross validities. The AusHEMO can be confidently used to predict long-term fracture-related outcomes and health economic evaluations when costs data are included. Health policy-makers in Australia can use the AusHEMO to select which osteoporosis interventions such as medications and public health interventions represent good value for money.

A retrospective descriptive analysis of race-day injuries of greyhounds in New Zealand.

OBJECTIVES: To describe the distribution, and determine the incidence, of veterinary reported injuries experienced by greyhounds during racing in New Zealand. MATERIALS AND METHODS: This retrospective cohort study utilised data obtained on all greyhound race starts and all racing injuries sustained in New Zealand between 10 September 2014 and 19 June 2019. Greyhound injuries were described by the number and percentage of the type, location, and presumed cause of injuries. The overall incidence of injuries per 1000 racing starts was calculated and stratified incidence rates were calculated for race year, racetrack, race number, sex of the greyhound, country of origin of the greyhound, starting box number, race type, race class and race distance. Poisson regression was used to calculate incidence rate ratios for the outcome of injury and race exposure variables. RESULTS: There were 213,630 race starts and 4100 injuries. The incidence of injury was 19.2 per 1000 starts, while the number of fatalities at the track was 1.3 per 1000 race starts. Most injuries experienced by greyhounds on race-day were minor (soft-tissue). Most injuries affected the limbs of the greyhounds (82.8%, n = 3393/4100). The rate of injuries was higher in Australian dogs compared with New Zealand dogs, the incidence rate of injury increased with advancing age group and the incidence rate varied among racetracks. CONCLUSION: The injury rates were similar to those previously reported for racing greyhounds in New Zealand. This study highlighted the need for greater uniformity and conciseness around the classification of injuries to permit comparisons across jurisdictions.

Snaps of a tiny amphipod push the boundary of ultrafast, repeatable movement.

Surprisingly, the fastest motions are not produced by large animals or robots. Rather, small organisms or structures, including cnidarian stinging cells, fungal shooting spores, and mandible strikes of ants, termites, and spiders, hold the world acceleration records.1-5 These diverse systems share common features: they rapidly convert potential energy - stored in deformed material or fluid - into kinetic energy when a latch is released.4-6 However, the fastest of these are not repeatable, because mechanical components are broken or ejected.5,6 Furthermore, some of these systems must overcome the added challenge of moving in water, where high density and viscosity constrain acceleration at small sizes. Here we report the kinematics of repeatable, ultrafast snaps by tiny marine amphipods (Dulichiella cf. appendiculata). Males use their enlarged major claw, which can exceed 30% of body mass, to snap a 1 mm-long dactyl with a diameter equivalent to a human hair (184 µm). The claw snaps closed extremely rapidly, averaging 93 µs, 17 m s-1, and 2.4 x 105 m s-2. These snaps are among the smallest and fastest of any documented repeatable movement, and are sufficiently fast to operate in the inertial hydrodynamic regime (Reynolds number (Re) >10,000). They generate audible pops and rapid water jets, which occasionally yield cavitation, and may be used for defense. These amphipod snaps push the boundaries of acceleration and size for repeatable movements, particularly in water, and exemplify how new biomechanical insights can arise from unassuming animals. VIDEO ABSTRACT.

trips4health: Protocol of a single-blinded randomised controlled trial incentivising adults to use public transport for physical activity gain.

BACKGROUND: Public transport (PT) users typically accumulate more physical activity (PA) than private motor vehicle users yet redressing physical inactivity through transport-related PA (TRPA) interventions has received limited attention. Further, incentive-based strategies can increase leisure-time PA but their impact on TRPA, is unclear. This study's objective is to determine the impact of an incentive-based strategy on TRPA in a regional Australian setting. METHODS: trips4health is a single-blinded randomised controlled trial with a four-month intervention phase and subsequent six-month maintenance phase. Participants will be randomised to: an incentives-based intervention (bus trip credit for reaching bus trip targets, weekly text messages to support greater bus use, written PA guidelines); or an active control (written PA guidelines only). Three hundred and fifty adults (≥18 years) from southern Tasmania will be recruited through convenience methods, provide informed consent and baseline information, then be randomised. The primary outcome is change in accelerometer measured average daily step count at baseline and four- and ten-months later. Secondary outcomes are changes in: measured and self-reported travel behaviour (e.g. PT use), PA, sedentary behaviour; self-reported and measured (blood pressure, waist circumference, height, weight) health; travel behaviour perspectives (e.g. enablers/barriers); quality of life; and transport-related costs. Linear mixed model regression will determine group differences. Participant and PT provider level process evaluations will be conducted and intervention costs to the provider determined. DISCUSSION: trips4health will determine the effectiveness of an incentive-based strategy to increase TRPA by targeting PT use. The findings will enable evidence-informed decisions about the worthwhileness of such strategies. TRIAL REGISTRATION: ACTRN12619001136190. UNIVERSAL TRIAL NUMBER: U1111-1233-8050.

Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study.

In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds 500 ml. However, the optimal dose, route and timing of administration are not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000 mg intravenously either pre- or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin < 130 g.l-1 ) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without anaemia. Current standard of care in the UK is to administer 1000 mg of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.

nkx3.2 mutant zebrafish accommodate jaw joint loss through a phenocopy of the head shapes of Paleozoic jawless fish.

The vertebrate jaw is a versatile feeding apparatus. To function, it requires a joint between the upper and lower jaws, so jaw joint defects are often highly disruptive and difficult to study. To describe the consequences of jaw joint dysfunction, we engineered two independent null alleles of a single jaw joint marker gene, nkx3.2, in zebrafish. These mutations caused zebrafish to become functionally jawless via fusion of the upper and lower jaw cartilages (ankylosis). Despite lacking jaw joints, nkx3.2 mutants survived to adulthood and accommodated this defect by: (a) having a remodeled skull with a fixed open gape, reduced snout and enlarged branchial region; and (b) performing ram feeding in the absence of jaw-generated suction. The late onset and broad extent of phenotypic changes in the mutants suggest that modifications to the skull are induced by functional agnathia, secondarily to nkx3.2 loss of function. Interestingly, nkx3.2 mutants superficially resemble ancient jawless vertebrates (anaspids and furcacaudiid thelodonts) in overall head shape. Because no homology exists in individual skull elements between these taxa, the adult nkx3.2 phenotype is not a reversal but rather a convergence due to similar functional requirements of feeding without moveable jaws. This remarkable analogy strongly suggests that jaw movements themselves dramatically influence the development of jawed vertebrate skulls. Thus, these mutants provide a unique model with which to: (a) investigate adaptive responses to perturbation in skeletal development; (b) re-evaluate evolutionarily inspired interpretations of phenocopies generated by gene knockdowns and knockouts; and (c) gain insight into feeding mechanics of the extinct agnathans.

Outbreak of Salmonella Newport associated with internationally distributed raw goats' milk cheese, France, 2018.

Raw milk cheeses are commonly consumed in France and are also a common source of foodborne outbreaks (FBOs). Both an FBO surveillance system and a laboratory-based surveillance system aim to detect Salmonella outbreaks. In early August 2018, five familial FBOs due to Salmonella spp. were reported to a regional health authority. Investigation identified common exposure to a raw goats' milk cheese, from which Salmonella spp. were also isolated, leading to an international product recall. Three weeks later, on 22 August, a national increase in Salmonella Newport ST118 was detected through laboratory surveillance. Concomitantly isolates from the earlier familial clusters were confirmed as S. Newport ST118. Interviews with a selection of the laboratory-identified cases revealed exposure to the same cheese, including exposure to batches not included in the previous recall, leading to an expansion of the recall. The outbreak affected 153 cases, including six cases in Scotland. S. Newport was detected in the cheese and in the milk of one of the producer's goats. The difference in the two alerts generated by this outbreak highlight the timeliness of the FBO system and the precision of the laboratory-based surveillance system. It is also a reminder of the risks associated with raw milk cheeses.

The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study.

Cell salvage is an important component of blood management in patients undergoing revision hip arthroplasty surgery. However concerns regarding efficacy and patient selection remain. The aims of this study were to describe intra-operative blood loss, cell salvage re-infusion volumes and red blood cell transfusion rates for revision hip procedures and to identify factors associated with the ability to salvage sufficient blood intra-operatively to permit processing and re-infusion. Data were collected from a prospective cohort of 664 consecutive patients undergoing revision hip surgery at a single tertiary centre from 31 March 2015 to 1 April 2018. Indications for revision surgery were aseptic (n = 393 (59%)) fracture (n = 160 (24%)) and infection (n = 111 (17%)). Salvaged blood was processed and re-infused when blood loss exceeded 500 ml. Mean (SD) intra-operative blood loss was 1038 (778) ml across all procedures. Salvaged blood was re-infused in 505 of 664 (76%) patients. Mean (SD) re-infusion volume was 253 (169) ml. In total, 246 of 664 (37%) patients received an allogeneic red blood cell transfusion within 72 h of surgery. Patients undergoing femoral component revision only (OR (95%CI) 0.41 (0.23-0.73)) or acetabular component revision only (0.53 (0.32-0.87)) were less likely to generate sufficient blood salvage volume for re-infusion compared with revision of both components. Compared with aseptic indications, patients undergoing revision surgery for infection (1.87 (1.04-3.36)) or fracture (4.43 (2.30-8.55)) were more likely to generate sufficient blood salvage volume for re-infusion. Our data suggest that cell salvage is efficacious in this population. Cases where the indication is infection or fracture and where both femoral and acetabular components are to be revised should be prioritised.

Strategies to minimize intraoperative blood loss during major surgery.

BACKGROUND: Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies. METHODS: This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient. RESULTS: Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays. CONCLUSION: Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.

ANTECEDENTES: La reducción de la pérdida hemática operatoria mejora los resultados y reduce los costes sanitarios. El objetivo de este artículo es revisar las estrategias actuales intraoperatorias quirúrgicas, anestésicas y hemostáticas de ahorro de sangre. MÉTODOS: Revisión descriptiva basada en publicaciones destacadas que analizaban la forma de reducir la pérdida de sangre en el paciente quirúrgico, seleccionadas a partir de una búsqueda bibliográfica en bases de datos relevantes hasta el 31 de julio de 2019. RESULTADOS: Las intervenciones se pueden iniciar precozmente en el período preoperatorio a través de la identificación de pacientes con elevado riesgo de hemorragia. Se pueden suspender los anticoagulantes de acción directa 48 horas antes de la mayoría de las operaciones quirúrgicas si la función renal es normal. Se puede continuar la administración de aspirina en la mayoría de las intervenciones. En el período intraoperatorio, se recomienda el uso de rescate celular cuando la pérdida de sangre prevista es superior a 500 ml y este método se puede continuar después de la operación en determinadas situaciones. La administración de ácido tranexámico es segura, barata y eficaz y se recomienda de forma rutinaria cuando la pérdida hemática prevista es alta. Sin embargo, la dosis óptima, el momento y la vía de administración no están bien establecidos. El uso de agentes tópicos, torniquetes y drenajes queda a discreción del cirujano. Las técnicas anestésicas incluyen la correcta posición del paciente, así como evitar la hipotermia y la anestesia regional. La hipotensión controlada puede ser beneficiosa en casos seleccionados. Las estrategias hemostáticas innovadoras incluyen agentes farmacológicos como la desmopresina, los concentrados del complejo de protrombina y concentrados de fibrinógeno, y el uso de hemostáticos viscoelásticos, pero se requiere disponer de evidencia sobre su beneficio. CONCLUSIÓN: La reducción de la pérdida hemática perioperatoria requiere un enfoque multimodal y multidisciplinario. Aunque existe evidencia de alta calidad en ciertas áreas, la evidencia general para reducir la pérdida hemática intraoperatoria sigue siendo limitada.

Evolutionary transformation of mouthparts from particle-feeding to piercing carnivory in Viper copepods: Review and 3D analyses of a key innovation using advanced imaging techniques.

BACKGROUND: Novel feeding adaptations often facilitate adaptive radiation and diversification. But the evolutionary origins of such feeding adaptations can be puzzling if they require concordant change in multiple component parts. Pelagic, heterorhabdid copepods (Calanoida) exhibit diverse feeding behaviors that range from simple particle feeding to a highly specialized form of carnivory involving piercing mouthparts that likely inject venom. We review the evolutionary history of heterorhabdid copepods and add new high-resolution, 3D anatomical analyses of the muscular system, glands and gland openings associated with this remarkable evolutionary transformation. RESULTS: We examined four heterorhabdid copepods with different feeding modes: one primitive particle-feeder (Disseta palumbii), one derived and specialized carnivore (Heterorhabdus subspinifrons), and two intermediate taxa (Mesorhabdus gracilis and Heterostylites longicornis). We used two advanced, high-resolution microscopic techniques - serial block-face scanning electron microscopy and two-photon excitation microscopy - to visualize mouthpart form and internal anatomy at unprecedented nanometer resolution. Interactive 3D graphical visualizations allowed putative homologues of muscles and gland cells to be identified with confidence and traced across the evolutionary transformation from particle feeding to piercing carnivory. Notable changes included: a) addition of new gland cells, b) enlargement of some (venom producing?) glands, c) repositioning of gland openings associated with hollow piercing fangs on the mandibles, d) repurposing of some mandibular-muscle function to include gland-squeezing, and e) addition of new muscles that may aid venom injection exclusively in the most specialized piercing species. In addition, live video recording of all four species revealed mandibular blade movements coupled to cyclic contraction of some muscles connected to the esophagus. These behavioral and 3D morphological observations revealed a novel injection system in H. subspinifrons associated with piercing (envenomating?) carnivory. CONCLUSIONS: Collectively, these results suggest that subtle changes in mandibular tooth form, and muscle and gland form and location, facilitated the evolution of a novel, piercing mode of feeding that accelerated diversification of the genus Heterorhabdus. They also highlight the value of interactive 3D animations for understanding evolutionary transformations of complex, multicomponent morphological systems.