Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial

Importance

Rib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures.

Objective

To determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures.

Design, Setting, and Participants

This multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023.

Interventions

Patients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone.

Main Outcomes and Measures

The primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points.

Results

A total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups.

Conclusions and Relevance

This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12621000040864.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Development and validation of a prognostic model for death 30 days after adult emergency laparotomy

The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.

Physician and patient perceptions of surgical procedures for osteoarthritis of the knee in the United States, Europe, and Japan: results of a real-world study

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis, with the knee being the joint most frequently affected, and symptomatic knee OA affecting around one quarter of the general population. For patients who do not respond to non-pharmacologic or pharmacologic treatment, surgery is a recommended option. The objectives of this study were to compare the willingness of patients with knee OA to undergo surgery, together with reasons for delaying surgery, and factors affecting successful outcomes.

METHODS

A point-in-time survey was conducted in 729 primary care physicians, rheumatologists, orthopedic surgeons, and 2,316 patients with knee OA across three geographical regions: Japan, the United States (US), and Europe (EUR: France, Spain, Italy, Germany, and the United Kingdom), in order to garner their perceptions of knee surgery. Regression models were used to identify factors that might affect patients' and physicians' perceptions of surgery, including severity of OA (mild/moderate/severe), number of affected joints, surgery status, and willingness to undergo or delay surgery.

RESULTS

Baseline demographics were similar between US and EUR, although patients in Japan were more likely to be female, older, and only 7% in fulltime employment. We found that few patients with end-stage knee OA, across all regions, but particularly Japan, were willing to undergo surgery (Japan 17%, US 32%, EUR 38%), either through fear, or the lack of awareness of the risk/benefits. Moreover, surgeons are prepared to delay surgery in elderly or unwilling patients, due to their dissatisfaction with the outcome, and may defer surgery in younger patients due to the need for future revision. We also identified a disconnect between physicians, of whom over 80% consider improved functioning to be the most important outcome of surgery, and patients, who seek pain relief (Japan 60%, US 35%, EUR 14%). Since physicians across all regions considered pain reduction to be an indication of surgery success (Japan 27%, US 47%, EUR 43%), this may indicate a need for improved communication to patients on the potential benefits of surgery.

CONCLUSION

Managing the expectations of patients undergoing surgery remains an important goal in the treatment of knee OA and may help guide physician choice.

Controlling the configuration space topology of mechanical structures

Linkages are mechanical devices constructed from rigid bars and freely rotating joints studied both for their utility in engineering and as mathematical idealizations in a number of physical systems. Recently, there has been a resurgence of interest in designing linkages in the physics community due to the concurrent developments of mechanical metamaterials, topological mechanics, and the discovery of anomalous rigidity in fiber networks and vertex models. These developments raise a natural question: to what extent can the motion of a linkage or mechanical structure be designed? Here, we describe a method to design the topology of the configuration space of a linkage by first identifying the manifold of critical points, then perturbing around such critical configurations. Unlike other methods, our methods are tractable and provide a simple visual toolkit for mechanism design. We demonstrate our procedure by designing a mechanism to gate the propagation of a soliton in a Kane-Lubensky chain of interconnected rotors.

Impact of osteoarthritis disease severity on treatment patterns and healthcare resource use: analysis of real-world data

OBJECTIVE

To understand treatment patterns and healthcare resource utilization (HCRU) related to osteoarthritis (OA) disease severity in patients in five European countries.

METHOD

Data were drawn from the Adelphi OA Disease Specific Programme™ (2017-18). Physicians classified their patients as having mild, moderate, or severe OA, and provided details on their current prescribed therapy and HCRU, including healthcare professional (HCP) consultations, diagnostics and testing, and hospitalizations. Comparisons between disease severity groups were made using analysis of variance and chi-squared tests.

RESULTS

The study included 489 physicians (primary care physicians, rheumatologists, orthopaedic surgeons) reporting on 3596 OA patients: 24% mild, 53% moderate, and 23% severe disease. Both physicians and patients reported decreasing satisfaction with treatment with greater disease severity, despite the number of classes of prescribed drugs and increased use of opioids, which were used in almost half of patients with severe OA. For patients whose treatment was not effective, physicians prescribed the same therapeutic options, which were cycled in subsequent treatment lines, with multiple treatment regimens being commonly used. Patients with greater symptom severity also had more physician consultations, while the numbers of tests/imaging, predominantly X-rays, conducted to diagnose or monitor OA increased significantly with disease severity. The type of HCP involvement in patient management also varied by OA severity.

CONCLUSIONS

Across five European countries, the use of both non-pharmacological and pharmacological treatments increases with greater disease severity. Those with more severe disease place a greater demand on healthcare resources, with HCP consultations, tests, and hospital visits increasing with severity.

POS0128 PHYSICIAN AND PATIENT PERCEPTIONS OF SURGICAL PROCEDURES FOR KNEE OA ACROSS JAPAN, THE US AND 5 EU COUNTRIES: RESULTS OF A REAL-WORLD STUDY

Background:

Patients with knee osteoarthritis (OA) who do not achieve adequate pain relief and functional improvement with a combination of non-pharmacologic and pharmacologic therapies are recommended an arthroplasty as an effective option to relieve severe pain and functional limitations. However, some patients are reluctant to undergo surgical interventions, and clinicians may choose to avoid or delay surgery due to safety risks and/or the financial cost. It is of interest to understand if the use and perception of surgery differs between countries, however, few published data exist.

Objectives:

To demonstrate how surgery and the use of surgical procedures differs across Japan, United States of America (US) and 5 major European countries (EU5) and to evaluate patient perception towards surgery.

Methods:

Data were drawn from the Adelphi OA Disease Specific Programme (2017-18), a point-in-time survey of primary care physicians (PCP), rheumatologists (rheums), orthopaedic surgeons (orthos) and their OA patients. Patients with physician-diagnosed knee OA were included and segmented into two categories: had previous surgery (PS) and never had surgery (NS). A Fisher’s exact test was performed on the two groups. Physicians reported on patient demographics; whether patients had undergone surgery; type of surgery; success of surgery; how success was defined; and reasons for wanting to delay surgery. Patients reported their willingness to undergo surgery; reasons for not wanting surgery; how successful their surgery was; and how they defined this success.

Results:

Physician/patient reported data were available for 302,230 (Japan), 527,283 (US) and 1487,726 (EU5) patients with diagnosed knee OA. Patients were categorised by their physicians as mild (40% Japan; 34% US; 24% EU5), moderate (49% Japan; 49% US; 56% EU5) or severe (9% Japan; 17% US; 19% EU5). Patients in Japan were more likely to be female (78% vs 54% US; 58% EU5), older (73 vs 65 US; 66 EU5) and have a lower BMI than patients in the US and EU5. Obesity and diabetes were much less prevalent among patients in Japan. One in ten patients in Japan had undergone a surgery (10%), far fewer than in the US (22%) or EU5 (17%). When surgery was performed, this was more likely to be a total joint replacement (TJR) in Japan, whereas in the EU and US, arthroscopic washout was more commonly performed.

For over half of Japanese patients (56%), successful surgery was more likely to be defined as having no more pain (vs. 35% US; 14% EU5). Improved mobility and a reduction in pain were also commonly reported reasons. Physicians (in each region) were more likely to suggest pain reduction, rather than no pain, and improved mobility as markers of success. Patients in Japan were much more likely to say they would not agree to surgery if recommended by their doctor, or were unsure (84% vs. 68% US; 62% EU5). The main reason for patient reluctance in Japan was fear of surgery, whereas in the US and EU5 the main reason given was that surgery was not needed. This finding was also evident among physicians in Japan, who frequently reported that patient reluctance was a key reason for delaying surgery. Physicians in Japan, do however, report that patient request was one of their main triggers for recommending surgery (45% vs 20% US; 16% EU5).

Conclusion:

Although surgery can be an effective option for those with OA who have exhausted other treatment options, some patients are reluctant to undergo surgery out of fear, especially in Japan, possibly due to the higher patient age. Physicians aiming to delay surgery were driven by patient reluctance in Japan, whereas cost to patient was a bigger factor in the US and EU5. The higher level of TJR vs. other surgery options among patients in Japan may suggest physicians are looking for higher levels of efficacy.

Disclosure of Interests:

Naoshi Fukui Speakers bureau: Pfizer, Consultant of: Pfizer, Philip G Conaghan Speakers bureau: Abbvie, Novartis, Consultant of: AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Kanae Togo Shareholder of: Pfizer, Employee of: Pfizer, Nozomi Ebata Shareholder of: Pfizer, Employee of: Pfizer, Lucy Abraham Shareholder of: Pfizer, Employee of: Pfizer, James Jackson: None declared, Jessica Jackson: None declared, Mia Berry: None declared, Hemant Pandit Paid instructor for: Bristol Myers Squibb, Consultant of: Johnson and Johnson, Grant/research support from: GSK

Evaluation of an Outpatient Pharmacist Consult Service at a Large Academic Medical Center

Objective:

To evaluate a novel outpatient pharmacist consult service in a large academic medical center.

Setting:

Four outpatient pharmacies that are part of a large academic medical center

Methods:

An outpatient pharmacist consult order was created and embedded in the electronic medical record (EMR). Medical center providers utilized this consult order when identifying patients in need of specific services provided by outpatient pharmacists. Descriptive data about each individual consult was collected including number completed, type of service, and duration. Rate of accepted pharmacy recommendations and patient cost savings were also evaluated. A survey was administered at the completion of the study period to assess provider and pharmacist satisfaction with the service. Patient demographic information was collected for those who had a documented completed consult.

Results:

A total of 193 consults were completed: 137 immunizations, 37 care affordability, 15 education, 3 polypharmacy and 1 OTC recommendation. 89% of completed consults took pharmacists 20 minutes or less to complete. Of completed care affordability consults (n=31), 55% of patients saved between $100 - $500 per medication fill. Of providers who completed a survey and utilized the service (n=12), 83.3% were extremely satisfied and 16.7% were satisfied with it. The provider acceptance rate of pharmacist’s recommendations was 74%.

Conclusion:

Implementation of an outpatient pharmacist consult service provided an alternative method for the utilization of pharmacist provided MTM services in outpatient pharmacies at a large academic medical center. The service was well received by both providers and pharmacists.

Female Multiple Orgasm: An Exploratory Internet-Based Survey

Women's multiorgasmic capacity has long been mentioned in the human sexuality literature. However, due in part to the conceptual vagueness surrounding this phenomenon, few empirical studies have focused on this topic, and our scientific knowledge is currently limited. This exploratory research is mainly aimed at providing a much-needed assessment of the profiles of women reporting multiorgasmic experiences. For this study, 419 sexually diverse women ages 18 through 69 who identified as multiorgasmic completed an online survey assessing variables pertaining to sociodemographic background, context and characteristics of a recent/typical multiorgasmic experience, relationships between multiple orgasm and sexual/nonsexual aspects of life, and sexual and orgasmic history. Data reduction analyses using principal component analysis pointed out that 15 variables of interest were distributed across six components, accounting for a large proportion of the sample's variance. A k-means cluster analysis further revealed that four distinct groups of women could be parsed out. These four groups could be differentiated by three sets of variables-sexual motivation, sexual history, and multiple orgasm characteristics-suggesting that female multiple orgasm is not a unitary phenomenon. This research provides to date the most comprehensive picture of female multiple orgasm and helps refine our conceptual understanding.

QTL analysis of cooking time and quality traits in dry bean (Phaseolus vulgaris L.)

Three robust QTL for dry bean cooking time shortened cooking time 11-26 min and co-localized with QTL for increased cooked seed protein concentration. Cooking time is a major factor associated with consumer preference of dry beans (Phaseolus vulgaris L.). The genetic control of cooking time was investigated with a quantitative trait loci (QTL) study on a recombinant inbred line (RIL) population developed from TZ-27 (slow cooking) and TZ-37 (fast cooking). The RIL population of 146 lines was grown on research farms over 2 years in Arusha and Morogoro, Tanzania. Arusha is an important mid-altitude bean-growing region, with moderate temperatures and reliable rainfall, whereas the low altitude and high temperatures in Morogoro make it unfavorable for bean production. The population exhibited large variation for cooking time with a range of 22-98 min. On average, beans grown in Arusha cooked 15 min faster than those grown in Morogoro. A linkage map developed with 1951 SNP markers was used for QTL analysis. Ten QTL were identified for cooking time, three of which were found in multiple environments. RILs with all three QTL (CT3.1, CT6.1, and CT11.2) cooked on average 11 min faster in Arusha and 26 min faster in Morogoro than RILs with none. Seed attributes were related to cooking time such that seeds with greater seed mass and less seed coat percentage cooked faster. Cooked seed protein concentration ranged from 17.8 to 30.8% across the years and locations. All three of the most robust cooking time QTL co-localized with QTL for protein concentration, and TZ-37 always contributed faster cooking time and increased protein concentration.

Topological transitions in the configuration space of non-Euclidean origami

Origami structures have been proposed as a means of creating three-dimensional structures from the micro- to the macroscale and as a means of fabricating mechanical metamaterials. The design of such structures requires a deep understanding of the kinematics of origami fold patterns. Here we study the configurations of non-Euclidean origami, folding structures with Gaussian curvature concentrated on the vertices, for arbitrary origami fold patterns. The kinematics of such structures depends crucially on the sign of the Gaussian curvature. As an application of our general results, we show that the configuration space of nonintersecting, oriented vertices with positive Gaussian curvature decomposes into disconnected subspaces; there is no pathway between them without tearing the origami. In contrast, the configuration space of negative Gaussian curvature vertices remains connected. This provides a new, and only partially explored, mechanism by which the mechanics and folding of an origami structure could be controlled.

Local Expansion of Donation After Circulatory Death Kidney Transplant Activity Improves Waitlisted Outcomes and Addresses Inequities of Access to Transplantation

In the United Kingdom, donation after circulatory death (DCD) kidney transplant activity has increased rapidly, but marked regional variation persists. We report how increased DCD kidney transplant activity influenced waitlisted outcomes for a single center. Between 2002-2003 and 2011-2012, 430 (54%) DCD and 361 (46%) donation after brain death (DBD) kidney-only transplants were performed at the Cambridge Transplant Centre, with a higher proportion of DCD donors fulfilling expanded criteria status (41% DCD vs. 32% DBD; p = 0.01). Compared with U.K. outcomes, for which the proportion of DCD:DBD kidney transplants performed is lower (25%; p < 0.0001), listed patients at our center waited less time for transplantation (645 vs. 1045 days; p < 0.0001), and our center had higher transplantation rates and lower numbers of waiting list deaths. This was most apparent for older patients (aged >65 years; waiting time 730 vs. 1357 days nationally; p < 0.001), who received predominantly DCD kidneys from older donors (mean donor age 64 years), whereas younger recipients received equal proportions of living donor, DBD and DCD kidney transplants. Death-censored kidney graft survival was nevertheless comparable for younger and older recipients, although transplantation conferred a survival benefit from listing for only younger recipients. Local expansion in DCD kidney transplant activity improves survival outcomes for younger patients and addresses inequity of access to transplantation for older recipients.

Progeria Syndrome with Characteristic Deformation of Proximal Radius Observed on Ct

The progeria syndrome (Hutchinson-Gilford) is an uncommon disease. A peculiar shape of the proximal radial metaphyseal region caused by an infolding of the cortex was observed on CT in 2 brothers suffering from this disorder, a feature not previously reported. A brief review of the radiologic literature was undertaken. This new observation needs to be further evaluated as it may provide a clinching diagnostic feature of this disease.

Ct Diagnosis of Macrodystrophia Lipomatosa

Radiographs and CT scans of a 45-year-old male with progressive enlargement of his right upper limb and shoulder are presented. Extensive soft-tissue hypertrophy with linear radiolucent bands (fat) limited to the lateral aspect of the limb were seen. Exostoses-like bony overgrowths were also seen along interphalangeal joints. At CT, hypertrophic adipose tissue intermingling with muscle fibers was demonstrated, a diagnostic finding distinguishing the lesion from plexiform neurofibrolipomatosis, Klippel-Trenaunay syndrome and other angiomatous lesions.

Promoting Healthy Child Development via a Two-Generation Translational Neuroscience Framework: The Filming Interactions to Nurture Development Video Coaching Program

In this article, we focus on applying methods of translational neuroscience to two-generation, family-based interventions. In recent years, a small but growing body of evidence has documented the reversibility of some of the neurobiological effects of early adversity in the context of environmental early interventions. Some of these interventions are now being implemented at scale, which may help reduce disparities in the face of early life stress. Further progress may occur by extending these efforts to two-generation models that target caregivers' capabilities to improve children's outcomes. In this article, we describe the content and processes of the Filming Interactions to Nurture Development (FIND) video coaching intervention. We also discuss the two-generation, translational neuroscience framework on which FIND is based, and how similar approaches can be developed and scaled to mitigate the effects of adversity.

Time for change? A national audit on bereavement care in intensive care units

INTRODUCTION

Bereaved ICU family members frequently experience anxiety, depression and post-traumatic stress disorder, which have been associated with significantly impaired quality of life. Recognising that their needs extend beyond the support provided by their friends and family, the Intensive Care Society had published in 1998 recommendations around bereavement care.

OBJECTIVE

The aim of the present national audit was to compare bereavement services in England against the nine recommendations set out by the Intensive Care Society guidelines.

METHODS

A telephone audit was carried out in all adult ICUs in England.

RESULTS

A total of 144 NHS Trusts (179 ICUs) met the inclusion criteria and 113 responses were collected (78% of Trusts, 63% of individual ICUs). Although most ICUs provided administrative information (96% had an information booklet), training (53%), auditing (19%) and adequate facilities (27%) did not meet the recommended standards.

CONCLUSION

Bereavement care is underdeveloped in English ICUs. This important but underreported topic should be prioritised in the critical care research agenda.

Two cases of culture proven Mycobacterium tuberculosis presenting with a broad-complex tachycardia and non-caseating granulomas

Tuberculosis is a leading cause of death worldwide. It affects pulmonary and extra-pulmonary sites with a multitude of differing presentations. In this report, we describe two cases in which TB causes myopericarditis and presents with a broad-complex tachycardia that did not respond typically to standard anti-arrhythmic therapy; a very rare presentation with limited description in the literature. Both patients required extensive investigation culminating in identifying lymph nodes amenable to biopsy under endobronchial ultrasound guidance. It was not until both patients received anti-tuberculous chemotherapy alongside anti-arrhythmic management that any improvement to their condition was witnessed. Therefore, we recommend that the clinician should have a high index of suspicion for TB in any patient presenting with a broad-complex tachycardia that is not responding to standard first line management, especially if the patient is from a high risk background. We recommend an active diagnostic pursuit, and lymph node biopsy under endobronchial ultrasound guidance.