Learning to Walk With Deep Reinforcement Learning: Forward Dynamic Simulation of a Physics-Based Musculoskeletal Model of an Osseointegrated Transfemoral Amputee.

This paper leverages the OpenSim physics-based simulation environment for the forward dynamic simulation of an osseointegrated transfemoral amputee musculoskeletal model, wearing a generic prosthesis. A deep reinforcement learning architecture, which combines the proximal policy optimization algorithm with imitation learning, is designed to enable the model to walk by using three different observation states. The first is a complete state that includes the agent's kinematics, ground reaction forces, and muscle data; the second is a reduced state that only includes the kinematics and ground reaction forces; the third is an augmented state that combines the kinematics and ground reaction forces with a prediction of the muscle data generated by a fully-connected feed-forward neural network. The empirical results demonstrate that the model trained with the augmented observation state can achieve walking patterns with rewards and gait symmetry ratings comparable to those of the model trained with the complete observation state, while there are no symmetric walking patterns when using the reduced observation state. This paper shows the importance of including muscle data in a deep reinforcement learning architecture for the forward dynamic simulation of musculoskeletal models of transfemoral amputees.

IMU-Based Classification of Locomotion Modes, Transitions, and Gait Phases with Convolutional Recurrent Neural Networks.

This paper focuses on the classification of seven locomotion modes (sitting, standing, level ground walking, ramp ascent and descent, stair ascent and descent), the transitions among these modes, and the gait phases within each mode, by only using data in the frequency domain from one or two inertial measurement units. Different deep neural network configurations are investigated and compared by combining convolutional and recurrent layers. The results show that a system composed of a convolutional neural network followed by a long short-term memory network is able to classify with a mean F1-score of 0.89 and 0.91 for ten healthy subjects, and of 0.92 and 0.95 for one osseointegrated transfemoral amputee subject (excluding the gait phases because they are not labeled in the data-set), using one and two inertial measurement units, respectively, with a 5-fold cross-validation. The promising results obtained in this study pave the way for using deep learning for the control of transfemoral prostheses with a minimum number of inertial measurement units.

Chilling Effects on Immigrants' Health Insurance Coverage After the 2016 Presidential Election.

BACKGROUND: Depressed enrollment in public benefits among immigrants and their families may occur due to concerns about deportation and obstacles to permanent residency status related to immigration policies. METHODS: Using data from the American Community Survey (ACS) from 2014 to 2019, we conducted an interrupted time series analysis to estimate Medicaid enrollment, private insurance enrollment, and uninsured rates among low-income non-citizen adults and their children, compared to U.S. citizens before and after the Trump administration entered office in January 2017. RESULTS: Compared to U.S. citizen adults, Medicaid enrollment among non-citizen adults decreased and the uninsured rate increased (1.5 percentage points per year, p < 0.05) from 2017 to 2019. Decreases in coverage starting in 2017 were larger among both children with at least one non-citizen parent and non-citizen children. DISCUSSION: These findings suggest that the Trump administration immigration policy climate is associated with decreased health insurance enrollment among this population.

Pit-and-fissure sealants on primary molars are a cost savings.

BACKGROUND: In this study, the authors examine the cost-effectiveness of light-polymerized resin-based fluoride sealants on primary molars in high caries risk children younger than 6 years. METHODS: The authors examined the cost-effectiveness of pit-and-fissure sealant (PFS) treatment on primary molars by comparing sealed and unsealed molars treated in the outpatient clinic or operating room. Using 1,884 primary molars followed over a 5-year period, the authors used a mixed-effects regression model to estimate the probability of caries development. They used restricted means to estimate years free of caries for carious molars. They used a decision tree to address uncertainty due to PFS treatment failure, predict the expected value associated with each strategy, and estimate the incremental cost-effectiveness ratio using a 3% discount rate to adjust future cost and outcomes to present value. RESULTS: Over 5 years, the cost of care was $90 for unsealed molars and $75 for sealed molars. Unsealed molars remained caries free for 4.32 years compared with 4.85 years in sealed molars. The cost-effectiveness of PFS treatment was dominant, leading to a savings of $25 for each caries-free year gained and overall savings of $742 million for the United States dental health system over a 5-year period. CONCLUSIONS: PFS treatment is associated with cost savings and a delay in caries development and should be considered in children with high caries risk. PRACTICAL IMPLICATIONS: Policy makers should consider reimbursement of PFS treatment on primary molars in high caries risk children.

Perceived oral health interventions by medical providers in Gugulethu, South Africa.

INTRODUCTION: The purpose of this study was to explore factors that impact patients' ability to access high quality, expeditious oral health care by understanding medical professionals' knowledge of oral health, the care they provide to patients presenting with oral health complaints, and their perceptions of potential interventions to improve oral health care delivery. METHODS: We conducted in depth qualitative interviews, which were analyzed using an inductive content analytical approach. The study was conducted in Gugulethu, a community located outside of Cape Town, South Africa. Local public sector health services provided free-of-charge are the main source of primary health and dental care for this population. Participants included the following medical providers: doctors, clinical nurse practitioners, professional nurses, and health promoters. RESULTS: Identified themes fell within the three broad subject areas: oral health knowledge, patient care, and potential interventions. Themes within oral health knowledge included (1) personal responsibility for hygiene, (2) routine oral health care, (3) lack of knowledge among medical professionals, (4) poverty, and (5) an oral-systemic connection. Participants cited both 'clinical care knowledge' and/or 'uncertainty' about patient care for oral health complaints. Participants independently suggested interventions in three broad areas: (1) education, (2) expanded provider roles, and (3) colocation of services. CONCLUSIONS: Our findings suggest that a variety of interventions, ranging from high to low resource investment, may impact access to and utilization of oral health services and thereby result in improved patient care. Future studies should develop and evaluate the suggested interventions in a range of care settings.

Integrating Competency-Based Didactic and Experiential Global Health Learning for Dental Students: The Global Health Learning Helix Model.

The aim of this study was to evaluate the feasibility and preliminary outcomes of immersive integrated experiential and didactic courses in strengthening competency-based global health learning in dental education. To address global inequities in oral health and student interest in global health, the Harvard School of Dental Medicine introduced two global health courses in 2017-18. The first was a didactic course in the core predoctoral curriculum, and the second, in collaboration with the Inter-American Center for Global Health, was a five-day elective experiential learning course in rural Costa Rica. The experiential course was an extension of the didactic course. All 33 second-year dental students completed the didactic course, and three of those students completed the experiential course. A pre-post survey and a six-month follow-up survey on self-reported knowledge based on course learning objectives were administered. The experiential course students also completed journals and interviews for qualitative analysis. Thirty-two students completed the pre-post didactic course surveys, for a response rate of 94%. There was a 100% response rate on the pre-post didactic surveys by those students who participated in the experiential learning course. While the experiential learning group scored similarly to the class average before the didactic course, they had higher scores than the class averages both immediately after and at the six-month follow-up. All three students reported that the experiential learning course was "extremely effective" in building on what they learned in the didactic course. Qualitative analysis of the journals and interviews suggested enhanced learning from the combination of didactic and experiential methods. These preliminary results support the Global Health Learning Helix Model, a theoretical competency-based teaching model for ethical student global health engagement to better prepare the future generation in tackling oral health disparities both locally and worldwide.

Developing an Open Access, Competency-Based Global Oral Health Curriculum: A Global Health Starter Kit.

Dental education has seen increases in global health and international educational experiences in many dental schools' curricula. In response, the Consortium of Universities for Global Health's Global Oral Health Interest Group aims to develop readily available, open access resources for competency-based global oral health teaching and learning. The aim of this study was to develop and evaluate a Global Health Starter Kit (GHSK), an interdisciplinary, competency-based, open access curriculum for dental faculty members who wish to teach global oral health in their courses. Phase I (2012-17) evaluated longitudinal outcomes from two Harvard School of Dental Medicine pilot global health courses with 32 advanced and 34 predoctoral dental students. In Phase II (2018), the Phase I outcomes informed development, implementation, and evaluation of the open access GHSK (45 enrollees) written by an interdisciplinary, international team of 13 content experts and consisting of five modules: Global Trends, Global Goals, Back to Basics: Primary Care, Social Determinants and Risks, and Ethics and Sustainability. In Phase III (summer and fall 2018), five additional pilot institutions (two U.S. dental schools, one U.S. dental hygiene program, and two dental schools in low- and middle-income countries) participated in an early adoption of the GHSK curriculum. The increase in perceived knowledge scores of students enrolled in the pilot global health courses was similar to those enrolled in the GHSK, suggesting the kit educated students as well or better in nearly all categories than prior course materials. This study found the GHSK led to improvements in learning in the short term and may also contribute to long-term career planning and decision making by providing competency-based global health education.

Cephalometric Measurements Of Non-Syndromic Oligodontia In Early Dental Age In A Japanese Population.

PURPOSE: Oligodontia significantly affects oral function and esthetics. Recognition of skeletal and dental patterns may aid in proper diagnosis and development of appropriate interventions. The aim of this study was to analyze skeletal and dental patterns for pre-adolescent patients with a diagnosis of oligodontia. PATIENTS AND METHODS: This study included 19 oligodontia patients (age: 9.5±1.3, Hellman's developmental stage IIIA~IIIB) along with a control group that comprised of 19 participants (age: 9.9±1.6) without any skeletal disharmony or congenitally missing teeth, with an Angle class I relationship and general crowding. Average cephalometric measurements among the oligodontia group were compared to the control group. The correlation between number of congenitally missing teeth (CMT) and each measurement was investigated. Skeletal measurements for both male and female patients in the oligodontia group and the control group were also compared. RESULTS: No significant difference between the experimental and the control group was observed with respect to skeletal angular and linear measurements, except the gonial angle. Differences in dental pattern measurements were observed. The oligodontia group had significantly smaller Mo-Ms and Is-Mo than the control group (p<0.01). No correlation was detected between severity of oligodontia (number of CMT) and skeletal measurement except for SNB (R=-0.4). For females with oligodontia, Mo-Ms (eruption of maxillary first molar) and Is-Mo (mesial location of maxillary first molar) significantly differed from females in the control group (p<0.01). In contrast, no differences in Mo-Ms or Is-Mo were detected for male patients when oligodontia and control group were compared. CONCLUSION: Among pre-adolescent Japanese patients with oligodontia in Hellman's developmental age IIIA~IIIB, no significant differences in skeletal characteristics were established when compared to the control group. However, tooth position of maxillary first molars indicated smaller vertical descent and mesial shift, which may suggest weak maxillary vertical development.

Long-Term Outcome of Patients With a Hematologic Malignancy and Multiple Organ Failure Admitted at the Intensive Care.

OBJECTIVES: Historically, patients with a hematologic malignancy have one of the highest mortality rates among cancer patients admitted to the ICU. Therefore, physicians are often reluctant to admit these patients to the ICU. The aim of our study was to examine the survival of patients who have a hematologic malignancy and multiple organ failure admitted to the ICU. DESIGN: This retrospective cohort study, part of the HEMA-ICU study group, was designed to study the survival of patients with a hematologic malignancy and organ failure after admission to the ICU. Patients were followed for at least 1 year. SETTING: Five university hospitals in the Netherlands. PATIENTS: One-thousand ninety-seven patients with a hematologic malignancy who were admitted at the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was 1-year survival. Organ failure was categorized as acute kidney injury, respiratory failure, hepatic failure, and hemodynamic failure; multiple organ failure was defined as failure of two or more organs. The World Health Organization performance score measured 3 months after discharge from the ICU was used as a measure of functional outcome. The 1-year survival rate among these patients was 38%. Multiple organ failure was inversely associated with long-term survival, and an absence of respiratory failure was the strongest predictor of 1-year survival. The survival rate among patients with 2, 3, and 4 failing organs was 27%, 22%, and 8%, respectively. Among all surviving patients for which World Health Organization scores were available, 39% had a World Health Organization performance score of 0-1 3 months after ICU discharge. Functional outcome was not associated with the number of failing organs. CONCLUSIONS: Our results suggest that multiple organ failure should not be used as a criterion for excluding a patient with a hematologic malignancy from admission to the ICU.

Can effusion-synovitis measured on ultrasound or MRI predict response to intra-articular steroid injection in hip osteoarthritis?

OBJECTIVES: Intra-articular steroid injection (IASI) is an effective therapy for hip osteoarthritis (OA), but carries risks and provides significant pain relief to only two thirds of patients. We attempted to predict response to IASI in hip OA patients using baseline clinical, ultrasound, and MRI data. METHODS: Observational study of 97 subjects with symptomatic hip OA presenting for IASI. At baseline and 8 weeks we obtained hip MRI, grayscale and Doppler ultrasound, clinical range of motion (ROM), timed-up and go test (TUG) scores, and self-reported Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain, stiffness, and function scores. Bone-capsule distance (BCD) measurements of inflammation on hip ultrasound and MRI were measured at three locations: the proximal-most uncovered portion of the femoral head, the superficial-most (apex) portion of the femoral head, and the largest fluid pocket at the femoral neck. RESULTS: Ultrasound and MRI BCD correlated with each other significantly and strongly at the apex and neck. Power Doppler findings did not correlate significantly with any other imaging indices. Eight weeks post-injection, WOMAC pain, function, and stiffness scores significantly improved and TUG time improved nearly to the level of significance, but there were no significant changes in ultrasound, MRI, or Doppler indices. Baseline variables were not significantly different between responder and nonresponder WOMAC pain or TUG time cohorts. CONCLUSION: Basic measures of inflammation on ultrasound and MRI are highly related to each other, but provide little insight into patient function and pain after IASI. Other mechanisms to explain improvement in patient status after IASI are likely at work.

Integrating student feedback during "Dental Curriculum Hack-A-thon".

BACKGROUND: The future of dental education is at crossroads. This study used the parameter of the 2016 Dental Curriculum Hack-a-Thon to assess intra- and inter-institutional agreement between student and faculty views regarding dental curriculums to determine if there is an impact in student perceptions towards dental education from before and after the event. METHODS: This exploratory, cross-sectional study involved two surveys, with Survey 1 being distributed among four faculty-student pairs of the four participating dental schools answering 14 questions. Survey 2 assessed the views of 20 participating dental students through 26 questions in a pre- and post- event survey design. Descriptive statistics were used to explore differences in perceptions towards dental education across both instrument surveys. RESULTS: The results revealed valuable student insights regarding intra- and inter-institutional agreement relevant for the change in dental curriculum that needs to occur. Survey 2 revealed that mandatory attendance in didactic courses, electronic based examination preferences, and the preference of preclinical courses being held in the first and second years of a four-year dental curriculum were of particular importance to student participants. CONCLUSIONS: The results of this study indicate that exposure and participation in subjects pertaining to dental education can be influential on student preferences and opinions on how dental education should be delivered in a four-year curriculum.

A National Survey of U.S. Dental Students' Experiences with International Service Trips.

Globalization, along with the increasing prevalence of non-communicable diseases, their risk factors, and poor oral health, demands global approaches to oral health care. Trained health care workers' providing volunteer services abroad is one model used for improving access to dental services for some communities. Currently, little is known about U.S. dental student involvement in international clinical service volunteerism. The aim of this exploratory study was to capture national survey data from predoctoral dental students about their interest in and experience with global health service trips. The survey sought to assess students' past experiences and current and future interest in programs providing dental and/or medical services in order to lay the foundation for further research. A 12-question web-based survey was distributed in May 2017 to 22,930 students enrolled in U.S. dental schools. A total of 1,555 students responded, for a response rate of 7%. Respondents were evenly distributed across the four academic years. Approximately 22% (n=342) of the respondents had already participated in a service trip experience, 83% reported interest in a service trip while in school, and 92% were interested after graduation. Reported motivations for international trips included the desire to care for the underserved and to obtain a more global view of health and disease. Concerns were expressed regarding costs and time constraints. This study provided preliminary, exploratory data on dental student engagement with international service trips. Both interest and participation in international service trips among responding students were high, reflecting current trends in both dentistry and medicine. Dental education may have an opportunity to guide student engagement in more sustainable and ethical volunteering in the U.S. and abroad.

Factors that Motivated Otherwise Healthy HIV-Positive Young Adults to Access HIV Testing and Treatment in South Africa.

The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm3 who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.

An improved model for the analysis of combined antimicrobials: a replacement for the Chou-Talalay combination index method.

AIMS: To rationalize confusion in the literature concerning the analysis of combined antimicrobials, specifically to see if the combination index (CI) method of analysis was as rigorous as claimed. METHODS AND RESULTS: Data from previous studies of the inhibition of Staphylococcus aureus by mixed antimicrobials were re-analysed using the CI method and a model which takes account of differences in the concentration exponents of individual antimicrobials. CONCLUSIONS: The Chou-Talalay combination index method for the analysis of combined antimicrobials was found to be valid only in the specific cases where concentration exponents were equal. In these cases, the CI method was found to be a function of the residuals of fitting the additive model to the observed data. Where concentration exponents were not equal, the CI method was invalid, whereas the additive model took these differences into account. SIGNIFICANCE AND IMPACT OF STUDY: The CI method can be replaced wholly by the additive model described. The model allows simple regression to be used to analyse whole data sets and provides simple graphical output.

"It was pain. That's it. It was pain." Lack of oral health care among otherwise healthy young adults living with HIV in South Africa: A qualitative study.

INTRODUCTION: The purpose of this study is to understand engagement with and availability of dental services among people living with HIV in a low-income community of South Africa. METHODS: In depth qualitative interviewing was used to collect data, which was analyzed using an inductive content analytical approach. The study was conducted in Gugulethu, a township community located outside of Cape Town, South Africa. Local public sector health services provided free of charge are the main source of primary health and dental care for this population. Participants included South African adults (age 18-35) recently diagnosed with HIV who had a CD4 count >350 cells/mm3. RESULTS: Many participants had little to no experience with dental care, did not know which health care providers are appropriate to address oral health concerns, were not aware of available dental services, utilized home remedies to treat oral health problems, harbored many misperceptions of dental care, avoided dental services due to fear, and experienced poverty as a barrier to dental services. CONCLUSIONS: Our findings suggest that integration of oral healthcare into medical care may increase patient knowledge about oral health and access to care. Leveraging the relatively robust HIV infrastructure to address oral disease may also be an effective approach to reaching these participants and those living in resource poor communities generally.

Fat metaplasia on MRI of the sacroiliac joints increases the propensity for disease progression in the spine of patients with spondyloarthritis.

OBJECTIVE: We tested the hypothesis that fat metaplasia on MRI of the sacroiliac joints (SIJ) increases the propensity for new bone formation in the spine of patients with spondyloarthritis. METHODS: We assessed baseline T1-weighted and short τ inversion recovery SIJ MRIs from patients in the Follow Up Research Cohort in Ankylosing Spondylitis (FORCAST). Radiographic progression was assessed using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Structural and inflammatory lesions were scored using the Spondyloarthritis Research Consortium of Canada (SPARCC) SIJ structural and SPARCC SIJ inflammation scores, respectively. Radiographic progression was compared in cases with and without definite MRI lesions (score ≥2 or <2) and the extent of MRI lesions at baseline was compared in patients with and without radiographic progression. The predictive capacity of MRI SIJ lesions for radiographic progression in the spine was assessed in univariate and multivariate regression analyses. RESULTS: The extent of MRI structural lesions in the SIJ at baseline was significantly greater in those patients who had spinal radiographic progression on follow-up (p=0.003, 0.02, 0.003 for fat metaplasia, backfill and ankylosis, respectively). Also, radiographic progression was significantly greater in cases with definite baseline SIJ ankylosis (p=0.008). In multivariate regression that included all types of MRI lesions and was adjusted for age, sex, symptom duration, duration of follow-up, CRP, baseline mSASSS and treatment, the extent of SIJ fat metaplasia and ankylosis at baseline were independently associated with radiographic progression. CONCLUSIONS: SIJ ankylosis and fat metaplasia but not inflammatory lesions increase the propensity for radiographic progression in the spine.

Evidence that eating baked egg or milk influences egg or milk allergy resolution: a systematic review.

BACKGROUND: It has been proposed that the frequent ingestion of baked hen's egg or cow's milk accelerates the resolution of hen's egg or cow's milk allergy. This practice is being introduced into clinical practice. OBJECTIVE: To systematically review the evidence to determine whether the introduction of baked hen's egg or cow's milk into the diet of children with hen's egg or cow's milk allergies respectively leads to a larger proportion of children outgrowing these allergies than expected. METHODS: A systematic review of the literature was conducted in Medline, Embase and CINAHL. The inclusion criteria were as follows: randomized control trials, case-control or cohort studies; children aged 0-18 years with hen's egg or cow's milk allergy; baked hen's egg or cow's milk intervention with or without a comparator; and resolution of the hen's egg or cow's milk allergy as determined by food challenge as the outcome. Studies were critically appraised using the quality assessment tool for quantitative studies. PROSPERO reference CRD42015026029. RESULTS: We identified 851 and 2816 hen's egg and cow's milk articles respectively. Only three hen's egg and three cow's milk studies fulfilled our pre-specified inclusion criteria. The studies concluded that baked products either increased the likelihood of the resolution of allergy or accelerated resolution. However, when critiqued, all studies were classified as weak because they were observational, lacking an appropriate control group; this brings into doubt the study's conclusions. There were a number of examples of severe reactions to baked products. CONCLUSION: There is little evidence to address the hypothesis that the ingestion of baked hen's egg or cow's milk results in more patients outgrowing their hen's egg or cow's milk allergy respectively. Data are required from a trial comparing the resolution rates of baked-tolerant participants who are randomized to ingest or avoid baked products to assess the accuracy of this hypothesis.

Modelling the effect of combined antimicrobials: A base model for multiple-hurdles.

Combining antimicrobials to reduce microbial growth and to combat the potential impact of antimicrobial resistance is an important subject both in foods and in pharmaceutics. Modelling of combined treatments designed to reduce or eliminate microbial contamination in foods (microbiological predictive modelling) has become commonplace. Two main reference models are used to analyse mixtures: the Bliss Independence and the Loewe reference models (LRM). By using optical density to analyse the growth of Aeromonas hydrophila, Cronobacter sakazakii and Escherichia coli in combined NaCl/NaCl (a mock combination experiment) and combined NaCl/KCl experiments, previous models for combined antimicrobials in foods, based on the Bliss approach, were shown to be inconsistent and that models based on the LRM more applicable. The LRM was shown, however, to be valid only in the specific cases where the concentration exponents of all components in a mixture were identical. This is assured for a mock combination experiment but not for a true mixture. This, essentially, invalidates the LRM as a general reference model. A new model, based on the LRM but allowing for mixed exponents, was used to analyse the combined inhibition data, and concluded that the NaCl/KCl system gave the additive effect expected from literature studies. This study suggests the need to revise current models used to analyse combined effects.

The OA Trial Bank: meta-analysis of individual patient data from knee and hip osteoarthritis trials show that patients with severe pain exhibit greater benefit from intra-articular glucocorticoids.

OBJECTIVE: To evaluate the efficacy of intra-articular (IA) glucocorticoids for knee or hip osteoarthritis (OA) in specific subgroups of patients with severe pain and inflammatory signs using individual patient data (IPD) from existing trials. DESIGN: Randomized trials evaluating one or more IA glucocorticoid preparation in patients with knee or hip OA, published from 1995 up to June 2012 were selected from the literature. IPD obtained from original trials included patient and disease characteristics and outcomes measured. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). The subgroup factors assessed included severe pain (≥70 points, 0-100 scale) and signs of inflammation (dichotomized in present or not) at baseline. Multilevel regression analyses were applied to estimate the magnitude of the effects in the subgroups with the individuals nested within each study. RESULTS: Seven out of 43 published randomized clinical trials (n = 620) were included. Patients with severe baseline pain had a significantly larger reduction in short-term pain, but not in mid- and long-term pain, compared to those with less severe pain at baseline (Mean Difference 13.91; 95% Confidence Interval 1.50-26.31) when receiving IA glucocorticoid injection compared to placebo. No statistical significant interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo and to tidal irrigation at all follow-up points. CONCLUSIONS: This IPD meta-analysis demonstrates that patients with severe knee pain at baseline derive more benefit from IA glucocorticoid injection at short-term follow-up than those with less severe pain at baseline.

Characteristics and outcomes of patients with a haematological malignancy admitted to the intensive care unit for a neurological event.

OBJECTIVES: Patients with haematological malignancies are at risk of concomitant critical neurological events warranting intensive care unit admission. We aimed to examine the characteristics and outcomes of this patient population, as more knowledge could facilitate decision making on ICU admission and treatment. DESIGN, SETTING AND PARTICIPANTS: A retrospective cohort study of 68 patients in adult ICUs of six Dutch university hospitals between 2003 and 2011. RESULTS: The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23 (IQR, 16-27), and 77% of patients needed mechanical ventilation within the first 24 hours of admission. Forty percent of patients had received an allogeneic stem cell transplantation, and 22% were neutropenic on admission. The most frequent underlying haematological condition was non-Hodgkin lymphoma (27%). Seizures were the most common neurological event for ICU admission (29%). The median ICU length of stay was 5 days (IQR, 1-13 days). ICU mortality (28%), hospital mortality (37%) and 3-month mortality (50%) were comparable with other studies of ICU patients with haematological malignancies. Factors associated with 3-month survival were baseline platelet count (113×10(9)/L in survivors v 39×10(9)/L in non-survivors, P<0.01) and APACHE II score (20 in survivors v 25 in non-survivors, P=0.02). CONCLUSIONS: Patients with a history of haematological malignancy presenting with a critical neurological event have comparable survival rates with other patients with a haematologic malignancy admitted to the ICU. Our findings suggest that restrictions in ICU care are not justified for this patient population.