Health worker education during the COVID-19 pandemic: global disruption, responses and lessons for the future-a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis identified early evidence quantifying the disruption to the education of health workers by the COVID-19 pandemic, ensuing policy responses and their outcomes. METHODS: Following a pre-registered protocol and PRISMA/AMSTAR-2 guidelines, we systematically screened MEDLINE, EMBASE, Web of Science, CENTRAL, clinicaltrials.gov and Google Scholar from January 2020 to July 2022. We pooled proportion estimates via random-effects meta-analyses and explored subgroup differences by gender, occupational group, training stage, WHO regions/continents, and study end-year. We assessed risk of bias (Newcastle-Ottawa scale for observational studies, RοB2 for randomized controlled trials [RCT]) and rated evidence certainty using GRADE. RESULTS: Of the 171 489 publications screened, 2 249 were eligible, incorporating 2 212 observational studies and 37 RCTs, representing feedback from 1 109 818 learners and 22 204 faculty. The sample mostly consisted of undergraduates, medical doctors, and studies from institutions in Asia. Perceived training disruption was estimated at 71.1% (95% confidence interval 67.9-74.2) and learner redeployment at 29.2% (25.3-33.2). About one in three learners screened positive for anxiety (32.3%, 28.5-36.2), depression (32.0%, 27.9-36.2), burnout (38.8%, 33.4-44.3) or insomnia (30.9%, 20.8-41.9). Policy responses included shifting to online learning, innovations in assessment, COVID-19-specific courses, volunteerism, and measures for learner safety. For outcomes of policy responses, most of the literature related to perceptions and preferences. More than two-thirds of learners (75.9%, 74.2-77.7) were satisfied with online learning (postgraduates more than undergraduates), while faculty satisfaction rate was slightly lower (71.8%, 66.7-76.7). Learners preferred an in-person component: blended learning 56.0% (51.2-60.7), face-to-face 48.8% (45.4-52.1), and online-only 32.0% (29.3-34.8). They supported continuation of the virtual format as part of a blended system (68.1%, 64.6-71.5). Subgroup differences provided valuable insights despite not resolving the considerable heterogeneity. All outcomes were assessed as very-low-certainty evidence. CONCLUSION: The COVID-19 pandemic has severely disrupted health worker education, inflicting a substantial mental health burden on learners. Its impacts on career choices, volunteerism, pedagogical approaches and mental health of learners have implications for educational design, measures to protect and support learners, faculty and health workers, and workforce planning. Online learning may achieve learner satisfaction as part of a short-term solution or integrated into a blended model in the post-pandemic future.

Sentinel lymph node biopsy alone in the management of early cervical carcinoma.

OBJECTIVE: Sentinel lymph node (SLN) biopsy aims to assess lymph node status with reduced surgical morbidity. The aim of the study was to determine the accuracy and safety of SLN biopsy in the management of early cervical carcinoma using a double technique (technetium-99m (Tc-99m) nanocolloid and methylene blue dye injection). METHODS: This was a 10-year study from January 2009 to January 2019 that recruited 103 consecutive women undergoing surgery for early cervical carcinoma, FIGO 2009 stage IA1 (grade 3, and grade 2 with lymphovascular space invasion) to IB1 (<2 cm), at the West Kent Gynaecological Oncology Centre, Maidstone, UK. All patients were given the choice of pelvic node dissection and SLN mapping or SLN only. All patients elected to undergo SLN only. In total 97 patients had SLN mapping performed laparoscopically. We used the combined method (Tc-99m nanocolloid and/or methylene blue dye). All SLN routinely underwent ultrastaging. RESULTS: At least one SLN was detected in all 103 patients, using at least one of the combined methods (Tc-99m nanocolloid or blue dye). Bilaterally SLN were removed in 85/103 women with an 83% bilateral detection rate. The median SLN count was 2.3 (range 1-6) nodes. Of 103 patients, 7 (6.7%) patients had lymph node involvement. There were no pelvic or para-aortic lymph node recurrences with a median follow-up of 53 (range 8-120) months. The specificity and negative predictive value of a negative SLN was 100%. None of our 103 patients reported lower extremity lymphedema. CONCLUSION: In carefully selected patients with early cervical carcinoma, SLN biopsy alone appears to be a safe method for lymph node assessment of women undergoing surgical staging. Ultrastaging is an essential part of histologic examination of SLN.

Migraine, Tension-Type Headache and Parkinson's Disease: A Systematic Review and Meta-Analysis.

Background and Objectives: The relationship between migraine and tension-type headache (TTH) with Parkinson's disease (PD) is controversial, while a common pathophysiological link remains obscure. The aim of this systematic review is to investigate the association between PD, migraine and TTH. Materials and Methods: Following PRISMA, we searched MEDLINE, WebofScience, Scopus, CINAHL, Cochrane Library and ClinicalTrials.gov up to 1 July 2022 for observational studies examining the prevalence and/or associations of PD with migraine and TTH. We pooled proportions, standardized mean differences (SMD) and odds ratios (OR) with random effects models. The risk of bias was assessed with the Newcastle-Ottawa scale (PROSPERO CRD42021273238). Results: Out of 1031 screened studies, 12 were finally included in our review (median quality score 6/9). The prevalence of any headache among PD patients was estimated at 49.1% (760 PD patients; 95% CI 24.8-73.6), migraine prevalence at 17.2% (1242 PD patients; 95% CI 9.9-25.9), while 61.5% (316 PD patients; 95% CI 52.6-70.1) of PD patients with migraine reported headache improvement after PD onset. Overall, migraine was not associated with PD (302,165 individuals; ORpooled = 1.11; 95% CI 0.72-1.72).However, cohort studies demonstrated a positive association of PD among lifetime migraineurs (143,583 individuals; ORpooled = 1.54, 95% CI 1.28-1.84), while studies on 12-month migraine prevalence yielded an inverse association (5195 individuals; ORpooled = 0.64, 95% CI 0.43-0.97). Similar findings were reported by 3 studies with data on the TTH-PD relationship (high prevalence, positive association when examined prospectively and an inverse relationship on 12-month prevalence). These data were not quantitatively synthesized due to methodological differences among the studies. Finally, PD patients suffering from any headache had a lower motor unified Parkinson's disease rating scale (UPDRS) score (503 PD patients; SMD -0.39; 95% CI -0.57 to -0.21) compared to PD patients not reporting headache. There is an unclear association of headaches in genetic PD cohorts. Conclusions: Observational data suggest that migraine and TTH could be linked to PD, but the current literature is conflicting.

Climate extremes and predicted warming threaten Mediterranean Holocene firs forests refugia.

Warmer and drier climatic conditions are projected for the 21st century; however, the role played by extreme climatic events on forest vulnerability is still little understood. For example, more severe droughts and heat waves could threaten quaternary relict tree refugia such as Circum-Mediterranean fir forests (CMFF). Using tree-ring data and a process-based model, we characterized the major climate constraints of recent (1950-2010) CMFF growth to project their vulnerability to 21st-century climate. Simulations predict a 30% growth reduction in some fir species with the 2050s business-as-usual emission scenario, whereas growth would increase in moist refugia due to a longer and warmer growing season. Fir populations currently subjected to warm and dry conditions will be the most vulnerable in the late 21st century when climatic conditions will be analogous to the most severe dry/heat spells causing dieback in the late 20th century. Quantification of growth trends based on climate scenarios could allow defining vulnerability thresholds in tree populations. The presented predictions call for conservation strategies to safeguard relict tree populations and anticipate how many refugia could be threatened by 21st-century dry spells.

A synthesis of radial growth patterns preceding tree mortality.

Tree mortality is a key factor influencing forest functions and dynamics, but our understanding of the mechanisms leading to mortality and the associated changes in tree growth rates are still limited. We compiled a new pan-continental tree-ring width database from sites where both dead and living trees were sampled (2970 dead and 4224 living trees from 190 sites, including 36 species), and compared early and recent growth rates between trees that died and those that survived a given mortality event. We observed a decrease in radial growth before death in ca. 84% of the mortality events. The extent and duration of these reductions were highly variable (1-100 years in 96% of events) due to the complex interactions among study species and the source(s) of mortality. Strong and long-lasting declines were found for gymnosperms, shade- and drought-tolerant species, and trees that died from competition. Angiosperms and trees that died due to biotic attacks (especially bark-beetles) typically showed relatively small and short-term growth reductions. Our analysis did not highlight any universal trade-off between early growth and tree longevity within a species, although this result may also reflect high variability in sampling design among sites. The intersite and interspecific variability in growth patterns before mortality provides valuable information on the nature of the mortality process, which is consistent with our understanding of the physiological mechanisms leading to mortality. Abrupt changes in growth immediately before death can be associated with generalized hydraulic failure and/or bark-beetle attack, while long-term decrease in growth may be associated with a gradual decline in hydraulic performance coupled with depletion in carbon reserves. Our results imply that growth-based mortality algorithms may be a powerful tool for predicting gymnosperm mortality induced by chronic stress, but not necessarily so for angiosperms and in case of intense drought or bark-beetle outbreaks.

Sport Participation and Ageing: Evidence from Marathon Events.

The purpose of this research is to study expectations regarding ageing (ERA) among individuals who participate in running events as well as to explore personality and demographic features as potential variables that influence ERA values. A quantitative questionnaire was selected as the predominant means of collecting the data and 196 successfully completed questionnaires were analyzed by means of the SPSS. Results indicate a positive correlation between ERA values and Change Seeker Index in our sample. Moreover gender and frequency of exercise found to have no significant effect on ERA score. Finally, ERA was examined among three generational cohorts and differences were noticed to physical subscale.

Location of Sentinel Lymph Node in Cervical Carcinoma and Factors Associated With Unilateral Detection.

OBJECTIVE: The aims of this study were to assess locality of the sentinel lymph node (SLN) in cervical carcinoma and examine factors affecting bilateral SLN detection. METHODS: This was a retrospective review of SLN data (anatomical location, count and laterality) in patients with early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA1 with lymphovascular space invasion to stage IIA) using intraoperative gamma probe and blue dye. The preoperative single-photon emission computed tomography with computed tomography was used to detect laterality, number of the SLNs, and rare locations. Patients were treated between January 2005 to January 2015 at the West Kent Gynaecological Oncology Centre, Maidstone Hospital, Maidstone, United Kingdom. RESULTS: A total of 132 women were investigated. The most common SLN location was the external iliac (38.6%) followed by obturator (25.3%) and internal iliac (23.6%) regions. A small percentage was identified in presacral (1.4%) and para-aortic regions (0.7%). Older age (P = 0.01) and an elevated body mass index (P = 0.03) were associated with decreased SLN count by preoperative single-photon emission computed tomography with computed tomography, and only age affected SLN count by gamma probe (P = 0.01). Initial surgery, large loop excision of the transformation zone, or cone biopsy of the cervix had no effect on SLN count. There was no difference observed in bilateral detection with respect to surgical approach (open: n = 48/laparoscopic: n = 84). However, older age was independently associated with a decrease in bilateral SLN detection (P = 0.003). In these patients who underwent unilateral full pelvic lymphadenectomy, all the nonsentinel nodes were negative. CONCLUSIONS: The majority of SLNs were located in the external iliac, obturator, and internal iliac regions. Both older age and an elevated body mass index were associated with a reduced SLN count. Unilateral detection of SLN was independently associated with older age, which may be due to sclerosis in the lymphatic vessels or reduced perfusion in the pelvis in these women. If no SLN is detected on one side, the consensus is to perform a full pelvic lymphadenectomy on that side of the pelvis.

Broadband cortical desynchronization underlies the human psychedelic state.

Psychedelic drugs produce profound changes in consciousness, but the underlying neurobiological mechanisms for this remain unclear. Spontaneous and induced oscillatory activity was recorded in healthy human participants with magnetoencephalography after intravenous infusion of psilocybin--prodrug of the nonselective serotonin 2A receptor agonist and classic psychedelic psilocin. Psilocybin reduced spontaneous cortical oscillatory power from 1 to 50 Hz in posterior association cortices, and from 8 to 100 Hz in frontal association cortices. Large decreases in oscillatory power were seen in areas of the default-mode network. Independent component analysis was used to identify a number of resting-state networks, and activity in these was similarly decreased after psilocybin. Psilocybin had no effect on low-level visually induced and motor-induced gamma-band oscillations, suggesting that some basic elements of oscillatory brain activity are relatively preserved during the psychedelic experience. Dynamic causal modeling revealed that posterior cingulate cortex desynchronization can be explained by increased excitability of deep-layer pyramidal neurons, which are known to be rich in 5-HT2A receptors. These findings suggest that the subjective effects of psychedelics result from a desynchronization of ongoing oscillatory rhythms in the cortex, likely triggered by 5-HT2A receptor-mediated excitation of deep pyramidal cells.

Intra-Abdominal Actinomycosis: An Indolent Masquerader of Malignancy.

This report describes the case of a 54-year-old female who presented with the constitutional symptoms of lethargy, weight loss, and asthenia. She had been extensively investigated for possible gynaecological malignancy but with no definitive outcome achieved. The symptoms were persistent and, partly due to occurring during the coronavirus disease 2019 (COVID-19) pandemic, a decision was made to progress with surgical management. Following an oncology multidisciplinary meeting, a decision was made for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Intra-operatively, there was an incidental finding of an extensive tumour infiltrating the liver, colon, anterior abdominal wall and urinary bladder. A surgical resection with ileostomy was performed on suspicion of an underlying malignancy. Unexpectedly, the histopathological diagnosis revealed actinomycosis. Following this discovery, our entire management plan was altered, and the patient was treated with a prolonged course of antibiotics and recovered well.

EASIER: A new model for online learning of minimally invasive surgery skills.

INTRODUCTION: Technology Enhanced Learning (TEL) can provide the tools to safely master minimally invasive surgery (MIS) skills in patient-free environments and receive immediate objective feedback without the constant presence of an instructor. However, TEL-based systems tend to work isolated from one another, focus on different skills, and fail to provide contents without a sound pedagogical background. OBJECTIVE: The objective of this descriptive study is to present in detail EASIER, an innovative TEL platform for surgical and interventional training, as well as the results of its validation. METHODS: EASIER provides a Learning Management System (LMS) for institutions and content creators that can connect and integrate TEL "external assets" (virtual reality simulators, augmented box trainers, augmented videos, etc.) addressing different skills. The platform integrates all skills under an Assessment Module that measures skills' progress in different courses. Finally, it provides content creators with a pedagogical model to scaffold contents while retaining flexibility to approach course design with different training philosophies in mind. Three courses were developed and hosted in the platform to validate it with end-users in terms of usability, performance, learning results in the courses and student self-perception on learning. RESULTS: In total 111 volunteers completed the validation. The study was limited due to the COVID-19 pandemic, which limited access to external assets (virtual reality simulators). Nevertheless, usability was rated with 73.1 in the System Usability Scale. Most positive aspects on performance were easiness to access the platform, easiness to change the configuration and not requiring additional plug-ins to use the platform. The platform was rated above average in the six scales of the User Experience Questionnaire. Overall, student results improved significantly across the three courses (p < 0.05). CONCLUSIONS: This study provides, within its limitations, evidence on the usefulness of the EASIER platform for distance learning of MIS skills. Results show the potential impact of the platform and are an encouraging boost for the future, especially in the aftermath of the COVID-19 pandemic.

A prospective single-center study of sentinel lymph node detection in cervical carcinoma: is there a place in clinical practice?

OBJECTIVE: To establish the accuracy of sentinel lymph node (SLN) detection in early cervical cancer. MATERIALS AND METHODS: Sentinel lymph node detection was performed prospectively over a 6-year period in 86 women undergoing surgery for cervical carcinoma by the combined method (Tc-99m and methylene blue dye). Further ultrastaging was performed on a subgroup of 26 patients who had benign SLNs on initial routine histological examination. RESULTS: The SLN was detected in 84 (97.7%) of 86 women by the combined method. Blue dye uptake was not seen in 8 women (90.7%). Sentinel lymph nodes were detected bilaterally in 63 women (73.3%), and the external iliac region was the most common anatomic location (48.8%). The median SLN count was 3 nodes (range, 1-7). Of the 84 women with sentinel node detection, 65 also underwent bilateral pelvic lymph node dissection, and in none of these cases was a benign SLN associated with a malignant non-SLN (100% negative predictive value). The median non-SLN count for all patients was 19 nodes (range, 8-35). Eighteen patients underwent removal of the SLN without bilateral pelvic lymph node dissection. Nine women (10.5%) had positive lymph nodes on final histology. One patient had bulky pelvic nodes on preoperative imaging and underwent removal of the negative bulky malignant lymph nodes and a benign SLN on the contralateral side. This latter case confirms the unreliability of the SLN method with bulky nodes. The remaining 8 patients had positive SLNs with negative nonsentinel lymph nodes. Fifty-nine SLNs from 26 patients, which were benign on initial routine histology, underwent ultrastaging, but no further disease was identified. Four patients (5%) relapsed after a median follow-up of 28 months (range, 8-80 months). CONCLUSION: Sentinel lymph node detection is an accurate and safe method in the assessment of nodal status in early cervical carcinoma.

Fertility-sparing surgery for early cervical cancer-approach to less radical surgery.

OBJECTIVE: To evaluate whether certain patients with early-stage cervical cancer are candidates for less radical surgery when considering fertility-sparing surgery. DESIGN: Prospective cohort study. SETTING: Two gynecologic cancer centers (St Thomas' Hospital, London; and West Kent Gynaecological Cancer Centre, Maidstone). POPULATION: Women with early-stage cervical cancer (n = 66) undergoing fertility-sparing surgery, either simple (SVT) or radical vaginal trachelectomy (RVT). METHODS: Prospective clinical data collection and review of patient notes, pathology and radiology data, and pregnancy outcomes. MAIN OUTCOME MEASURES: Postoperative complications, surgical specimen histologic analysis, follow-up data, and obstetric outcome. RESULTS: A total of 66 women underwent either SVT (n = 15) or RVT (n = 51), with pelvic lymphadenectomy, for stage IA2 or IB1 cervical cancer. There was no residual disease in the SVT specimen in 53% versus 29% after RVT. Clear surgical margins in 100% of SVT specimens with residual disease versus 94% after RVT. Two patients had positive lymph nodes after RVT; one of these declined adjuvant treatment until after egg harvesting and subsequently died of disease (1.5%). Median follow-up was 96 months (range, 12-120 months). One patient had a mid vaginal recurrence (1.5%). Twenty-four women have tried to conceive to date, with 14 women having 17 live births. Live birth pregnancy rate was 70.8%. CONCLUSIONS: It is possible to select patients for a less radical fertility-sparing procedure through identification of measurable low-risk factors and thus reduce the morbidity caused by conventional RVT. The selection criteria should be stringent and applied within the setting of a cancer center.

The effect of a clinically effective and non-effective dose of lorazepam on 7.5% CO2-induced anxiety.

Symptoms of anxiety induced by 7.5% CO2 inhalation can be attenuated by acute administration of GABA(A) receptor anxiolytics such as lorazepam and alprazolam. This study investigated if these effects are dose-related, by comparing a 0.5 mg dose (considered non-clinically effective) and a 2 mg dose of lorazepam (clinically effective) on 7.5% CO2 inhalation. Eighteen healthy males (mean age 20.6 years, SD 1.29), judged physically and mentally fit, attended three visits, each one week apart, to take each treatment in a randomised double-blind crossover design. Drugs were given 60 min prior to 20 min air inhalation, followed by 20 min 7.5% CO2 inhalation. The order of gas presentation was single blind. Subjective ratings using visual analogue scales (VAS) and questionnaires were recorded before and after each inhalation. Blood pressure (BP), heart rate (HR), respiration rate (RR) and expired CO2 were recorded during each inhalation. Inhalation of 7.5% CO2 significantly raised BP, HR, RR and expired CO2. Ratings of feeling like leaving the room were significantly lower on 2 mg compared with 0.5 mg and placebo, and dose-dependent trends were seen in scores for VAS fearful, anxious, stressed, tense, and worried. Results may be indicative of dose-dependent effects of lorazepam in a CO2 model of anxiety.

Circulating Interleukin-6 Levels and Incident Ischemic Stroke: A Systematic Review and Meta-analysis of Prospective Studies.

BACKGROUND AND OBJECTIVES: Human genetic studies support a key role of interleukin-6 (IL-6) in the pathogenesis of ischemic stroke. However, there are only limited data from observational studies exploring circulating IL-6 levels as a risk factor for ischemic stroke. We set out to perform a systematic review and meta-analysis of aggregate data on cohort studies to determine the magnitude and shape of the association between circulating IL-6 levels and risk of incident ischemic stroke in the general population. METHODS: Following the PRISMA guidelines, we systematically screened the PubMed search engine from inception to March 2021 for population-based prospective cohort studies exploring the association between circulating IL-6 levels and risk of incident ischemic stroke. We pooled association estimates for ischemic stroke risk with random-effects models and explored nonlinear effects in dose-response meta-analyses. Risk of bias was assessed with the Newcastle-Ottawa Scale (NOS). We used funnel plots and trim-to-fill analyses to assess publication bias. RESULTS: We identified 11 studies (n = 27,411 individuals; 2,669 stroke events) meeting our eligibility criteria. Mean age of all included participants was 60.5 years and 54.8% were female. Overall, quality of the included studies was high (median 8 out of 9 NOS points, interquartile range 7-9). In meta-analyses, 1 SD increment in circulating log-transformed IL-6 levels was associated with a 19% increase in risk of incident ischemic stroke over a mean follow-up of 12.4 years (relative risk 1.19; 95% confidence interval 1.10 to 1.28). A dose-response meta-analysis showed a linear association between circulating IL-6 levels and ischemic stroke risk. There was only moderate heterogeneity and the results were consistent in sensitivity analyses restricted to studies of low risk of bias and studies fully adjusting for demographic and vascular risk factors. The results also remained stable following adjustment for publication bias. DISCUSSION: Higher circulating IL-6 levels in community-dwelling individuals are associated with higher long-term risk of incident ischemic stroke in a linear pattern and independently of conventional vascular risk factors. Along with findings from genetic studies and clinical trials, these results provide additional support for a key role of IL-6 signaling in ischemic stroke.

A prospective study of sentinel lymph node detection in vulval carcinoma: is it time for a change in clinical practice?

OBJECTIVES: To determine the accuracy of sentinel lymph node (SLN) detection in vulval carcinoma and to report the reliability and safety of this procedure. METHODS/MATERIALS: For a period of 6 years, we recruited women undergoing surgery for vulval carcinoma. All women had a preoperative biopsy confirming the depth of invasion greater than 1 mm. Sentinel lymph node detection was performed using the combined method (Tc-99m and methylene-blue dye). The standard management included complete inguinofemoral lymphadenectomy. When inguinofemoral lymph nodes were found grossly to be enlarged, these nodes were debulked, and the women subsequently treated with radiotherapy with or without chemotherapy. During the last 2 years of the study, a selected group of women had an SLN dissection alone. The SLNs were ultrastaged when they were negative on routine hematoxylin and eosin examination. RESULTS: Among 60 women undergoing SLN detection, SLN was detected in 59 women (98.3%) with combined method. Blue dye did not detect an SLN in 3 women resulting in a 93.3% detection rate. The median SLN count was 2 nodes (range, 1-9). Of the 60 women, 41 had inguinofemoral lymphadenectomy, 4 had only enlarged inguinofemoral nodes debulked, and 15 had the SLN only removed. The non-SLN count was 9 nodes (range, 3-17). There were no false-negative SLNs. Twenty-one women (35%) had positive nodes on final histology. Ultrastaging increased detection of metastases in 6.9% of nodes relative to routine hematoxylin and eosin examination and upstaged 12% of women. The median follow-up was 24 months (range, 2-66 months). CONCLUSIONS: Sentinel lymph node detection is safe and accurate in assessing lymph node status in women with vulval cancer undergoing staging. The combined method using Tc-99m and methylene blue dye injection for SLN detection has the best detection rate. Routine ultrastaging of negative SLN improves the detection of nodal metastases.

Gender dysphoria in the field of obstetrics and gynecology.

Obstetrics/gynecology (OB/GYN) clinicians often manage gender dysphoric patients but frequently lack the necessary training. These individuals comprise a vastly heterogeneous group and gender clinics, staffed by multi-disciplinary teams, should become the standard of care, promoting a holistic approach. All OB/GYN clinicians need to be aware of basic aspects of gender dysphoria.

CSF and Circulating NfL as Biomarkers for the Discrimination of Parkinson Disease From Atypical Parkinsonian Syndromes: Meta-analysis.

PURPOSE OF REVIEW: To evaluate whether CSF and circulating neurofilament light chain (NfL), a marker of axonal damage, could discriminate Parkinson disease (PD) from atypical parkinsonian syndromes (APSs). RECENT FINDINGS: MEDLINE and Scopus were systematically searched, and 15 studies were included (1,035 patients with PD and 930 patients with APS). CSF NfL levels were 1.26 SDs higher in the APS group compared to the PD group (g = 1.26 [95% confidence interval 0.99-1.53]), and circulating NfL levels were 1.53 SDs higher in the APS group compared to the PD group (g = 1.53 [95% confidence interval 1.15-1.91]); 4 studies, 307 patients with PD, 197 patients with APS. Pooled areas under the curve were 0.941 (0.916-0.965) and 0.874 (0.802-0.946) for CSF and circulating NfL, corresponding to average sensitivities of 86% (79%-90%) and 91% (86%-95%), and specificity of 88% (82%-92%) and 76% (62%-85%), respectively. SUMMARY: These results strongly support the high diagnostic accuracy of both CSF and circulating NfL in differentiating PD from APS, highlighting their usefulness as promising biomarkers.

Laparoscopically assisted vaginal hysterectomy (LAVH) versus total abdominal hysterectomy (TAH) in endometrial carcinoma: prospective cohort study.

OBJECTIVE: To determine the feasibility and safety of laparoscopically assisted vaginal hysterectomy in the treatment of presumed stage I endometrial cancer. STUDY DESIGN: This was a prospective cohort study without randomization of 182 consecutive patients who underwent surgery for early endometrial cancer or atypical hyperplasia at the West Kent Gynaecological Oncology Centre, UK. Seventy-four had laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy (BSO), and 108 had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy was performed in 153 patients, and lymph node sampling was performed in 2 patients. Twenty-seven patients with serous papillary endometrial cancer in addition had an omentectomy. The groups were compared for epidemiological and clinical characteristics, surgical outcomes, hospital stay, lymph node harvest, and intraoperative and postoperative complications. RESULTS: The patients in the laparoscopy group had less blood loss, similar number of lymph nodes removed, less need for analgesia, and shorter hospital stay but longer operative time than those treated by laparotomy. In our study, we had 4 conversions (5.4%) from laparoscopy to laparotomy. Twenty-eight (41%) patients who had laparoscopic surgery were obese (body mass index [BMI] >30 kg/m2). Postoperative complications were more common in the laparotomy group (34%) than in the laparoscopy group (6%). No major complications occurred in the laparoscopy group. Wound infection was the most common complication in laparotomy patients, and this invariably happened to obese patients (BMI >30 kg/m2). There were 6 readmissions, all from the laparotomy group. CONCLUSIONS: Laparoscopic surgery is a safe and reliable alternative to open surgery in the management of early endometrial cancer patients, with significantly reduced hospital stay and complications, especially in those patients with an elevated BMI.

Bilateral Total Knee Arthroplasty for Charcot Arthropathy After Cauda Equine Syndrome: A Case Report.

Charcot arthropathy of the knee is a relatively rare and poorly understood condition. Diagnosis requires detailed history of the patient, radiological investigation and exclusion of other causes of arthropathy. Conservative treatment is sufficient only in early stages. In late stages, either arthrodesis or total knee arthroplasty is the treatment of choice. We report a case of a 65-year-old woman who presented with Charcot arthropathy in both knees, after a spinal fracture 35 years ago, which caused cauda equine syndrome with diminished sensation of both legs. She underwent bilateral total knee arthroplasty using hinged knee prosthesis.

Left Ventricular Hypertrophy and Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Left ventricular hypertrophy (LVH) is associated with the risk of stroke and dementia independently of other vascular risk factors, but its association with cerebral small vessel disease (CSVD) remains unknown. Here, we employed a systematic review and meta-analysis to address this gap. METHODS: Following the MOOSE guidelines (PROSPERO protocol: CRD42018110305), we systematically searched the literature for studies exploring the association between LVH or left ventricular (LV) mass, with neuroimaging markers of CSVD (lacunes, white matter hyperintensities [WMHs], cerebral microbleeds [CMBs]). We evaluated risk of bias and pooled association estimates with random-effects meta-analyses. RESULTS: We identified 31 studies (n=25,562) meeting our eligibility criteria. In meta-analysis, LVH was associated with lacunes and extensive WMHs in studies of the general population (odds ratio [OR]lacunes, 1.49; 95% confidence interval [CI], 1.12 to 2.00) (ORWMH, 1.73; 95% CI, 1.38 to 2.17) and studies in highrisk populations (ORlacunes: 2.39; 95% CI, 1.32 to 4.32) (ORWMH, 2.01; 95% CI, 1.45 to 2.80). The. RESULTS: remained stable in general population studies adjusting for hypertension and other vascular risk factors, as well as in sub-analyses by LVH assessment method (echocardiography/electrocardiogram), study design (cross-sectional/cohort), and study quality. Across LV morphology patterns, we found gradually increasing ORs for concentric remodelling, eccentric hypertrophy, and concentric hypertrophy, as compared to normal LV geometry. LVH was further associated with CMBs in high-risk population studies. CONCLUSION: s LVH is associated with neuroimaging markers of CSVD independently of hypertension and other vascular risk factors. Our findings suggest LVH as a novel risk factor for CSVD and highlight the link between subclinical heart and brain damage.