'You make the call': Improving radiology staff scheduling with AI-generated self-rostering in a medical imaging department

INTRODUCTION

New Zealand's shortage of medical imaging technicians has intensified due to factors like illness, the pandemic, and an ageing workforce. Addressing staff retention issues requires attention to intrinsic factors like workplace satisfaction and work-life balance. Self-rostering has proven effective in healthcare by enhancing work-life balance, job satisfaction, and retention, but it has not been implemented widely in radiology. This study aimed to explore the perceptions, benefits, and challenges of implementing AI-generated self-rostering in a radiology department through simulated trials.

METHODS

This study simulated an AI-generated roster in a regional New Zealand radiology department, engaging 23 staff members. A mixed-methods approach included surveys and discussion groups. Community-based participatory action methodology guided discussion groups and informed modifications.

RESULTS

The AI-generated self-rostering method demonstrated success by meeting a high percentage of shift preferences while fulfilling service demands. Participants perceived potential benefits in work-life balance and autonomy, though uncertainties persisted regarding implementation and fairness. Despite staff reservations, we found that an AI-generated self-rostering system may be fairer than manual self-rostering, while saving radiology staff time and cost.

CONCLUSION

AI-generated self-rostering offers an innovative solution to an old problem. This self-rostering system provides a fair way for staff to have a say in the shifts they do, which increases feelings of work-life balance and autonomy. In this simulation, AI-generated self-rostering was well received, and most staff were receptive to moving to pilot the programme.

IMPLICATIONS FOR PRACTICE

Self-rostering could be a potential solution to staff retention issues in radiology; we recommend a pilot study is implemented. When switching to self-rostering, departments should consider implementing one-on-one support systems to assist staff with entering preferences. Education is essential to encourage staff understanding and cooperation.

Community involvement in addressing the antibiotic crisis

Increasing student interest and success in STEM education is a top priority for many postsecondary educational institutions. One well-documented approach to both priorities is to have students participate in a Course Undergraduate Research Experience (CURE). Faculty from several technical colleges and universities in Wisconsin teamed up with the Tiny Earth organization to offer a CURE to address the search for new antibiotics. Students enrolled in undergraduate microbiology courses engaged in research and participated in community outreach. To involve the community, faculty from various institutions joined an NFL team, the Green Bay Packers, and created the Tiny Earth in Titletown symposium. Here, students presented their work via scientific posters, to community and industry members, and networked with other scientists from around the region. The Tiny Earth in Titletown symposium started in 2018, was held again in 2019, and returned in 2022 following a 2-year hiatus due to the COVID-19 pandemic. Record attendance in 2022 suggests that community outreach and education may be helping restore trust in science that was lost during the pandemic.

Ambiguous Encounters: Young women's expectations and experiences with intoxicated sexual relations in Danish nightlife

This article is based on 28 in-depth interviews with young women (18–25) about their experiences with intoxicated sexual encounters in Danish nightlife. Little research has examined the role intoxication plays in the processes of consensual and non-consensual sex. Using theories of intoxication and sexual scripts, this article focuses on how alcohol is used and perceived by these young women as a potential way of modifying behaviours and norms in their sexual encounters; how they characterize sexual consent and how they navigate intoxicated behaviour that can result in inappropriate, transgressive or victimizing situations. While the women talk about pleasurable and regrettable experiences, many described situations took on a much more ambiguous, fluid and nuanced role. The study points to the lack of knowledge on how ambiguity may play an active role in managing processes of sexual consent in intoxicated settings, especially for the youngest age groups.

Fusion-driven Spindle Cell Rhabdomyosarcomas of Bone and Soft Tissue: A Clinicopathologic and Molecular Genetic Study of 25 Cases

The evolving classification of rhabdomyosarcoma (RMS) now includes spindle cell RMS (SRMS). Bone/soft tissue SRMS often harbor TFCP2, or less often MEIS1 rearrangements. We studied 25 fusion-driven SRMS involving bone (n = 19) and soft tissue (n = 6). Osseous SRMS occurred in 13 women and 6 men (median age: 41 years) and involved the pelvis (5), sacrum (2), spine (4), maxilla (4), mandible (1), skull (1), and femur (2). Follow-up (median: 5 months) demonstrated local recurrence in 2/16 and distant metastases in 8/17 patients (median time to metastasis: 1 month). Eight patients died of disease; 9 were alive with disease. Soft tissue SRMS occurred in 4 men and 2 women (median: 50 years). Follow-up (median: 10 months) revealed distant metastasis at diagnosis (1), alive with unresected tumor (1), and no evidence of disease (4). Next-generation sequencing demonstrated FUS::TFCP2 (12), EWSR1::TFCP2 (3) and MEIS1::NCOA2 (2); FISH identified EWSR1 (2) rearrangements. Most TFCP2-rearranged SRMS (13/17) showed spindled/epithelioid morphology, rarely with rhabdomyoblasts. The bone tumors were diffusely desmin and MyoD1 positive with limited myogenin; 10/13 were ALK -positive and 6/15 were keratin positive. Soft tissue SRMS harbored EWSR1::TFCP2, MEIS1::NCOA2, ZFP64::NCOA2, MEIS1::FOXO1, TCF12::VGLL3 and DCTN1::ALK, and displayed spindled/epithelioid, leiomyomatous, and myxofibrosarcoma-like morphologies. Immunohistochemistry (IHC) was positive for MyoD1 (6/6), focal desmin (5/6), myogenin (3/6), and keratin (1/6). We conclude that TFCP2-rearranged SRMS of bone and soft tissue show consistent morphologic and IHC features, likely representing a distinct subset of RMS. Non-TFCP2 fusion-positive SRMS could represent a single RMS subset, multiple subtypes of RMS, or "fusion-defined" sarcomas with rhabdomyoblastic differentiation.

Prognostic Value of Frailty for Heart Failure Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review

Frailty is associated with poor clinical outcomes in heart failure patients. The impact of frailty on outcomes following left ventricular assist device (LVAD) implantation, however, is less clearly defined. We therefore sought to conduct a systematic review to evaluate current frailty assessment strategies and their significance for patients undergoing LVAD implantation. We conducted a comprehensive electronic search of PubMed, Embase, and CINAHL databases from inception until April 2021 for studies examining frailty in patients undergoing LVAD implantation. Study characteristics, patient demographics, type of frailty measurement, and outcomes were extracted. Outcomes were organized into 5 basic categories: implant length of stay (iLOS), 1-year mortality, rehospitalization, adverse events, and quality of life (QOL). Of the 260 records retrieved, 23 studies involving 4935 patients satisfied the inclusion criteria. Approaches to measuring frailty varied, with the 2 most common being sarcopenia determined by computed tomography and Fried's frailty phenotype assessment. Outcomes of interest were also widely variable, with iLOS stay and mortality being the most frequently reported, albeit with differing definitions of both between studies. The heterogeneity among included studies precluded quantitative synthesis. Narrative synthesis showed that frailty by any measure is more likely to be associated with higher mortality, longer iLOS, more adverse events and worse QOL post-LVAD implant. Frailty can be a valuable prognostic indicator in patients undergoing LVAD implantation. Further studies are needed to determine the most sensitive frailty assessment, as well as the ways in which frailty may serve as a modifiable target to improve outcomes following LVAD implantation.

Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation

Background

Oral anticoagulation (OAC) is the mainstay of secondary prevention in ischemic stroke patients with atrial fibrillation (AF). However, in AF patients with large vessel occlusion stroke treated by endovascular therapy (ET) and acute carotid artery stenting (CAS), the optimal antithrombotic medication remains unclear.

Methods

This is a subgroup analysis of the German Stroke Registry—Endovascular Treatment (GSR-ET), a prospective multicenter cohort of patients with large vessel occlusion stroke undergoing ET. Patients with AF and CAS during ET were included. We analyzed baseline and periprocedural characteristics, antithrombotic strategies and functional outcome at 90 days.

Results

Among 6635 patients in the registry, a total of 82 patients (1.2%, age 77.9 ± 8.0 years, 39% female) with AF and extracranial CAS during ET were included. Antithrombotic medication at admission, during ET, postprocedural and at discharge was highly variable and overall mortality in hospital (21%) and at 90 days (39%) was high.

Among discharged patients (n = 65), most frequent antithrombotic regimes were dual antiplatelet therapy (DAPT, 37%), single APT + OAC (25%) and DAPT + OAC (20%). Comparing DAPT to single or dual APT + OAC, clinical characteristics at discharge were similar (median NIHSS 7.5 [interquartile range, 3–10.5] vs 7 [4–11], p = 0.73, mRS 4 [IQR 3–4] vs. 4 [IQR 3–5], p = 0.79), but 90-day mortality was higher without OAC (32 vs 4%, p = 0.02).

Conclusions

In AF patients who underwent ET and CAS, 90-day mortality was higher in patients not receiving OAC.

Registration: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-022-00207-7.

Acute myocarditis during the COVID-19 pandemic: A single center experience

Objective

We sought to compare the occurrence and characteristics of patients with acute myocarditis admitted during the coronavirus disease 2019 pandemic to those admitted prior.

Design

We performed a retrospective chart review of patients with the primary discharge diagnosis of acute myocarditis from September 1st 2017 through August 31st 2020.

Results

We identified 67 patients, 45 (67%) admitted pre-pandemic, and 22 (33%) during the pandemic. Rate of admissions for acute myocarditis was 1.5/month [95% CI 1.04–1.95] pre-pandemic, and 3.7/month [95% CI 2.36–4.97] (p < 0.001) during the first 6 months of the pandemic. Of the 22 patients admitted during the pandemic, 10 (45%) tested positive for SARS-CoV-2. Patients who tested positive for SARS-CoV-2 were older and had lower peak troponin levels.

Conclusions

During the pandemic, less than half of the patients admitted with acute myocarditis tested positive for SARS-CoV-2. Patients who tested positive were older and had lower peak troponin levels.

OP0117 REAL-WORLD EFFECTIVENESS OF TNFI VERSUS NON-TNFI BIOLOGICS ON DISEASE ACTIVITY IN PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM THE ACR’S RISE REGISTRY

Background:

Our understanding of how medications such as biologic disease modifying anti-rheumatic drugs and targeted small molecules (b/tsDMARDs) influence disease activity in RA is based largely on randomized controlled trials (RCTs). However, most U.S. trials in RA are limited by small sample sizes and have often excluded patients who are older, male, and from racial/ethnic minorities. Whether effectiveness of b/tsDMARDs varies in these populations has largely been unexplored.

Objectives:

We aimed to examine differences in longitudinal RA disease activity by demographic and clinical characteristics using a novel electronic health record data source of rheumatology providers across the U.S. We simulated various treatment assignments of b/tsDMARDs that have been examined in RCTs: namely, TNF-inhibitors (TNFi) and non-TNFi.

Methods:

We included 16,448 individuals from the ACR’s RISE registry with ≥ 2 RA diagnoses (ICD-9: 714.0) ≥ 30 days apart, who had at least 2 recorded clinical disease activity index (CDAI) scores and no historical b/tsDMARD use documented in RISE. b/tsDMARD use and CDAI scores were assessed at each quarter; covariates included sex, race (white, Black, Asian, other), ethnicity (Hispanic/non-Hispanic), age, smoking, obesity, area deprivation index, other DMARD use, RF status, anti-CCP status, and practice type. Longitudinal targeted maximum likelihood estimation estimated the average treatment effect (ATE) of cumulative TNFi vs. non-TNFi use over a 12-month period on CDAI score among the entire population and across various subgroups based on demographic and clinical characteristics, accounting for censoring and time-varying confounding.

Results:

Approximately 75% of patients were female with a mean age of 65.1 (+/- 13.7) years. Sixty percent of patients were white, 8% black, 2% Asian, and 30% other/mixed or unknown race; 6% were Hispanic. The mean CDAI score at baseline was 11.3 (+/- 10.7). For the overall population, there was no significant difference in disease activity between TNFi and non-TNFi at 12 months (ATE= 0.85, 95% CI -0.26, 1.96; Table 1). Stratified analyses found higher disease activity for TNFi compared to non-TNFi among patients of Black and Asian race, non-Hispanic ethnicity, and female sex. Among Black race patients, TNFi use was associated with a 6.08 point higher CDAI score compared to non-TNFi use (95% CI 1.99, 10.17). In contrast, in Hispanic/Latino ethnicity patients, TNFi use was associated with a lower CDAI score compared to non-TNFi use (ATE= -2.64, 95% CI -3.99, -1.30).

Table 1.

Average treatment effect (ATE) of cumulative TNFi vs. non-TNFi use at 12-months on CDAI score in patients with RA

TNFiNon-TNFiATE (95% CI)Overall (n=16,448)8.847.990.85 (-0.26, 1.96)Race White (n=9,814)8.246.811.42 (0.03, 2.81)* Black (n=1,358)13.917.836.08 (1.99, 10.17)* Asian (n=301)6.542.743.80 (2.93, 4.67)*Ethnicity Non-Hispanic (n=14,216)8.927.631.29 (0.08, 2.51)* Hispanic (n=938)5.698.33-2.64 (-3.99, -1.30)*Sex Female (n=12,527)8.987.471.51 (0.31, 2.72)* Male (n=3,921)8.579.49-0.92 (-3.42, 1.58)

*P<0.05

Conclusion:

Results from this RCT simulation study suggest that non-TNFi may have an important role as first-line agents in the treatment of Black and Asian patients, but not Hispanic patients. These novel findings fill gaps where RCTs have not been conducted, highlight the need for inclusion of diverse populations in future trials, and have the potential to lead to a more personalized approach to rheumatologic care.

References:

Disclosure of Interests:

Milena Gianfrancesco: None declared, Jing Li: None declared, Michael Evans: None declared, Maya Petersen: None declared, Gabriela Schmajuk: None declared, Jinoos Yazdany Consultant of: Eli Lilly and Astra Zeneca, unrelated to this project., Grant/research support from: Gilead, unrelated to this project.

[Telemedicine in stroke-pertinent to stroke care in Germany]

BACKGROUND AND OBJECTIVE

Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution.

METHODS

The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks.

RESULTS

Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states.

CONCLUSION

Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

University Student Perspectives of Entomophagy: Positive Attitudes Lead to Observability and Education Opportunities

Positive experiences with insect food items that highlight the benefits of insect production and reduce the novelty of entomophagy are needed. Toward this goal, we developed an experiential learning lesson plan that would provide a positive experience with entomophagy and associate key educational content related to insect food items. First, two cricket powder brownie taste-test surveys were conducted with groups of university students to evaluate attitudes relating to insects as food, sustainability of insect production, and nutritional content. Students displayed a taste preference for cricket flour brownies but could not consistently differentiate between brownie types, ranked environmental and nutritional benefits associated with insect food products over taste factors alone, and indicated a positive attitude toward purchasing insect products in the future. Willingness to try other insect products in the future was significantly greater for students with increased experience with consuming insect products. These results were then used to create an university lesson plan that will allows for future evaluation of student attitudes while increasing exposure to entomophagy and providing education on the positive aspects of insects as food production. Our work highlights the favorable attitude toward insect food products shown by university students and how positive perception of entomophagy increases with continued exposure to the practice.

In vivo fluorescence molecular tomography of induced haemarthrosis in haemophilic mice: link between bleeding characteristics and development of bone pathology

Background

Haemophilic arthropathy is a chronic and debilitating joint disease caused by recurrent spontaneous joint bleeds in patients with haemophilia. Understanding how characteristics of individual joint bleeds relate to the subsequent development of arthropathy could improve management and prevention of this joint disease. Here, we aimed to explore relations between joint bleed characteristics and development of bone pathology in a mouse model of haemophilic arthropathy by using novel in vivo imaging methodology.

Methods

We characterised induced knee bleeds in a murine model of haemophilic arthropathy by quantitative in vivo fluorescence molecular tomography (FMT) and by measurements of changes in the diameter of the injured knee. Wild-type mice and non-injured haemophilic mice acted as controls. Development of arthropathy was characterised by post mortem evaluation of bone pathology by micro-CT 14 days after bleed-induction. In an in vitro study, we assessed the effect of blood on the quantification of fluorescent signal with FMT.

Results

In most injured haemophilic mice, we observed significant loss of trabecular bone, and half of the mice developed pathological bone remodelling. Development of pathological bone remodelling was associated with significantly increased fluorescent signal and diameter of the injured knee just 1 day after induction of the bleed. Further, a correlation between the fluorescent signal 1 day after induction of the bleed and loss of trabecular bone reached borderline significance. In the in vitro study, we found that high concentrations of blood significantly decreased the fluorescent signal.

Conclusion

Our results add novel insights on the pathogenesis of haemophilic arthropathy and underline the importance of the acute phase of joint bleeds for the subsequent development of arthropathy.

Stroke Etiology Modifies the Effect of Endovascular Treatment in Acute Stroke

Background and Purpose—

Stroke etiology drives thrombus composition. We thus hypothesized that endovascular treatment shows different efficacy in cardioembolic versus noncardioembolic large-vessel occlusions (LVOs).

Methods—

Procedural characteristics, grade of reperfusion, and functional outcome at discharge and 90 days were compared between patients with cardioembolic versus noncardioembolic LVO from the GSR-ET (German Stroke Registry–Endovascular Treatment; n=2589). To determine associations with functional outcome, adjusted odds ratios and 95% CIs were calculated using ordinal multivariable logistic regression models adjusting for potential baseline confounder variables.

Results—

Endovascular treatment of cardioembolic LVO had a higher rate of successful reperfusion (85.6% versus 81.0%; P =0.002) and a higher rate of complete reperfusion after a single thrombectomy pass (45.7% versus 38.1%; P <0.001) compared with noncardioembolic LVO. Cardioembolic LVO was associated with better functional outcome at discharge (adjusted odds ratio, 1.61 [95% CI, 1.37–1.88]) and 90 days (adjusted odds ratio, 1.29 [95% CI, 1.09–1.53]). In mediation analysis, reperfusion explained 47% of the effect of etiology on functional outcome at discharge.

Conclusions—

These results provide evidence for higher efficacy of endovascular treatment in cardioembolic LVO compared with noncardioembolic LVO.

Routine Analysis of Proteins by Kjeldahl and Dumas Methods: Review and Interlaboratory Study Using Dairy Products

The Kjeldahl and Dumas (combustion) methods were compared in 11 laboratories analyzing samples of milk, skim milk powder, whole milk powder, whey protein concentrate, infant formula, casein, caseinate, 2 reference compounds (glycine and EDTA), and a secondary reference skim milk powder. The comparison was conducted by using international standards where applicable. Overall means were 8.818 g N/100 g by the Kjeldahl method and 8.810 g N/100 g by the Dumas method. No evidence was found for a consistent bias between methods that may be of concern in the trading of dairy produce. A review of more than 10 related trials revealed a lack of consensus in the bias between the 2 methods, suggesting that differences in methodology and sources of systematic error may be contributors. For samples containing &gt;2 g N/100 g, the Dumas relative repeatability and reproducibility standard deviations were consistently about 0.35 and 0.75%, respectively, whereas the corresponding Kjeldahl values declined generally with N content and were significantly larger. The Dumas precision characteristics may be due to the dominance of Leco analyzers in this trials, and in most other recent trials, rather than an inherent method attribute. Protein determination methods for dairy products need to be reviewed and updated. The Dumas method needs Codex Alimentarius status as a recognized test method.

New Lipsothrix (Diptera: Limoniidae) from Korea

Lipsothrix odaesana Podenas Petersen, sp. nov. from South Korea is described and illustrated. It is the only species of Lipsothrix Loew, 1873 recorded so far from the Korean Peninsula. Elevation range, period of activity, habitat information and a distribution map are presented.

Preclinical pharmacokinetics and biodistribution of subcutaneously administered glycoPEGylated recombinant factor VIII (N8-GP) and development of a human pharmacokinetic prediction model

Essentials N8-GP is an extended half-life recombinant factor VIII (FVIII) for the treatment of hemophilia A. Subcutaneous (SC) FVIII dosing might reduce the treatment burden of prophylaxis. SC N8-GP has a favorable PK profile in animal models and disappears from skin injection sites. Combined animal (SC) and clinical (IV) data suggest that daily SC dosing may provide prophylaxis.

SUMMARY

Background N8-GP is an extended half-life recombinant factor VIII (FVIII) for the treatment of hemophilia A. Subcutaneous administration of FVIII may reduce the treatment burden of prophylaxis; however, standard FVIII products have low bioavailability after subcutaneous dosing in animals. Objective To evaluate the pharmacokinetics, effectiveness and local distribution of subcutaneously administered N8-GP in preclinical models and predict the human pharmacokinetic (PK) profile. Methods The pharmacokinetics of subcutaneously administered N8-GP were evaluated in FVIII knockout (F8-KO) mice and cynomolgus monkeys; a human PK prediction model in hemophilia A patients was developed. The hemostatic effect was evaluated in a tail vein bleeding model in F8-KO mice. The injection-site distribution and absorption of subcutaneously administered N8-GP were assessed in F8-KO mice by the use of temporal fluorescence imaging and immunohistochemistry. Results Subcutaneously administered N8-GP had a bioavailability, a first-order absorption rate and a half-life, respectively, of 24%, 0.094 h-1 and 14 h in F8-KO mice, and 26%, 0.33 h-1 and 15 h in cynomolgus monkeys. A dose-dependent effect of subcutaneously administered N8-GP on blood loss was observed in mice. A minimal amount of N8-GP was detected at the injection site 48-72 h after single or multiple dose(s) in F8-KO mice. Subcutaneously administered N8-GP was localized to the skin around the injection site, with time-dependent disappearance from the depot. PK modeling predicted that subcutaneously administered N8-GP at a daily dose of 12.5 IU kg-1 will provide FVIII trough levels of 2.5-10% in 95% of patients with severe hemophilia A. Conclusions Subcutaneously administered N8-GP may provide effective hemophilia A prophylaxis. A phase I clinical trial is underway to investigate this possibility.

Hypobaric hypoxia exposure in rats differentially alters antidepressant efficacy of the selective serotonin reuptake inhibitors fluoxetine, paroxetine, escitalopram and sertraline

Treatment-resistant depression, a chronic condition that affects 30% of depressed patients on antidepressants, is highly linked to suicidal behavior. Chronic hypoxia exposure via living at altitude (hypobaric hypoxia) or with chronic hypoxic diseases is demographically linked to increased risk for depression and suicide. We previously demonstrated that housing rats at altitude for a week incrementally increases depression-like behavior in the forced swim test (FST) in females, but not males. In animal models, high altitude exposure reduces brain serotonin, and selective serotonin reuptake inhibitors (SSRIs) can lose efficacy when brain serotonin levels are low. To address whether residence at moderate altitude is detrimental to SSRI function, we examined SSRI efficacy in the FST after a week of housing rats at altitudes of 4500 ft. or 10,000 ft. as compared to at sea level. In females, the tricyclic antidepressant desipramine (positive control) functioned well in all groups, increasing latency to immobility and decreasing immobility, by increasing climbing. However, the SSRIs fluoxetine, paroxetine and escitalopram were ineffective in females in all groups: only paroxetine improved swimming in the FST as expected of a SSRI, while all three unexpectedly reduced climbing. Fluoxetine was also ineffective in male rats. Sertraline was the only SSRI with antidepressant efficacy at altitude in both females and males, increasing swimming, climbing and latency to immobility, and reducing immobility. Hypobaric hypoxia thus appears to be detrimental to efficacy of the SSRIs fluoxetine, paroxetine and escitalopram, but not of sertraline. Unlike the other SSRIs, sertraline can improve both serotonergic and dopaminergic transmission, and may be less impacted by a hypoxia-induced serotonin deficit. A targeted approach may thus be necessary for successful antidepressant treatment in patients with depression who live at altitude or with chronic hypoxic diseases, and that sertraline may be the SSRI of choice for prescription for this population.

Analgesic consumption trajectories in 8975 patients 1 year after fast-track total hip or knee arthroplasty

BACKGROUND

Persistent or increased long-term opioid consumption has previously been described following total hip- (THA) and knee arthroplasty (TKA). However, detailed information on postoperative analgesic consumption trajectories and risk factors associated with continued need of analgesics in fast-track THA and TKA is sparse.

METHODS

This is a descriptive multicentre study in primary unilateral fast-track THA or TKA with prospective data on patient characteristics and information on reimbursement entitled dispensed prescriptions of paracetamol, non-steroidal anti-inflammatory drugs, opioids, anticonvulsants and antidepressants 1 month preoperatively and 1 year postoperatively. Patients were stratified according to preoperative opioid use. Postoperative analgesic consumption trajectories were stratified as increased, decreased or no use compared to the preoperative period.

RESULTS

Of 8975 patients (4849 THA/4126 TKA), 33.9% had relevant reimbursed prescriptions 9-12 months postoperatively. Of 2136 (23.8%) patients with preoperative opioid use, 3.4% had unchanged opioid consumption at 9-12 months postoperatively. However, increased opioid consumption after 9-12 months occurred in 17.6 (TKA) and 10.2% (THA) compared to 9.9 and 6.3% in opioid-naive TKA and THA patients, respectively. Increased NSAID and paracetamol use was seen in 11.5 and 12.4% of all patients. Preoperative analgesic use (any), TKA, psychiatric disorder, tobacco abuse, cardiac disease and use of walking aids were associated with increased opioid consumption.

CONCLUSION

Continued and increased opioid and other analgesic use occur in a clinically significant proportion of fast-track TKA and THA patients 9-12 months postoperatively, suggesting treatment failure and need for early intervention. Preoperative risk assessment may allow identification of patients in risk of increased postoperative opioid consumption.

SIGNIFICANCE

We found a considerable fraction of patients with continued or increased opioid consumption 9-12 months after fast-track THA and TKA. Increase in opioid consumption was more frequent in preoperative opioid users than opioid-naive patients, but a pattern of increased analgesic consumption was present across all analgesics. Our data demonstrate a need for increased focus on long-term analgesic strategies and postoperative follow-up after THA and TKA, especially in preoperative opioid users.

[Sealing of the hepatic resection area using hemostat devices does not improve results of adequate surgery]

PURPOSE

In hepatic resections, there has been a high quality demand. The aim of this systematic clinical, prospective, unblinded unicenter observational study with two arms in an unselected patient cohort was to investigate whether hemostat device can significantly improve outcome in resective liver surgery, in particular, in high risk patients.

METHODS

All consecutive patients (mean age, 60.5 [range, 17 - 96] years) who underwent hepatic resection (ntotal = 770) were prospectively documented in a computer-based registry at a university hospital (tertiary center) over a time period of 10 years and retrospectively evaluated specifically with regard to the use (-/+; in daily practice and intraoperative decision-making) of hemostat device (Tissucol(®), n = 59/Tachocomb(®), n = 202/combination, n = 55) indicated (among others) by drainage volume, inflammatory parameters and rate of specific complications (nvalidated = 541 [100 %]).

RESULTS

Most frequently, (a-)/typical segmental resections were used: n = 192/90 (3-segment resection, only n = 38). 1) For the assignment of patients to the two different groups (-/+ hemostat device), weight loss and type of resection were found as significant factors (trend: ASA, cirrhosis), for the amount of drainage volume, ASA, sex, Karnofsky Performance Scale and also type of resections using independent distributed statistical tests (such as χ(2), U test [Mann/Whitney]; H test [Kruskal-Willis]; correlation coefficient by Spearman) - no impact: smoking, diabetes, BMI, ethanol. 2) Not taking into account these parameters, the use of hemostat device was characterized by an increased drainage volume (negative control < Tissucol = Tachocomb < combination). 3) Using multifactorial analysis of variance, it was found even under correction by the factors with significant impact elucidated in the single test that the application of hemostat device onto the hepatic resection area resulted unexpectedly rather in an increase than a decrease of the drainage volume but 4) under accompanying more pronounced increase of the white blood cell count (leucocytosis). 5) General and specific complications such as postoperative bleeding, biliary fistula and subhepatic abscess were not further lowered in a significant manner using hemostat device.

CONCLUSION

Adequate surgery in the operative management of hepatic resection area cannot further be improved or optimized using hemostat device. In this context, drainage volume may not be considered a sufficient rather an orienting parameter. However, there is an inflammatory response detectable most likely indicated by a(n un-)specific effusion and increase of white blood cell count, which can be interpreted as a) being characteristic for the problematic group of patients, in whom hemostat device was decided to be useful and was finally used in daily prectice, or b) reactive inflammation to foreign material.

Health-related quality of life in adolescents with inflammatory bowel disease depends on disease activity and psychiatric comorbidity

Adolescent patients with inflammatory bowel disease (IBD) show an increased risk for behavioral and emotional dysfunction. Health-related quality of life (HRQoL) is influenced by medical illnesses, as well as by psychiatric disorders, but for adolescents with IBD, the extent to which HRQoL is influenced by these two factors is unclear. For 47 adolescent IBD patients, we analyzed disease activity, HRQoL and whether or not a psychiatric disorder was present. Disease activity was estimated using pediatric Ulcerative Colitis Activity Index and pediatric Crohn's Disease Activity Index. The IMPACT-III and the EQ-5D were used to measure HRQoL and QoL, respectively. In addition, patient and parent diagnostic interviews were performed. 55.3 % patients fulfilled DSM-IV criteria for one or more psychiatric disorders. In all patients, psychiatric comorbidity together with disease activity contributed to a reduction in quality of life. Adolescents with IBD are at a high risk for clinically relevant emotional or behavioral problems resulting in significantly lower HRQoL. We conclude that accessible, optimally structured psychotherapeutic and/or psychiatric help is needed in adolescent patients with IBD.

The evolutionary history of Lipsothrix Loew (Diptera : Tipuloidea) inferred through systematic revision and historical biogeographical analysis

The evolutionary history of the crane fly genus Lipsothrix Lowe, 1873 was examined through a systematic revision of specimens maintained in natural history collections, parsimony analysis using TNT based on immature and adult morphology, and dispersal–vicariance analyses in RASP (Bayesian and S-DIVA). The genus Lipsothrix was found to contain 29 valid species, one subspecies (L. nobilis iranica) and three species maintained but in need of further evaluation (Lipsothrix burmica, L. heitfeldi, L. yakushimae). One species complex (L. shasta complex) was further resolved using ordination and cluster analyses. One new species is described, L. nullusarma, sp. nov., and three species are synonymised (L. fulva, L. mirifica, L. yamamotoana omogoensis). Phylogenetic analysis recovered a strongly supported and monophyletic Lipsothrix. The historical biogeographical analyses of Lipsothrix inferred an ancestral area in the Western Palearctic region that likely dates to the Eocene. One, or several, dispersal events occurred from the Western Palearctic before major diversification events occurred in the Oriental and Eastern Palearctic + Nearctic regions. Two major paleogeographical developments occurring in the Oriental and Eastern Palearctic + Nearctic regions are largely responsible for Lipsothrix diversification, the collision of the Indian plate with Asia and the rise of the trans-Beringian land bridges during the Tertiary and Quaternary.