Exteriorization of the uterus reduces fetoscopic cannula-induced stress and strain: A finite element model analysis.

OBJECTIVE: To estimate stresses and strains in the uterine wall and fetal membranes with single/multi-port fetoscopy, simulating either a percutaneous access or via exteriorized uterus. STUDY DESIGN: Finite element models based on anatomical dimensions, material properties and boundary conditions were created to simulate stresses, strains and displacements on the uterine wall and fetal membranes during simulated fetal surgery either via exteriorized uterus or percutaneous approach, and with one or three cannulas. Clinically, we measured the anatomical layer thickness and cannula entry point displacement in patients undergoing single port percutaneous fetoscopy. RESULTS: Simulations demonstrate that single port percutaneous fetoscopy increases stress on the fetal membranes (+105%, 128 to 262 kPa) and uterine wall (+115%, 0.89 to 1.9 kPa) compared to exteriorized uterine access. Using three ports increases stress by 110% (148 to 312 kPa) on membranes and 113% (1.08 to 2.3 kPa) on uterine wall. Finite Element Method showed 0.75 cm uterine entry point displacement from the cutaneous entry, while clinical measurements demonstrated displacement of more than double (1.69 ± 0.58 cm), suggesting modeled measurements may be underestimations. CONCLUSION: The stresses and strains on the fetal membranes and uterus are double as high when entering percutaneously than via an exteriorized uterus. Based on what can be clinically measured, this may be an underestimation.

Prevalence of dilated mid-ascending aorta in individuals 15 years and older: In search of optimal diagnostic criteria and their effect on the burden of disease.

BACKGROUND: Controversy regarding the definition of the upper limit of normal (ULN) for dilated mid-ascending aorta (mAA) stems from variation in criteria, based on several small-sized studies with small datasets of normal subjects (DONS). The present study was carried out to demonstrate this variation in the prevalence of mAA dilation and to identify the optimal definition by creating the largest DONS. METHODS: Echocardiographic studies of patients ≥ 15 years of age performed at a large tertiary care center over 4 years (n = 49,330) were retrospectively evaluated. The leading-edge-to-leading-edge technique was used to measure the mAA in diastole. The largest-to-date DONS (n = 2334) was created, including those who were normal on medical record review, did not have any of the 28 causes of dilated aorta, and had normal echocardiograms. Because age had the strongest correlation with mAA (multivariate adjusted R2 = 0.26), as compared with sex, height, and weight, we created a new ULN based on the DONS with narrow age stratification (10-year intervals). RESULTS: The prevalence of dilated mAA varied between 17% and 23% when absolute criteria were used with sex stratification, and it varied between 6% and 11% when relative criteria (relative to age, body surface area, and sex) were used. Based on new criteria from the DONS, it was 7.6%, with a ULN of 3.07-3.64 cm in women and 3.3-3.91 cm in men. CONCLUSIONS: These data demonstrate the undesirable variation in the prevalence of dilated mAA based on prior criteria and propose a new ULN for dilated mAA.

Complete Kawasaki disease after COVID-19 infection in an infant.

Kawasaki disease is a generalized systemic vasculitis that affects blood vessels throughout the body. The aetiology of Kawasaki disease is still unknown but is thought to be related to the combined effects of the immune response, genetic susceptibility, and infections including COVID-19. In this case report, we present a seven months old male infant who presented to us with fever, swollen lips, ulcers in the mouth, enlarged tonsils, strawberry tongue, conjunctivitis and generalised non-blanchable maculopapular rash. The detailed workup fulfilled the criteria of Kawasaki disease. The COVID-19 IgM antibodies were positive. The patient was treated with IV Immunoglobulins, IV methylprednisolone and Aspirin. The repeat echocardiography on six weeks follow-up turned out normal. In conclusion, there should be a high index of suspicion of Kawasaki disease while evaluating pediatric patients with COVID-19 infection so that timely intervention can be made to prevent complications. Prospective studies are needed to evaluate the relationship between Kawasaki Disease and COVID-19 infection.

Surgery Is Underutilized in the Management of Tertiary Hyperparathyroidism.

INTRODUCTION: Tertiary hyperparathyroidism (3HPT) is observed in up to 40% of renal transplant patients. Standard guidelines defining 3HPT and indications for operative intervention are not well described. METHODS: We conducted a retrospective, single-institution cohort study of patients who underwent renal transplant between January 1, 2012 and January 30, 2018, with a minimum of 13-month follow-up and at least 1 y of allograft function. We defined 3HPT as having elevated serum level parathyroid hormone (>88 pg/mL) after successful renal transplantation or multiple instances of elevated serum calcium starting at least 3 mo after transplant. We compared graft failure rates after stratifying the cohort based on management strategy: expectant, medical management with cinacalcet, and parathyroidectomy. RESULTS: Out of the 381 transplanted patients with functional grafts at 1 y, 178 patients (46.6%) were found to have 3HPT. One hundred twenty-nine patients (72.5%) were managed expectantly without medications, 35 patients (19.7%) were managed medically, and 14 patients (7.8%) were managed with parathyroidectomy. Twenty-two patients (17.1%) in the observation group had graft failure, 4 patients (11.4%) in the medically managed group had graft failure, and 0 patients in the surgery group had graft failure. Surgical intervention was associated with decreased renal allograft failure when compared to the combined cohort of nonoperative 3HPT patients (P = 0.03). All patients who underwent parathyroidectomy were cured and did not have graft failure as of December 30, 2019. Calcium elevation, but not PTH elevation, was associated with referral for parathyroidectomy on multivariable logistic regression analysis (P < 0.01). CONCLUSIONS: At our institution, the referral rate for parathyroidectomy among patients with 3HPT remains low. Parathyroidectomy was associated with high cure rates and reduced graft failure. Surgery may be underutilized in the management of 3HPT.

Refining the upper limit of normal for the ascending aorta: In search of optimal criteria -- a large database study of normal individuals.

OBJECTIVES: The cutoff for dilated mid-ascending aorta (mAA) is controversial and has several definitions. The present study was carried out to determine the prevalence of mAA dilation based on published definitions and to identify the optimal cutoff. METHODS: Echocardiographic studies of patients >15 years of age performed at a large tertiary care center over 4 years, n = 49,330, were retrospectively evaluated. Leading-edge-to-leading-edge technique was used to measure the mAA in diastole. Several cutoff criteria were included. In addition, we defined normals in our database as those who, after 28 causes of dilated aorta were excluded, were normal both clinically and echocardiographically (n = 2334). RESULTS: The mean age was 64.2 ± 17.1 years, and 31.5% were men. The prevalence of dilated mAA based on absolute criteria with sex stratification varied between 17% and 23% and based on relative criteria (to age, body surface area, and sex) varied between 6% and 11%. It further decreased to 7.6% on the addition of narrow age stratification (10 year intervals) performed on normals in our database. The multivariate adjusted R2 (for variation in mAA diameter) was 0.25 for age, decreasing to 0.12 for weight and 0.07 for sex and height. CONCLUSIONS: The lowest prevalence of 7.6% probably represents the optimal cutoff for dilated mAA because it includes age, which explains most of the variation in mAA, in narrow (10 year) intervals only performed in our normals, which represents the largest sample size to date.

Synthesis and Characterization of Hydroxyethyl Cellulose Grafted with Copolymer of Polyaniline and Polypyrrole Biocomposite for Adsorption of Dyes.

The emerging concepts of sustainable textiles and controlled production strategy demands ideally zero emissions of contaminants into the aquatic environment. However, the currently in-practiced conventional processes in textiles dispose of a number of contaminants especially super toxic synthetic dyes as effluents. In recent years, nanomaterials have become attractive choice for eco-friendly removal of organic dyestuff. Accordingly, this article reports synthesis and characterization of biocomposite wherein copolymer of polyaniline (PANI) and Polypyrrole (PPY) was grafted onto hydroxyethyl cellulose (HEC). Further, adsorption properties of as-prepared composite were evaluated using textile dyes Rhodamine B (RhB) and methyl Orange (MO)- as model adsorbate. The characterization of novel biocomposite (HEC/PANI-PPy) was carried out using Fourier Transform Infrared (FT-IR), Brunauer-Emmett-Teller analyzer (BET), Scanning Electron Microscope (SEM), and powder X-ray diffraction (XRD). The operational parameters such as dye initial concentration, adsorbent amount, pH and contact time were also studied to evaluate the efficiency level of the prepared biocomposite. Interestingly, the composite-mediated adsorption of RhB and MO followed pseudo-second order and the Langmuir isotherm. It is found that the adsorption capacity HEC/PANI-PPy is 30.06 and 29.3 for RhB and MO respectively. Thus, HEC/PANI-PPy is an inexpensive and highly efficient adsorbent that could be employed for could be employed for the separation and removal of toxic organic dyes from polluted textile effluents.

Cation Incorporation and Synergistic Effects on the Characteristics of Sulfur-Doped Manganese Ferrites S@Mn(Fe2O4) Nanoparticles for Boosted Sunlight-Driven Photocatalysis.

In the present work, sulfur-doped manganese ferrites S@Mn(Fe2O4) nanoparticles were prepared by using the sol-gel and citrate method. The concentration of sulfur varied from 1 to 7% by adding Na2S. The samples were characterized by performing Fourier Transformed Infrared Spectroscopy (FTIR), Energy Dispersive X-ray (EDX), X-ray diffraction (XRD), Scanning Electron Microscopy (SEM) and Ultraviolet-Visible spectroscopy (UV-Visible). The synthesized sulfur-doped manganese ferrites were applied to evaluate the photocatalytic degradation of the dyes. Further, the degradation studies revealed that the nanoparticles successfully degraded the methylene blue dye by adding a 0.006 g dose under the sunlight. The sulfur-doped manganese ferrite nanoparticles containing 3% sulfur completely degraded the dye in 2 h and 15 min in aqueous medium. Thus, the ferrite nanoparticles were found to be promising photocatalyst materials and could be employed for the degradation of other dyes in the future.

Improving the Thermal Behavior and Flame-Retardant Properties of Poly(o-anisidine)/MMT Nanocomposites Incorporated with Poly(o-anisidine) and Clay Nanofiller.

The synthesis of MMT and poly(o-anisidine) (MMT/POA) clay nanocomposites was carried out by using the chemical oxidative polymerization of POA and MMT clay with POA, respectively. By maintaining the constant concentration of POA, different percentage loads of MMT clay were used to determine the effect of MMT clay on the properties of POA. The interaction between POA and MMT clay was investigated by FTIR spectroscopy, and, to reveal the complete compactness and homogeneous distribution of MMT clay in POA, were assessed by using scanning-electron-microscope (SEM) analysis. The UV-visible spectrum was studied for the optical and absorbance properties of MMT/POA ceramic nanocomposites. Furthermore, the horizontal burning test (HBT) demonstrated that clay nanofillers inhibit POA combustion.

Emergency medical staffs' knowledge and attitude about organ donation after circulatory determined death (DCD) and its related factors.

BACKGROUND: Adverse attitudes and insufficient knowledge about organ donation after Circulatory Determined Death (DCD) among emergency staff can have important consequences for the proper identification of potential DCD donors. This is aided by the constant application of donation after Circulatory Determined Death policies, and the relative strength of support for this type of donation. Therefore, this study was conducted to investigate the awareness and attitude of emergency personnel about organ donation after Circulatory Determined Death. METHODS: This descriptive study was carried out with the participation of 49 physicians and 145 nurses working in the emergency departments of educational and medical centers of Tabriz University of Medical Sciences. Nurses were selected by simple random sampling, and all physicians working in the emergency departments were included in the study. The questionnaire of Knowledge and Attitude regarding Organ Donation after Circulatory Determined Death designed by Rodrigue et al. was used. Data were analyzed using descriptive statistics and independent samples t-test, one-way ANOVA, and chi-square test. RESULTS: Most of the nurses (62.8%) and physicians (66.7%) had a high level of knowledge about organ donation after circulatory determined death. The mean attitude score was 101.84 (SD: 9.88) out of 170 for nurses and 106.53 (SD: 11.77) for physicians. Physicians who carried organ donation cards had a more positive attitude toward organ donation after circulatory determined death. CONCLUSION: According to this study findings, knowledge and attitude of the emergency staff about organ donation was both high and positive. It is recommended to devise necessary guidelines for organ donation in Iranian emergency departments to assist in the training of colleagues in organ donation ensuring no necessary measures are missed. The results of this study would support the development of guidelines for the successful introduction of DCD in Iran.

Hemoglobin, Ferritin levels and RBC Indices among children entering school and study of their correlation with one another.

OBJECTIVE: To study correlation of various complete blood count variables with one another and to ascertain the values of intercept and slope among those having strong correlation. METHODS: The cross-sectional study was conducted in Marach 2017 in the Rabwah town of Punjab province in Pakistan, and comprised randomly selected one in four children studying under the Nazrat Taleem School System. Serum sample from each subject was used to analyse complete blood count on an automated analyser, and ferritin levels were checked by enzyme-linked immunosorbent assay. SPSS20 was used for data analysis. RESULTS: There were 299 children with a median age of 67 months. Mean haemoglobin level was 12.09±0.82gm/dl. There was a very strong positive correlation between haemoglobin and haematocrit; mean corpuscular volume; and red cell distribution width; mean corpuscular volume and mean corpuscular haemoglobin; red cell distribution width and mean corpuscular haemoglobin (p<0.001).Moderate positive correlation was found between haemoglobin and red blood cell count; haematocrit and red blood cell count; mean corpuscular haemoglobin and mean corpuscular haemoglobin concentration (p<0.05). Moderate negative correlation was present between red blood cell count and mean corpuscular volume; red blood cell count and red cell distribution width; red blood cell count and mean corpuscular haemoglobin (p<0.05). CONCLUSIONS: There were strong to moderate correlation between various complete blood count variables in the studied population. Ferritin level was the only variable which did not have any correlation with any of the other variables.

Alpha-glucosidase inhibition and molecular docking studies of 1,2-benzothiazine 1,1-dioxide based carbohydrazides.

Diabetes Mellitus is a chronic disease in which the infected cells do not have the ability to produce sufficient amount of insulin that resulted in the abnormality of carbohydrates metabolism and an increase in blood glucose level. Long time exposure to Diabetes Mellitus resulted in failure or dysfunction of different organs like kidneys, nerves, heart, eyes, etc. A common practice to cure diabetes is the use of α-glucosidase inhibitors which help in lowering the blood glucose level. We presented 1,2-benzothiazine 1,1-dioxide derivatives as novel and more potent α-glucosidase inhibitors via their in vitro and in silico screenings. Excellent enzyme inhibitions were observed for compounds 2, 8, 10 and 12 having IC50 values of 6.91, 14.0, 4.2, 5.9 and 29.2µ respectively which were found better than the reference acarbose (IC50=38.31µM). Molecular docking studies suggested high binding energies and good binding interactions of these compounds with the active site residues of the receptor protein. A good agreement was found between the results of both modes of evaluation. Moreover, the envisioned candidates have a good potential to treat diabetes.

Visually guided TEE probe insertion, making a case based on anatomic variation: A cadaveric study.

AIMS: The variations in upper esophageal anatomy currently are unknown. This study was carried out to evaluate this variation and assess its impact on transesophageal echocardiography probe insertion. METHODS: We included 9 consecutive cadavers studied at the University of Maryland School of Medicine's Clinical Surgical Laboratory. Each cadaver was first intubated blindly by an echocardiographer (KAA) and then under direct vision with a UE Medical VL 400 video laryngoscope (Newton, MA) by an anesthesiologist (JD). RESULTS: The visually guided method took a shorter average time (19.4 ± 13.4 seconds) and fewer passes (2.4 ± 2.1 passes) than blind insertion (30.3 ± 19.1 seconds, 5.3 ± 3.3 passes). None of the cadavers had the esophagus located directly posterior to the trachea. The esophageal hiatus was posterior and to the right of the trachea in most (n = 6); in these, the traditional "forward" jaw thrust helped to open the esophageal hiatus. Two cadavers had the esophagus and trachea located almost side by side, and in these the "forward" jaw thrust method failed. Instead, the jaw needed to be pulled to the left in order to advance the probe. CONCLUSION: This is the first study to describe anatomic variations in the location of and relationship between the upper esophageal sphincter and the larynx for the purpose of transesophageal echocardiography probe insertion. Awareness of the side-by-side anatomic variation can help to improve esophageal intubation by prompting the use of a new "pull to the side" technique instead of the traditional "forward" jaw thrust.

Coping mechanisms as predictors of suicidal ideation among the medical students of Pakistan.

OBJECTIVE: To identify the coping mechanisms as positive and negative predictors of suicidal ideation among medical students. METHODS: This cross-sectional analytical study was conducted from January to October 2017, and comprised students aged 19-25 years selected from 3 public-sector medical colleges located in Gujrat and Lahore, both in the Punjab province of Pakistan. Multilevel mixed methods sampling was used. Two standardised scales were used to assess the suicidal ideation and coping mechanisms of the participants. RESULTS: Of the 1200 subjects, 640(53%) were males and 560(47%) were females. Besides, 390(32%) subjects hailed from Gujrat and 810(68%) from Lahore. Self-distraction (p<0.05)), active coping (p<0.0001), use of emotional support (p<0.05), use of instrumental support (p<0.001) positive reframing (p<0.0001), planning (p<0.001), humour (p>0.05), acceptance (p<0.001) and religion (p<0.0001) were negative predictors of suicidal ideation whereas denial (p<0.0001), substance use (p<0.05), venting (p>0.05) and self-blame (p<0.0001) were positive predictors of suicidal ideation. CONCLUSIONS: A psycho-educational programme must be introduced for medical students to enable them to adopt the right coping strategies in order to handle stressful situations.

Frequency of underweight and stunting among children entering school in a small urban locality and their association with academic performance.

OBJECTIVE: To determine the frequency of underweight and stunting among the children entering first year of school and to assess its associated factors. METHODS: This descriptive, analytical study was conducted at 5 schools of Rabwah, Pakistan, from August to September 2015, and comprised all students who got admission in the selected schools during the study period. Name, father's name, gender, weight, height, status of height, and weight on Z-score charts, and marks obtained in the test were recorded. SPSS 20 was used for statistical analysis. RESULTS: Of the 478 participants, 212(44.4%) were boys and 266(55.6%) were girls. The overall mean age was 66.6±5.966 months (range: 41-129 months). Overall, 53(11.1%) were underweight, 22(4.6%) were severely underweight, 55(11.5%) had stunting and 12(2.5%) had severe stunting. Median marks (Interquartile Range [IQR]) in admission test for obese, overweight, normal, underweight and severely underweight children were 76.3%(37.2-84.7), 65.9%, 66.7%(56.4-72.3), 64.6%(47-71), and 67%(55.3-78), respectively. Median marks (IQR) in admission test for tall, normal height, stunted and severe stunted children were 24.1%, 67%(57.3-73), 57%(31.1-67.8), and 62.6%(49.7-68.3), respectively. Children with stunting scored significantly fewer marks compared to children of normal height (p<0.05). CONCLUSIONS: Stunting and underweight were common problems among children starting school. Stunting was found to be associated with lower marks in admission test.

Temperature on admission among cases of neonatal sepsis and its association with mortality.

OBJECTIVE: To ascertain the prevalence of hyperthermia and different categories of hypothermia among the cases of probable and culture-proven neonatal sepsis, and to evaluate association of mortality rate with axillary temperature at admission. METHODS: This analytical study was conducted at Fazl-e-Omar Hospital, Rabwah, Pakistan, from January to December 2013, and comprised all cases of culture-proven and probable neonatal sepsis admitted in the neonatal intensive-care unit of the hospital. Using World Health Organisation classification, cases were categorised according to their temperature on admission, and outcome was recorded. SPSS 20 was used for data analysis. RESULTS: Of the 374 patients, 47(12.6%) died. Besides, 217(58%) cases had normal temperature, 49(13.1%) had hyperthermia, 50(13.4%) had mild hypothermia, and 58(15.5%) had moderate hypothermia. Mortality rate was high among cases with mild and moderate hypothermia i.e. 15(32.6%) and 15(33%), compared with the mortality rate in cases with normal temperature i.e. 12(6.1%). Mortality rate among cases with hyperthermia was 5(11.6%). In early onset cases, 33(16.2%) had mild and 45(22.1%) had moderate hypothermia. In late onset cases, 37(21.8%) had hyperthermia. CONCLUSIONS: Most cases with neonatal sepsis had normal temperature. Mild and moderate hypothermia were found to be associated with higher mortality rate.

The effect of ω-fatty acids on the expression of phospholipase A2 group 2A in human gastric cancer patients.

BACKGROUND: Studies show that polyunsaturated fatty acids (PUFAs) may have an inhibitory role in carcinogenesis. It was previously shown that PLA2 group 2A (PLA2G2A) messenger RNA (mRNA) expression is associated with less frequent metastasis and longer survival in gastric adenocarcinoma. This study intends to investigate the effect of PUFAs on the expression of PLA2G2A in patients with gastric cancer. MATERIALS AND METHODS: Thirty-four patients with gastric cancer (GC) were randomly divided into two groups. The first group received cisplatin medication. The second group received cisplatin medication and supplements of ω-fatty acids for three courses. The total RNA was extracted from the tissues and cDNA was synthesized. The gene expression of PLA2G2A was evaluated by the real-time polymerase chain reaction (PCR) method. To confirm the changes in gene expression, frozen section was utilized. The frozen tissue samples were sectioned and stained using the immunohistochemistry technique. RESULTS: After chemotherapy and chemotherapy plus supplement, the relative mean of PLA2G2A gene expression increased 1.5 ± 0.5-fold and 7.4 ± 2.6-fold, respectively (P = 0.006). The relative mean of gene expression in patients who received cisplatin and ω-fatty acids supplement increased more significantly (7.5 ± 3.3-fold) than in patients who received only cisplatin (P = 0.016). CONCLUSION: It was found that PUFAs increased the gene and protein expression of PLA2G2A in gastric cancer. Concerning the fact that studies reveal protective function of PLA2G2A in gastric cancer, it is suggested that increased expression of PLA2G2A is helpful. Furthermore, PUFAs can be considered as a useful therapeutic supplement for patients with gastric cancer.

Isolated RING2 domain of parkin is sufficient for E2-dependent E3 ligase activity.

The E3 ubiquitin ligase activity of the parkin protein is implicated in playing a protective role against neurodegenerative disorders including Parkinson's, Huntington's, and Alzheimer's diseases. Parkin has four zinc-containing domains: RING0, RING1, IBR (in-between ring), and RING2. Mutational analysis of full-length parkin suggests that the C-terminal RING2 domain contains the catalytic core. Here, a catalytically competent recombinant RING2 containing an N-terminal GB1 solubility peptide is described. In cell-free in vitro ubiqitination reactions, the RING2 construct catalyzes the transfer of ubiquitin from the E2 enzyme UbcH7 to the attached GB1 tag. This intramolecular autoubiquitination reaction indicates that (a) ubiquitination by RING2 can occur in the absence of other parkin domains and (b) UbcH7 can interact directly with RING2 to transfer its bound ubiquitin. Mass spectrometry identified sites of mono- and diubiquitin attachment to two surface-exposed lysine residues (Lys24 and Lys39) on the GB1 peptide. The sites of diubiquitination involved Lys11 and Lys48 linkages, which have been identified as general signals for proteasome degradation. Cleaving the linker between the GB1 tag and RING2 resulted in loss of ubiquitination activity, indicating that the substrate must be tethered to RING2 for proper presentation to the active site. Atomic absorption spectrometry and selective mutation of zinc ligands indicated that only one of the two zinc binding sites on RING2, the N-terminal site, needs to be occupied by zinc for expression of ubiquitination activity. This is consistent with the hypothesis that the second, C-terminal, zinc binding site on RING2 has a regulatory rather than a catalytic function.

Association between alcohol consumption and systolic ventricular function: a population-based study.

BACKGROUND: Although moderate alcohol consumption is associated with decreased clinical heart failure, there are no population-based studies evaluating the relationship between alcohol consumption and left ventricular (LV) systolic function. We sought to evaluate the relationship between alcohol consumption and LV systolic function in the community. METHODS: In a population-based random sample of 2,042 adults, age ≥45 years, we assessed alcohol consumption by a self-administered questionnaire. Responders were categorized by alcohol consumption level: abstainer, former drinker, light drinker (<1 drink a day), moderate drinker (1-2 drinks a day), and heavy drinker (>2 drinks a day). Systolic function was assessed by echocardiography. RESULTS: We identified 38 cases of systolic dysfunction in 182 abstainers, 309 former drinkers, 1,028 light drinkers, 251 moderate drinkers, and 146 heavy drinkers. A U-shaped relationship was observed between alcohol consumption and moderate systolic dysfunction (LV ejection fraction [LVEF] ≤40%), with the lowest prevalence in light drinkers (0.9%) compared to the highest prevalence in heavy drinkers (5.5%) (odds ratio 0.14, 95% CI 0.04-0.43). This association persisted across different strata of risk factors of systolic dysfunction as well as in multivariate analysis. No significant association between alcohol consumption and systolic function was seen in subjects with LVEF >50% or ≤50%. CONCLUSIONS: There is a U-shaped relationship between alcohol consumption volume and LVEF, with the lowest risk of moderate LV dysfunction (LVEF ≤40%) observed in light drinkers (<1 drink a day). These findings are parallel to the relationship between alcohol consumption and cardiovascular disease prevalence.

High-fidelity, low-cost synthetic training model for fetoscopic spina bifida repair.

BACKGROUND: Fetoscopic spina bifida repair is increasingly being practiced, but limited skill acquisition poses a barrier to widespread adoption. Extensive training in relevant models, including both ex vivo and in vivo models may help. To address this, a synthetic training model that is affordable, realistic, and that allows skill analysis would be useful. OBJECTIVE: This study aimed to create a high-fidelity model for training in the essential neurosurgical steps of fetoscopic spina bifida repair using synthetic materials. In addition, we aimed to obtain a cheap and easily reproducible model. STUDY DESIGN: We developed a 3-layered, silicon-based model that resemble the anatomic layers of a typical myelomeningocele lesion. It allows for filling of the cyst with fluid and conducting a water tightness test after repair. A compliant silicon ball mimics the uterine cavity and is fixed to a solid 3-dimensional printed base. The fetal back with the lesion (single-use) is placed inside the uterine ball, which is reusable and repairable to allow for practicing port insertion and fixation multiple times. Following cannula insertion, the uterus is insufflated and a clinical fetoscopic or robotic or prototype instruments can be used. Three skilled endoscopic surgeons each did 6 simulated fetoscopic repairs using the surgical steps of an open repair. The primary outcome was surgical success, which was determined by water tightness of the repair, operation time <180 minutes and an Objective Structured Assessment of Technical Skills score of ≥18 of 25. Skill retention was measured using a competence cumulative sum analysis of a composite binary outcome of surgical success. Secondary outcomes were cost and fabrication time of the model. RESULTS: We made a model that can be used to simulate the neurosurgical steps of spina bifida repair, including anatomic details, port insertion, placode release and descent, undermining of skin and muscular layer, and endoscopic suturing. The model was made using reusable 3-dimensional printed molds and easily accessible materials. The 1-time startup cost was €211, and each single-use, simulated myelomeningocele lesion cost €9.5 in materials and 50 minutes of working time. Two skilled endoscopic surgeons performed 6 simulated, 3-port fetoscopic repairs, whereas a third used a Da Vinci surgical robot. Operation times decreased by more than 30% from the first to the last trial. Six experiments per surgeon did not show an obvious Objective Structured Assessment of Technical Skills score improvement. Competence cumulative sum analysis confirmed competency for each surgeon. CONCLUSION: This high-fidelity, low-cost spina bifida model allows simulated dissection and closure of a myelomeningocele lesion. VIDEO ABSTRACT.