483 Complete Sciatic Nerve Transection from A Closed Femoral Fracture: A Case Report

Introduction

Complete transection of the sciatic nerve following a closed femoral fracture is exceedingly uncommon. Delayed diagnosis may result due to this unrecognised injury pattern.

Case Description:

An 18-year-old male motorcyclist was referred following a significantly displaced closed, femoral fracture. The patient was sedated at the scene and transferred to theatre for definitive fixation, where an open reduction was performed via an anterior approach. Symptoms of paresthesia and weakness were reported immediately postoperatively, and formal neurological examination prompted an emergency MRI. On this basis, the patient was transferred to plastics and underwent surgical exploration, where complete transection of the sciatic nerve was identified just proximal to the bifurcation into the common peroneal and tibial nerve. A nerve gap of five centimetres was identified requiring reconstruction with grouped fascicular sural nerve grafts.

Discussion:

Complete transection of the sciatic nerve is a devastating injury that compromises the function of the posterior compartment of the thigh and all motor function below the knee. To our knowledge, reports of complete sciatic nerve transection secondary to a closed fracture of the femoral shaft are extremely rare in the pertinent literature, with only two other cases reported to date.

Throat Packs in Cleft and Craniofacial Surgery

ABSTRACT

Throat packs are used in a wide range of surgical and dental procedures. Indications for use include; airway stabilization, reducing the risk of aspiration, and postoperative nausea and vomiting. Despite these perceived benefits, a retained throat pack can be fatal. This has been highlighted since the 1970s but as of yet no effective fail-safe mechanisms exist to prevent the potential tragic consequences of a retained throat pack.A multifaceted questionnaire was distributed at the annual Craniofacial Society of Great Britain and Ireland 2017 to identify current views and practices amongst cleft surgeons. The questionnaire contained seventeen questions related to throat pack use. The responses to the questions were collated and discussed in the context of the current literature.Twenty-four cleft surgeons completed the questionnaire; 67% always use a throat pack, with 84% not securing the throat pack in any way. Almost half (48%) had encountered a serious adverse incident secondary to the use of a throat pack.This survey and review of the literature highlight ongoing discrepancies and a lack of standardization on a national basis. Adverse incidents and fatalities are still occurring. Overwhelming evidence now confirms the lack of benefit regarding postoperative nausea and vomiting and the authors urge both surgeons and anesthetists to strongly consider the need for a throat pack in routine elective procedures.

HIDRADENITIS SUPPURATIVA IN POSTMENOPAUSE

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, debilitating disease with a profound impact on the quality of life of patients.

OBJECTIVES

To describe a rare case of HS with postmenopausal onset, to review the literature data regarding late onset HS and to discuss the current knowledge on the role of endocrine abnormalities in the development of HS.

CASE REPORT

We report the case of a 68-year-old patient in whom HS occurred 10 years after menopause. She was referred to our clinic for the presence of an open fistula on the left groin, fibrotic scars and visible alteration of the vulvar anatomy due to numerous surgical interventions. The patient shared features of the metabolic syndrome (obesity, arterial hypertension, dyslipidemia, aortic atherosclerosis), but showed no signs of virilism and no hormonal abnormality. HS was controlled using antiseptics, topical retinoids and antibiotics.

CONCLUSIONS

This case is of particular interest given the late onset of HS, long time after menopause. The development of HS requires a complex interaction between genetic predisposing factors, endocrine dysregulation, metabolic alterations, bacterial overgrowth and an aberrant inflammatory response. Evidence points to an important role of sex-hormones in the emergence and progression of the disease, but the underlying mechanisms are still unclear. A better understanding of HS pathogenesis is needed to elucidate the precise way in which endocrine factors influence the disease onset and course. This would guide the way to novel therapies and a better control of this challenging disease.

Just try it: A six months protocol for borderline personality disorder impulsivity and symptoms reduction

Introduction

Borderline Personality Disorder is defined from its impulsivity issues regarding relationships, abandonment and rejection issues and emotional regulation problems. This personality disorder issue are hard to treat and often related to poor treatment outcomes. Nonetheless, Dialectical Behavioral Therapy stands as a great therapeutical approach that can be adapted.

Objectives

We tested a 6-month CBT protocol (ECCCLORE)-3 modules respectively working on emotion regulation, distress tolerance and relationships- in a French context to compare its effectiveness to treatment as Usual (TAU).

Methods

We recruited 56 patients suffering from BPD, 34 receiving ECCCLORE treatment and 22 receiving TAU. We assessed BPD traits, impulsivity with UPPS, aggressiveness with AQ12, Suicidal risk with SBQr and Hopelessness with H.

Results

Our results revealed the effectiveness of this 6 months DBT adaptation for decreasing BPD traits and most of clinical dimensions. The dynamic analysis revealed the mediating effect of AQ12.

Conclusions

Shortened treatment protocol are effective for reducing symptoms. Further research is needed to replicate these results.

Experimental and theoretical study of photo-dissociation spectroscopy of pyrene dimer radical cations stored in a compact electrostatic ion storage ring

In this paper, we present an experimental and theoretical study of the photo-dissociation of free-flying dimer radical cations of pyrene (C16H10)2+. Experimentally, the dimers were produced in the plasma of an electron cyclotron resonance ion source and stored in an electrostatic ion storage ring, the Mini-Ring for times up to 10 ms and the photo-dissociation spectrum was recorded in the 400 to 2000 nm range. Two broad absorption bands were observed at 550 (2.25 eV) and 1560 nm (0.79 eV), respectively. Theoretical simulations of the absorption spectrum as a function of the temperature were performed using the Density Functional based Tight Binding approach within the Extended Configuration Interaction scheme (DFTB-EXCI) to determine the electronic structure. The simulation involved all excited electronic states correlated asymptotically with the five lowest excited states D1-D5 of the monomer cation and a Monte Carlo exploration of the electronic ground state potential energy surface. The simulations exhibit three major bands at 1.0, 2.1 and 2.8 eV respectively. They allow assigning the experimental band at 1560 nm to absorption by the charge resonance (CR) excited state correlated with the ground state of the monomer D0. The band at 550 nm is tentatively attributed to dimer states correlated with excited states D2-D4, in the monomer cation. Simulations also show that the CR band broadens and shifts towards longer wavelength with increasing temperature. It results from the dependence on the geometry of the energy gap between the ground state and the lowest excited state. The comparison of the experimental spectrum with theoretical spectra at various temperatures allows us to estimate the temperature of the stored (C16H10)2+ in the 300-400 K range, which is also in line with the expected temperatures of the ions deduced from the analysis of the natural decay curve.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

The Operative Incidence of Syndactyly in Northern Ireland. A 10-Year Review

BACKGROUND

Syndactyly is a common congenital condition that can present sporadically or in relation to an underlying genetic condition. Little contemporary published data exists detailing specific rates of presentation and surgical intervention, especially in Western European population. This is the first published review of operative intervention rates for the condition over time in Northern Ireland.

METHODS

A ten-year retrospective review of electronic operative records from January 2007 - October 2017 was carried out within Northern Ireland's regional tertiary centre Royal Belfast Hospital for Sick Children (RBHSC). All congenital hand surgery in the country was performed here during the period reviewed, by a single surgeon. Patient age at surgical intervention, their sex, digits involved and clinical grade of syndactyly was recorded.

RESULTS

One hundred and twenty four cases were returned following the review. On individual analysis 22 cases were excluded as they were not primary congenital syndactyly. The remaining 102 cases were all Caucasian. Six cases were toe syndactyly while 96 cases involved the upper limb digits. The group consisted of 70 males and 32 female infants. Age range at time of surgical intervention was 8 months to 14 years with a median age of 26 months. For clinical grade of upper limb syndactyly; 35 cases in the data set were classed as simple incomplete, 34 cases as simple complete, 17 as complex and 5 cases as complicated syndactyly. The remaining 5 cases lacked clear documentation. The most common site of syndactyly was between the ring and middle finger (40/102). Annual frequency of operative intervention has trended upwards in the period studied.

CONCLUSION

This case review adds epidemiological data on the operative incidence of syndactyly cases in Northern Ireland - a relatively isolated genetic population. Overall rates of incidence have increased over the past 10 years. It remains unclear if this is due to new environmental influences on the developing population or increased referral for surgical intervention over time.Levels of evidence - IV (Case Series).

Erratum: Fast Domain Wall Motion Governed by Topology and Œrsted Fields in Cylindrical Magnetic Nanowires [Phys. Rev. Lett. 123, 217201 (2019)]

This corrects the article DOI: 10.1103/PhysRevLett.123.217201.

Developing an interprofessional transition course to improve team-based HIV care for sub-Saharan Africa

BACKGROUND

With funding from the United States Health Resources Service Administration (HRSA), a consortium of health professional training institutions from Africa developed HIV-specific, interprofessional, team-based educational resources to better support trainees during the transition period between pre-service training and professional practice.

METHODS

Ten faculty members representing nine medical and nursing schools in sub-Saharan Africa (SSA) developed a training package of modules focused on core clinical, public health, interprofessional education (IPE), and quality improvement (QI) domains related to HIV service delivery. Curriculum development was informed by a rapid needs assessment of existing tools and future needs for HIV education across 27 SSA health professions training institutions. A total of 17 modules were developed, targeted at newly qualified health care professionals to be taught in a series of two-day workshops meant to complement existing institution specific HIV-curricula.

RESULTS

Between April and July 2019, a comprehensive case-based HIV training package was developed to support trainees in transition from pre-service training to independent professional practice. Each module, addressing different elements of interprofessional practice, was intended to be delivered in an interprofessional format. Thus far, 70 health professions training institutions in 14 countries have implemented the program; 547 educators facilitated STRIPE workshops, with a total of 5027 learners trained between September 2019 and September 2020.

CONCLUSIONS

To our knowledge this is the first IPE HIV-specific curriculum explicitly focused on enhancing the quality of training provided to graduating health care professionals working in SSA. The collaborative, cross-institutional, interprofessional approach to curriculum development provides a benchmark for how best-practice approaches to education can be disseminated in SSA.

Ensemble Random Forests as a tool for modeling rare occurrences

Relative to target species, priority conservation species occur rarely in fishery interactions, resulting in imbalanced, overdispersed data. We present Ensemble Random Forests (ERFs) as an intuitive extension of the Random Forest algorithm to handle rare event bias. Each Random Forest receives individual stratified randomly sampled training/test sets, then down-samples the majority class for each decision tree. Results are averaged across Random Forests to generate an ensemble prediction. Through simulation, we show that ERFs outperform Random Forest with and without down-sampling, as well as with the synthetic minority over-sampling technique, for highly class imbalanced to balanced datasets. Spatial covariance greatly impacts ERFs’ perceived performance, as shown through simulation and case studies. In case studies from the Hawaii deep-set longline fishery, giant manta ray Mobula birostris syn. Manta birostris and scalloped hammerhead Sphyrna lewini presence had high spatial covariance and high model test performance, while false killer whale Pseudorca crassidens had low spatial covariance and low model test performance. Overall, we find ERFs have 4 advantages: (1) reduced successive partitioning effects; (2) prediction uncertainty propagation; (3) better accounting for interacting covariates through balancing; and (4) minimization of false positives, as the majority of Random Forests within the ensemble vote correctly. As ERFs can readily mitigate rare event bias without requiring large presence sample sizes or imparting considerable balancing bias, they are likely to be a valuable tool in bycatch and species distribution modeling, as well as spatial conservation planning, especially for protected species where presence can be rare.

The Cleft Nurse Specialist: A Key Building Block in the Cleft Multidisciplinary Team

INTRODUCTION

The cleft nurse specialist (CNS) plays a key role in counselling and supporting parents from the diagnosis onward. The CNS started in 2012 and we aimed to perform a qualitative study to determine the benefits this brought to the cleft community from the parents' perspective.

METHODS

The cleft database was used to locate babies born in 2010/2011 and 2013/2014. Parents were contacted by phone by 2 authors and completed a questionnaire on the care and support they received following the diagnosis, in the early days and around the time of surgery.

RESULTS

Parents of 38 babies completed the survey. In 2010/2011, only 21% had an antenatal diagnosis compared to 47% in 2013/2014.2011/2012: 3 unilateral cleft lip and palate (UCLP), 3 bilateral cleft lip and palate (BCLP), 4 CLO, 9 cleft palate only (CPO).2013/2014: 5 UCLP, 7 BCLP, 7 CPO.2011/2012: 68% were counselled by a surgeon, 42% were seen >1 week after birth, with some over a month.2013/2014: 84% were counselled by the CNS, 53% were seen within 48 hours, and 100% within 7 days.Parents in 2013/2014 felt more supported by the cleft team throughout pregnancy and the early days, with home visits being particularly advantageous.

CONCLUSION

The introduction of the CNS to the cleft multidisciplinary team has significantly improved the pathway for parents and is a key link with the wider cleft team. With the improvement in antenatal diagnosis, counselling occurs at an earlier stage and prepares parents for the difficulties commonly experienced in the early days. Key themes included; home visits and direct contact with the CNS.

Same-day surgery may reduce the risk of losing pain perception in dogs with thoracolumbar disc extrusion

OBJECTIVES

To compare the proportions of dogs with thoracolumbar disc extrusion that lose pelvic limb pain perception if surgery is performed on the day of admission or delayed overnight. To describe the outcome of those dogs that deteriorate to lose pain perception.

MATERIALS AND METHODS

Retrospective, single centre study on 273 client-owned dogs with thoracolumbar disc extrusion and intact pain perception, but inability to walk unaided on their pelvic limbs. Dogs were subdivided into two groups: early surgery (spinal decompression between their examination at day of admission and the following morning), and delayed surgery (did not undergo surgery between admission and the following morning). The proportion of dogs that lost pelvic limb pain perception overnight was compared between the early and delayed surgery groups.

RESULTS

Seven of 151 dogs in the early surgery group lost pain perception overnight compared to 15 of 122 in the delayed surgery group (Fisher's exact test, P = 0.025). Number-needed-to-treat analysis suggested that 14 dogs (95% confidence interval: 7-106 dogs) need early surgery to prevent one losing pain perception overnight. Five of the seven dogs that lost pain perception in the early surgery group recovered pain perception by 3 weeks post-operatively, compared to eight of 14 in the delayed group.

CLINICAL SIGNIFICANCE

This study suggests that an overnight delay before spinal decompression increases the risk of clinically meaningful deterioration in dogs unable to walk following thoracolumbar disc extrusion.

An investigation of micronutrient supplementation in weaner lambs to improve growth rates in southeast Australia

OBJECTIVE

A producer survey by questionnaire assessed supplements used in sheep and reasons for use. This was followed by field trials on eight sheep properties in SE NSW to determine the effect of commonly used commercially available supplements on growth rates of Merino and crossbred lambs.

DESIGN

On each property, 450 lambs were selected at weaning and randomly allocated to nine groups of 50 sheep (eight treatment and a control group). Supplements were applied as per manufacturer's recommendation every 6-12 weeks. At each application, all sheep were weighed and data on general flock health and management were collected.

RESULTS

All but one of the survey respondents (n = 77) had used supplements in their sheep at some stage. The reasons for use were most commonly for general health and production benefits (n = 21; 26.9%) and to prevent or treat specific diseases/deficiencies (n = 7; 9.0%). The average daily weight gains (ADWG) of the lambs over the trial period varied from 0.074 kg to 0.213 kg/head/day. Statistical analysis showed that overall there was not a significant difference (P = 0.587) between ADWG among lambs that received supplements and lambs that did not.

CONCLUSION

Results of this study show that application of supplements were not linked to improved growth rates in clinically normal crossbred and Merino lambs under the trial farm conditions between weaning and 15 months of age. Effects of supplements on health and production in adult sheep and how supplement response can be best measured in sheep flocks (especially in relation to health and welfare) and linked to productivity requires further investigation.

Hybrid triad provides fracture plane stability in a computational model of a Pauwels Type III hip fracture

The study utilized finite element method to determine displacements and stresses in a set of Pauwels Type III femoral neck fractures repaired using 3 techniques (cannulated screws (Triad), sliding hip screw (SHS), and a Hybrid (SHS + cannulated screws). The research found that shear displacement doubled between the 65° and 75° fracture angles regardless of fixation construct. The SHS alone was the least stable construct, with highest construct stresses and shear displacement along the fracture plane. The stability of the Hybrid and Triad constructs were similar, but stress in the Hybrid was lower suggesting it would provide a higher load to failure than the Triad.

Stacked volume holographic gratings for extending the operational wavelength range in LED and solar applications

A novel stacking procedure is presented for volume phase holographic gratings (VPHGs) recorded in photopolymer material using Corning Willow Glass as a flexible substrate in order to achieve broader angular and spectral selectivity in a diffractive device with high efficiency for solar and LED applications. For the first time to our knowledge, we have shown a device designed for use with a white LED that has the same input and output angles and high efficiency when illuminated by different wavelengths. In this paper, two VPHGs were designed, experimentally recorded, and tested when illuminated at normal incidence. The experimental approach is based on stacking two individual gratings in which the spatial frequency and slant have been tailored to the target wavelength and using real-time on-Bragg monitoring of the gratings in order to control the recorded refractive index modulation, thereby optimizing each grating efficiency for its design wavelength. Lamination of the two gratings together was enabled by using a flexible glass substrate (Corning Willow Glass). Recording conditions were studied in order to minimize the change in diffraction efficiency and peak diffraction angle during lamination and bleaching. The final fabricated stacked device was illuminated by a white light source, and its output was spectrally analyzed. Compared to a single grating, the stacked device demonstrated a twofold increase in angular and wavelength range. The angular and wavelength selectivity curves are in good agreement with the theoretical prediction for this design. This approach could be used to fabricate stacked lenses for white light LED or solar applications.