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RESULTS Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values less then 53% compared to baseline when pressure was quadrupled. Normalizing CSF pressure led to an intense hyperperfusion of up to 186% at the cervical level and 151% within the lumbar region. CONCLUSIONS CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to 'drainage-related' iatrogenic reperfusion injury-aggravating the risk of delayed spinal cord injury-and should therefore be avoided. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.BACKGROUND In market-based systems, the possibility to switch is an important precondition for a well-functioning health insurance market. To assess whether such a market works as intended, insight into the considerations and perceived barriers of insured is needed. This study examines the rates and reasons for not switching health insurer in the Netherlands, and whether these reasons differ between the general population and the population of people with a chronic illness. METHODS We made use of survey data collected in 2017 among two panels representing the general population (n = 659, response 44%) and the chronically ill population (n = 1593, response 86%). RESULTS We found differences regarding the reasons for not switching insurer. The chronically ill population seems to attach more importance to reasons related to the coverage of the health plan, whereas the general population is more focused on the level of service. Some people who considered switching experienced barriers, however, these barriers were not significantly more experienced by the chronically ill population. CONCLUSIONS This study reveals differences between the general population and the chronically ill population when examining reasons for not switching related to quality and coverage. A subset from the people who initially considered to switch experienced barriers which might have altered their decision. Further research is recommended to include questions about information search behaviour to examine which consumers make an informed decision for not switching, and for whom barriers limit switching. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.The 'Seguro Médico Siglo XXI' (SMSXXI), a universal coverage medical insurance programme for children under 5 years of age, started in 2006 to help avoid catastrophic health expenditures in poor families without social security in Mexico. The study used information from the National Health Information System for the 2006-14 period. An ecological approach was followed with a panel of the 2457 municipalities of Mexico as the units of analysis. The outcome variables were the municipality-level neonatal mortality and infant mortality rates in population without access to social security. The programme variable was the coverage of the SMSXXI programme at the municipality level, expressed as a proportion. Demographic and economic variables defined at the municipality level were included as covariates. Impact was estimated by fitting a fixed-effects negative binomial regression model. see more Results reveal that the SMSXXI significantly reduced both infant and neonatSal mortality in the target population, although in a non-linear fashion, with minimum mortality levels found around the 70% coverage range. The effect is mostly given by the transition from the first quintile to the fourth quintile of coverage ( less then 13% vs 70.5-93.7% coverage), and it is attenuated significantly at coverage levels very close to or at 100%. The observed risk reduction amounted to an estimated total of 11 358 infant deaths being avoided due to the SMSXXI during the 2006-14 period, of which 48% were neonatal. In conclusion, we found a significant impact of the SMSXXI programme on both infant mortality and neonatal mortality. An attenuation of the effect of the insurance on mortality rates at levels close to 100% coverage may reflect the saturation of health units in detriment of the quality of care. © The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail [email protected] This meta-analysis of Kaplan-Meier-estimated individual patient data was designed to evaluate the effects of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) on the long-term all-cause mortality rate, to examine the potential time-varying effect and to model their hazard ratios (HRs) over time. Moreover, we sought to compare traditional meta-analytic tools and estimated individual patient data meta-analyses. METHODS Trials comparing TAVI versus SAVR were identified through Medline, Embase, Cochrane databases and specialist websites. The primary outcome was death from any cause at follow-up. Enhanced secondary analyses of survival curves were performed estimating individual patient time-to-event data from published Kaplan-Meier curves. Treatments were compared with the random effect Cox model in a landmark framework and fully parametric models. RESULTS We identified 6 eligible trials that included 6367 participants, randomly assigned to undergo TAVI (3252) or SAVR (3115). According to the landmark analysis, the incidence of death in the first year after implantation was significantly lower in the TAVI group [risk-profile stratified HR 0.85, 95% confidence interval (CI) 0.73-0.99; P = 0.04], whereas there was a reversal of the HR after 40 months (risk-profile stratified HR 1.31, 95% CI 1.01-1.68; P = 0.04) favouring SAVR over TAVI. This time-varying trend of HRs was also confirmed by a fully parametric time-to-event model. Traditional meta-analytic tools were shown to be biased because they did not intercept heterogeneity and the time-varying effect. CONCLUSIONS The mortality rates in trials of TAVI versus SAVR are affected by treatments with a time-varying effect. TAVI is related to better survival in the first months after implantation whereas, after 40 months, it is a risk factor for all-cause mortality. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.OBJECTIVES Early removal of chest tube is an important step in enhanced recovery after surgery protocols. However, after pulmonary resection with a wide dissection plane, such as pulmonary segmentectomy, prolonged air leak, a large volume of pleural drainage and the risk of developing empyema in patients can delay chest tube removal and result in a low rate of completion of the enhanced recovery after surgery protocol. In this study, we aimed to assess the safety of discharging patients with a chest tube after pulmonary segmentectomy. METHODS We retrospectively reviewed a single surgeon's experience of pulmonary segmentectomy from May 2019 to September 2019. Patients who fulfilled the criteria for discharging with a chest tube were discharged and provided written instructions. They returned for chest tube removal after satisfactory resolution of air leak or fluid drainage. RESULTS In total, 126 patients underwent pulmonary segmentectomy. Ninety-five (75%) patients were discharged with a chest tube postoperatively. The mean time to chest tube removal after discharge was 5.6 (range 2-32) days, potentially saving 532 inpatient hospital days. Overall, 90 (95%) patients experienced uneventful and successful outpatient chest tube management. No life-threatening complications were observed. No patient experienced complications resulting from chest tube malfunction. Five (5%) patients experienced minor complications. Overall, all patients reported good-to-excellent mobility with a chest tube. CONCLUSIONS Successful postoperative outpatient chest tube management after pulmonary segmentectomy can be accomplished in selected patients without a major increase in morbidity or mortality. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.A best evidence topic was constructed according to a structured protocol. The question addressed was whether the application of an enhanced recovery protocol or pathway improves patient outcomes after cardiac surgery. A total of 3091 papers were found using the reported search. Finally, 12 papers represented the best available evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Six studies referred to enhanced recovery protocol as fast track (FT) and another 6 studies referred to it as enhanced recovery after surgery (ERAS). Significant differences from conventional care were reported for time to extubation or intubation time in 4 studies (3 FT, 1 ERAS), duration of intensive care unit stay in 6 studies (4 FT, 2 ERAS), length of hospital stay (LOS) in 8 studies (5 FT, 3 ERAS), cost in 5 studies (4 FT, 1 ERAS), pain scores in 2 studies (2 ERAS) and opioid use in 3 studies (3 ERAS). We conclude that FT or ERAS improve postoperative outcomes including length of stay and pain control, without increasing morbidity, mortality or readmission. However, there is a need for prospective studies and standardized protocols. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.Frontotemporal dysconnectivity is a key pathology in schizophrenia. The specific nature of this dysconnectivity is unknown, but animal models imply dysfunctional theta phase coupling between hippocampus and medial prefrontal cortex (mPFC). We tested this hypothesis by examining neural dynamics in 18 participants with a schizophrenia diagnosis, both medicated and unmedicated; and 26 age, sex and IQ matched control subjects. All participants completed two tasks known to elicit hippocampal-prefrontal theta coupling a spatial memory task (during magnetoencephalography) and a memory integration task. In addition, an overlapping group of 33 schizophrenia and 29 control subjects underwent PET to measure the availability of GABAARs expressing the α5 subunit (concentrated on hippocampal somatostatin interneurons). We demonstrate-in the spatial memory task, during memory recall-that theta power increases in left medial temporal lobe (mTL) are impaired in schizophrenia, as is theta phase coupling between mPFC and mTL. Importantly, the latter cannot be explained by theta power changes, head movement, antipsychotics, cannabis use, or IQ, and is not found in other frequency bands. Moreover, mPFC-mTL theta coupling correlated strongly with performance in controls, but not in subjects with schizophrenia, who were mildly impaired at the spatial memory task and no better than chance on the memory integration task. Finally, mTL regions showing reduced phase coupling in schizophrenia magnetoencephalography participants overlapped substantially with areas of diminished α5-GABAAR availability in the wider schizophrenia PET sample. These results indicate that mPFC-mTL dysconnectivity in schizophrenia is due to a loss of theta phase coupling, and imply α5-GABAARs (and the cells that express them) have a role in this process. © The Author(s) (2020). Published by Oxford University Press on behalf of the Guarantors of Brain.
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