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A novel positive end-expiratory pressure titration using electrical impedance tomography in spontaneously breathing acute respiratory distress syndrome patients on mechanical ventilation:an observational study from the MaastrICCht cohort
No full textThere is no universally accepted method for positive end expiratory pressure (PEEP) titration approach for patients on spontaneous mechanical ventilation (SMV). Electrical impedance tomography (EIT) guided PEEP-titration has shown promising results in controlled mechanical ventilation (CMV), current implemented algorithm for PEEP titration (based on regional compliance measurements) is not applicable in SMV. Regional peak flow (RPF, defined as the highest inspiratory flow rate based on EIT at a certain PEEP level) is a new method for quantifying regional lung mechanics designed for SMV. The objective is to study whether RPF by EIT is a feasible method for PEEP titration during SMV. Single EIT measurements were performed in COVID-19 ARDS patients on SMV. Clinical (i.e., tidal volume, airway occlusion pressure, end-tidal CO 2) and mechanical (cyclic alveolar recruitment, recruitment, cumulative overdistension (OD), cumulative collapse (CL), pendelluft, and PEEP) outcomes were determined by EIT at several pre-defined PEEP thresholds (1–10% CL and the intersection of the OD and CL curves) and outcomes at all thresholds were compared to the outcomes at baseline PEEP. In total, 25 patients were included. No significant and clinically relevant differences were found between thresholds for tidal volume, end-tidal CO 2, and P0.1 compared to baseline PEEP; cyclic alveolar recruitment rates changed by -3.9% to -37.9% across thresholds; recruitment rates ranged from − 49.4% to + 79.2%; cumulative overdistension changed from − 75.9% to + 373.4% across thresholds; cumulative collapse changed from 0% to -94.3%; PEEP levels from 10 up to 14 cmH 2O were observed across thresholds compared to baseline PEEP of 10 cmH 2O. A threshold of approximately 5% cumulative collapse yields the optimum compromise between all clinical and mechanical outcomes. EIT-guided PEEP titration by the RPF approach is feasible and is linked to improved overall lung mechanics) during SMV using a threshold of approximately 5% CL. However, the long-term clinical safety and effect of this approach remain to be determined.</p
Large-scale pretrained frame generative model enables real-time low-dose DSA imaging:An AI system development and multi-center validation study
No full textBACKGROUND: Digital subtraction angiography (DSA) devices are commonly used in numerous interventional procedures across various parts of the body, necessitating multiple scans per procedure, which results in significant radiation exposure for both doctors and patients. Inspired by generative artificial intelligence techniques, this study proposes GenDSA, a large-scale pretrained multi-frame generative model-based real-time and low-dose DSA imaging system. METHODS: GenDSA was developed to generate 1-, 2-, and 3-frame sequences following each real frame. A large-scale dataset comprising ~3 million DSA images from 27,117 patients across 10 hospitals was constructed to pretrain, fine-tune, and validate GenDSA. Two other datasets from 25 hospitals were used for evaluation. Objective evaluations included SSIM and PSNR. Five interventional radiologists independently assessed the quality of the generated frames using the Likert scale and visual Turing test. Scoring consistency among the radiologists was measured using the Kendall coefficient of concordance (W). The Fleiss' kappa values were used for inter-rater agreement analysis for visual Turing tests. FINDINGS: Using only one-third of the clinical radiation dose, videos generated by GenDSA were perfectly consistent with real videos. Objective evaluations demonstrated that GenDSA's performance (PSNR = 36.83, SSIM = 0.911, generation time = 0.07 s/frame) surpassed state-of-the-art algorithms. Subjective ratings and statistical results from five doctors indicated no significant difference between real and generated videos. Furthermore, the generated videos were comparable to real videos in overall quality (4.905 vs. 4.935) and lesion assessment (4.825 vs. 4.860). CONCLUSIONS: With clear clinical and translational values, the developed GenDSA can significantly reduce radiation damage to both doctors and patients during DSA-guided procedures. FUNDING: This study was supported by the National Key R&D Program and the National Natural Science Foundation of China
Navigating Life With Parkinson's Disease:A Focus Group Study on Coping Strategies and Considerations for Self-Management Support
No full textAim :To investigate the experiences of people with Parkinson's disease in coping with and adapting to their disease and to identify considerations for a tailored self-management support program. Design :A descriptive phenomenological focus group study. Methods :Five semi-structured focus groups were conducted between April 2023 and June 2023 in the Netherlands, with 12 people with Parkinson's disease. Two researchers independently performed an inductive content analysis. Results :Three principal categories emerged: (1) Rational realisation versus emotional experience: the coping strategy transition. This category includes three main coping strategies: denial or avoidance coping, acknowledging with less active coping and proactive and task-oriented coping. (2) Factors that influence coping, including mindset and skills, social circles and communication and access to support and care. (3) Considerations for successful self-management of Parkinson's disease, highlighting key areas such as psycho-emotional guidance, nutrition and lifestyle, peer support and maintaining autonomy and sense of identity. Conclusion: Coping and adaptation strategies are individual and dynamic processes, with multiple key or turning points during the transition between strategies. Tailored self-management support can enhance coping abilities during these transitions, fostering adaptation to a life with Parkinson's disease. Implications for the Profession and/or Patient Care: A patient-focused version of an existing blended self-management support program for family caregivers will be developed, which will be delivered by healthcare professionals. Impact: This study can help healthcare professionals tailor support for people with Parkinson's disease, emphasising their role in facilitating coping and adaptation. Enhancing self-management can improve self-efficacy, quality of life and potentially reduce healthcare utilisation in people with Parkinson's disease. Reporting Method: Findings are reported according to the COREQ guidelines. Patient or Public Contribution: Patients and Parkinson's disease experts participated in the preparation and implications of the findings. All participants could contribute to the self-management support program, either through video interviews or content feedback
Clarifying and expanding equity in assessment by considering three orientations:Fairness, inclusion and justice
No full textContext:Despite increasing discussion and scholarship, equity in assessment is rarelydefined and distinguished in a way that allows for shared understanding in medicaleducation. This paper seeks to clarify and expand the conversation about equity inassessment by critically reviewing three distinct and evolving orientations towardequity in assessment. Orientations refers to the positions, attitudes, interests or pri-orities individuals can hold toward equity in assessment. The three orientationsinclude fairness-oriented assessment, assessment for inclusion and justice-orientedassessment. While fairness-oriented assessment is a prevailing orientation in medicaleducation, assessment for inclusion and justice-oriented assessment, originally devel-oped in other fields of education, deserve careful consideration. Methods:In this paper, the authors explore unique underpinning assumptions ofeach orientation by critically examining the foundational literature of each orienta-tion. They reflect on the unique perspectives each orientation provides, including theactions one might take and what advantages and disadvantages might result fromlooking at equity in assessment from any one orientation. Conclusions:Informed by this reflection, the authors propose that to more effec-tively advance equity in assessment in medical education, those working in the fieldshould clearly identify their respective orientations, intentionally choose methods,tools and measures aligned with their orientations and expand their work by explor-ing alternative orientations
Splenic hypertrophy predicts liver-specific complications in patients undergoing major liver resection for colorectal liver metastases, after preoperative chemotherapy
No full textBackground: In patients with colorectal liver metastases (CRLM), preoperative chemotherapy may increase resectability and survival outcomes. However, cytotoxic agents can also cause chemotherapyassociated liver injury (CALI), leading to increased rates of postoperative complications. This study evaluates the association between splenic hypertrophy (SH) after preoperative chemotherapy and postoperative liverspecific complications (LSC), in patients undergoing major liver resection for CRLM. Methods: This retrospective study included patients who underwent major curative liver resection of CRLM following preoperative chemotherapy at the University Hospital RWTH Aachen (UH-RWTH) between 2010-2021. Patients with missing radiological images, incomplete data on chemotherapy regimens, or prior splenectomy were excluded. Volumetric measurements of the spleen were performed on preoperative computerized tomography (CT) and magnetic resonance imaging (MRI) images, using segmentation software (3D-Slicer). Receiver-operating characteristic (ROC) analysis was performed to determine the optimal SH cut-off for predicting postoperative LSC. Independent risk factors of postoperative LSC were examined using logistic regression. Results: A total of 115 patients were included in the study, of which 78 (68%) received oxaliplatin as part of their preoperative chemotherapy regimen. A threshold of 8.6% SH (Youden Index =0.25) was identified as predictive of postoperative LSC. Patients with SH >8.6% (n=62) received oxaliplatin significantly more often (84% vs. 49%; P<0.001) and exhibited higher rates of liver fibrosis (72% vs. 52%, P=0.03) and LSC (63% vs. 38%, P=0.007). Multivariable logistic regression analysis identified SH >8.6% as an independent risk factor Conclusions: Preoperative SH may be a valuable predictor of postoperative LSC in patients undergoing major liver resection for CRLM, following chemotherapy. Further studies are necessary to investigate the impact on a larger cohort and find preventive strategies to mitigate and treat CALI
Changes in participatory and societal outcomes during the waiting period for cochlear implantation - an observational study
No full textINTRODUCTION: Various factors, including an aging population and expanding eligibility criteria, may increase the demand for cochlear implants (CIs), potentially resulting in longer waiting times. In most Dutch CI centers, the time between referral and surgery exceeds 6 months. Clinical experience suggests that during the waiting period for cochlear implantation, hearing and communication difficulties increase. Simultaneously, there is an interest in outcomes more closely aligned with patient values and needs, which resulted in the SMILE (Societal Merit of Interventions on hearing Loss Evaluation) study. This paper presents results on observed changes in societal and participatory outcomes during waiting time in participants with a time to CI surgery exceeding 6 months. METHODS: SMILE is a prospective multi-center study including 232 individuals who were referred for unilateral CI. Continuous and nominal data from multiple questionnaires, sent immediately after referral and shortly before surgery, were analyzed by computing differences, Cohen's D, and odds ratios. RESULTS: Of the total 232 participants, 102 had a time between inclusion and surgery exceeding 6 months. Of these, 89 had (partially) filled out surveys at both time points. Of all the domain scores 55% did not show differences between timepoints. All Cohen's D estimates were relatively small, ranging from - 0.298 to 0.388 for those outcomes that showed noteworthy changes. CONCLUSION: Waiting time from referral to surgery, even though exceeding 6 months, was observed to not seriously affect non-clinically-prioritized patients in an adverse way. Future investigations should identify subgroups on tolerable waiting times regarding short- and long-term outcomes. TRIAL REGISTRATION: Trial registration number at ClinicalTrials.gov: NCT05525221, 25-8-2022
Risk factors and outcomes of conversions in robotic and laparoscopic liver resections:A nationwide analysis
No full textBackground: Unfavorable intraoperative findings or incidents during minimally invasive liver surgery may necessitate conversion to open surgery. This study aimed to identify predictors for conversion in minimally invasive liver surgery and gain insight into outcomes following conversions. Methods: This nationwide, retrospective cohort study compared converted and non-converted minimally invasive liver surgery procedures using data from 20 centers in the Dutch Hepatobiliary Audit (2014–2022). Propensity score matching was applied. Subgroup analyses of converted robotic liver resection versus laparoscopic liver resection and emergency versus non-emergency conversions were performed. Predictors for conversions were identified using backward stepwise multivariable logistic regression. Results: Of 3,530 patients undergoing minimally invasive liver surgery (792 robotic liver resection, 2,738 laparoscopic liver resection), 408 (11.6%) were converted (4.9% robotic liver resection, 13.5% laparoscopic liver resection). Conversion was associated with increased blood loss (580 mL [interquartile range 250–1,200] vs 200 mL [interquartile range 50–500], P < .001), major blood loss (≥500 mL, 58.8% vs 26.7%, P < .001), intensive care admission (19.0% vs 8.4%, P = .005), overall morbidity (38.9% vs 21.0%, P < .001), severe morbidity (17.9% vs 9.6%, P = .002), and a longer hospital stay (6 days [interquartile range 5–8] vs 4 days [interquartile range 2–5], P < .001) but not mortality (2.2% vs 1.2%, P = .387). Emergency conversions had increased intraoperative blood loss (1,500 mL [interquartile range 700–2,800] vs 525 mL [interquartile range 208–1,000], P < .001), major blood loss (87.5% vs 59.3%, P = .005), and intensive care admission (27.9% vs 10.6%, P = .029), compared with non-emergency conversions. Robotic liver resection was linked to lower conversion risk, whereas American Society of Anesthesiologists grade ≥3, larger lesion size, concurrent ablation, technically major, and anatomically major resections were risk factors. Conclusion: Both emergency and non-emergency conversions negatively impact perioperative outcomes in minimally invasive liver surgery. Robotic liver resection reduces conversion risk compared to laparoscopic liver resection.</p
Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures
No full textOver the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions
How perceived coercion polarizes unvaccinated people:The mediating role of conspiracy beliefs
No full textDuring the COVID-19 pandemic, different policies were implemented to increase vaccination uptake. Meanwhile, conspiracy theories spread widely, and vaccinated versus unvaccinated people increasingly polarized against each other. This study examined the associations between perceived vaccination coercion, conspiracy beliefs and polarization. We tested the relationship of vaccination status with perceived vaccination coercion, conspiracy beliefs, and polarization, with a total sample size of N = 1202 (n = 400 in China, n = 401 in the US, and n = 401 in the UK), among them n = 603 were vaccinated and n = 599 were unvaccinated. As pre-registered, unvaccinated people perceived more vaccination coercion and endorsed more conspiracy theories. Conspiracy mentality was positively related to perceived coercion. Contrary to our hypotheses, vaccinated people were more polarized toward unvaccinated people than vice versa. Finally, conspiracy beliefs mediated the link between perceived coercion and polarization among unvaccinated people
The BMP7-Derived Peptide p[63-82] Reduces Cartilage Degeneration in the Rat ACLT-pMMx Model for Posttraumatic Osteoarthritis
No full textObjective: Osteoarthritis (OA) is characterized by articular cartilage erosion, pathological subchondral bone changes, and signs of synovial inflammation and pain. We previously identified p[63-82], a bone morphogenetic protein 7 (BMP7)-derived bioactive peptide that attenuates structural cartilage degeneration in the rat medial meniscal tear-model for posttraumatic OA. This study aimed to evaluate the cartilage erosion-attenuating activity of p[63-82] in a different preclinical model for OA (anterior cruciate ligament transection—partial medial meniscectomy [anterior cruciate ligament transection (ACLT)-pMMx]). The disease-modifying action of the p[63-82] was followed-up in this model for 5 and 10 weeks. Design: Skeletally mature male Lewis rats underwent ACLT-pMMx surgery. Rats received weekly intra-articular injections with either saline or 500 ng p[63-82]. Five and 10 weeks postsurgery, rats were sacrificed, and subchondral bone characteristics were determined using microcomputed tomography (µCT). Histopathological evaluation of cartilage degradation and Osteoarthritis Research Society International (OARSI)-scoring was performed following Safranin-O/Fast Green staining. Pain-related behavior was measured by incapacitance testing and footprint analysis. Results: Histopathological evaluation at 5 and 10 weeks postsurgery showed reduced cartilage degeneration and a significantly reduced OARSI score, whereas no significant changes in subchondral bone characteristics were found in the p[63-82]-treated rats compared to the saline-treated rats. ACLT-pMMx-induced imbalance of static weightbearing capacity in the p[63-82] group was significantly improved compared to the saline-treated rats at weeks 5 postsurgery. Footprint analysis scores in the p[63-82]-treated rats demonstrated improvement at week 10 postsurgery. Conclusions: Weekly intra-articular injections of p[63-82] in the rat ACLT-pMMx posttraumatic OA model resulted in reduced degenerative cartilage changes and induced functional improvement in static weightbearing capacity during follow-up.</p