Prognostic accuracy of qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients presenting with suspected infection to the emergency department (PASSEM) Multicenter prospective external validation cohort study protocol.

BACKGROUND: Early identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department. METHODS AND ANALYSIS: PASSEM study is an international prospective external validation cohort study. For 9 months, each participating center will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalization. We will collect patients' demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., ≥72 hours), and 30- as well as 90-days all-cause mortality. The study started in December 2021 and planned to enroll 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses. DISCUSSION: PASSEM study will be the first international multicenter prospective cohort study that designated to externally validate qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients with suspected infection presenting to the ED in the Middle East region. STUDY REGISTRATION: The study is registered at ClinicalTrials.gov (NCT05172479).

Variable-Sized bis(4-spiro-fused-ß-lactam)-Based Unsaturated Macrocycles: Synthesis and Characterization.

The synthesis with structural identifications including NMR and HRMS spectral data along with single-crystal X-ray diffraction analysis (for 20b, 23b, 25b-27b) of a family of 14 new syn/anti bis-4-spiro-ß-lactam-based unsaturated macrocycles (19a,b-27a,b), obtained by multistep synthesis including (i) diimine formation, (ii) Staudinger [2 + 2] ketene-imine cycloaddition, and (iii) ring-closing metathesis (RCM), is reported.

Sequential Diimination, Staudinger [2 + 2] Ketene-Imine Cycloaddition, and Ring-Closing Metathesis (RCM) Reactions: In Route to Bis(4-spiro-fused-ß-lactams)-Based Macrocycles.

Based on sequential organic transformations, that is, diimine formation, Staudinger [2 + 2] ketene-imine cycloaddition, and ring-closing metathesis (RCM) reactions, the synthesis with full structural identification including NMR and HRMS spectral data along with single X-ray diffraction analysis (for anti 7b, anti 8b, syn 9a, and anti 9b) of the first syn/anti bis-4-spiro-ß-lactams-based azacrown ethers (7a,b-9a,b) is reported.

An ultra-stable 1.5 T permanent magnet assembly for qubit experiments at cryogenic temperatures.

Magnetic fields are a standard tool in the toolbox of every physicist and are required for the characterization of materials, as well as the polarization of spins in nuclear magnetic resonance or electron paramagnetic resonance experiments. Quite often, a static magnetic field of sufficiently large, but fixed, magnitude is suitable for these tasks. Here, we present a permanent magnet assembly that can achieve magnetic field strengths of up to 1.5 T over an air gap length of 7 mm. The assembly is based on a Halbach array of neodymium magnets, with the inclusion of the soft magnetic material Supermendur to boost the magnetic field strength inside the air gap. We present the design, simulation, and characterization of the permanent magnet assembly, measuring an outstanding magnetic field stability with a drift rate of |D| < 2.8 ppb/h. Our measurements demonstrate that this assembly can be used for spin qubit experiments inside a dilution refrigerator, successfully replacing the more expensive and bulky superconducting solenoids.

Socio-Demographic Characteristics and Patterns of Substance Use Disorder in Oman: A retrospective study of the National Registry Surveillance Programme between 2004 and 2018.

OBJECTIVES: Substance use disorder is a global challenge. Therefore, this study aimed to provide an updated view of socio-demographic characteristics and patterns of substance use in Oman. METHODS: This retrospective descriptive study was conducted between 2004 and 2018. Data were retrieved from Oman's National Drug Addict Registry. The data collected included the socio-demographic characteristics of registered cases, the proportion of various psychoactive substances' consumption and their routes of administration, the associated sociodemographic determinants as well as comorbid conditions. RESULTS: A total of 6,453 cases were registered during the study's timeframe. The majority of which were Omani (97.9%), male (98.7%), single (57.9%), unemployed (50.2%), had an education level below university (81.0%) and were adolescents and young adults (77.0%). Opiates were the most common substance used (66.6%) and more than half of the sample were polydrug users (51.0%). Injecting-drug users constituted 53.4% of the total registered cases. The proportion of people with hepatitis virus C, hepatits virus B and HIV among the registered cases were 46.9%, 5.1% and 3.7%, respectively. CONCLUSION: The findings are in favour of rapidly escalating the introduction of a substance use preventive programme at all school levels as well as making opioid substitution therapy and other harm reduction programmes available in Oman.

The effect of triclosan-coated sutures on the rate of surgical site infection after hip and knee arthroplasty: a double-blind randomized controlled trial of 2546 patients.

Aims: Surgical site infection (SSI) is a common complication of surgery with an incidence of about 1% in the United Kingdom. Sutures can lead to the development of a SSI, as micro-organisms can colonize the suture as it is implanted. Triclosan-coated sutures, being antimicrobical, were developed to reduce the rate of SSI. Our aim was to assess whether triclosan-coated sutures cause a reduction in SSIs following arthroplasty of the hip and knee. Patients and Methods: This two-arm, parallel, double-blinded study involved 2546 patients undergoing elective total hip (THA) and total knee arthroplasty (TKA) at three hospitals. A total of 1323 were quasi-randomized to a standard suture group, and 1223 being quasi-randomized to the triclosan-coated suture group. The primary endpoint was the rate of SSI at 30 days postoperatively. Results: The baseline characteristics of age, gender and comorbidities were well matched in the two groups. The rates of superficial SSI were 0.8% in the control group and 0.7% in the intervention group (p = 0.651), and when deep and superficial SSIs were combined the rates were 2.5% and 1.8 (p = 0.266). The length of stay in hospital and the rates of medical complications did not differ significantly between the groups (p = 1.000). Conclusion: This trial provided no evidence that the use of triclosan-coated sutures at THA and TKA leads to a reduction in the rate of SSI. Cite this article: Bone Joint J 2018;100-B:296-302.

Autologous serum skin test as a diagnostic aid in chronic idiopathic urticaria.

Background. Chronic urticaria is defined as urticaria persisting daily for more than six weeks. A significant number of patients had autoimmune basis where autologous serum skin test is widely used for detection of chronic autoimmune urticaria. Objectives. To estimate the frequency of autoimmune urticarial in Iraqi patients utilizing the autologous serum skin test and to evaluate its results with the variable clinical features of chronic idiopathic urticaria. Methods. In this prospective study, 54 patients with chronic idiopathic urticaria were investigated with autologous serum skin test where its results were examined with the different clinical parameters of chronic autoimmune urticaria. Results. Twenty two patients (40.7%) out of 54 patients with chronic idiopathic urticarial had positive autologous serum skin test. Statistical analysis of the clinical variables did not show a significant difference between patients with positive and negative autologous serum skin test except for the distribution of wheals on the face and extremities which was significantly associated with positive autologous serum skin test results (P value 0.004). Conclusion. Autologous serum skin test is a simple, office-based test for detecting chronic autoimmune urticaria patients who have no distinctive clinical features differentiating them from chronic idiopathic urticaria patients.

Upper gastrointestinal bleeding in haemophiliacs: incidence and relation to use of non-steroidal anti-inflammatory drugs.

This multicentre study sought to estimate the incidence of upper gastrointestinal (UGI) bleeding in haemophiliacs and its relationship to use of non-steroidal anti-inflammatory drugs (NSAIDs). Cox models were used to estimate relative hazards (RH) with 95% confidence intervals (CI) for postulated risk factors. Conditional logistic regression and stored sera were used to assess UGI bleeding risk with Heliobacter pylori seropositivity in cases compared with closely matched controls. During a mean of 17.4 months (range 2-34), 2285 participants, ages 13-89 (mean 36.5) were followed for 3309 person-years (py). Forty-two experienced a UGI bleeding event (incidence 1.3 per 100 py), most from ulcer (11), gastritis (four), varices (five) and Mallory Weiss tears (eight). RH was significantly increased with traditional NSAID use for <1 month (OR: 3.66; 95% CI: 1.1-11.9), but not with coxibs use. RH was significantly and independently increased with age >46 years (3.5; 95% CI: 1.1-10.6) and hepatic decompensation (4.4; 95% CI: 1.7-11.6). Likelihood of bleeding was substantially but not significantly increased (OR: 4.6; 95% CI: 0.3-83.9) with H. pylori seropositivity. These findings suggest that coxibs are a safer alternative than traditional NSAIDs in the treatment of haemophilic arthropathy.

The corporo-glans ligament: description and functional significance of a ligament connecting the corpora cavernosa to the glans penis.

The two corpora cavernosa (CC) end blindly under cover of the glans penis (GP). The method of attachment of the CC to the GP could not be traced in the literature. The current communication investigated the hypothesis of a ligamentous attachment existing between the two corporal ends and the GP. In all, 18 male cadaveric specimens were studied by direct dissection and histologically. Six were neonates and 12 adults (mean age 32.3+/-10.6 s.d. y). After examining and photographing the connection between the CC and GP, sagittal, parasagittal, and coronal sections of the connection were stained and studied microscopically. A triangular fibrous tissue band connected the distal blind ends of the two CC with the GP. The base of this band was attached to the tunica albuginea of the two CC, while the apex was continuous with the fibrous septa between the sinusoids of the cavernous tissue of the GP. Microscopically, the ligament consisted of collagen and elastic fibers; in some sections, the collagen fibers of the tunica albuginea were continuous with those of the band. A band of collagen and elastic fibers could be identified connecting the two CC to the GP; we term it the 'corporo-glans ligament'. This ligament presumably affords the connection with rigidity, flexibility, and tissue strength. We suggest that it firmly connects the GP to the CC during penile thrusting. Further studies are required to assess the possible role of this ligament in erectile dysfunction.

The histomorphologic structure of the levator ani muscle and its functional significance.

The levator ani muscle (LAM), unlike other striated muscles has resting myoelectric activity, the cause of which is not precisely known. In a recent study this activity was suggested to be related to the presence of smooth muscle bundles in the LAM. The present study investigated this point in 25 cadaveric specimens (10 neonates, 15 adults). Histologic examination of the LAM was performed in 12 specimens, three to six slices being taken from the lateral to the medial side of each muscle, processed and stained with H&E and Masson's trichrome stain. The remaining 13 specimens were studied by direct dissection and photographed. Microscopic examination of specimens from adult cadavers showed that the lateral part of the LAM consisted of purely skeletal muscle bundles, mostly of the small-caliber type and few of the large or intermediate type. As we proceeded medially, smooth muscle bundles started to appear. Examination of slices medial to the midportion of the LAM showed that the muscle began to be separated into two layers: a deep (pelvic) one formed of smooth fibers and a superficial (perineal) one of skeletal fibers, separated by a neurovascular plane. Microscopic examination of specimens from neonates showed that the whole LAM consisted of skeletal fibers; no smooth fibers or separation into two layers were identified. By direct dissection of the adult specimens the medial part of the LAM consisted of two layers, superficial and deep, which were separated by fascia containing vessels and nerves. The muscle was thicker at its medial part and tapered laterally, with loss of demarcation, into two layers. Specimens from neonates showed no differentiation of the LAM, into two layers. It is suggested that the deep layer of the LAM, which was formed of smooth fibers, acts involuntarily, supporting the pelvic viscera by its tone and responding to variations in intra-abdominal pressure by adaptation of this tone. The superficial layer of the LAM, made of skeletal fibers, appears to represent the functional mobile part that acts voluntarily during urination or defecation. The presence of the smooth fibers in the adult LAM and not in neonates seems to be adaptational, caused by the action of intra.abdominal pressure and visceral weight. The skeletal fibers pass into various histologic stages before they transform to smooth fibers.

Rectosigmoid junction: anatomical, histological, and radiological studies with special reference to a sphincteric function.

The existence of a sphincter at the rectosigmoid junction (RSJ) is controversial. Recent studies have demonstrated a high-pressure zone within the RSJ which responds to sigmoid colon or rectal contractions by relaxation or contraction, respectively. These findings suggest the presence of a "physiological" sphincter at the RSJ. The current study investigated the anatomical and histological structure and the radiological picture of the RSJ in view of the possible existence of an anatomical sphincter at the RSJ and elucidating its function. The RSJ was studied in 28 cadavers (18 adults and 10 fully mature neonates) by dissection. A histological study of the RSJ was performed in 5 cadavers. Radiological examination using double-contrast barium enema was carried out in 50 healthy volunteers (mean age 44.2+/-14.4 years; 32 men, 18 women). The mucous membrane of the RSJ was found in folds forming a "mucosal rosette" of a mean length of 2.8+/-0.9 cm in adult specimens and 0.7+/-0.2 cm in neonates. The distal end of the mucosal rosette was sharply delineated and in some specimens protruded into the rectal lumen as a small nipple, which was surrounded by a "rectal fornix" on either side. The histological examination of the RSJ showed mucosal foldings with deep crypts surrounded by lymphocytic aggregates and marginated by muscularis mucosa. The circular muscle coat showed gradually increasing thickness towards the rectum. Nerve cells in the submucosa were located at three levels: in the vicinity of the muscularis mucosa, in the middle of the submucosa, and in the proximity of the circular muscle. Radiologically the opening of the sigmoid colon into the RSJ presented as a ring or crescent. Radiological striations representing the mucosal rosette were demonstrated. The RSJ appeared as a narrow contractile segment. The anatomical, histological, and radiological findings thus indicate that the RSJ is a segment which can be identified by its interior rather than outer aspect. The study suggests the presence of an anatomical sphincter at the RSJ which seems to regulate the passage of stools from the sigmoid colon to the rectum.

Pathological fractures of the proximal femur treated with the Variwall reconstruction nail.

Ten patients with pathological proximal femoral fractures were treated with the Variwall reconstruction nail. There were five intertrochanteric, one combined shaft and neck, and four subtrochanteric fractures fixed by this method. The mean age was 71 (54-90). The purpose of this study was to assess the use of a reconstruction nail in pathological fractures around the intertrochanteric region. The Variwall nail was found to be relatively easy to insert with no operative complications. Follow up was for a minimum 4 months. Most patients achieved our aim of good pain relief coupled with improved mobility and thus were easier to nurse. Even with extensive metastases in the femur, the nail provided sound stability to permit early weight bearing. There were no complications related to the nail.

Unstable intertrochanteric fractures treated with the Variwall reconstruction nail.

Forty consecutive patients with unstable intertrochanteric fractures were treated with the Variwall reconstruction nail. Twelve of these had subtrochanteric extensions to their fractures, while most were highly comminuted grade 5 fractures. This nail was found to be relatively easy to use with a mean operative time of 58 min. Mean follow up was 5.8 months. Clinically, 86 per cent had occasional pain or none at all. There were no external rotation deformities, and only one case of shortening. Radiologically there were no non-unions and no case of shaft fractures. Failure occurred in one case, but in the remaining 39 no varus collapse occurred. In conclusion this method of fixation in unstable intertrochanteric fractures provides the necessary stability to give good results.

Hinged silastic implants of the great toe.

Since 1982, hinged silastic implants have been used in the treatment of hallux valgus and hallux rigidus in preference to excision arthroplasty or metatarsophalangeal joint fusion. The results of this treatment in 106 feet in 89 patients are satisfactory to subjective and objective assessment over an average follow-up period of 27.7 months (range, 12-60 months). Hinged prosthesis overcomes the problems associated with resection arthroplasty.