Pilot study of an arts- and theatre-based HIV prevention intervention for men who have sex with men and transgender women migrants in South Africa: acceptability, feasibility and preliminary efficacy.

Innovative approaches addressing the elevated human immunodeficiency virus (HIV) risk among men who have sex with men (MSM) or transgender women (TGW) migrants in South Africa are urgently needed. We sought to present the acceptability, feasibility and preliminary efficacy of 'Externalize and Mobilize!', a multi-session arts- and theatre-based HIV prevention group intervention for MSM and TGW migrants in South Africa. Fourteen participants-MSM (n = 7; 50%), genderqueer/nonbinary persons (n = 4; 29%) and TGW (n = 3; 21%)-in Cape Town were recruited and enrolled in the intervention and administered pre- and post-intervention assessments of HIV knowledge, HIV risk-reduction self-efficacy, stigma and resilience. The intervention, delivered over 4 days, was completed by all 14 participants. Scores on HIV knowledge and HIV risk-reduction self-efficacy were statistically significantly higher at post-intervention compared with pre-intervention. Additionally, participants responded affirmatively (i.e. 'Agree' or 'Strongly agree') on all items assessing intervention acceptability. Findings demonstrate the high acceptability, feasibility and preliminary efficacy of an arts- and theatre-based intervention for increasing HIV knowledge and HIV risk-reduction self-efficacy among MSM and TGW migrants in South Africa. This study provides further support for the use of creative and innovative interventions to address entrenched HIV disparities in South Africa.

Pediatric maxillary expansion has a positive impact on hearing? A systematic review and meta-analysis.

OBJECTIVE: Hearing loss is a highly prevalent condition in the pediatric population. Pediatric maxillary expansion is a widespread treatment to address transverse maxillary deficiency. First reports describing an association between improvements for patients with HL and PME initiated in the 1960s. In this systematic review and meta-analysis we aim to review the role of maxillary expansion in reducing conductive hearing loss in pediatric population. REVIEW METHODS: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked. Main outcome was expressed as the difference between air-bone gap, compliance, ear volume and conductive hearing thresholds before and after treatment and the 95% confidence interval. RESULTS: A total of 10 studies (218 patients) met inclusion criteria. The pooled data in the meta-analysis under a random effects model shows a statistically significant difference of 10.57dB mean reduction after palatal expansion. The air-bone gap was significantly reduced by 5.39dB (CI 95% 3.68, 7.10). Compliance and volume were assessed in three studies, with a non-significant positive difference in the compliance (0.14) and a statistically significant difference for volume (0.80) after palatal expansion. CONCLUSION: This systematic review and meta-analysis found a positive effect of pediatric maxillary expansion in conductive hearing loss in well-select children. However, results cannot be extrapolated for children with conductive hearing loss without an accompanying orthodontic indication (maxillary constriction). It showed that the existing prospective studies exhibited qualitative pitfalls, limiting the ability to obtain conclusive evidence about the role of pediatric maxillary expansion on conductive hearing loss in children.

"Minimally Invasive" Skin Grafting With Enzymatic Debridement and Autologous Skin Cell Spray: A Retrospective Case Series.

Minimally invasive surgery is becoming the standard of care across surgical subspecialties. Several new "minimally invasive" options for burn debridement and autografting exist. Enzymatic bromelain-based debridement (BBD) and autologous skin cell spray (ASCS) have independently proven to reduce the rate of split-thickness skin grafting (STSG) and decrease donor site size when grafting is performed. There is a paucity in the literature regarding the combination of these two therapies. The purpose of this study is to characterize a cohort of patients treated with both BBD and ASCS and qualitatively compare data to expected outcomes without these therapies. This retrospective study of a single academic burn center's experience using BBD and ASCS together included 13 patients with a total burn surface area (TBSA) from 1-30% and all had >50% deep partial thickness. All patients received BBD and ASCS. Deeper burns additionally received STSG with ASCS overspray. Median burn size was 14% TBSA (IQR:5.45,20), donor site size was 225 sq cm (IQR:28.5,556.5), and ratio of donor site area to total treatment area of 0.082 (IQR: 0.039, 0.241) was observed. Median observed length of stay (LOS) was 19 days (IQR:10,27), expected LOS was 15.4 days, and O/E ratio 1.06. Donor sites in both groups of patients were much smaller than expected versus treatment with conventional meshed STSG alone and length of stay is lower than expected based on burn size. An emphasis on expenses and scar development will guide future studies into the patient subset and wound features that are best for this combination treatment.

La chirurgie mini-invasive devient le standard de traitement dans de nombreuses spécialités. Il y a de telles possibilités en brûlologie comme de débridement enzymatique à la bromélaïne (DEB) et la pulvérisation de cellules cutanées autologues (PCCA) qui ont chacun permis de diminuer le recours aux autogreffes et de réduire la surface de la zone donneuse. La littérature est pauvre en ce qui concerne la combinaison des 2. Cette étude rétrospective rapporte une cohorte de 13 patients traités dans notre centre par combinaison de DEB et PCCA, et compare le résultat avec celui attendu avec un traitement conventionnel. Les patients étaient brûlés sur 1 à 30% de SCT (médiane 14, IQR 5,45-20) dont au moins la moitié de 2ème profond, ayant tous reçu une combinaison de DEB et PCCA. Les atteintes plus profondes étaient greffées, avec une PCCA par dessus. Le site donneur avait une surface médiane de 225 cm2 (IQR 28,5-556,5) avec un rapport surface donneuse/surface traitée de 0,082 (IQR 0,039-0,241). La durée médiane de séjour est de 19 jours (IQR 10-27) quand elle était supposée être de 15,4 jours (rapport 1,06). Les sites donneurs étaient plus exigus que sous traitement conventionnel et la durée de séjour plus courte que supposée. Une étude plus précise sur les séquelles et les coûts permettrait de cibler plus précisément les patients susceptibles de bénéficier de ce protocole.

Hydroxocobalamin Administration After Inhalation Injury Is Not Associated With Mesenteric Ischemia.

Hydroxocobalamin has been administered in the United States since 2006 by first responders and burn centers as a safe antidote for cyanide toxicity, a serious complication of smoke inhalation. There are no current contraindications to the use of this rescue measure. A recent retrospective French publication reported a potential correlation between hydroxcobalamin administration and acute mesenteric ischemia (AMI) in critically ill burn and inhalation injury patients. The purpose of this study is to characterize the risk of AMI related to hydroxocobalamin. A retrospective review of hydroxocobalamin administration among adult burn patients was conducted at a regional burn center over a 2-year period. Injury characteristics, demographics, and outcomes including presence of mesenteric ischemia (defined as presence of pneumatosis or perforation on CT scan or necrotic bowel on laparotomy) were recorded. Of 17 confirmed inhalation injuries, patients had a median (interquartile range) age, total body surface area (TBSA), and abbreviated burn severity (ABSI) index as follows: 60 (45, 65 IQR), 8.5 (1.8, 39 IQR), and 6 (5,7 IQR). Inhalation injury was diagnosed with bronchoscopy, carboxyhemoglobin, or clinical suspicion. Eighty-two percent of those with bronchoscopy had an inhalation grade of 2 or greater. None (0%) of the patients showed signs of mesenteric ischemia, tube feeding intolerance, pneumatosis/perforation on CT, or necrotic bowel on laparotomy. Aware of the study limitations, we conclude that hydroxocobalamin does not increase risk for AMI.

L'hydroxocobalamine (OHB12), antidote peu dangereux en cas d'intoxication cyanhydrique (complication grave de l'inhalation de fumées), est administrée depuis 2006 par les premiers secours étatsuniens. Il n'existe actuellement pas de contre- indication à son utilisation. Une étude rétrospective française récente a rapporté la possible association entre OHB12 et ischémie mésentérique (IM) chez des brûlés graves ayant inhalé des fumées. Cette étude se propose d'étudier cette éventuelle corrélation. Il s'agit d'une étude rétrospective conduite pendant 2 ans dans un CTB régional. Les caractéristiques démographiques, celles de la brûlure et l'évolution (en recherchant particulièrement une IM) ont été relevées. Le diagnostic d'IM était posé devant des images scannographiques évocatrices (pneumopéritoine, perforation digestive) ou la constatation per- opératoire d'une nécrose digestive. Dix- sept patients avaient une inhalation de fumées confirmée par endoscopie (dans ce cas, 87% des patients avec inhalation de fumées avaient des lésions de grade 2 ou plus) ou carboxyhémoglobine ou simple suspicion clinique. Leur âge médian était de 65 ans (Q1: 45, Q3 : 35), leur surface brûlés de 8,5% (Q1: 1,8, Q3 : 39), leur ABSI de 6 (Q1 : 5 ; Q3 : 7). Aucun patient n'a développé une IM ni une intolérance digestive. Bien que cette étude ait des limitations, nous concluons que OHB12 n'est pas un facteur de risque d'IM.

An Adjusted Ideal Body Weight Index Formula With Fresh Frozen Plasma (FFP) Rescue Decreases Fluid Creep During Burn Resuscitation.

Severe burn injury requires significant volume resuscitation, but over-resuscitation can be deadly. Accurate resuscitation of obese patients is challenging due to the decreased vascularity of adipose tissue. This study compares an adjusted ideal body weight index formula with fresh frozen plasma rescue to historical controls resuscitated with Parkland-based resuscitation. A retrospective review was conducted of adult patients admitted to our regional burn center with ≥ 20% total body surface area (TBSA) burns from 2010 to 2017 who survived more than 48 hours. Historical controls were resuscitated with Parkland-based resuscitation with occasional albumin. The adjusted ideal body weight (AIBW) patients were resuscitated with 2-4 mL/kg/%TBSA using an adjusted ideal body weight with fresh frozen plasma (FFP) rescue. Outcomes were compared with nonparametric statistics. A total of 161 patients met inclusion criteria: 40 patients received AIBW resuscitation and 121 patients were included as controls. The AIBW group received less fluid (3.30 vs. 4.15 mL/kg/%TBSA, p<0.001). A significant reduction in acute kidney injury requiring dialysis in the AIBW group was appreciated (5% vs. 19%, p=0.03) with improved mortality in AIBW patients as well (5% vs. 20%, p=0.03). Using an adjusted ideal body weight with FFP rescue to resuscitate patients with severe burn injury leads to a significant reduction in fluid administration without increase in acute kidney injury requiring dialysis and with improved mortality.

Les brûlés graves ont besoin d'un remplissage vasculaire majeur, pouvant toutefois être mortel s'il est exagéré. Il est particulièrement difficile chez les obèses, en raison de la faible vascularisation du tissu adipeux. Cette étude compare une formule basée sur le poids idéal (PI) et utilisant du PFC à des séries historiques utilisant la formule de Parkland. Cette étude rétrospective a revu les dossiers des patients admis dans notre CTB, ayant survécu plus de 48 h, entre 2010 et 2017. Les 121 cas historiques recevaient un remplissage selon Parkland (et de l'albumine au besoin). Les 40 patients à l'étude recevaient 2 à 4 mL/kg/% de PFC, le volume étant calculé sur le poids idéal. Ce groupe recevait significativement (p < 0,001) moins (3,3 mL/kg/%) de volume que le groupe contrôle (4,15). Ils avaient aussi moins fréquemment besoin d'épuration extra- rénale (5% VS 19%, p= 0,03) et leur mortalité était moindre (5% VS 20%, p= 0,03).

Animal welfare in the context of World Trade Organization dispute settlement.

This paper was written to give veterinarians and decision-makers an overview of World Trade Organization (WTO) findings relevant to animal welfare. The article has a practical focus and does not attempt to provide a legal analysis of WTO dispute settlement. The author has simplified very technical legal language so that the paper will be useful to a broader audience. The global trade rules comprise a series of legal agreements that came into effect in 1995, when the WTO was established. The overarching objective of the WTO is to promote international trade by avoiding unjustified discrimination between trading partners. The harmonisation of national measures with relevant international standards is encouraged by the WTO to facilitate safe trade. The broad objective of the World Organisation for Animal Health (OIE) is to promote global improvements in animal health and welfare, and veterinary public health. To this end, the OIE sets intergovernmental standards and works to strengthen the capacities of Members to implement them. The OIE standards are recognised as WTO references with respect to animal health and zoonotic diseases and a significant number of WTO disputes have addressed the relevance of these OIE standards to international trade measures. In addition to animal health standards, the OIE also sets standards for animal welfare, and has implemented regional and global strategies to encourage their adoption by Members. In comparison with measures to protect animal health or food safety, few WTO disputes have considered animal welfare related measures. A lack of WTO case law has contributed to uncertainty about the consistency of WTO animal welfare measures. This paper considers some WTO disputes and findings relevant to animal welfare. The outcomes of these disputes suggest that WTO Panels and the Appellate Body are prepared to accept the right of Members to regulate for animal welfare purposes, providing that they respect the established WTO disciplines. This article draws two main conclusions. Firstly, regardless of whether measures are adopted to protect animal welfare or animal health, for WTO consistency, they must not result in unjustifiable, arbitrary or unnecessary discrimination. Secondly, regardless of how the WTO deals with animal welfare, governments must respond to the growing interest of consumers in farm animal welfare. The OIE standards, as recognised references for trading countries and the WTO, will continue to be influential in relation to global trade in animal products. It is important that the OIE update its animal welfare standards regularly, to ensure that they are consistent with latest scientific understanding and appropriate to consumer expectations for ethical food production.

Cet article vise à donner aux vétérinaires et aux décideurs politiques un aperçu des conclusions de l'Organisation mondiale du commerce (OMC) se rapportant au bien-être animal. L'article a une portée pratique et ne prétend aucunement fournir une analyse juridique du système de règlement des différends de l'OMC. L'auteure s'exprime dans des termes simples sans recourir à un langage trop technique ou juridique afin que son texte soit utile à un large public. Les règles du commerce mondial sont constituées par un ensemble d'accords juridiques entrés en vigueur en 1995 lors de la création de l'OMC. L'objectif primordial de l'OMC est de promouvoir un commerce international sûr en évitant toute discrimination injustifiée entre partenaires commerciaux. L'OMC encourage les pays à harmoniser leurs mesures nationales avec les normes internationales pertinentes afin de faciliter les échanges internationaux sûrs. L'Organisation mondiale de la santé animale (OIE) a pour vocation principale de soutenir les améliorations apportées à la santé et au bien-être animal ainsi qu'à la santé publique vétérinaire dans le monde. À cette fin, l'OIE élabore des normes intergouvernementales et s'emploie à renforcer les capacités de ses Membres à les mettre en oeuvre. Les normes de l'OIE étant reconnues par l'OMC en tant que références dans le domaine de la santé animale et des maladies zoonotiques, un nombre significatif de différends portés devant l'OMC a examiné la pertinence des normes de l'OIE pour les mesures appliquées aux échanges internationaux. Outre les normes relatives à la santé animale, l'OIE a également élaboré des normes sur le bien-être animal et lancé un certain nombre de stratégies régionales et mondiales pour encourager ses Membres à les adopter. Comparativement aux mesures visant à protéger la santé animale ou la sécurité sanitaire des aliments, les mesures en lien avec le bien-être animal ont très rarement été invoquées lors du traitement de différends portés devant l'OMC. Cette absence de jurisprudence au sein de l'OMC a suscité quelques interrogations sur la cohérence des mesures de l'OMC relevant du bien-être animal. L'auteure examine certains différends et conclusions de l'OMC se rapportant au bien-être animal. Les conclusions sur ces litiges semblent indiquer qu'aussi bien les groupes spéciaux de l'OMC que son organe d'appel sont disposés à reconnaître le droit des Membres à imposer des règles relevant du bien-être animal, à condition que les disciplines établies de l'OMC soient respectées. L'auteure en tire deux conclusions principales. La première est qu'indépendamment du fait que le motif des mesures adoptées soit de protéger la santé animale ou le bien-être animal, l'impératif de cohérence de l'OMC exige qu'elles ne se traduisent pas par une discrimination injustifiée, arbitraire ou inutile. La deuxième conclusion est qu'indépendamment du traitement par l'OMC des questions de bien-être animal, les gouvernements doivent désormais tenir compte de la place croissante qu'occupe le bien-être des animaux d'élevage dans les préoccupations des consommateurs. Étant des références reconnues aussi bien pour les pays participant aux échanges commerciaux que pour l'OMC, les normes de l'OIE continueront à exercer une influence décisive sur le commerce mondial de produits d'origine animale. Il est important que l'OIE réactualise régulièrement ses normes de bien-être animal afin de s'assurer qu'elles tiennent compte des connaissances scientifiques les plus récentes et qu'elles répondent aux attentes des consommateurs en faveur d'une éthique de la production des denrées alimentaires.

La autora presenta a veterinarios e instancias decisorias una panorámica de las conclusiones a las que ha llegado la Organización Mundial del Comercio (OMC) que de algún modo inciden en la cuestión del bienestar animal, privilegiando sobre todo un enfoque práctico, esto es, sin tratar de ofrecer un análisis jurídico de la casuística de solución de controversias de la OMC y simplificando el lenguaje jurídico, tan proclive a los tecnicismos, para que estas líneas resulten de utilidad a un público más amplio. Las reglas que rigen el comercio mundial comprenden una serie de acuerdos jurídicos que entraron en vigor en 1995, cuando se fundó la OMC con el objetivo general de promover el comercio internacional evitando toda discriminación injustificada entre socios comerciales. Con el fin de facilitar un comercio seguro, la OMC promueve la armonización de las medidas nacionales con las normas internacionales pertinentes. La Organización Mundial de Sanidad Animal (OIE) tiene por objetivo general promover la mejora a escala mundial de la sanidad y el bienestar animales y de la salud pública veterinaria. Para ello, la OIE establece normas intergubernamentales y se esfuerza por dotar a sus Países Miembros de mayor capacidad para aplicarlas. La OMC tiene reconocidas las normas de la OIE como textos de referencia en materia de sanidad animal y enfermedades zoonóticas y buen número de las controversias que se han planteado en la OMC tenían que ver con la pertinencia de esas normas de la OIE con respecto a una u otra medida de comercio internacional. Además de fijar normas zoosanitarias, la OIE también establece normas referidas al bienestar de los animales y ha implantado estrategias regionales y mundiales para alentar a sus Países Miembros a adoptarlas. En comparación con las medidas destinadas a proteger la sanidad animal o la inocuidad de los alimentos, son pocas las controversias de la OMC que han tenido por objeto medidas relativas al bienestar de los animales. La falta de jurisprudencia de la OMC ha contribuido a generar incertidumbre sobre la coherencia de las medidas de la OMC en materia de bienestar animal. La autora examina algunas de las controversias y conclusiones de la OMC que guardan algún tipo de relación con el bienestar animal. El desenlace de esas controversias lleva a pensar que los grupos especiales y el Órgano de Apelación de la OMC están dispuestos a aceptar el derecho de los Miembros a reglamentar con fines de bienestar animal, siempre y cuando respeten las disciplinas instauradas por la OMC. La autora llega a dos conclusiones principales. En primer lugar, con independencia de que se adopten medidas destinadas a proteger el bienestar de los animales o la sanidad animal, la coherencia de la propia OMC exige que tales medidas no se traduzcan en discriminación alguna que sea injustificable, arbitraria o innecesaria. En segundo lugar, al margen del tratamiento que haga la OMC de la cuestión del bienestar animal, los gobiernos deben dar respuesta al creciente interés de los consumidores por el bienestar de los animales de granja. Las normas de la OIE, reconocidas como textos de referencia para la OMC y los países que intervienen en transacciones comerciales, seguirán pesando en el comercio mundial de productos de origen animal. Es importante que la OIE actualice periódicamente sus normas de bienestar animal para que integren el conocimiento científico más reciente y respondan a las expectativas del consumidor en cuanto a producción ética de los alimentos.

Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale.

INTRODUCTION: We recently proposed a scale for assessment of patient-relevant functional limitations following an episode of venous thromboembolism (VTE). Further development of this post-VTE functional status (PVFS) scale is still needed. METHODS: Guided by the input of VTE experts and patients, we refined the PVFS scale and its accompanying manual, and attempted to acquire broad consensus on its use. RESULTS: A Delphi analysis was performed involving 53 international VTE experts with diverse scientific and clinical backgrounds. In this process, the number of scale grades of the originally proposed PVFS scale was reduced and descriptions of the grades were improved. After these changes, a consensus was reached on the number/definitions of the grades, and method/timing of the scale assessment. The relevance and potential impact of the scale was confirmed in three focus groups totaling 18 VTE patients, who suggested additional changes to the manual, but not to the scale itself. Using the improved manual, the κ-statistics between PVFS scale self-reporting and its assessment via the structured interview was 0.75 (95%CI 0.58-1.0), and 1.0 (95%CI 0.83-1.0) between independent raters of the recorded interview of 16 focus groups members. CONCLUSION: We improved the PVFS scale and demonstrated broad consensus on its relevance, optimal grades, and methods of assessing among international VTE experts and patients. The interobserver agreement of scale grade assignment was shown to be good-to-excellent. The PVFS scale may become an important outcome measure of functional impairment for quality of patient care and in future VTE trials.

Determining the minimal clinically important difference for the PEmbQoL questionnaire, a measure of pulmonary embolism-specific quality of life.

Essentials The minimal clinically important difference (MCID) for PEmbQoL has not yet been determined. We estimated the MCID for PEmbQoL and its subscales via anchor- and distribution-based approaches. Our results indicate that MCID for PEmbQoL appears to be 15 points. Our work enables interpretation of changes or differences in PEmbQoL. SUMMARY: Background Pulmonary embolism (PE) reduces quality of life (QOL). The PEmbQoL questionnaire, a PE-related QOL measure, was recently developed and validated and has been used to quantify disease-specific QOL in clinical studies of patients with PE. However, to date, interpretation of PEmbQoL scores has been limited by a lack of information on the minimal clinically important difference (MCID) of this measure. Objective To determine the MCID for PEmbQoL and its subscales using anchor-based and distribution-based approaches. Methods We analyzed data from the ELOPE Study, a prospective, multicenter cohort study of long-term outcomes after a first episode of acute PE. At baseline and 1, 3, 6 and 12 months after PE, we measured generic QOL (SF-36), PE-specific QOL (PEmbQoL) and dyspnea severity (UCSD Shortness of Breath Questionnaire). We used time-varying repeated-measures mixed-effect models to estimate anchor-based MCID and effect sizes to estimate distribution-based MCID. Results Eighty-two patients participated in this sub-study. Their mean age was 49.4 years, 60% were male and 84% had PE diagnosed in an outpatient setting. Using both anchor- and distribution-based approaches, the MCID for PEmbQoL appears to be 15 points. Based on this MCID, 42%, 59%, 66% and 75% of patients experienced at least one MCID unit of improvement in PEmbQoL from baseline to 1, 3, 6 and 12 months, respectively. Conclusion Our results provide new information on the MCID of PEmbQoL, a PE-specific QOL questionnaire that can be used by researchers and clinicians to measure and interpret changes in PE-specific QOL over time, or as an outcome in clinical trials.

Development of a clinical prediction model for the postthrombotic syndrome in a prospective cohort of patients with proximal deep vein thrombosis.

Essentials We developed a prediction model for postthrombotic syndrome (PTS) after deep vein thrombosis (DVT). High risk predictors were iliac vein DVT, BMI>35 and moderate-severe Villalta category. Patients with a score ≥4 had an odds ratio of 5.9 (95% CI 2.1-16.6) for PTS. SOX-PTS score may select DVT patients for close monitoring or aggressive strategies to treat DVT. SUMMARY: Background Postthrombotic syndrome (PTS) is a chronic complication that develops in 20-50% of patients after deep vein thrombosis (DVT). Although individual risk factors for PTS have been characterized, the ability to predict which DVT patients are likely to develop PTS remains limited. Objective To develop a clinical prediction score for PTS in patients with DVT. Methods The derivation cohort consisted of participants in the SOX Trial, a randomized double-blind placebo-controlled trial of elastic compression stockings versus placebo stockings worn for 2 years after DVT to prevent PTS in patients with a first proximal DVT, enrolled in 24 community and tertiary-care hospitals from 2004 to 2010. Multivariable logistic regression analysis of baseline characteristics was performed. The outcome was the occurrence of PTS, diagnosed starting from 6 months or later according to Ginsberg's criteria. Results Seven hundred and sixty-two patients were included in the analysis. The median follow-up was 728 days. The model includes three independent predictors, and has a range of possible scores from 0 to 5. High-risk predictors were: index DVT in the iliac vein; body mass index of ≥ 35 kg m-2 ; and moderate-severe Villalta severity category at DVT diagnosis. As compared with patients with a score of 0, those with a score of ≥ 4 had an odds ratio of 5.9 (95% confidence interval 2.1-16.6) for developing PTS. Conclusions To our knowledge, this is the first clinical prediction score for PTS. We identified three independent predictors that, when combined, predicted PTS risk after a first proximal DVT. The SOX-PTS score requires external validation before it can be considered for clinical use.

Prehospital hydroxocobalamin for inhalation injury and cyanide toxicity in the United States - analysis of a database and survey of ems providers.

Prehospital use of hydroxocobalamin as an antidote for cyanide toxicity, a serious complication of smoke inhalation, has yet to be universally adopted in the United States though its efficacy and safety have been demonstrated since 2006. The purpose of this study was to characterize practices of prehospital hydroxocobalamin administration via a survey of emergency medical services (EMS) and to report a case series from an EMS database to track use of hydroxocobalamin. The Fire Smoke Coalition Newsletter emailed a voluntary survey to EMS subscribers regarding hydroxocobalamin use. Survey responses were analyzed in addition to survival data from the Smoke Inhalation Treatment Database (SITD), a publically available, self-reported, online database for EMS regarding smoke inhalation patient outcomes. Analysis was compared to current published data from PubMed. The survey had a 14% response rate (284/2000). Only 38% reported prehospital utilization of a hydrogen cyanide antidote with 46% using hydroxocobalamin. 20% of responders reported a formal ALS protocol was in place for hydroxocobalamin use. For the SITD, 12 of 13 (92%) patients who received hydroxocobalamin for suspected inhalation survived. Other studies found a survival rate of 72% and 42% after administration of hydroxocobalamin for smoke inhalation. Prehospital administration of hydroxocobalamin for cyanide toxicity is uncommon in the United States, as evidenced by this analysis, despite well-documented safety and efficacy. Although a small sample, patients who received prehospital hydroxocobalamin had improved survival. This survival rate is significantly greater than those reported previously.

L'utilisation préhospitalière de l'hydroxocobalamine (OHB12) comme antidote du cyanure, intoxication grave compliquant les inhalations de fumées (IF), n'est toujours pas réalisée partout aux États-Unis, bien que son innocuité et son efficacité aient été démontrées dès 2006. Les buts de cette étude était de caractériser l'utilisation préhospitalière d'OHB12 à travers les données des services d'urgences (SU) et de rapporter une série de cas issus de leurs dossiers. La « Fire Smoke Coalition Newsletter ¼ a proposé par courriel aux services d'urgence abonnés un étude sur l'utilisation d'OHB12, basée sur le volontariat. En plus des réponses, nous avons analysé les données de la « Smoke Inhalation Treatment Database ¼ (STID), banque de données publique abondée par les SU, colligeant le devenir des patients victimes d'une IF et les avons comparées aux données de la littérature, retrouvée dans PubMed. Le taux de réponse au questionnaire a été de 14% (284/2 000). Trente huit pour cent des répondeurs utilisent des antidotes au cyanure en préhospitalier, qui est OHB12 dans 46% des cas. Vingt pour cent des répondeurs attestent de l'existence d'un protocole formalisé quant à l'utilisation d'OHB12. Selon STID, 92% (12/13) des patients ayant reçu OHB12 ont survécu. D'autres études retrouvent des taux de survie de 72% et 42% après administration de OHB12 dans le cadre de l'IF. Cette étude confirme que l'utilisation préhospitalière d'OHB12 dans le cadre de l'intoxication au cyanure n'est pas habituelle aux États-Unis, malgré une efficacité et une innocuité reconnues. Bien que l'échantillon soit faible, les patients ayant reçu OHB12 en préhospitalier ont un taux de survie nettement amélioré par rapport à ceux précédemment rapportés.

Exploring residual risk for diabetes and microvascular disease in the Diabetes Prevention Program Outcomes Study (DPPOS).

AIM: Approximately half of the participants in the Diabetes Prevention Outcomes Study (DPPOS) had diabetes after 15 years of follow-up, whereas nearly all the others remained with pre-diabetes. We examined whether formerly unexplored factors in the DPPOS coexisted with known risk factors that posed additional risk for, or protection from, diabetes as well as microvascular disease. METHODS: Cox proportional hazard models were used to examine predictors of diabetes. Sequential modelling procedures considered known and formerly unexplored factors. We also constructed models to determine whether the same unexplored factors that associated with progression to diabetes also predicted the prevalence of microvascular disease. Hazard ratios (HR) are per standard deviation change in the variable. RESULTS: In models adjusted for demographics and known diabetes risk factors, two formerly unknown factors were associated with risk for both diabetes and microvascular disease: number of medications taken (HR = 1.07, 95% confidence intervals (95% CI) 1.03 to 1.12 for diabetes; odds ratio (OR) = 1.10, 95% CI 1.04 to 1.16 for microvascular disease) and variability in HbA1c (HR = 1.02, 95% CI 1.01 to 1.03 for diabetes; OR = 1.06, 95% CI 1.04 to 1.09 for microvascular disease per sd). Total comorbidities increased risk for diabetes (HR = 1.10, 95% CI 1.04 to 1.16), whereas higher systolic (OR = 1.22, 95% CI 1.13 to 1.31) and diastolic (OR = 1.14, 95% CI 1.05 to 1.22) blood pressure, as well as the use of anti-hypertensives (OR = 1.41, 95% CI 1.23 to 1.62), increased risk of microvascular disease. CONCLUSIONS: Several formerly unexplored factors in the DPPOS predicted additional risk for diabetes and/or microvascular disease - particularly hypertension and the use of anti-hypertensive medications - helping to explain some of the residual disease risk in participants of the DPPOS.

Long-term outcomes of cancer-related isolated distal deep vein thrombosis: the OPTIMEV study.

Essentials Clinical significance of cancer-related isolated distal deep vein thrombosis (iDDVT) is unknown. We studied patients with iDDVT, with and without cancer, and proximal DVT with cancer. Cancer-related iDDVT patients have a much poorer prognosis than iDDVT patients without cancer. Cancer-related iDDVT patients have a similar prognosis to cancer-related proximal DVT patients. SUMMARY: Background Isolated distal deep vein thrombosis (iDDVT) (infra-popliteal DVT without pulmonary embolism [PE]) is a frequent event and, in the absence of cancer, is usually considered to be a minor form of venous thromboembolism (VTE). However, the clinical significance of cancer-related iDDVT is unknown. Methods Using data from the observational, prospective multicenter OPTIMEV cohort, we compared, at 3 years, the incidences of death, VTE recurrence and major bleeding in patients with cancer-related iDDVT with those in cancer patients with isolated proximal DVT (matched 1:1 on age and sex) and patients with iDDVT without cancer (matched 1:2 on age and sex). Results As compared with patients with cancer-related isolated proximal DVT (n = 92), those with cancer-related iDDVT (n = 92) had a similar risk of death (40.8% per patient-year (PY) vs. 38.3% per PY; aHR = 1.0, 95% CI[0.7-1.4]) and of major bleeding (3.8% per PY vs. 3.6% per PY, aCHR = 0.9 [0.3-3.2]) and a higher risk of VTE recurrence (5.4% per PY vs. 11.5% per PY; aCHR = 1.8 [0.7-4.5]). As compared with patients with iDDVT without cancer (n = 184), those with cancer-related iDDVT had a nine times higher risk of death (3.5% per PY vs. 38.3% per PY; aHR = 9.3 [5.5-15.9]), a higher risk of major bleeding (1.8% per PY vs. 3.6% per PY; aCHR = 2.0 [0.6-6.1]) and a higher risk of VTE recurrence (5.0% per PY vs. 11.5% per PY; aCHR = 2.0 [1.0-3.7]). The results remained similar in the subgroup of patients without history of VTE. Conclusion Patients with cancer-related iDDVT seem to have a prognosis that is similar to that of patients with cancer-related isolated proximal DVT and a dramatically poorer prognosis than patients with iDDVT without cancer. This underlines the high clinical significance of cancer-related iDDVT and the need for additional studies.

Long-term risk of venous thromboembolism recurrence after isolated superficial vein thrombosis.

Essentials Long-term risk of recurrence of isolated superficial vein thrombosis (SVT) is under-studied. We analyzed data from a cohort of first SVT and proximal deep vein thrombosis (DVT) without cancer. The risk of recurrence as DVT or pulmonary embolism is twice lower in SVT patients. However, overall risk of recurrence is similar between SVT and proximal DVT patients. Click to hear Dr Decousus' perspective on superficial vein thrombosis SUMMARY: Background Isolated superficial vein thrombosis (iSVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) is a frequent event, but available data on long-term outcomes are scarce and retrospective. Therefore, we aimed to determine prospectively the risk and type of venous thromboembolism (VTE) recurrence after iSVT and compare them with those of proximal DVT. Methods Using data from the prospective, multicenter, observational, OPTIMEV study, we assessed, at 3 years and after anticoagulants were stopped, the incidence and the type of VTE recurrence (iSVT/DVT/PE) of patients with a first objectively confirmed iSVT without cancer (n = 285), and compared these with those of patients with a first proximal DVT without cancer (n = 262). Results As compared with proximal DVT patients, iSVT patients had a similar overall incidence of VTE recurrence (5.4% per patient-year [PY] versus 6.5% per PY, adjusted hazard ratio [aHR] 0.9, 95% confidence interval [CI] 0.5-1.6), but iSVT recurred six times more often as iSVT (2.7% versus 0.6%, aHR 5.9, 95% CI 1.3-27.1) and 2.5 times less often as deep-VTE events (2.5% versus 5.9%, aHR 0.4, 95% CI 0.2-0.9). Varicose vein status did not influence the risk or the type of VTE recurrence. Saphenian junction involvement by iSVT was not associated with a higher risk of recurrence (5.2% per PY versus 5.4% per PY), but was associated with recurrence exclusively as deep-VTE events. Conclusion In patients with a first iSVT without cancer, after stopping anticoagulants, the incidence of deep-VTE recurrence is half that of DVT patients, but the overall risk of recurrence is similar. Ssaphenian junction involvement seems to influence the risk of deep-VTE recurrence, whereas varicose vein status has no impact or a low impact on VTE recurrence.

Feline discrete high-grade gastrointestinal lymphoma treated with surgical resection and adjuvant CHOP-based chemotherapy: retrospective study of 20 cases.

The aim of this retrospective study was to evaluate the outcome of cats treated with surgical intervention for a discrete intermediate-/high-grade gastrointestinal lymphoma prior to CHOP-based chemotherapy. Variables including sex, breed, haematocrit, white blood cell count, serum albumin concentration, clinical stage of disease, gastrointestinal obstruction and peritonitis were assessed for their effect on survival. Twenty cats met the inclusion criteria with three cats still alive at the time of data analysis. The overall median survival time (MST) was 417 days (range: 12-2962 days). The disease-free interval (DFI) was 357 days (range: 0-1585 days) with six cats still deemed in remission prior to death. Only clinical stage had a significant effect on both MST and DFI. Cats with discrete intermediate/high-grade gastrointestinal lymphoma that undergo surgical resection followed by adjuvant CHOP chemotherapy may achieve acceptable overall survival times.

The postthrombotic syndrome: current evidence and future challenges.

Postthrombotic syndrome (PTS) is a chronic complication of deep vein thrombosis (DVT) that develops in 20-50% of patients. PTS manifests as a spectrum of symptoms and signs of chronic venous insufficiency that can impose significant morbidity and have a negative impact on quality of life. Chronic venous hypertension caused by a combination of residual venous obstruction and valvular reflux is believed to play a major role in the pathophysiology of PTS. The Villalta scale is the most widely applied clinical scale used to diagnose and define PTS. Proximal DVT and recurrent ipsilateral DVT are the two principal established risk factors for PTS, and efforts in recent years have been focused on identifying a combination of clinical and biomarker predictors that will define high-risk patients and possibly new therapeutic targets. The best way to prevent PTS is to prevent the occurrence of DVT, and to provide optimal anticoagulation for the acute phase of DVT once it occurs. Recent years have brought progress in our understanding of the role of endovascular techniques in the prevention and treatment of PTS and the subgroups of patients that may benefit from these modalities. Pharmacomechanical catheter-directed thrombolysis is the most promising interventional modality for prevention of PTS. This review summarizes the current state of evidence on PTS of the lower limbs, and highlights areas where uncertainty still exists that require further research.

Massive Hemorrhage From Multiple Hepatic Artery Aneurysms.

A 66-year-old man, with an abnormal porta hepatis, consistent with tumor or inflammation, developed massive bleeding from one of numerous hepatic artery aneurysms, and coil embolization achieved control of bleeding. He died of subsequent multisystem organ failure, and the most likely diagnosis was either polyarteritis nodosa or segmental arterial mediolysis. Although the dual hepatic blood supply allows a degree of arterial embolization, this case demonstrates the risks associated with large territory hepatic arterial embolization in the presence of hemodynamic instability. We discuss the management issues related to massive hepatic bleeding when no surgical approach is possible.

Extravascular Revascularization of a Chronic Total Occlusion Using the Dual Bull's-Eye Technique.

PURPOSE: To describe the dual bull's-eye technique to achieve successful extravascular revascularization of an occlusion after vessel perforation when the antegrade and retrograde catheters are too far apart for salvage with a reentry catheter. TECHNIQUE: The dual bull's-eye technique, which is an adaptation of the "gun-sight" method for transjugular portosystemic shunt procedures, is demonstrated in a popliteal artery occlusion in which multiple recanalization attempts have produced vessel perforation. Via antegrade femoral and retrograde anterior tibial artery accesses, 10-mm Amplatz GooseNeck snares were advanced in plane from each access to rendezvous in the popliteal fossa to obtain through-and-through wire access. A 15-cm Chiba needle was advanced percutaneously in plane through both snares, and a hydrophilic guidewire was maneuvered across an extravascular tract parallel to the popliteal artery. The tract was carefully predilated, and a 5×100-mm Viabahn stent-graft was deployed across the extravascular tract. CONCLUSION: Owing to potential complications (limited patency, injury to adjacent structures) and only single-case use, this new technique should be considered a bailout strategy exclusively employed for limb salvage when traditional methods have failed and there are no viable surgical options.

Full-thickness wounds resulting from 'do-it-yourself' cryolipolysis: a case study.

This report reviews the case of a 55-year-old woman who suffered frostbite while attempting a 'do-it-yourself' version of cryolipolysis without the guidance of a medical professional. Cryolipolysis is a well-understood process through which the careful application of below-freezing temperatures is used to induce adipose cell death while sparing the skin, reducing body fat. This patient used dry ice in lieu of professional medical equipment, resulting in 4% total body surface area full- and partial-thickness wounds to her abdomen. Ultimately, the more superficial wounds healed with xenograft and a silver-impregnated dressing. The superior, deeper wound was excised and primarily closed with a fleur-de-lis panniculectomy. Her hospital course and recovery were uneventful. This case illustrates how online information of dubious quality can put the uneducated patient at risk of injury. Health-care professionals should be aware of the questionable resources available online, and should help patients become more discerning consumers of online information. Strategies to prevent such injury should be developed on a national scale.