The modeling analysis projects that in 2023, 2028, and 2033, there will be shortages of 10%, 23%, and 35% adult hepatology providers, respectively, and 19%, 20%, and 16% pediatric hepatology providers, respectively. In sensitivity analyses, a shortage of hepatology providers is predicted even under optimistic assumptions. Among the respondents to the survey, the median age was higher among gastroenterologists and general hepatologists compared with transplant hepatologists. The most common category treated by transplant hepatologists was general hepatology.

There is an impending critical shortage of adult and pediatric hepatology providers. Strategies are needed to encourage clinicians to pursue hepatology, especially in areas outside of transplant centers.

There is an impending critical shortage of adult and pediatric hepatology providers. Strategies are needed to encourage clinicians to pursue hepatology, especially in areas outside of transplant centers.

 This study aimed to evaluate the construct validity and reliability of real-time assessment of a previously developed neonatal intubation scoring instrument (NISI).

 We performed a randomized controlled simulation study at a simulation-based research and training facility. Twenty-four clinicians experienced in neonatal intubation („experts”) and 11 medical students („novices”) performed two identical elective intubations on a neonatal patient simulator. Subjects were randomly assigned to either the intervention group, receiving predefined feedback between the two intubations, or the control group, receiving no feedback. Using the previously developed NISI, all intubations were assessed, both in real time and remotely on video. Construct validity was evaluated by (1) comparing the intubation performances, expressed as percentage scores, with and without feedback, and (2) correlating the intubation performances with the subjects’ level of experience. The intrarater reliability, expressed as intraclass corr. · It is suitable for formative assessment, i.e., providing direct feedback during procedural training..

· Our neonatal intubation scoring instrument has construct validity.. · Our instrument can be reliably employed to assess neonatal intubation skills directly in real time.. · It is suitable for formative assessment, i.e., providing direct feedback during procedural training..The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in changes to perinatal and neonatal care, concentrating on minimizing risks of transmission to the newborn and health care staff while ensuring medical care is not compromised for both mother and infant. Current recommendations on infant care and feeding when mother has COVID-19 ranges from mother-infant separation and avoidance of human milk feeding, to initiation of early skin-to-skin contact and direct breastfeeding. Health care providers fearing risks of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) maternal-infant transmission may veer toward restricted breastfeeding practices. We reviewed guidelines and published literature and propose three options for infant feeding depending on various scenarios. Option A involves direct breastfeeding with the infant being cared for by the mother or caregiver. In option B, the infant is cared for by another caregiver and receives mother’s expressed milk. In the third option, the infant is not breastfed directly and does not receive mother’s expressed milk. We recommend joint decision making by parents and the health care team. This decision is also flexible as situation changes. We also provide a framework for counseling mothers on these options using a visual aid and a corresponding structured training program for health care providers. Future research questions are also proposed. We conclude that evidence and knowledge about COVID-19 and breastfeeding are still evolving. Our options can provide a quick and flexible reference guide that can be adapted to local needs. KEY POINTS · SARS-CoV-2 is unlikely transmitted via human milk.. · A shared decision making on infant feeding is the preferred approach.. · Mothers can safely breastfeed with appropriate infection control measures..BACKGROUND  Clinically significant post-endoscopic bleeding (CSPEB) is a common complication following colonic endoscopic mucosal resection (EMR). Current prediction tools are clinical and do not use the appearance of the post-EMR mucosal defect. We aimed to predict CSPEB by analyzing blood vessel morphology within the post-EMR mucosal defect. METHODS  43 patients with CSPEB were matched to 43 non-bleeders for clinical variables associated with CSPEB. Computerized image analysis quantified the morphologic characteristics of the blood vessels in the defect. Variables were measured in relation to the mucosal defect area. Multivariate analysis and a neural network (NNET) were used as prediction models. RESULTS  The CSPEB group vessels had larger maximum diameter (113.07 vs. 69.03; P  less then  0.001), larger minimum radius (5.09 vs. 3.28; P = 0.002), larger perimeter value (337.82 vs. 193.86; P  less then  0.001), larger vessel length-of-outline (351.83 vs. 220.68; P = 0.002), and larger fractal dimension (1.11 vs. 1.10; P = 0.005) compared with non-bleeders. Discriminant analysis yielded 86 % sensitivity and 76.7 % specificity and an NNET classifier yielded 100 % sensitivity and 76.9 % specificity for identifying patients at risk. CONCLUSIONS  Blood vessel morphology in the post-EMR defect can be used to predict bleeding following colonic EMR.

Endoscopic retrograde cholangiopancreatography (ERCP) is often unsuccessful in patients with duodenal stenosis or malignant ampullary infiltration. While endoscopic ultrasound-guided biliary drainage (EUS-BD) has been proposed as an alternative, EUS-guided gallbladder drainage (EUS-GBD) is an attractive option when both approaches fail. We aimed to assess the effectiveness and safety of EUS-GBD as rescue therapy for malignant distal bile duct obstruction.

A multicenter retrospective study was performed on patients with unresectable malignant distal bile duct obstruction who underwent EUS-GBD between 2014 and 2019 after unsuccessful ERCP and EUS-BD. Clinical success was defined as a decrease in serum bilirubin of > 50 % within 2 weeks.

28 patients were included, with a lumen-apposing metal stent used in 26 (93 %) and a self-expandable metal stent in two (7 %). The technical success rate was 100 %. The clinical success rate was 93 %, with an improvement in bilirubin (7.3 [SD 5.4] pre-procedure vs. 2.8 [SD 1.1] post-procedure;

 = 0.001). Delayed adverse events included food impaction of the stent (n = 3), with a further two patients developing cholecystitis and bleeding.

This study demonstrates the feasibility of gallbladder drainage to relieve malignant distal bile duct obstruction in patients with failed ERCP and EUS-BD.

This study demonstrates the feasibility of gallbladder drainage to relieve malignant distal bile duct obstruction in patients with failed ERCP and EUS-BD.

 To examine women with pelvic floor dysfunction (PFDs) and identify factors associated with sexual activity (SA) status that impacts quality of life (QoL).

 We conducted a cross-sectional study that included women > 18 years old who presented with at least one PFD symptom (urinary incontinence [UI] and/or pelvic organ prolapse [POP]), in outpatient clinics specializing in urogynecology and PFD in Fortaleza, state of Ceará, Brazil, using a service evaluation form and QoL questionnaires.

 The analysis of 659 women with PFD included 286 SA (43.4%) women and 373 non-sexually active (NSA) (56.6%) women, with a mean age of 54.7 (±12) years old. The results revealed that age (odds ratio [OR] = 1.07, 95% confidence interval [CI] 1.03-1.12) and post-menopausal status (OR = 2.28, 95% CI 1.08-4.8) were negatively associated with SA. Being married (OR = 0.43, 95% CI 0.21-0.88) was associated with SA. Pelvic organ prolapse (OR = 1.16, 95% CI 0.81-1.68) and UI (OR = 0.17, 95% CI 0.08-0.36) did not prevent SA. SF-36 Health Survey results indicated that only the domain functional capacity was significantly worse in NSA women (

 = 0.012). Two King’s Health Questionnaire domains in NSA women, impact of UI (

 = 0.005) and personal relationships (

 < 0.001), were significantly associated factors. Data from the Prolapse Quality-of-life Questionnaire indicated that NSA women exhibited compromised QoL.

 Postmenopausal status and age negatively affected SA. Being married facilitated SA. Presence of POP and UI did not affect SA. However, NSA women with POP exhibited compromised QoL.

 Postmenopausal status and age negatively affected SA. Being married facilitated SA. Presence of POP and UI did not affect SA. However, NSA women with POP exhibited compromised QoL.

 To determine the average body composition (percentage of body fat), the anthropometric markers, and the intensity of clinical pain in women with a clinical diagnosis of chronic pelvic pain (CPP) secondary to endometriosis.

 A case-control study performed with 91 women, 46 of whom with CPP secondary to endometriosis and 45 of whom with CPP secondary to other causes. They underwent an evaluation of the anthropometric parameters by means of the body mass index (BMI), the perimeters (waist, abdomen, hip), and the percentage of body fat (%BF), which were assessed on a body composition monitor by bioimpedance; the intensity of the clinical pain was evaluated using the visual analog scale (VAS), and the symptoms of anxiety and depression, using the hospital’s anxiety and depression scale (HAD).

 The groups did not differ in terms of mean age, BMI, %BF or regarding the available waist-to-hip ratio (WHR). The mean intensity of the clinical pain by the VAS was of 7.2 ± 2.06 in the group with CPP secondary to endometriosis, and of 5.93 ± 2.64 in the group with CPP secondary to other causes (

 = 0.03), revealing significant differences between the groups.

 We concluded that, despite the difference in the pain score assessed between the two groups, there was no difference regarding body composition and anthropometry.

 We concluded that, despite the difference in the pain score assessed between the two groups, there was no difference regarding body composition and anthropometry.

 To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications.

 A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure.

 We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d’Obstétrique, FIGO, in French), most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR] 0.97; 95% confidence interval [95%CI] 0.96-0.98) and the classificatiofibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

 To analyze the rates of cesarean delivery longitudinally in a university hospital using the Robson classification.

 Data related to births performed between 2014 and 2018 and recorded in the Maternal and Neonatal Health Information System (Sistema de Informações em Saúde Materna e Neonatal, SISMATER, in Portuguese) were analyzed using the Robson classification. As an aid, we used articles published in the last five years that approach the same topic in other Brazilian maternity hospitals; they were retrieved from the LILACS, MEDLINE, CINAHL, Scopus, Web of Science and Cochrane Library databases.

 There was little variation in the total rate of cesarean sections in the period; however, the profile of each group changed over the years. It was possible to verify a significant reduction in the participation of groups of pregnant women with lower risk and an increase in high-risk pregnancies, attributable to the decrease in beds in the institution, with a greater transfer of patients. In addition, there was a reduction in cesarean sections among the lower-risk groups, while the rate among the higher-risk groups remained stable.

 The use of the Robson classification to stratify cesarean deliveries contributes to a better analysis of the indications for cesarean delivery, enabling the establishment of strategies to reduce the rates, generating a positive impact on hospital management and quality of care.

 The use of the Robson classification to stratify cesarean deliveries contributes to a better analysis of the indications for cesarean delivery, enabling the establishment of strategies to reduce the rates, generating a positive impact on hospital management and quality of care.Diagnostic and therapeutic advancements have improved clinical outcomes for patients with focal chondral injuries of the knee. An increased number and complexity of surgical treatment options have, in turn, resulted in a commensurate proliferation of patients requiring postoperative evaluation and management. In addition to patient-reported clinical outcomes, magnetic resonance imaging (MRI) offers clinicians with noninvasive, objective data to assist with postoperative clinical decision making. However, successful MRI interpretation in this setting is clinically challenging; it relies upon an understanding of the evolving and procedure-specific nature of normal postoperative imaging. Moreover, further research is required to better elucidate the correlation between MRI findings and long-term clinical outcomes. This article focuses on how specific morphologic features identified on MRI can be utilized to evaluate patients following the most commonly performed cartilage repair surgeries of the knee.Cartilage defects in the knee are common resulting in significant pain and morbidity over time. These defects can arise in isolation or concurrently with other associated injuries to the knee. The treatment of small ( less then  2-3 cm2) cartilage deficiencies has changed as our basic science knowledge of tissue healing has improved. Advancements have led to the development of new and more effective treatment modalities. It is important to address any associated knee injuries and limb malalignment. Surgical options are considered when nonoperative treatment fails. The specific procedure depends on individual patient characteristics, lesion size, and location. Debridement/chondroplasty, microfracture, marrow stimulation plus techniques, fixation of unstable osteochondral fragments, osteochondral autograft transfer, and osteochondral allograft transplantation, all have roles in the treatment of small cartilage defects.Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.The purpose of this study was to describe the pattern of meniscus and cartilage pathology in multiligament knee injuries (MLKIs) and determine the relationship between surgical timing and injury mechanism with degree of intra-articular injury. Patients with surgically treated MLKIs over a 15-year period were retrospectively reviewed and grouped based on surgical intervention, time to intervention, and injury mechanism. The presence or absence of meniscus and chondral injury were recorded at the time of surgery. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Over the 15-year study period, 207 patients with MLKIs were identified. Compared with acutely managed patients, the delayed intervention group had significantly more meniscus (p = 0.03) and cartilage (p  less then  0.01) pathology. Meniscus injury rates in MLKIs sustained during sporting activity did not differ from nonsporting injuries (p = 0.63). However, the nonsporting group had significantly more chondral injuries (p  less then  0.01). High-energy injury mechanism was associated with increased cartilage (p = 0.02), but not meniscus (p = 0.61) injury rates. In conclusion, surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology.Central transpatellar tendon portal (CTP) was suggested first for complex meniscal lesion and subsequently for a better femoral footprint view during reconstruction of anterior cruciate ligament (ACL). A comprehensive evaluation of possible consequences of using the CTP performing an ACL reconstruction does not exist. Our hypothesis was that the use of CTP for ACL reconstruction does not lead to a higher rate of complications or clinically evident radiological abnormalities. In total, 141 patients were prospectively evaluated, 69 underwent ACL reconstruction using a standard high medial portal as view portal, and 72 where a CTP was used. Clinical evaluation, Kujala’s score, patellar height, and magnetic resonance (MR) abnormalities were evaluated up to 1-year follow-up. Clinical complications were reported in 16 cases with no statistically significant differences between the two groups. The group 2 had significantly more MR abnormalities (p = 0.048), but the differences in MR alterations do not have any clinical repercussion even in a sports-active population. No differences were found between the groups in Kujala’s score, time to return to work, and sport or patellar height. The overall mean preoperative Caton-Deschamps Index decreased significantly (p = 0.034) postoperatively. Postoperative patellar height seems to slightly decrease after ACL reconstruction regardless of the kind of the portals used intraoperatively and the initial patellar height. Nevertheless, this change in patellar height does not influence the postoperative outcome. CTP used for ACL reconstruction does not lead to significative major clinical complications.The goal of this study is to investigate the effects of tendon and cannulated drill bit diameter on the strength of the bone and site hold tendon inside (BASHTI) fixation technique for an anterior cruciate ligament (ACL) reconstruction. Bovine digital tendons and Sawbones blocks were used to mimic the ACL reconstruction. Mechanical strength of the specimens was measured using a cyclic loading continued by a single cycle pullout load until failure to simulate the real postsurgical loading conditions. Finally, failure modes of specimens and ultimate failure load were recorded. The maximum possible tendon surface strain (i.e., tendon compression [TC]) for tendon diameters of 6, 7, 8, and 9 mm were 0.73, 0.8, 0.7, and 0.65, respectively. Eighty per cent of the specimens with tendon diameter of 6 mm and 20% of specimens with tendon diameter of 7 mm failed on the torn tendon. All samples with larger tendon diameters (i.e., 8 and 9 mm) failed on the fixation slippage. The maximum fixation strength according to the most suitable core bones for 6, 7, 8, and 9 mm tendons were 148 ± 47 N (core 9.5 mm), 258 ± 66 N (core 9.5 mm), 386 ± 128 N (core 8.5 mm), and 348 ± 146 N (core 8.5 mm), respectively. The mode of tendon failure was significantly influenced by the tendon diameter. Also, an increase in TC raised the fixation strength for all tendon diameters; however, tendon over compression decreased the fixation strength for the 8 mm tendon group. Finally, an empirical equation was proposed to predict BASHTI fixation strength.Patient-specific instrumentation (PSI) has been introduced to simplify and make total knee arthroplasty (TKA) surgery more precise, effective, and efficient. We performed this study to determine whether the postoperative coronal alignment is related to preoperative deformity when computed tomography (CT)-based PSI is used for TKA surgery, and how the PSI approach compares with deformity correction obtained with conventional instrumentation. We analyzed pre-and post-operative full length standing hip-knee-ankle (HKA) X-rays of the lower limb in both groups using a convention > 180 degrees for valgus alignment and less then 180 degrees for varus alignment. For the PSI group, the mean (± SD) pre-operative HKA angle was 172.09 degrees varus (± 6.69 degrees) with a maximum varus alignment of 21.5 degrees (HKA 158.5) and a maximum valgus alignment of 14.0 degrees. The mean post-operative HKA was 179.43 degrees varus (± 2.32 degrees) with a maximum varus alignment of seven degrees and a maximum valgus alignment of six degrees. There has been a weak correlation among the values of the pre- and postoperative HKA angle. The adjusted odds ratio (aOR) of postoperative alignment outside the range of 180 ± 3 degrees was significantly higher with a preoperative varus misalignment of 15 degrees or more (aOR 4.18; 95% confidence interval 1.35-12.96; p = 0.013). In the control group (conventional instrumentation), this loss of accuracy occurs with preoperative misalignment of 10 degrees. Preoperative misalignment below 15 degrees appears to present minimal influence on postoperative alignment when a CT-based PSI system is used. The CT-based PSI tends to lose accuracy with preoperative varus misalignment over 15 degrees.The purpose of this study was to evaluate Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) 2 years following knee surgery, and identify preoperative factors associated with postoperative PROMIS PF. Three hundred and sixty-five patients, age 17 years and older, undergoing knee surgery at one institution were studied. Patients completed multiple questionnaires prior to surgery and again 2 years postoperatively including PROMIS PF, International Knee Documentation Committee (IKDC), joint and body numeric pain scales (NPS), Tegner’s activity scale (TAS), and Marx’s activity rating scale (MARS). Mean PROMIS PF improved from 41.4 to 50.9 at 2 years postoperatively (p  less then  0.001) and was strongly correlated with 2-year IKDC scores. Older age, female gender, non-Hispanic ethnicity, unemployment, lower income, government insurance, smoking, preoperative opioid use, having a legal claim, comorbidities, previous surgeries, higher body mass index (BMI), and knee arthroplasty were associated with worse 2-year PROMIS PF. Multivariable analysis confirmed that lower BMI, less NPS body pain, and higher MARS were independent predictors of greater 2-year PROMIS PF and better improvement in PROMIS PF. In this large, broad cohort of knee surgery patients, multiple preoperative factors were associated with PROMIS PF 2 years postoperatively. PROMIS PF scores improved significantly, but worse 2 year PROMIS PF scores and less improvement from baseline were independently predicted by higher BMI, greater NPS body pain, and lower MARS activity level. PROMIS PF can be implemented as an efficient means to assess outcomes after knee surgery.The aim of this study was to determine if the type of reamer used in tibial tunnel creation during anterior cruciate ligament (ACL) reconstruction influences the dimensions of the tunnel’s outer aperture. Tibial tunnels were created in tibial saw bones by reaming over a guidewire using an 8 mm acorn or fluted reamer in an antegrade manner. Reaming was aimed either in line with the guidewire, or with 10-degree inferior/superior deviation in relation to the wire. The shape and size of the outer aperture of the tibial tunnel were compared between the two reamers. When using the acorn reamer, a 10-degree deviation in relation to the guidewire resulted in minimal change in outer aperture length (mean 13.6 vs. 15.6 mm, p = 0.11) and width (11.6 vs. 11.1 mm, p = 0.51). However, when using the fluted reamer, although the aperture width showed no substantial change with reamer/guidewire deviation (11.4 vs. 11.2 mm, p = 0.71), the mean length almost doubled (14.7 vs. 28.1 mm, p = 0.002). The use of a fluted reamer when reaming the tibial tunnel creates a distal aperture which is inconsistently sized, larger, and of oblong shape compared with an acorn-shaped reamer. This should be taken in consideration when using a fluted reamer for creating the tibial tunnel in ACL reconstruction.This study aims to compare the rate of meniscal tears after anterior cruciate ligament (ACL) reconstruction in patients who have undergone concomitant meniscal repair during the index procedure with that in patients who have not undergone such surgery. It also evaluates other risk factors, such as age, gender, race, body mass index (BMI), site of concomitant meniscal surgery, and ACL graft failure. This is a retrospective study conducted at a large tertiary public hospital. Patients who underwent primary anterior cruciate ligament reconstruction (ACLR) surgery with or without concomitant meniscal repair from 2011 to 2016 were identified. Patients with old meniscal tears and previous meniscal surgeries were excluded. The aforementioned demographical, injury, and surgical details were obtained and analyzed using univariate and multivariate logistic regression analysis. Our study cohort included 754 patients. Primary ACLR surgery was performed with meniscal repair in 172 (22.8%) of the patients, with meniscectomy in 202 (26.8%) of the patients, and without concomitant meniscal surgery in 380 (50.4%) of the patients. A total of 81 (10.7%) patients developed meniscal tears after the index procedure. Such tears occurred in 12.2% (21 of 172) of the patients who had undergone concomitant meniscal repair during the index ACLR, and in 10.3% (60 of 582) of the patients who had not undergone concomitant meniscal repair (p = 0.30). On multivariate analysis, only ACL graft failure was significantly associated with new meniscal tears (p  less then  0.001, odds ratio 18.69, 95% confidence interval 9.18-38.05). ACL graft failure is the only independent risk factor for meniscal tears after ACLR surgery in our large cohort of patients. Concomitant meniscal repair was not an associated risk factor.The effects of smoking on unicompartmental knee arthroplasty (UKA) are unknown. The purpose of this study was to evaluate the effects of smoking on short-term outcomes following primary UKA. A query of the National Surgical Quality Improvement Project (NSQIP) database was used to identify cases of primary UKA performed during years 2006 to 2017. Patient demographics, operative times, and postoperative complications were compared between smoking and nonsmoking cohorts. Descriptive statistics, univariate analyses, and multivariate analyses were conducted to evaluate the effects of smoking on primary UKA. A total of 10,593 cases of UKA were identified; 1,046 of these patients were smokers. Univariate analysis demonstrated smokers to have higher rates of any complication (4.6 vs. 3.3%, p = 0.031), any wound complication (1.82 vs. 0.94%, p = 0.008), deep wound infection (0.57 vs. 0.13%, p = 0.006), and reoperation (1.34 vs. 0.68%, p = 0.018) relative to nonsmokers. Multivariate analysis demonstrated smokers to have higher rates of any wound complication (odds ratio [OR] = 1.79; 95% confidence interval [CI] 1.06-2.95) and reoperation (OR = 2.11; 95% CI 1.12-3.97). Smokers undergoing primary UKA are at higher risk for any wound complication and reoperation relative to nonsmokers in the first 30 days postoperatively. Further studies evaluating the long-term effects of smoking on outcome following UKA, as well as the impact of smoking cessation on outcomes following UKA, are needed.The objectives of this study are to assess perioperative opioid use in patients undergoing knee surgery and to examine the relationship between preoperative opioid use and 2-year postoperative patient-reported outcomes (PROs). We hypothesized that preoperative opioid use and, more specifically, higher quantities of preoperative opioid use would be associated with worse PROs in knee surgery patients. We studied 192 patients undergoing knee surgery at a single urban institution. Patients completed multiple PRO measures preoperatively and 2-year postoperatively, including six patient-reported outcomes measurement information system (PROMIS) domains; the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale (NPS) scores for the operative knee and the rest of the body, Marx’s knee activity rating scale, Tegner’s activity scale, International Physical Activity Questionnaire, as well as measures of met expectations, overall improvement, and overall satisfaction. Total morphine equivalenes for function, activity, and knee pain. Preoperative opioid use and TMEs were neither independent predictors of met expectations, satisfaction, patient-perceived improvement, nor improvement on any PROs. Our findings demonstrate that preoperative opioid use is associated with clinically relevant worse patient-reported knee function and pain after knee surgery.The controversial issue of homeopathy’s scientificity will, in all probability, not be settled by means of clinical trials alone, as long as uncertainty or ignorance about methodological, philosophical, and socio-economical essentials prevail on both sides of the argument. Rather than uncritically adopt the standards of the currently predominant paradigm, homeopathy should not forget its roots, peculiarities, and self-conception. Contrary to conventional medicine, it is based on a teleological image of humanity, a holistic and sustainable approach towards curing sickness, and an up-to-date concept of medical theory in terms of healing arts. However, under today’s frameworked conditions of industrialisation, commercialisation and commodification, the strengths of homeopathy tend to be disregarded or even attacked, and a special kind of reductionist and materialist rationality, compatible with expanding markets and profits, is preferably facilitated. To reveal and demonstrate these developments and relationships on a scientific level, there is a need for multidisciplinary research on the part of the humanities, such as history and theory of medicine, history and theory of science, history of economics, sociology of scientific knowledge, and philosophy.The rapid spread of coronavirus disease (COVID-19) worldwide justifies global effort to combat the disease but also the need to review effective preventive strategies and medical management for potentially high-risk populations during the pandemic. Data regarding the COVID-19 manifestations in adults with underlying endocrine conditions, especially diabetes mellitus, are increasingly emerging. Albeit children and adolescents are considered to be affected in a milder manner, paucity of information regarding COVID-19 in children who suffer from endocrinopathies is available. The present review comprehensively collects recommendations issued by various health organizations and endocrine associations for the management of pediatric endocrine conditions during the pandemic. Adhering to the specific „sick day management rules” and undelayed seeking for medical advice are only needed in most of the cases, as the vast majority of children with endocrine disorders do not represent a high-risk population for contamination or severe presentation of COVID-19. Psychological implications in these children and adolescents are also considered.

 This study was designed to evaluate the publication performance of management teams consisting of chief and senior physicians in German university cardiac surgery units over a 10-year period and to facilitate benchmarking.

 The cutoff date for consideration of staffing from the unit Web site and publications was July 1, 2017. The literature search was based on an evaluation of the PubMed database. The 5-year impact factor (IF) from 2016 was assigned to each journal.

 Two thousand five hundred thirty-five publications (average IF 3.02) were registered, published in 323 journals. Of a total of 341 management team members, 235 (68.9%) published as first or last author over the 10-year period. The number of publications from the units divided into quintiles varied considerably with the first six units contributing 39.0% of all publications and the last nine units 9.4%. With a cumulative IF total of 3265, the publications of the first six units accounted for 42.7% of the cumulative IF, the last unit quintile amounted to 621 (8.1%) of the cumulative IF. When considering publications per managing member, the first quintile averaged 11.9 publications (29.6 IF) per managing member, the last quintile 3.3 publications (8.0 IF) per member.

 The six units of the first quintile published on average 3.6 times more per managing member than the nine units in the last quintile and the average cumulative IF per member in the first quintile was almost five times higher. Further investigation must show whether this considerable difference in publication activity between the university units is also observed in other operative fields.

 The six units of the first quintile published on average 3.6 times more per managing member than the nine units in the last quintile and the average cumulative IF per member in the first quintile was almost five times higher. Further investigation must show whether this considerable difference in publication activity between the university units is also observed in other operative fields.The current COVID-19 pandemia affects health care systems worldwide, however, to a variable extent depending on the caseload in each country. We aimed to provide a cross-sectional overview of current limitations or adaptions in lung transplant programs in Germany in from January to May 2020 due to the COVID-19 pandemia caused by severe acute respiratory syndrome coronavirus 2. A cross-sectional survey assessing various aspects of lung transplant activity was sent to all active lung transplant programs (n = 12) in Germany. Eight centers (66%) responded to the survey within the requested time frame. Four centers (50%) reported their activity is not restricted at all and four centers (50%) reported on moderate general limitations. The overall lung transplant activity in Germany from January to May 2020 contains 128 bilateral and 11 single lung transplantations, which is similar to the same period in the year 2019 (126 bilateral transplantations and 12 single lung transplantations). The results suggest that the influence of the COVID-19 pandemia on lung transplantation activity in Germany has been moderate so far. Nevertheless, adaptions such as extensive testing of donors and recipients were introduced to reduce the likelihood of infections and increase patient safety. Alertness to changes in COVID-19 reproduction rates might be required until effective antiviral therapy or vaccination is available.

 This is a preclinical cadaveric study to investigate the feasibility of a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci single port (SP) for transcervical dissection.

 Two transcervical esophagectomies with the DaVinci SP surgical system were performed as training procedures. In the third transcervical cadaveric procedure, the DaVinci SP was installed for the transcervical approach and the DaVinci X surgical system for the abdominal transhiatal phase. Primary outcomes were operating time and lymphadenectomy.

 The mobilization of the esophagus was successfully completed in 118 minutes by using the DaVinci SP for the transcervical phase and the DaVinci X for the transhiatal abdominal phase simultaneously. In total 18 lymph nodes were dissected in the thorax; 3 were located paratracheal right, 3 paratracheal left, 4 subcarinal, 4 para-aortic, 2 paraesophageal upper mediastinal, and 2 paraesophageal middle mediastinal.

 This preclinical study demonstrated that a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci SP for transcervical dissection was feasible with adequate lymphadenectomy in a cadaver model. Future research will elucidate the indications for the use of the fully robotic transhiatal and transcervical esophagectomy.

 This preclinical study demonstrated that a fully robotic McKeown esophagectomy in simultaneous rendezvous technique using the DaVinci X for transhiatal dissection and the DaVinci SP for transcervical dissection was feasible with adequate lymphadenectomy in a cadaver model. Future research will elucidate the indications for the use of the fully robotic transhiatal and transcervical esophagectomy.

 Although tumor size is included in the definition of T descriptor in the tumor-node-metastasis (TNM) classification of many solid tumors, it is not considered for thymomas. This study aimed to assess the relationship of tumor diameters (the largest tumor diameter [LTD] and the mean tumor diameter [MTD]) with survival in thymoma patients undergoing surgical resection in a single center.

 The study included 127 thymoma patients (age, 49.2 ± 15.2 years; 65 males), who were evaluated based on pathological tumor sizes according to the LTD and MTD ([largest diameter + shortest diameter] / 2) and divided into three subgroups for each parameter as patients with an LTD of ≤5 cm, 5.1 to 10 cm, and >10 cm and patients with an MTD of ≤5, 5.1 to 10, and >10 cm.

 In thymoma patients, survival significantly differed according to the presence of myasthenia gravis (

 = 0.018), resection status (R0 or R1;

 = 0.001), T status (

 = 0.015), and the Masaoka-Koga stage (

 = 0.003). In the LTD subgroups, the overall survival of those with R0 resection was lower in those with an LTD of 5.1 to 10 cm than in those with an LTD of ≤5 cm (

 = 0.051) and significantly lower in those with an MTD of 5.1 to 10 cm than in those with an MTD of ≤5 cm (

 = 0.027). In the MTD subgroups, survival decreased as the tumor size increased.

 Both smaller tumor size and complete resection are associated with better survival in thymoma patients. Therefore, the largest or the mean tumor size might be considered as a criterion in the TNM staging for thymoma.

 Both smaller tumor size and complete resection are associated with better survival in thymoma patients. Therefore, the largest or the mean tumor size might be considered as a criterion in the TNM staging for thymoma.The frozen elephant trunk (FET) procedure enables easier replacement of the entire aortic arch because it does not require reaching the distal part of the left subclavian artery (LSCA). However, it requires additional management for reconstruction of the LSCA, which is associated with bleeding events. However, the fenestrated FET technique confers a risk of endoleakage from the fenestration site. We report our unique novel technique in which the proximal side of the hybrid stent graft is cut into V-shape around the subclavian artery and sutured continuously around the orifice of the subclavian artery during aortic stump fixation.

Trial of labor after cesarean delivery (TOLAC) is a common practice worldwide but the evidence is still scant regarding this practice in women who underwent 2 previous cesareans. The purpose of this study is to retrospectively review our experience with vaginal birth after two previous cesarean sections (VBA2C), with specific attention to the indications for previous cesarean and to the women’s motivation for attempting trial of labor.

This was a retrospective cohort study conducted in a primary care hospital between January 2011 and December 2019. Inclusion criteria were singleton pregnancies, absence of morphological abnormalities at ultrasonographic screening of the second trimester (or at any other stage of pregnancy), and two previous cesarean sections.

The final analysis included 114 cases for maternal and neonatal outcomes. In total, 40.4% of women chose trial of labor after two cesarean delivery (TOLA2C group). TOLA2C was associated with a success rate of 76.1%, a higher gestational age at birthvide clinicians useful information.. · Mode of delivery in women with two previous cesareans is strongly associated with doctor’s counseling..

· Selection of candidates and motivation of the patients represent key elements for successful TOLA2C.. · A careful record of obstetrical history and previous deliveries can provide clinicians useful information.. · Mode of delivery in women with two previous cesareans is strongly associated with doctor’s counseling..• IUI is a risk factor for spontaneous preterm birth and contributes to prematurity-associated mortality and morbidity.• HCA greatly affected Apgar’s score and lung management of VLBWI at birth and later on with increased incidence of BPD.• HCA + FUN did not significantly impact on respiratory outcome.

Intrauterine inflammation or infection (IUI) is a risk factor for spontaneous preterm birth and contributes to prematurity-associated mortality and morbidity. IUI can include inflammation, as well as infections of varying degrees of severity and duration. Histological chorioamnionitis (HCA) remains the „gold standard” for the diagnosis but clinical, microbiological, and biochemical criteria are often used to define chorioamnionitis. The impact of intrauterine inflammation on respiratory outcome, in infants with very low birth weight, is still unclear and previous data are conflicting showing increase, decrease, or no risk of respiratory complications.

This is a retrospective study aimed to investigate the rotus arteriosus (PDA), and incidence of BPD compared with no-HCA (GA, 30 weeks; BW, 1,210 g). Length of hospital stay and mortality were higher in HCA group (

 = 0.01) and an increasing trend was present for HCA + FUN compared with HCA alone.

HCA greatly affected Apgar’s score and lung management of VLBW infants (VLBWI) at birth and later on with increased incidence of BPD, thus impacting length of stay and quality of life, while HCA + FUN did not significantly impact on respiratory outcome. Further studies are needed to clarify the role of HCA and FUN in VLBW neonates.

HCA greatly affected Apgar’s score and lung management of VLBW infants (VLBWI) at birth and later on with increased incidence of BPD, thus impacting length of stay and quality of life, while HCA + FUN did not significantly impact on respiratory outcome. Further studies are needed to clarify the role of HCA and FUN in VLBW neonates.

This study aimed to describe the epidemiology of vertically transmitted sepsis (VS) and nosocomial sepsis (NOS) in very low birth weight (VLBW) neonates (birth weight ≤ 1,500 g) over the past 22 years in Spain.

This is a retrospective analysis of prospectively collected VS and NOS in neonates from 1996 to 2018 in the 44 neonatal units integrated in the Spanish Neonatal Network Grupo Castrillo.

A total of 2,676 episodes of VS were recorded in 2,196,129 live births (LBs; 1.2/1,000 LBs) over the study period (1996-2018). The incidence declined from 2.4 to 1 to 1.2/1,000 LBs (

 < 0.0001). Of the 2,676 episodes, 95.7% were early onset (≤72 hours) and 4.3% cases late onset VS. Group B streptococcus (GBS) (33.1%) and

(29.3%) were the most frequently isolated pathogen. The GBS incidence declined significantly from 1.25 to 0.21/1,000 LBs (

 < 0.0001).

incidence showed a significant increase trend in VLBW infants (

 < 0.05). The global mortality per 1000 LBs decreased from 0.21 to 0.13/1,000. A al sepsis may change over time; therefore, a national surveillance network is essential to provide accurate information..

· Grupo Castrillo is a Spanish network for neonatal infections surveillance.. · A neonatal sepsis definition based on epidemilogical and not only chronological criteria was established.. · Epidemiology of neonatal sepsis may change over time; therefore, a national surveillance network is essential to provide accurate information..

Coinciding with the publication of the Canadian congenital diaphragmatic hernia (CDH) Collaborative’s clinical practice guidelines (CPG), we developed a mobile smartphone app to increase guideline utilization and promote knowledge translation.

This mobile app was organized into sections corresponding to the phases of CDH care (prenatal, perinatal/postnatal, and child/adolescent), and contained 22 recommendations supported by evidence summaries, PubMed links, levels of evidence, and strength of expert consensus. Download statistics were collected from September 2018 to June 2020 after release of two iOS versions and an Android platform. Data regarding user numbers/location, most visited sections, and individual session details were analyzed.

During the study period, the CDH app had 1,586 users predominantly from Canada (40%), United States (30%), and Brazil (12%). The Android release increased app visibility, particularly in Brazil, which had the largest number of new users. Of 3,723 sessions, roughly onile smartphone technology provides an optimal platform for guideline dissemination.. · International uptake supports worldwide CPG relevance.. · Future initiatives include the development of patient and family resources..

This study aimed to describe a rare case of a serous borderline ovarian tumor (BOT) diagnosed during pregnancy in a 15-year old adolescent.

The suspect of BOT was raised at a transvaginal ultrasound scan in early first trimester (at 5 weeks of amenorrhea), due to the presence of a moderately vascularized irregular papilla in the context of a unilocular low-level right ovarian cyst. The patient and her parents required termination of pregnancy, irrespective of the diagnosis of an ovarian lesion. After termination of pregnancy, the patient underwent laparoscopic enucleation of the ovarian mass, omentectomy, and peritoneal biopsies. No intra-abdominal spillage of the ovarian mass occurred, and the surgical specimens were put in an endobag and extracted transvaginally. Final pathological examination confirmed the diagnosis of a serous borderline ovarian tumor. The patient of free of disease after 8 months of follow-up.

Although rare, borderline ovarian tumors can be diagnosed in an adolescent during pregnancy. The combination of specific sonographic assessment and minimally invasive conservative surgery appears as a very effective approach in this type of patient.

· BOTs can occur in pregnant adolescents.. · Transvaginal ultrasound is crucial to suspect BOT.. · Laparoscopic conservative treatment is feasible..

· BOTs can occur in pregnant adolescents.. · Transvaginal ultrasound is crucial to suspect BOT.. · Laparoscopic conservative treatment is feasible..Neonatal adrenal hemorrhage (NAH) in newborn infants is a rare event that is associated with specific anatomical and vascular characteristics. It is more common in term infants and occurs more often in neonates who feature perinatal asphyxia. Symptoms that more frequently prompt to diagnosis are prolonged jaundice, detection of an abdominal mass, anemia, scrotal discoloration and/or swelling, hypotonia, lethargy, and hypertension. However, NAH may also occur without symptoms with its detection being occasional. Imaging through ultrasound scans is the cornerstone of diagnosis and follow-up monitoring over time. Here we report on a small NAH case series comprising three full-term, macrosomic infants who were born by vaginal delivery. The first and second ones showed clear signs of birth asphyxia, whereas the third was completely asymptomatic. In all three patients, only the right adrenal gland was involved, in line with what happens in 70% of cases. NAH is usually self-limiting and prone to a progressive resolution in a time ranging between 3 weeks and 6 months and so did in our three patients. KEY POINTS · NAH is caused by perinatal asphyxia.. · It is diagnosed with addominal ultrasound.. · It is usually self-limiting..

This study aimed to describe the first two cases of electrical cardiometry applied to newborn with hypoplastic left heart syndrome for hemodynamical assessment in the first days of life before surgical correction and see if this can help decision making process in these patients.

We describe two case series of two full-term newborn with hypoplastic left heart syndrome in the Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, between December 2019 and January 2020.

Case 1 was persistently hemodynamically stable with prostaglandin E1 infusion at 0.01 mcg/kg/min, showing good capillary refill time, good diuresis, no difference between pre- and postductal values of oxygen saturation or blood pressure. Electrical cardiometry monitoring constantly showed cardiac output values higher than 300 mL/kg/min. Case 2 showed poor clinical condition needing prostaglandin E1 infusion up to 0.05 mcg/kg/min, intubation and septostomy associated with low cardiac output around 190 mL/kg/min. Once cardiac output has begun to rise and reached values constantly over 300 mL/kg/min, clinical condition improved with amelioration in oxygen saturation, diuresis, blood pressure, and blood gas analysis values.