Notes

Pathology involving deadly soften brain injury throughout serious non-penetrating mind shock.
Chronic cavitary pulmonary aspergillosis (CCPA) is a slow destructive type of chronic pulmonary aspergillosis, characterised by multiple pulmonary cavities that develop and expand over several months or years. Pleural involvement in the form of pneumothorax has been rarely reported in CCPA. We report such an unusual case of an immunocompromised male, with a history of chronic cough and fever, presenting with acute onset of shortness of breath. Chest imaging showed bilateral multiple cavitating nodules, ground glass opacities and dense right middle lobe consolidations and right-sided pneumothorax. Bronchoalveolar lavage (BAL) showed septate hyaline hyphae on KOH (potassium hydroxide) staining and fungal culture grew Aspergillus fumigatus BAL and serum galactomanan were positive and serum IgG for A. fumigatus was 58 MgA/L (0-40MgA/L) confirming the cause of spontaneous secondary pneumothorax in our patient as CCPA.
To compare the success rates and ease of use of three intraosseous (IO) access devices used in term neonates.

A three-arm randomised controlled simulation study was conducted.

A simulation laboratory.

Seventy-two paediatric residents completing their emergency department rotation as part of their residency training, and 20 paediatric specialists.

Using an animal bone model, the one-attempt success rate of the EZ-IO drill, the NIO-I needle and the Jamshidi needle was compared. Uncooked Cornish Hen bones were used because of their similarity in length and diameter to the bones of neonates. Participants were asked to record the perceived ease of use of their assigned device using a 5-point Likert Scale.

The main outcome was the visualisation of flow emerging from the distal end of the bone, and perceived ease of use of the three IO devices.

The EZ-IO, NIO-I and Jamshidi groups included 30, 31 and 31 participants, respectively, with median (IQR) years of experience of 3 (2-5), 3 (2-6) and 4 (3-5) years. Participants had significantly lower one-attempt success rates with the EZ-IO drill than with the NIO-I and the Jamshidi needles (14 of 30 (46.7%) vs 24 of 31 (77.4%); p=0.016, and 14 of 30 (46.7%) vs 25 of 31 (80.7%); p=0.007, respectively). The median (IQR) ease-of-use score of the EZ-IO drill was higher than that of the NIO-I and Jamshidi needles (5 (4-5) vs 4 (4-5); p=0.008, and 5 (4-5) vs 4 (3-4); p=0.0004, respectively).

Although easier to use, the EZ-IO drill demonstrated lower success rates than the IO needles in establishing IO access on a neonatal bone model.
Although easier to use, the EZ-IO drill demonstrated lower success rates than the IO needles in establishing IO access on a neonatal bone model.
Admission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified.

To systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives.

MEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched.

Randomised controlled trials and before-and-after studies.

Individuals aged <18 years.

Studies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second.

Twenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies.

There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.
There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.
To investigate the optic nerve and macular parameters of children who recovered from COVID-19 compared with healthy children using optical coherence tomography (OCT).

Cohort study.

Hospital Clinico San Carlos, Madrid.

Children between 6 and 18 years old who recovered from COVID-19 with laboratory-confirmed SARS-CoV-2 infection and historical controls were included.

All patients underwent an ophthalmological examination, including macular and optic nerve OCT. Demographic data, medical history and COVID-19 symptoms were noted.

Peripapillary retinal nerve fibre layer thickness, macular retinal nerve fibre layer thickness, macular ganglion cell layer thickness and retinal thickness.

90 patients were included 29 children who recovered from COVID-19 and 61 controls. Patients with COVID-19 presented an increase in global peripapillary retinal nerve fibre layer thickness (mean difference 7.7; 95% CI 3.4 to 12.1), temporal superior (mean difference 11.0; 95% CI 3.3 to 18.6), temporal inferior (mean difference 15.6; 95% CI 6.5 to 24.7) and nasal (mean difference 9.8; 95% CI 2.9 to 16.7) sectors. Macular retinal nerve fibre layer analysis showed decreased thickness in the nasal outer (p=0.011) and temporal inner (p=0.036) sectors in patients with COVID-19, while macular ganglion cell layer thickness increased in these sectors (p=0.001 and p=0.015, respectively). No differences in retinal thickness were noted.

Children with recent history of COVID-19 present significant changes in peripapillary and macular OCT analyses.
Children with recent history of COVID-19 present significant changes in peripapillary and macular OCT analyses.
To define and quantify the upper lid contour by adapting Bézier curves with a newly developed software in normal subjects, assessing their reliability.

Fifty eyes of 50 healthy patients with no ocular pathology were included in this study from October 2020 to November 2020. All measurements were performed on Bézier curves adjusted to the upper lid contour. An original software was used to measure the radial and vertical midpupil-to-lid margin distances (MPLD), temporal-to-nasal (T/N) ratios, contour peak location and grade of superposition (GS) and asymmetry (GA) indexes. We calculated differences in the variables measured regarding age, gender or the side of the eye being assessed.

The mean Bézier curve showed an excellent level of inter-rater reliability (intraclass correlation coefficient of 0.99). The median GS index of each eyelid to the mean Bézier curve was 95.4%, 8.5 IQR, and the median GA index was 3%, 3.4 IQR. The mean contour peak location was -0.35 mm, SD 0.45. Overall, the mean central MPLD was 4.1 mm, SD 0.6. No significant differences were found between male and female patients in variables derived from Bézier curves.

Bézier curves may become a very useful tool for the assessment of upper lid contour, contour peak and symmetry. GS and GA indexes, along with the T/N area ratio are potential outcomes for this purpose. All current variables can be obtained just from one single Bézier curve measurement. Our results offer an in-depth exhaustive description of these variables and their distribution in the normal population.
Bézier curves may become a very useful tool for the assessment of upper lid contour, contour peak and symmetry. GS and GA indexes, along with the T/N area ratio are potential outcomes for this purpose. All current variables can be obtained just from one single Bézier curve measurement. Our results offer an in-depth exhaustive description of these variables and their distribution in the normal population.
To evaluate the cost-effectiveness of non-invasive monitoring tests to detect the onset of neovascular age-related macular degeneration (nAMD) in the unaffected second eye of patients receiving treatment for unilateral nAMD in a UK National Health Service (NHS) hospital outpatient setting.

A patient-level state transition model was constructed to simulate the onset, detection, and treatment of nAMD in the second eye. Five index tests were compared self-reported change in visual function, Amsler test, clinic measured change in visual acuity from baseline, fundus assessment by clinical examination or colour photography, and spectral domain optical coherence tomography (SD-OCT). Diagnosis of nAMD was confirmed by fundus fluorescein angiography (FFA) before prompt initiation of antivascular endothelial growth factor treatment. Quality-adjusted life-years (QALYs) and costs of health and social care were modelled over a 25-year time horizon.

SD-OCT generated more QALYs (SD-OCT, 5.830; fundus assessment, 5.787; Amsler grid, 5.736, patient's subjective assessment, 5.630; and visual acuity, 5.600) and lower health and social care costs (SD-OCT, £19 406; fundus assessment, £19 649; Amsler grid, £19 751; patient's subjective assessment, £20 198 and visual acuity, £20 444) per patient compared with other individual monitoring tests. Probabilistic sensitivity analysis indicated a high probability (97%-99%) of SD-OCT being the preferred test across a range of cost-effectiveness thresholds (£13 000-£30 000) applied in the UK NHS.

Early treatment of the second eye following FFA confirmation of SD-OCT positive findings is expected to maintain better visual acuity and health-related quality of life and may reduce costs of health and social care over the lifetime of patients.
Early treatment of the second eye following FFA confirmation of SD-OCT positive findings is expected to maintain better visual acuity and health-related quality of life and may reduce costs of health and social care over the lifetime of patients.
The BEVORDEX trial compared outcomes of eyes with diabetic macular oedema (DMO) randomised to receive either intravitreal dexamethasone (DEX-) implant or bevacizumab over 2 years. We assessed long-term efficacy and safety outcomes 5 years from enrolment.

Patients received standard clinical care after they finished the study. Their files were reviewed for visual and anatomical outcomes, post-trial treatments and complications.

Three-year and five-year data were available for 82% and 59% of eyes enrolled in the BEVORDEX study, respectively. Visual acuity gains at end of trial were generally lost by both treatment groups at 5 years but the macular thickness did not change from end of trial to 5 years. A similar proportion of eyes from each treatment group gained ≥10 letters at 5 years from enrolment in the BEVORDEX trial.Eyes that were initially randomised to the DEX-implant group had significantly fewer treatments but were more likely to develop proliferative diabetic retinopathy (PDR) over the 5-year period compared with eyes initially randomised to bevacizumab. see more The proportion of eyes that had cataract surgery by 5 years was similar between initial treatment groups.

Eyes in the BEVORDEX trial had similar 5-year rates of cataract surgery, however, more eyes converted to PDR in the group initially treated with DEX-implant. Eyes that were initially treated for 2 years with either intravitreal DEX-implant of bevacizumab followed by standard of care had similar visual and anatomical outcomes at 5 years.
Eyes in the BEVORDEX trial had similar 5-year rates of cataract surgery, however, more eyes converted to PDR in the group initially treated with DEX-implant. Eyes that were initially treated for 2 years with either intravitreal DEX-implant of bevacizumab followed by standard of care had similar visual and anatomical outcomes at 5 years.
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