Fluctuating course of delirium and complexities of ICU care mean delirium symptoms are hard to identify or commonly confused with other disorders. Delirium is difficult to diagnose, and clinicians and researchers may combine assessments from multiple tools. We evaluated diagnostic accuracy of different combinations of delirium assessments performed in each enrolled patient.Data were obtained from a previously conducted cross-sectional study. Eligible adult patients who remained admitted to ICU for >24 hours with at least one family member present were consecutively enrolled as patient-family dyads. Clinical delirium assessments (Intensive Care Delirium Screening Checklist [ICSDC] and Confusion Assessment Method-ICU [CAM-ICU]) were completed twice daily by bedside nurse or trained research assistant, respectively. Family delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily by family members. We pooled all delirium assessment tools in a single two-class latent model and pairwise  Bayesian analyses.Seventy-three patient-family dyads were included. Among clinical delirium assessments, the ICDSC had lower sensitivity  and higher specificity  using Bayesian analyses compared to pooled latent class analysis and CAM-ICU had higher sensitivity  and higher specificity . Among family delirium assessments, the Family Confusion Assessment Method had higher sensitivity  and higher specificity  using Bayesian analyses compared to pooled latent class analysis and the Sour Seven had higher specificity  but lower sensitivity .Results from delirium assessment tools are often combined owing to imperfect reference standards for delirium measurement. Pairwise Bayesian analyses that explicitly accounted for each tool’s (performed within same patient) prior sensitivity and specificity indicate that two combined clinical or two combined family delirium assessment tools have fair diagnostic accuracy. One third of patients admitted to the intensive care unit (ICU) will develop delirium , 2 that A systematic review and psychometric analysis on five clinical delirium assessment tools  from 36 patient cohorts reported the Intensive Care Delirium Screening Checklist (ICDSC) and Confusion Assessment Method-ICU (CAM-ICU) had the highest validity and reliability among critically ill adults . Family The diagnostic accuracy of a delirium assessment tool is determined by comparing the results from a delirium assessment to a gold standard test [with 100% accuracy] . There iLatent class models are employed widely to estimate diagnostic accuracy without a gold standard  as this This diagnostic evaluation study used data from a previously published cross-sectional study  and is rRecruitment of participants was performed at a large, tertiary care academic hospital  within a single-payer health system. A multidisciplinary care team staffs the 28 closed beds of the FMC medical-surgical ICU. Eligibility criteria for study participation are listed in The study collected data in ICU up to a maximum of five days. Patient and family demographics  were collected at first delirium assessment. Patient clinical characteristics  were obtained from eCritical, a beside clinical information system validated for research purposes .Two clinical delirium assessments were completed by assessors  blind to the results of the family administered delirium assessments. The ICDSC was conducted twice daily  and is valid and reliable to screen for delirium on eight independent domains  . ICDSC dTwo family administered delirium assessments were performed once daily by family members of critically ill patients blind to results from clinical assessments. Family members assessed patient delirium using the Family Confusion Assessment Method (FAM-CAM) and the Sour Seven. Using the FAM-CAM, family members answered 11-items regarding sudden changes to patient attention, orientation, perception or concentration . The FAMboth pairwise assessments within 6-hour time windows, chosen to account for the fluctuation in delirium presentation  is not available for delirium detection and the development of such a test is likely not feasible or practical , 33. In Thomas et al.  referredLatent class analysis is frequently used to estimate diagnostic accuracy from imperfect diagnostic tests , 28. ThiOur results are in line with our earlier report  such thaWe have previously shown feasibility and acceptability of employing family administered delirium assessment tools in adult ICU , and repThe results of our study must be interpreted cautiously and there are several limitations worth noting. First, this study was conducted as a secondary analysis of data collected in an earlier observational study. Second, our data was collected from patients admitted to a single medical center. Although this center serves a large catchment area of approximately 1.8 million people and should be reasonably representative of multisystem ICU patients in academic hospitals, these finding may not be generalizable to all ICU patients. Third, nearly 20% of our sample were patients with a neurological admission status in whom delirium diagnosis is especially challenging as neurologic patients fall more under the term acute encephalopathy rather than delirium . Our abiCaring for critically ill patients includes multiple tools to identify ICU delirium. Results from delirium assessment tools employed at different times during patient care are often combined owing to no gold standard and imperfect reference standards for delirium but using several tools at a single time is impractical and infeasible. Using pairwise Bayesian analyses to explicitly account for each tool’s prior sensitivity and specificity all in the same patient within 6-hours, we report that two combined clinical or two combined family delirium assessment tools have fair diagnostic accuracy.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Pregnancy is known to be a risk factor for venous thromboembolism (VTE). We report the case of a pregnant patient with difficult to diagnose iliac vein thrombosis, establishing a definite diagnosis by clues of great saphenous vein reflux.A 37-year-old G1P0 woman at 35 weeks of assisted twin gestation presented with a complaint of persistent left lower limb edema and tenderness. A vascular ultrasound was used to examine the bilateral lower limb. Doppler of left lower extremity revealed continuous great saphenous vein reflux. Right saphenofemoral veins demonstrated venous stasis and no reflux. Unilateral continuous great saphenous vein reflux suggested left iliac veins obstruction or extrinsic compression. Anterograde venography showed a completely occlusive filling defect of the left external iliac vein, which is the definitive diagnosis of acute deep venous thrombosis. The patient underwent a cesarean delivery following inferior vena cava filter (IVCF) placement, and no signs of deep venous thrombosis (DVT) or pulmonary embolism (PE) were reported after delivery.In pregnant women with suspected deep vein thrombosis, it is imperative to assess the presence of unilateral continuous great saphenous vein reflux. Pregnancy is one of the major risk factors in the development of venous thromboembolism (VTE), with pregnant women having a fourfold increased risk of VTE compared with non-pregnant women . PregnanA 37-year-old pregnant woman G1P0 at 35 weeks of twin gestation complained of left leg swelling and pain for approximately 1 week. In an external imaging facility, she underwent a lower extremity ultrasound, which revealed varicosis of the left great saphenous vein.History of past illness .Colour venous doppler ultrasound of the bilateral lower extremity revealed that the deep femoral vein, popliteal vein, proximal segments of crural veins were normal. Imaging revealed unilateral continuous saphenofemoral reflux in the left lower extremity Fig. . The sapPregnancy is a pro-coagulant state . CombineD-dimer is physiologically elevated during pregnancy, so its utility during pregnancy is limited to ruling out DVT. According to an analysis of a prospective study  evaluatiThe recommended treatment for thromboembolism in pregnant patients consists of weight-based unfractionated heparin or low-molecular weight heparin throughout pregnancy until at least 6 weeks postpartum . The redIVCF was widely used in the daily clinical practice to prevent PE. An inferior vena cava (IVC) filter can act as a mechanical barrier in the prevention of a lower extremity or pelvic venous thrombosis from embolising to become a potentially lethal pulmonary embolus. The intended dwell time of a temporary IVCF is 7 to 35 days. Complications of IVC filters include trauma at insertion, fracture and/or migration, occlusion by thrombus or endothelialisation, penetration of the IVC and failed retrieval .Because of the morbidity and mortality associated with pregnancy-related thrombosis, a more accurate DVT diagnosis remains an important focus of future research. We present the case of a patient with suspected DVT in whom to establish a definite diagnosis by great saphenous vein reflux. Anatomical communications between superficial and deep veins should be remembered. In the lower limb, the most important superficial veins are the greater and lesser saphenous veins. Continuous great saphenous vein reflux may be a signal of iliac vein thrombosis.During my pregnancy, I had symptoms of my left leg swelling and tenderness. The doctors told me that it might be a thrombosis in my leg, I got several tests; however, the doctors were still unsure about the thrombosis. Vascular ultrasound suggested left iliac veins obstruction or extrinsic compression. Anterograde venography confirmed the diagnosis. Although I was disappointed about the diagnosis, I was glad to hear the doctors had finally a definite diagnosis.


Staging of disease allows for the estimation of disease severity based on the identification of important points in the natural history of a disease. Crucially, grouping together patients at similar stages of disease severity permits for the enrichment of clinical trials . In Alzhin vivo. Several recent clinical trials screened potential participants prior to enrolment in order to only include individuals who could benefit from a specific therapy. Moreover, the recent phase II donanemab clinical trial also restricted enrolment criteria to intermediate levels of tau pathology as determined by tau-PET. A potential strategy could be to assign amyloid-β positive participants to different clinical trials depending on their severity of tau pathology, evaluated using PET-based Braak staging. Having groups of participants with greater similarity in rates of short-term cognitive decline could increase statistical power for future trials by reducing standard error of the mean for cognitive decline within a group. Using PET for disease staging has two important advantages over fluid biomarkers. The topographical information for PET imaging allows for inferences regarding AD severity in an individual subject. Furthermore, because phosphorylated tau (p-tau) biomarkers in both CSF and plasma are more closely associated with amyloid-β plaques than tau neurofibrillary tangles [Individuals without cognitive impairment are highly heterogenous in terms of their risk of future cognitive decline . Even re tangles , especiaTau-PET may also be useful for monitoring disease modification as a secondary outcome in pivotal randomized controlled trials. While it is not fully understood whether tau tangles themselves are causative of cognitive decline or merely upstream of it, a therapy that is associated with lower rates of tau accumulation in the experimental group could be interpreted to indicate successful disease modification. For example, if amyloid-positive individuals receiving an anti-amyloid monoclonal antibody do not accumulate tau outside of Braak I–II regions while the placebo arm does, this finding could be used to support primary outcome data (presumably differences in cognitive trajectories) as evidence of disease modification. Such a finding would also provide evidence in humans to support numerous animal models of amyloid-β pathology potentiating tau aggregation and spreading.In conclusion, disease staging systems using PET imaging have the potential to inform the design, enrichment and monitoring of randomized clinical trials in the field of AD. Given the recent success of lecanemab and the renewed interest in investments into the AD field, PET-based disease staging may increase the success of future anti-amyloid monoclonal antibody therapies, or therapies based on other mechanisms. Despite some evidence suggesting that atypical clinical variants of AD largely have tau distributions compatible with the Braak staging system , future


This study investigates mortality differences by income among first- and second-generation immigrants and the native ancestral population in Sweden. Despite immigrants’ various vulnerabilities and the exhaustive evidence for a persistent inverse relationship between income and mortality in general Western populations, previous studies from outside Sweden demonstrated surprisingly weak income gradients in mortality among first-generation immigrants. Examining these associations among second-generation immigrants may help to understand this paradox.Swedish register data from 2002 to 2016 were used to study the association between individual income rank positions and all-cause mortality. The study population was restricted to ages 25-64 years. Based on ‘relative indices of inequality’ (RII) derived from Poisson regressions, we measured mortality differentials between the least and most deprived income rank positions stratified by nativity group and sex. Correspondingly, we assessed absolute differences in mortality between the most and least deprived by using ‘slope indices of inequality’ (SII).Largest inequalities in mortality by relative income rank positions (based on RII) were found for the Swedish native ancestral population that showed on average a nearly doubled mortality risk for least compared to most deprived rank position. Immigrants disclosed weak or even nullified associations between relative income rank and all-cause mortality. Mortality inequalities by income among second-generation immigrants were substantially higher relative to first-generation immigrants but somewhat lower compared to the native ancestral population. These patterns were consistent between males and females, and confirmed by the use of SII.Distinct exposures to inequality structures but also first-generation immigrants’ ‘mortality advantage’ likely contribute to the considerable mortality differences by income between the studied nativity groups.• Despite their social and economic vulnerabilities, first-generation immigrants in Sweden disclose weak associations between relative income rank and all-cause mortality.• Second-generation immigrants in Sweden show notably higher magnitudes in income-related mortality compared with first-generation immigrants.


Liver transplantation is currently the only curative treatment for patients with end-stage liver disease. However, liver transplantation can be associated with catastrophic complications in the early postoperative setting, including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT). Postoperative complications are associated with hepatic artery resistive index (RI) < 6, systolic acceleration time (SAT) > 0.08 seconds and peak systolic velocity (PSV) > 200 cm/s on doppler ultrasound (DUS). DUS is also used in an intraoperative setting to assess patency and early complications prior to the end of the operative period, allowing for early correction. This literature review evaluates the prevalence of DUS use in intraoperative settings to identify transplant complications. A lack of consistency and minimal knowledge of intraoperative DUS warrants additional research into its usage and standardization. A liver transplant (LT) is the only curative treatment for children and adults with end-stage liver disease. The first LT performed by Starzl in 1967 was from a deceased donor. A whole donor liver replaced the resected liver and was called an orthotopic liver transplant (OLT) . The intGeneral considerations in liver transplant ultrasound The standard technique for perioperative Doppler ultrasound (DUS) involves using a 2-5 MHz convex transducer positioned with a probe angle < 60 degrees to the long axis of the vessel. Typically, hepatic artery measurements are made just proximal to the hepatic artery bifurcation -15. The Postoperative Doppler ultrasoundIn 1994, Dodd et al. were among the first to associate quantitative DUS findings in the postoperative period with hepatic arterial complications following a liver transplant. Their findings from a retrospective cohort identified a significant decrease in the hepatic arterial resistive index (RI) and a significant increase in systolic acceleration time (SAT) in patients that experienced arterial complications (thrombosis or stenosis). Peak systolic velocity (PSV) and absent arterial waveforms were not associated with vascular complications. The results suggested that a RI < 0.5 and SAT > 0.08 seconds were predictive of hepatic arterial complications . These fThe incidence of early hepatic artery thrombosis (eHAT), defined as hepatic artery thrombosis (HAT) within one month of transplant, is a well-documented complication following both OLT and SLT. eHAT occurs in 2-5% of adults following LT -20. A reHepatic artery stenosis (HAS) occurs later than HAT postoperatively . It occuIntraoperative Doppler ultrasoundCheng et al. demonstrated the utility of intraoperative DUS in a case series of nine patients with identified vascular complications. The subsequent intervention resulted in surgical correction at the time of transplant and 100% graft survival . Gu et aIntraoperative Doppler ultrasound has clinical impact in identifying sequelae of the hepatic artery buffer response. Blood flows into the liver through the portal vein and hepatic artery. The liver receives nearly 25% of cardiac output and performs first-pass filtration from the splanchnic circulation ,33. The Hepatic venous outflow obstruction occurs in 1-6% of OLTs due to inferior vena cava (IVC) torsion, compression, or anastomotic stenosis . TypicalAlternative ultrasound types in transplantHom et al. performed a study comparing patients who had undergone a liver transplant with contrast-enhanced ultrasound to conventional color DUS . ContrasThe literature on intraoperative DUS in liver transplants is relatively sparse despite increased use. The present case reports and case series have demonstrated the utility of qualitative DUS assessment to detect immediate graft complications. However, only a handful of single-center studies have investigated quantitative parameters that would allow for increased standardization of DUS interpretation. This review concludes that focused investigations into intraoperative DUS findings are necessary for continued liver transplant success.


Indocyanine green fluorescence angiography (ICGFA) is commonly used in colorectal anastomotic practice with limited pre-training. Recent work has shown that there is considerable inconsistency in signal interpretation between surgeons with minimal or no experience versus those consciously invested in mastery of the technique. Here, we deconstruct the fluorescence signal patterns of expert-annotated surgical ICGFA videos to understand better their correlation and combine this with structured interviews to ascertain whether such interpretative capability is conscious or unconscious.n = 24) were quantitatively interrogated using a boutique intensity tracker (IBM Research) to generate signal time plots. Such fluorescence intensity data were examined for inter-observer correlation  at specific curve milestones: the maximum fluorescence signal (Fmax), the times to both achieve this maximum (Tmax), as well as half this maximum (T1/2max) and the ratio between these (T1/2/Tmax). Formal tele-interview with contributing experts (n = 6) was conducted with the narrative transcripts being thematically mapped, plotted, and qualitatively analyzed.For fluorescence signal analysis, expert-annotated ICGFA videos (excellent (ICC0.9–1.0) for Fmax, Tmax, and T1/2max  and moderate (0.5–0.75) for T1/2/Tmax (0.729). While all experts narrated a deliberate viewing strategy, their specific dynamic signal appreciation differed in the manner of description.Correlation by mathematical measures was Expert ICGFA users demonstrate high correlation in mathematical measures of their signal interpretation although do so tacitly. Computational quantification of expert behavior can help develop the necessary lexicon and training sets as well as computer vision methodology to better exploit ICGFA technology.The online version contains supplementary material available at 10.1007/s00464-022-09299-3. Indocyanine green fluorescence angiography (ICGFA) has been rapidly adopted across many surgical disciplines . It has Therefore, here we follow on the initial observer variability discovery work with a focused investigation of the interpretation and cognitive processes occurring at expert user level in that study via semi-structured interviews as well as detailed quantitative analysis of observed video signal interpretation. The purpose of our study was to evaluate factors underlying the better correlation seen between experts and to establish whether this occurs due to conscious act in order to inform how best to advance ICGFA interpretation among others.n = 14, 9 showing perfusion signals at the time of proximal colonic transection, five showing anastomotic/small bowel perfusion) obtained during routine laparoscopic colorectal surgery to both experienced  and inexperienced  observers via an innovative video display and annotation platform (Mindstamp: The Interactive Video Platform www.mindstamp.io). All ICGFA transection perfusion videos demonstrated the white-light tissue appearances as well as the near-infrared (NIR) appearances and an overlay, false-colored view of the NIR signal on the white-light image simultaneously using the Pinpoint Endolaparoscopic Near-infrared system (Stryker©). Using Mindstamp, observers were able to record their interpretations of the fluorescence signal of the proximal colonic segment directly onto the video segment, indicating their choice of stapler positioning across the colon based on their interpretation of the fluorescence signal. This allowed comparison of interpretations between experienced and inexperienced users and showed significant differences in interpretation between the two groups with experienced users showing higher levels of agreement in signal interpretation.This research    of four intraoperative ICG angiograms used in the prior study were analyzed using a boutique intensity tracker (IBM Research Ireland ) to genesee Fig.  (camera max), the time required for it to rise to fifty percent of the maximum fluorescence intensity (T1/2max), and the time to achieve the full peak (Tmax), as well as the ratio of the two (T1/2/Tmax)  for one video and charted as scatter plots, with Chi-squared confidence ellipses charted to visually demonstrate expert/inexpert clustering of curve features.The generated fluorescence intensity data were recorded on Microsoft Excel v2012 . Specific curve milestones identified previously as those most clinically meaningful indicators of appropriate ICGFA perfusion signal , 11 werewww.wordclouds.com . Although not academically quantitative, this method of graphical representation groups commonest words used by size with increasing font size indicating more frequently used terms as a simple visual means of summarizing common words and terms.To understand any conscious viewing strategy applied by each experienced user in the study, each underwent formal interview conducted by teleconference using a template of open and closed questions relating to specific and general uses of ICG fluorescence with particular reference to signal interpretation (see supplementary information). Responses were recorded, transcribed, and qualitatively assessed via thematic analysis  (in shorn = 6) were synthesized from the ICGFA videos (n = 4).Six thousand forty data points per expert  levels of correlation among these experienced users regarding peak intensity (Fmax 0.925) and chronological flags (Tmax 0.938 and T1/2max 0.925) and moderate (0.5–0.75) correlation for the T1/2max/Tmax ratio (0.729).Once plotted, the quantitative fluorescence curves were analyzed regarding Fn = 2) with the former espousing the benefit of simultaneous interpretation of white-light image appearances. Minimalist systems with fewer options for signal output manipulation were favored. Among considerations other than on-screen fluorescence signal, advocacy for standardization to fixed dosing and administrative method protocols was common with less regard for exact dosing, titration to weight, or ideal signal performance. With respect to inflow signal interpretation, homogeneity of distribution and maximal brightness were prioritized criteria although there was otherwise divergence in opinions re the other proposed criteria. A single expert admitted to using the chronology of the fluorescence as a discrete transection modifying criteria, while two others actively expressed that they did not feel this to be important.Structured discussion with each experienced observer demonstrated that each use ICGFA as a confirmatory rather than directive measure with respect to sufficiency of bowel perfusion  with a focus on inflow alone and each employs a deliberate interrogative viewing strategy to do so. Furthermore, all advocated a conscious systematic approach to learning including preclinical simulation as opposed to operative experiential learning although none had done so themselves or has such a facility in their departments. The experts however described their exact methodology in a variety of ways without common precise terminology , the time to achieve this zenith (Tmax), and the threshold period at which half this incline has been achieved (T1/2max) demonstrated excellent correlation. Interestingly, compound metrics identified experimentally as prognostically sensitive for anastomotic leakage (T1/2max/Tmax) [Our experienced users showed excellent tacit agreement in their selections of bowel locations for proximal transections and their selection points were found to have highly similar curve profiles suggesting a common acquired ability to similarly dissect the dynamic signal being observed and flag the most relevant clinical location in a highly concordant fashion. Specifically, the peak intensity (Fax/Tmax)  resultedThis study’s findings do suggest a method for explaining to others how best to extract the most useful information from ICGFA through its observation, perhaps in training libraries that users can study as they accrue their own clinical experience showing patterns of ICGFA signaling at different areas across a screen with indication of where an expert surgeon would choose to affect a clinical decision. Furthermore, the digital deconstruction of ICGFA methodology it uses could also be used for post hoc reflection on trials and experiences most especially those with equivocal or negative results . This stThis work so prompts further study and informs any future investigators regarding potentially useful parameters to investigate in future collaborative, multicentered work to cultivate greater datasets and a body of evidence to guide best practice and aid in surgical simulation, training, and research.This work is of course limited by the relatively small numbers involved but it does enable larger studies now to be performed to test and tease out these findings more robustly and indeed determine the usefulness of interpretation training for surgeons beginning their ICGFA use. It is possible too that actual intraoperative interpretations  differ from those made when watching isolated video alone and this also needs greater understanding (likely best through studies of inter- and intra-observer interpretations in theater versus out of theater).In conclusion, ICGFA interpretation appears to standardize with experience although at present such expertise is tacitly acquired. Computational charting of the fluorescence signal into quantitative ICGFA plots over time seems able to provide a mathematical way to understand clinical mastery in interpretation potentially allowing introduction of a standard lexicon to verbally articulate the peaks and troughs of these visible intensity fluctuations. More complete understanding of expert interpretation may also inform machine-based analysis methods to automatically provide ICGFA interpretation in the future although further work is necessary to achieve this goal.Supplementary file1 (DOCX 13 kb)Below is the link to the electronic supplementary material.


Transportation needs among lower-income older adults is understudied, particularly regarding how transportation utilization is related to leisure constraints. This preliminary study included 39 adults residing in subsidized housing in North Carolina and Pennsylvania  and assessed reported modes of transportation for daily activities and perceived leisure activity constraints. Much of the sample reported driving (57.9%) or relying on others to drive (70.3%) with a significant sample reporting use of public transportation (48.6%). Transportation utilization was differentially correlated with leisure constraints. Perceived difficulties getting to/from activities in the community was associated with greater utilization of having ‘others drive you’ , but lower utilization of ‘driving oneself’ . Walking as a mode of transportation was associated with lower  perceived difficulties getting to/from activities in the housing complex. These results indicate the importance of further exploring the association between transportation and leisure needs of these lower-income older adults.


After forced migration, pregnant women and new mothers face specific challenges in the host country. Little research focuses on the impact these challenges have on forced migrant (FM) women’s mental health (MH). The study’s aim shed light on FM women’s mental wellbeing in the perinatal period.For this mixed-method study 15 individual problem-centered interviews were carried out in Arabic with FM mothers living in Germany within the postnatal period to one year postpartum. The transcripts were analysed using the Framework Analysis. In addition, structured quantitative interviews with 3070 new mothers were conducted on 3 obstetric wards in Berlin over a period of 23 months using an adapted version of the MFMCQ and the PHQ4. FM women (n = 187) were compared with immigrant (n = 1192) and non-immigrant women (n = 1673). A Kruskal-Wallis-Test was performed to compare the three groups.In the qualitative interviews mothers stated having depression and varied emotions . Most FM mothers indicated contextual factors (e.g. bad housing conditions) and structural barriers in perinatal healthcare as negatively impacting their MH. The preliminary quantitative analysis of the interviews conducted in birth clinics directly after birth showed no significant differences in the mean scores of the PHQ-4 within the compared groups .While the quantitative study part indicates that PHQ-4 scores are independent of FM experience, the qualitative part shows that FM new mothers face particular burdens in their living conditions that make them vulnerable to MH issues. Inconsistent results could be attributed to the different timing in which the structured questionnaires and qualitative interviews were conducted.• To promote Mental health of new mothers, we advocate for a diversity oriented, responsive healthcare system.• Effective approaches must be provided to include FM mothers in existing Early Childhood Intervention programs.


Empathy is a social emotive skill that let to experience the same feelings of another person without being in the same situation. It changes during the growth becoming more over sophisticated with the involving of cognitive functions such as perspective taking . Several researches observed a correlation between empathy and psychopathologies that involve cognitive functions such as attention and executive functions  or decision-making .To investigate the impact of cognitive impairment on different empathy dimensions.80 subjects with severe neurocognitive deficit were examined. WAIS-R, neuropsychological battery and IRI test were performed.The impairment of perspective-taking dimension was significantly noticeable (=or<17/30). In addition, impairments of self-regulation process and inner-state monitoring mechanisms were also observed (=or<18/40).According to previous researches, this study confirms that empathy can be reduced when cognitive functions are compromised by psychopathologies or other medical conditions. Personal distress and perspective taking are empathy dimensions more affected in these cases.


Transfemoral transcatheter aortic valve implantation (TAVI) under conscious sedation is the most widely used method of implantation. Echocardiography is used to detect complications and to assess the implantation result. The aim of this paper is to provide a time-efficient protocol when transthoracic echocardiography (TTE) is used to guide TAVI procedures.The online version contains supplementary material available at 10.1186/s44156-022-00005-6. Transfemoral transcatheter aortic valve implantation (TAVI) undertaken with conscious sedation, rather than with general anaesthesia, is the most widely practised mode of implantation in Europe. Transthoracic echocardiography (TTE) is the main form of imaging employed in these procedures and is used to detect complications, assess the result of transcatheter heart valve (THV) implantation and guide further management. We propose a time-efficient, focused protocol for echocardiographers to follow when echocardiography is used to guide transfemoral TAVI undertaken with conscious sedation. This protocol provides guidance on which key assessments are required, important pitfalls and provides examples of important complications that may arise in order to allow timely identification and effective management. In the modern era of minimalist TAVI with transfemoral access and conscious sedation, transoesophageal echocardiography (TOE) may be preferable in a small proportion of TAVI procedures undertaken with general anaesthesia, with the benefit of continuous echocardiographic monitoring and reduced risk of contamination of the sterile field. TOE guidance may also be preferable in patients with severe renal insufficiency, particularly in conjunction with fusion imaging, to minimize contrast use and the consequent risk of renal injury.Aortic stenosis is the most prevalent valvular lesion in Europe and North America, 2. The On-table pre-procedure assessmentImmediate post THV deployment assessmentPre-cath lab exit assessmentIntraprocedural echocardiographic imaging is used principally to assess prosthetic valve function post-deployment and to allow early detection of complications. There are 3 distinct phases where TTE is employed in TAVI procedures:A rapid assessment should be made whilst preparations are underway for gaining vascular access. The value of this is to allow a baseline study for comparison with changes that may develop during the procedure. The location of optimal echocardiographic windows should be carefully noted in order to improve quality and avoid suboptimal images which may delay the procedure and hamper accurate assessment. Where necessary, slight tilting of the patient with a wedge under the right chest may be employed to improve echocardiographic image quality. Careful positioning at the start of the procedure is important as the patient may be unable to move and reposition themselves during the procedure. Additionally, image acquisition should be done with ECG-triggering as standard Fig. A. This eImmediately post THV deployment echocardiography should be undertaken to rapidly identify complications, to assess prosthesis function and paravalvular regurgitation.The first imaging window is the subcostal region to assess for development of pericardial effusion which may indicate injury to the annular complex or LVOT 1C Right). A comparison with the immediate pre-procedure images is important to help determine new changes  and transvalvular aortic regurgitation (TAR) may be seen post THV deployment. Assessment should be made from short axis, left parasternal long axis and apical windows. TAR may be artefactually caused by the stiff catheter delivery wire. A transverse, short-axis view just below the THV in the LVOT is particularly useful in differentiating wire-induced TAR from PVR . Jet lies within the THV frame and adjacent to the delivery wire.Additional file 3: Video S3: Apical 5 chamber view showing TAR jet within the THV frame and ‘hugging’ the delivery wire.Additional file 4: Video S4: Small PVR jets at 12 o’clock. Larger PVR jet at 3 o’clock. PVR lies outside the THV frame.Additional file 5: Video S5: Apical 5 chamber view showing PVR jet outside the THV.Additional file 6: Video S6: Parasternal long axis view showing small VSD post deployment of balloon expandable THV.Additional file 7: Video S7: Short axis view at LVOT level showing VSD.


Using thecorrected imputed genomic dataset, the average predictive abilitiesobtained across traits and model runs increased by 0.008 for thebenchmark main-effect model G-BLUP when compared to predictiveabilities obtained with the original dataset. Based on these results, theestimated effect of the error on the published genomic predictiveabilities was negligible. When repeating GWAS using the correcteddataset, differences between the original and the corrected results wereobserved. A revised Supplementary Table 3 containing a list ofsignificant marker-trait associations identified using GWAS that wasbased on the corrected genomic dataset was provided.


Ecological momentary assessment (EMA) was used to understand the influence of individual differences in stress reactivity measured by the Perceived Stress Reactivity Scale (PSRS) and the cortisol awakening response (CAR) on emotional reactivity to stressors, operationalized as the within-person change in negative affect (NA) associated with stressor exposure. Five times per day for 10 days, 178 working adults ages 20-80 years old  reported in EMAs their current NA and whether they had experienced a stressor since the previous survey. During the same period, participants provided seven salivary cortisol samples per day. Samples collected at awakening and 30-minutes post-awakening were used to calculate the CAR. Steeper CARs are hypothesized to have a role in preparing individuals to cope with upcoming daily demands. Before the EMA period, participants completed the PSRS, including its Work Overload Reactivity subscale. Multilevel models revealed a significant 3-way interaction between Stressor Exposure x CAR x Work Overload Reactivity predicting daily NA. Individuals with high Work Overload generally reported greater NA, regardless of stressor exposure or the magnitude of their CAR. Individuals with low Work Overload reported lower levels of NA on days they experienced more stressors than usual and had steeper CARs. Effects remained significant after controlling for neuroticism and the Perceived Stress Scale. Findings suggest the CAR’s potential role of preparing individuals for upcoming demands is moderated by work-related stress reactivity. Steeper CARs on days with more stressor exposure may provide enhanced emotional benefits for individuals low in workload reactivity.


Figure 1) ruled out pulmonary embolism revealing bilateral pleural effusions and a diagnostic thoracocentesis showed a predominantly neutrophilic exudate with normal pH and quite low glucose level (71mg/dl). A high titre of rheumatoid factor in the neutrophilic exudate plus the medical history of rheumatoid arthritis set the provisional diagnosis of a rheumatoid arthritis’ pleurisy and the patient was referred. Upon our clinical examination, diminished lung sounds in both lung bases were found without additional lung sounds. A new diagnostic thoracocentesis was performed which revealed surprisingly a predominantly lymphocytic exudate with normal pH but again quite low glucose level (62mg/dl). The adenosine deaminase (ADA) value was high (84 IU/L) highly suggestive of tuberculosis, mesothelioma, or lymphoma. A full body computed tomography  was performed which was negative for solid tumour, pleural thickening or enlarged lymph nodes. The Ziehl-Neelsen staining of the pleural fluid revealed an acid-fast organism and the next day the polymerase chain reaction was positive for mycobacterium tuberculosis. A three regimen antituberculosis therapy was initiated and in the follow up of the patient  bilateral pleural effusions were reduced. Pleural exudate in patients with known rheumatoid arthritis should not be always attributed to their condition, as thorough investigation might reveal tuberculosis or malignancy.An 86-year-old woman, non-smoker, with a medical history of rheumatoid arthritis for 20 years (stable at 5mg of prednisolone) was referred from a peripheral hospital to the Department of Respiratory Medicine of our tertiary hospital for further evaluation of bilateral pleural effusions with the provisional diagnosis of rheumatoid arthritis pleurisy. The patient reported frailty starting two months prior, low-grade fever, and mild small joints’ arthralgias for one week and pleurodynia in her right hemithorax starting two days ago. A computed tomography pulmonary angiogram (


Knee osteoarthritis (OA) is one of the leading causes of pain in older adults. Previous studies indicated clinic-based transcranial direct current stimulation (tDCS) was effective to reduce pain in various populations, but no published studies have reported the efficacy of home-based self-administered tDCS in older adults with knee OA using randomized clinical study. Thus, the purpose of this study was to evaluate the efficacy and safety of tDCS on clinical pain intensity in adults with knee OA pain. One hundred twenty participants aged 50–85 years with knee OA pain were randomly assigned to receive fifteen daily sessions of 2 mA tDCS for 20 min (n = 60) or sham tDCS (n = 60) over 3 weeks with remote supervision via telehealth. Clinical pain intensity was measured by asking participants to rate their knee pain using a numeric rating scale from 0 (no pain) to 100 (worst pain imaginable). Participants  had a mean age of 66 years and the mean body mass index in the sample was 32.59 kg/m2. There have been no adverse events. Active tDCS significantly reduced pain intensity compared to sham tDCS after completion of the fifteen daily sessions . We demonstrated that home-based self-administered tDCS was safe and reduced clinical pain intensity in older adults with knee OA, which can increase its accessibility. Future studies with multi-site randomized controlled trials with various populations are needed to validate our findings.


Several theories exist regarding the underlying mechanism of type V endoleaks (T5EL), which remains unclear. Torikai et al. (2018) describe sac expansion in cases with patchy heterogenous enhancement of peripheral thrombus and postulate these are due to atypical type II endoleaks (T2EL) from proliferated vasa vasora. These cases of apparent endotension pose a therapeutic challenge as continued sac expansion warrants active intervention.Retrospective review of T5EL cases was performed who underwent multidisciplinary discussion at our institution between 2020–2021. Clinical history and imaging were reviewed by a vascular interventional radiologist aiming to identify the underlying mechanism of sac expansion.Two cases of these specific T5ELs were identified. One patient underwent endovascular management and image-guided aspiration of intra-sac fluid whilst another underwent open surgical ligation and sac plication. In both cases, fluid re-accumulated with re-expansion of the aneurysmal sac on follow-up. Careful review of CT imaging showed subtle foci of peripheral sac enhancement, suggestive of vasa vasora causing occult T2ELs. This was not visible on single phase CTA, super-selective angiography or cone beam CT.We identified two complex cases with unexplained sac expansion following EVAR suggestive of T2ELs from proliferated vasa vasora. Transcatheter embolisation of this network of vessels although challenging has been previously considered to stunt sac expansion. We suggest this phenomenon is under-diagnosed. Nevertheless, long-term surveillance is warranted as continued sac expansion risks changes in aneurysm morphology leading to potential loss of the proximal/distal seal zones. Type V endoleaks (T5ELs) describe aneurysm sac expansion after endovascular aortic repair (EVAR) without a demonstrable type I-IV endoleak /imaging was performed and reviewed by a vascular interventional radiologist in attempts to identify a potential mechanism for sac expansion. For this type of study formal ethical approval is not required.Cases of T5EL with heterogenous appearances of the aneurysm sac that underwent multidisciplinary discussion at our tertiary referral centre between 1Two cases of the specific subtype of T5EL were identified in male patients aged 84–85 years. Both patients underwent elective EVAR with Zenith endografts  between 2007–2010 for infra-renal abdominal aortic aneurysms and later presented with persistent aneurysm sac expansion. No endoleak was identified on CTA nor were there any inflammatory changes around the aneurysm sac. Both patients underwent diagnostic catheter angiography with cone beam CT, but a cause of sac expansion could not be identified. This included super-selective catheter angiograms scrutinising the SMA/internal iliac vessels for small T2ELs.Both patients had been treated for other endoleaks in the past, prior to presentation with unexplained sac expansion. These were managed endovascularly by transcatheter embolisation of T2ELs or endograft relining with a Nellix endovascular aneurysm sealing system  in the first patient for a type IIIb endoleak.Duplex ultrasound (US) of the aneurysm sac in the first patient demonstrated a large central anechoic fluid component with peripheral echogenic thrombus and no endoleak Fig. . Given tA T2EL endoleak from left lumbar arteries in the second patient was resistant to attempts at endovascular embolisation. Due to persistent sac expansion, the patient underwent open sac plication. Intraoperatively, T2ELs from previously embolised left lumbar arteries and the IMA were ligated. A small type IIIb endoleak from the main body was repaired with bioglue. Sac haematoma and formerly deployed embolic material was evacuated and the sac was plicated. Similarly, surveillance US found re-expansion of the sac to pre-operative dimensions without an endoleak. The sac size remained stable on surveillance. However, the patient presented a year later with aortic rupture due to disruption of the distal endograft seal zone and was treated by palliation with no further interventions.A careful review of pre and post contrast CTA in both patients showed subtle enhancement of sac thrombus adjacent to the aortic wall Fig. , which iPatients with enlarging aneurysm sacs but no identifiable endoleaks are diagnosed as having T5ELs. These patients pose diagnostic and therapeutic challenges, as the underlying mechanism remains unclear. As T5ELs do not involve pressurised blood entering the aneurysmal sac, one could argue it carries a low rupture risk and active intervention should be reserved for symptomatic patients. The first patient we describe remains asymptomatic and under active surveillance. However, as with our second patient, continued expansion may alter the morphology of the aneurysm sac. This in turn risks disruption of the endograft seal zones and the development of secondary type I/III endoleaks.We found that despite percutaneous aspiration and surgical plication, sac re-expansion occurred to pre-treatment dimensions. Other authors also report similar challenges. Derboghossian et al.  Derbogh, describWilliams  reportedThese cases may in fact represent atypical T2ELs involving retrograde flow from the vasa vasora. Insertion of covered stents has been shown to cause proliferation of vasa vasora from the adventitia to the intima (Sanada et al. On careful review of the images in our patients, subtle peripheral foci of arterial enhancement in the aneurysm wall Fig.  could beFurthermore, the vasa vasora are tiny vessels that do not opacify readily even on super-selective catheter angiography or cone-beam CT, as in our experience. Toriaki’s group used a combination of superselective angiography and on-table CT to confirm vasa vasorum involvement and perform successful embolisation. Unfortunately, such facilities are not available in all institutions.Other reports of T5EL describe sac hygroma – a gelatinous material within the aneurysm sac (Risberg et al. Our findings suggest the specific type of T5ELs we describe above actually represent occult T2EL from vasa vasora. We propose that this obscure phenomenon may go underdiagnosed, unsurprising given the diagnostic challenges we outlined above. In addition to unenhanced and delayed phase CTA, contrast-enhanced US of peripheral sac thrombus and super-selective angiograms of lumbar/inferior mesenteric arteries may be warranted to confirm or exclude this entity as a cause of unexplained sac expansion.Long-term surveillance is essential to identify an occult source of endoleak and to maintain the original sealing zones. As for the optimal therapeutic intervention, this remains a challenge and a topic for discussion as experience accrues of this phenomenon.


Regular mammographic screening can reduce breast cancer morbidity and mortality. Participation rates are suboptimal in Australia’s fully funded biennial breastscreening program (BreastScreen) for women aged 50-74. Despite obesity being a well-established risk factor for post-menopausal breast cancer, cross sectional data suggests obesity may be a risk factor for non-participation in recommended screening, due to adverse screening experiences. This research aimed to ascertain the link obesity and non-participation by using data linkage of routinely collected data.Data for women age eligible for breast screening were linked between the NSW Cancer Registry and the Australian Longitudinal Study of Women’s Health (ALSWH) to create a cohort of women who either participated in screening as recommended or not. Women from the 1946-1951 ALSWH birth cohort were included in the study. These women reported BMI via 8 survey waves. The primary outcome was adherence to breast screening measured by frequency of screening over the follow-up period (1998-2016). Unadjusted risk ratios were calculated using mixed-effects logistic regression for the association between BMI and screening participation.The study included 2804 linked records of age eligible women (mean age of 52.37[SD 5.47]). 22.8% of the cohort were obese (BMI>30kg/m2). Obesity was significantly associated with non-recommended screening participation (screening within 3 years of last breast screen); odds ratio 1.63 .Obesity has a significantly impact on recommended participation in a nationally provided breast screening program, despite obesity being a risk factor for post- menopausal breast cancer. Optimising participation among higher risk and under-screened women in under utilised breast cancer screening programs is warranted. Development of targeted interventions to increase screening participation among these higher risk women is needed.• Women living with obesity and less likely to participate in recommended breast screening.• Targeted interventions are needed to optimise participation in breast screening to ensure these higher risk women are not at higher risk of adverse outcomes due to breast cancer.


Physical fitness outcomes are considered major health biomarkers to assess and monitor exercise-based interventions across the lifespan. Recent studies provide evidence that many adult and childhood chronic diseases should have their origins in gestational or fetal life. To date, a few pioneering studies have showed associations between prenatal predictors and selected physical fitness tests (strength and cardiorespiratory). Nevertheless, there is a lack of knowledge about the influence of prenatal factors on childhood performance on a comprehensive fitness test battery including speed and coordination. The innovative purpose of the current study is to analyse the relative weight of prenatal predictors on schoolchildren's physical fitness outcomes.We obtain data from1188 children (571 girls) aged 6-11 years and 1020 adolescents (495 girls) aged 12-17 years. Prenatal predictors  were self-reported from offspring's mothers. The ALPHA fitness test battery for youth was used to assess offsprinǵs physical fitness . Regression analysis were performed to predict the different physical fitness outcomes.The main findings of the present study indicate that the presence of gestational anemia significantly predicted lower scores of lower-body explosive muscular strength (standing long jump) and motor fitness (4x10-m shuttle run) and predicted moderately lower scores of upper-body isometric muscular strength (handgrip strength test). . Moreover, gestational anemia better predicted lower scores of muscular strength and motor fitness in children than in adolescents  . While gestational age and length of gestation (>34- ?42 weeks) predict better cardiorespiratory fitness (20 m shuttle-run test)  and motor fitness . .This evidence suggests that preventive strategies by health-care institutions, policy makers and technicians must be two-fold: a) to effectively reduce gestational anemia in order to prevent offsprinǵs predisposition to low levels of physical fitness, and b) to intervene with toddlers and children at risk to provide tailored physical activity programs and regular physical fitness evaluation.


Individual Placement and Support (IPS) is an evidence-based supported employment program that helps people with severe mental illness to achieve steady meaningful employment in competitive mainstream jobs. Employment specialists are an integral part of IPS service delivery. The primary goal of an employment specialist is to help IPS users obtain competitive employment by providing targeted job development and ongoing support to workers and employers for as long as it is required.This study aims to investigate the impact of the covid-19 restrictions on the delivery of IPS services in Northern Norway and how this may have affected the employment specialists’ perception their work environment.We conducted four phases of a longitudinal work environment panel survey with the IPS employment specialists in Northern Norway. Phase 1: January-February 2020 (pre-covid), phase 2: June-July 2020 (during covid) and phase 3: October-November 2020 (during covid) were not related to covid and collected data on fourteen work environment indicators. Phase 4: October 2020 was a covid specific survey and collected data about the impact of covid-19 restrictions on IPS service delivery.Employment specialists perceived that they had less collaborative engagement with clinical teams and employers after covid-19 restrictions were introduced. This was accompanied by a significant decline in four of the employment specialists’ work environment indicators.The covid-19 restrictions appear to have created obstacles for IPS service delivery in Northern Norway. These challenges may have negatively impacted the employment specialists’ perception of their work environment, creating job dissatisfaction and potentially increasing employee attrition.No significant relationships.


Older adults who are homebound or socially isolated have high rates of loneliness and depression with fewer opportunities for treatment. Our team extended an existing psychotherapy intervention (Engage & Connect) to improve access to mental health care for older adults who are homebound. We iteratively created a tablet-based application (Engage PRISM) leveraging a user-centered design approach to provide older adults, particularly those with limited technology experience, an easy-to-use application to support social reward. Engage PRISM connects clients with the psychotherapy intervention and additional features to increase social reward exposure virtually. All eligible participants received a K92 ZTE tablet, equipped with the Engage PRISM application, internet service, Zoom, and access to Selfhelp’s Virtual Senior Center. Participants were then enrolled in the 9-week Engage & Connect intervention delivered by a licensed mental health counselor via Zoom on the tablet each week. We evaluated feasibility of the intervention and preliminary effect on depressive symptoms through a weekly PHQ-9. Feasibility was assessed through participants’ ability to use the tablet to access mental health treatment. We provided tablets to eight participants ages 67 to 84; participants demonstrated 100% feasibility of use of the tablet intervention. We dropped two participants from the study due to a greater level of care needed. All participants were provided with referrals prior to ending the study. Preliminary evidence indicates that four of the six remaining participants had experienced a reduction in depressive symptoms  three weeks into the study reporting over a 30% reduction on average.


Background: Medical tape is used routinely for a variety of tasks across healthcare settings. The literature contains numerous publications in which common practices around medical tapes have been suspected to lead to infection transmission. Healthcare providers can turn to individually packaged single-patient-use medical tape rolls to help reduce cross-contamination risk by limiting exposure to environmental contaminants, minimizing contact with hospital surfaces and equipment, and minimizing exposure to healthcare workers’ hands and other patients. Methods: We evaluated the effect of individually packaged tape on cross contamination using a controlled laboratory assay. Ceramic tiles were inoculated with microorganisms evenly spread across the surface and allowed to air dry. Using gloves, packaged and unpackaged tapes were rolled over their entire outside circumference onto the contaminated tiles to simulate cross contamination. Using new gloves, the packaged tapes were then removed from their package with minimum contact. All cross-contaminated tape rolls were placed in phosphate-buffered water and mixed in a vortexer for bacterial recovery procedures. Serial dilutions were plated on appropriate media for bacterial enumeration. The average log10 colony-forming unit (CFU) recovery was measured for comparison. We used 4 types of tapes in this study . We used 4 different microorganisms as inoculates: Staphylococcus aureus (methicillin-resistant), Enterococcus faecium (vancomycin-resistant), Klebsiella pneumoniae (carbapenem-resistant), and Clostridium difficile (spore). Each test (tape and bacteria combination) was done in 3 or 6 replicates; each bacterial enumeration was the average of duplicate plates. The detection limit for this method is 8 CFU per sample, which is equivalent to 0.9 log10. Results: The results for all tapes tested showed a statistically significant lower mean log10 recovery of each of the microorganisms tested for packaged versus unpackaged tape  to 4.64 log10 (for K. pneumoniae on Medipore H). This is equivalent to 99%–99.99% cross-contamination protection from the 4 organisms tested. Conclusions: Individual packaging of medical tape rolls protects them from external contaminants. Even if the packaging becomes contaminated, the tape retrieved from the package will be significantly less contaminated than it would have been from exposure to the same contaminants without packaging.Funding: 3M CompanyDisclosures: None


Clostridioides difficile infection (CDI) in observational studies (cure rates >90%) but efficacy in controlled clinical trials appears lower.Microbiota restoration is highly effective to treat recurrent We performed an updated meta-analysis to assess the efficacy of microbiota restoration for recurrent CDI in open-label registered prospective clinical trials compared to randomized controlled trials (RCTs).A systematic search of Embase, Web of Science and Scopus was performed up to June 2022 to identify studies of interest. Clinical trials of microbiota restoration for recurrent CDI with clinical resolution with one dose as the primary outcome were included. We calculated both unweighted and weighted pooled resolution rates (UPR and WPR) with 95% confidence intervals (CI).I2of 86%. Analysis of trials with a control arm (non-microbiota restoration) revealed CDI resolution in 357 of 496 patients  with microbiota restoration. Among the 9 open-label clinical trials, CDI resolution was seen in 524 of 653 patients after initial microbiota restoration . Comparison of resolution rates between RCTs and open-label trials revealed a lower cure rate in RCTs compared to open-label trials .Eighteen studies  with 1149 CDI patients were included. Of the patients treated with microbiota restoration, 881 experienced symptom resolution . There was significant heterogeneity among studies with an I2of 61%. Comparison of cure rates with microbiota restoration vs antibiotics showed higher cure rate with microbiota restoration . There were no serious adverse events reported.Analysis of the 10 trials with non-microbiota restoration revealed CDI resolution in 201 of 397 patients with antibiotics . There was significant heterogeneity among the included studies with an Microbiota restoration in a randomized controlled setting leads to lower resolution rates compared to open label and observational settings, likely due to stricter definitions and inclusion criteria. Resolution rates in open label studies were similar to observational studies.NoneNone Declared


Studies of thalamic structure and function in Progressive Supranuclear Palsy (PSP) suggest it may play a role in key aspects of the clinical syndrome. This study examined thalamic changes across PSP phenotypes investigating (i) thalamic atrophy (ii) thalamic functional connectivity and (iii) the relationship between thalamic structural and functional connectivity changes with clinical severity.Participants92 participants with PSP  and 104 age-matched controls were recruited from the Cambridge Centre for Parkinson's Plus Disorders cohort. Clinical assessments and imaging were conducted within 1 year of diagnosis.Structural AnalysisThalamic volumes (TVs) were obtained using FreeSurfer. Bayesian multiple regression  was used to model (i) mean TVs (ii) group differences in mean TVs (iii) relationships between Z-standardised clinical scores and TVs with age, gender, and total grey matter as covariates.Functional AnalysisVoxel-wise seed-based functional connectivity of the thalamus used the Functional Magnetic Resonance Imaging Expert Analysis Tool (FEAT) in FMRIB's Software Library (FSL). Inter-group differences and relationships between clinical scores and functional connectivity for each group were assessed using a general linear model with age and gender as covariates.Structural AnalysisTVs for all PSP subgroups were smaller than controls. No differences between PSP subgroups were detected. There was evidence for a relationship between TVs for the entire PSP group and Revised Addenbrooke's Cognitive Examination (ACER) scores . Subgroup analysis showed evidence for a relationship between ACER scores and TVs in PSP-RS  and PSP-cortical  phenotypes. A negative influence of TVs on total PSP rating scale scores was found for the PSP cohort a whole .Functional AnalysisPSP patients as a group showed decreased thalamic functional connectivity in higher cortical regions. Subgroup analysis revealed decreased connectivity in those areas compared to controls but in distinct distributions and magnitude. Increased thalamic connectivity with the middle temporal gyrus correlated with ACER scores for PSP patients as a group and in the PSP-cortical subtype.Thalamic volume loss is a prominent aspect of PSP and is associated with a wide network of changes in functional connectivity that may be distinct between PSP subtypes. Changes in thalamic structure and function predict clinical severity, particularly in PSP-RS and PSP-cortical subtypes.


Healthcare services are primarily focusing on medical and physical treatment of COVID-19 while psychosocial and mental health needs are not considered a priority.The purpose of this study was to explore how recovered individuals with COVID-19 adapted to their psychological and social stressors during infection period.A descriptive phenomenological approach conducted using a purposeful sample of 13 individuals recovered from COVID-19 in Jordan. Data collected using unstructured interviews.Perception of being diagnosed with COVID-19 revealed to three major themes; positive learning , tolerating ambiguity , and resilience .The study indicates that there is a need to integrate psychosocial and mental health care services into healthcare plans provided to individuals with COVID-19.No significant relationships.


The progeroid syndrome includes a group of rare, severe genetic disorders clinically characterized by premature physical ageing. Severe aortic stenosis has been described in progeria patients, but no previous surgical aortic valve replacement was reported. We describe a successful surgical aortic valve replacement combined with coronary artery bypass grafting in a progeria patient with severe aortic stenosis and a small aortic annulus. Progeroid syndrome (PS) includes a group of rare, severe genetic disorders clinically characterized by premature physical ageing [1]. Progeroid syndrome (PS) includes a group of rare, severe genetic disorders clinically characterized by premature physical ageing . The lifA 33-year-old woman who suffered from chest pain, dyspnoea and fatigue due to severe aortic stenosis was admitted for aortic valve intervention. The patient characteristics are presented in Table Echocardiographic parameters are presented in Table The operation was performed through the median sternotomy and central arterial and venous cannulation. A transversal aortotomy revealed senile degeneration of the aortic leaflets, which were meticulously removed. There was no annulus calcification or subvalvular membrane. In order to implant the mechanical prosthesis size 17 (ST Jude Regent) in a very small aortic annulus, the ascending aorta was completely transected above the sinotubular ridge. In addition, the coronary arteries were carefully mobilized and secured with rubber tapes  has a longer life expectancy, and most often, patients die of myocardial infarction in the mid-50s [The estimated prevalence of patients with PS is one in 4–8 million new births. 2 and projected indexed effective orifice area, there was no danger of patient-prosthesis mismatch with 17 mm prosthesis size. It was previously demonstrated that prosthesis implantation using interrupted mattress sutures with the pledgets placed on the left ventricular side of the annulus (the supra-annular implantation technique) allowed the use of a larger prosthesis for a given annulus than the intra-annular implantation technique with the pledgets located above the aortic annulus. However, the pledgets placed on the ventricular side of the annulus may obstruct the left ventricular outflow tract and decrease the effective orifice area of the prosthesis . Transaortic or simple interrupted sutures placement technique could be a satisfactory alternative to the aortic root enlargement technique, which requires an advanced surgical skill level.Conflict of interest: none declared. Reviewer information: Interactive CardioVascular and Thoracic Surgery thanks Jose G. Fragata and the other anonymous reviewer(s) for their contribution to the peer review process of this article.


A 9-year-old girl presented with a cough and dyspnea. Thoracic computed tomography (CT) detected a giant cystic lesion and mediastinal shift . The patEchinococcus granulosus,Hydatid cyst disease continues to be an important public problem today. The causative agent of this disease is a parasite belonging to the cestode class,


Staphylococcus haemolyticus strains isolated from a mouse fibrotic lung tissue and exhibiting proapoptotic activity on human lung alveolar epithelial cells. The genomes were obtained from a combination of Illumina MiSeq and Oxford Nanopore MinION sequencing.We report here the complete genome sequences of three  Staphylococcus and Streptococcus genera (Idiopathic pulmonary fibrosis (IPF) is a disease of unknown etiology, and the lung microbiome of IPF patients is characterized by increases in s genera . We demos genera . Tissuess genera . To isols genera  were inoStaphylococcus epidermidis) as a reference. The sequence reads from each of strains 1b and 7b were assembled by Unicycler as a single circular chromosome and three circular plasmids (Bandage assembly graph viewer) . MiSeq reads were trimmed using Trimmomatic v0.38, retaining reads longer than 30 bp . Long re. MiSeq r viewer) . The rea viewer) . The 16SPRJNA707584. The Sequence Read Archive (SRA) for the raw reads and the NCBI RefSeq accession numbers are provided in The sequences have been deposited in the GenBank database under BioProject accession number


The authorship has changed: Wanawan Pragot regrettably publishedthe work that she carried out during her Ph.D. at the University ofAberdeen under the supervision of Waheed Afzal where this work hadbeen assisted by (then) post-doc Ara Carballo-Meilan and (then Ph.D.student) Lewis McDonald. Wanawan Pragot regrets her action and wantsto correct it. She notes that Chaiwat Photong helped her in proofreadingthe manuscript before she submitted. We believe that the contributionof Chaiwat Photong does not merit being the first author. The revisedorder and new additions reflect the contributions.The Acknowledgmentand Author contributions have also been revisedas given here.


Teaching Point: The acute appendicitis in a context of Malone appendicostomy complication is very rare but can occur and may be challenging to diagnose due to its unusual position. Figure 1, red arrow axial image) and enlargement of the appendicostomy due to a large 30 × 10 mm appendicolith  with discrete fat stranding  and local reactional mesenteric lymph nodes. No bowel perforation was detected. The retained diagnosis was acute appendicitis, and the patient was treated conservatively with a satisfactory clinical evolution. Years later, relapsing symptoms led to surgical ablation of the appendicostomy. MA anastomoses the appendix to the deep part of the umbilicus and includes a valve mechanism allowing for antegrade colonic enema flushing without stool leakage in patients with fecal incontinence. Frequent complications of MA include stomal orifice stenosis as well as stomal infection and appendiceal perforation during catheterization [A 33-year-old male patient with a history of Malone appendicostomy (MA) for neonatal ano-rectal malformation presented with fever (40°C), increasing periumbilical pain, diarrhoea and nausea. Clinical examination revealed periumbilical cutaneous inflammation. Bloods showed only discrete increase of CRP. Abdominal computed tomography (CT) examination revealed wall thickening (


There is a limited published data on the treatment of blood stream infections (BSI) in patients receiving extracorporeal membrane oxygenation (ECMO). Traditionally, the management of only fungal and Gram-positive BSIs require follow-up blood cultures to document clearance. The presence of large retained cannulas in ECMO create concern for persistent bacteremia. This study investigates whether certain variables are predictive of blood stream infections with positive repeat cultures (BSIPRC) and if BSIPRC is associated with increased mortality.All positive blood cultures from patients receiving ECMO at Brooke Army Medical Center identified between September 2012 and October 2021 were included in this study. Blood cultures were excluded if they were determined to be contaminants by the primary team. For each positive blood culture, charts were retrospectively reviewed. Date of clearance was defined as the first negative blood culture after a positive. BSIPRC was defined as re-isolation of the same organism on repeat blood cultures following an initial positive blood culture.A total of 60 patients and 87 BSI were investigated (38.5 BSI per 1000 ECMO days). Gram-positive (GP) organisms caused a majority of BSI  followed by Gram-negative (GN)  and fungal  infections. Of the 80 (92%) BSIs who had repeat blood cultures drawn, patients had BSIPRC in 35 (44%) of cases. There were no clinical features that differentiated patients with positive repeat cultures (Table). There was no difference in survival to discharge for patients with BSIPRC as compared to single day BSI (20 (58%) vs. 28 (63%), p=0.78). In 6 patients with BSIPRC with Gram-negative organisms, two (33%) died before clearance and five (83%) died before decannulation.Characteristics of patients and all blood stream infections.There were no clinical findings that differentiated patients with BSIPRC from those who had a single day of positivity. BSIPRC was associated with high mortality in patients with Gram-negative bacteremia. In the absence of clear predicative factors in demonstrating clearance of BSI, repeat blood cultures may be necessary. Future studies are needed to determine why Gram-negative BSIPRC are associated with a high mortality.All Authors: No reported disclosures.


In chronic total occlusion (CTO) intervention, it has been determined that it is impossible to create a reentry from a subintima to a true lumen with regular guidewire manipulation. Therefore, antegrade dissection and reentry (ADR) using Stingray system  was developed. In the present case, ADR using a Stingray balloon failed to create a reentry. Intravascular ultrasound (IVUS) observation revealed the damaged part of the wall by ADR. We could create a reentry at the damaged part by an exact vertical directional puncture using the tip detection method with an AnteOwl WR-IVUS  .A 74-year-old man suffered from effort angina pectoris due to a CTO lesion in the left anterior descending coronary artery because of occlusion of bypass grafting to it. Computed tomography and angiography showed severe calcification in the CTO Fig. A, B. An Supplementary file1 Intravascular ultrasound images during the puncture of the true lumen using the tip detection method. (MP4 22361 KB)Below is the link to the electronic supplementary material.


Clustering algorithms are commonly used to identify disease clusters. New Clustering algorithms are benchmarked on synthetic data to assess their accuracy. These datasets lack the complexities of real electronic health record (EHR) producing a partial assessment of the algorithm. We developed a synthetic EHR cluster generator for benchmarking clustering algorithms.We have created a synthetic EHR cluster generator, clustEHR, based on Synthea, a synthetic EHR generator that produces datasets (with parameterized noise and cluster separation) of known clusters and with clinically relevant patient outcomes. We evaluated clustEHR by generating multiple datasets of variable cluster separation and percentage of noise variables to reflect easy and hard clustering problems. We used a linear model to assess the relationship between these parameters and cluster problem difficulty. K-means accuracy was used as a proxy to measure cluster problem difficulty.We have developed a tool for generating synthetic EHR cluster data with clinically relevant outcomes based on the rate of decline of medical observations (e.g. blood pressure). The following parameters are supported: a) number of clusters, b) number of patients in each cluster, c) number and data type of features, d) separation through defining clusters as either diseases such as COPD or dementia (high separability) or inter-disease conditions such as emphysema and chronic bronchitis within COPD (low separability), and e) noise variables through identifying variables not predictive of true cluster outcomes random forest feature importance metric. We show that high cluster separation significantly increases k-means accuracy (coefficient of 0.33). Smaller percent of noise variables increase accuracy though not significantly (coefficient 0.42).ClustEHR offers realistic mixed data types as well as outcomes which are frequently used to evaluate clusters when subtyping diseases. The evaluating results suggest that the difficulty of the cluster data can be user determined. The tool can be used to create realistic datasets for evaluating clustering approaches.


A(ii) the first three lanes for the actin loading control were mistakenly duplicated in the last three lanes of the image panel. A representative data from several repeated experiments is now provided in corrected Figure 3A(ii). The revised figure shows results obtained with new NIK antibody because initial antibody is no longer available. In two cell lines (BEAS2B and H358) the new antibody revealed better NIK expression than it was shown with original antibody. This observation does not affect the conclusions of the manuscript that some melanoma cell lines exhibit a higher-level NIK protein and a higher level of NIK protein associated with IKK than normal human epidermal melanocytes (NHEMs).In the original version of Figure 3NIK expression in various cell lines. Whole-cell extracts were harvested in RIPA buffer and 40 ug of total protein for each cell line were loaded for Western blot. After proteins were transferred to nitrocellulose membrane, the membrane was cut between 50 KD and 75 KD. The upper part was blotted with anti-NIK antibody  and signal was detected with Enhanced Chemiluminescence (ECL) method. The lower part of the blot was developed with anti-β-actin antibody  and signal was detected with fluorescence method (LI-COR). Wild type mouse mammary fibroblast (NIK WT MEF) and NIK knock-out mouse mammary fibroblast (NIK WT MEF) were used as positive and negative controls for the NIK antibody.


As the use of antiretroviral therapy (ART) increases, the issue of treatment failure is still a global challenge, particularly in a resource limited settings including Ethiopia. The results of former studies in Ethiopia were highly variable and inconsistent across studies. Thus, this systematic review and meta-analysis intended to provide the pooled estimation of treatment failure and associated factors among children on antiretroviral therapy.2 test and Cochrane Q test statistics. We run Begg’s regression test to assess publication bias. A random-effects meta-analysis model was performed to estimate the pooled prevalence of treatment failure.We searched international databases  during the period of February 30 to April 7, 2021. All identified observational studies reporting the proportion of treatment failure among HIV positive children in Ethiopia were included. Heterogeneity of the studies was checked using IThe estimated pooled prevalence of treatment failure among children in Ethiopia was 12.34 . Subgroup analysis of this review showed that the highest prevalence was observed in Addis Ababa (15.92%), followed by Oromia region (14.47%). Poor ART adherence , advanced WHO clinical staging , and opportunistic infections (AOR = 2.64 CI: 2.19, 4.31 were found to be significantly associated factors with childhood treatment failure.This study revealed that treatment failure among children on ART was high in Ethiopia. Poor ART adherence, advanced WHO clinical staging, opportunistic infections, and low level of CD4 cell counts increased the risk of treatment failure. Acquired immune deficiency syndrome (AIDS) is a viral disease caused by human immunodeficiency virus (HIV) that weakens the immune system and makes the body susceptible to opportunistic infections . The HumAntiretroviral therapy (ART) is crucial to decrease progress of HIV/AIDS by suppressing viral replication which in turn reestablishes the immune function of HIV-infected individuals ,7. In adThe current guidelines recommend that, virological failure is more informative to assess treatment failure . The JoiIn Ethiopia, studies were conducted to estimate the magnitude as well as to identify associated factors of treatment failure among HIV-infected children –27. ThesAdditionally, there was no a country wide data which represents a national treatment failure and its associated factors among HIV positive children. Hence, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence and associated factors of treatment failure among children on ART using available studies in Ethiopia. The findings of this systematic review and meta-analysis will highlight the prevalence and associated factors of TF with implications to improve health care workers’ interventions, assist decision makers and other concerned stakeholders to design, implement and evaluate interventions to improve level of ART adherence. Furthermore, the findings will enable the country to sustain treatment successes and to hasten the decline of childhood treatment failure in Ethiopia.The result of this systematic review and meta-analyses was prepared and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline . The proWe carried out a systematic review and meta-analysis to estimate the pooled prevalence of TF and associated factors among HIV-positive children in Ethiopia which is located in east Africa. To find potentially relevant articles, a comprehensive search was carried out on PubMed, Web of Science, Google Scholar, Scopus, and Cochrane Library databases. To find unpublished relevant literatures to this study, some online repository library centers were searched. Besides, gray literatures were searched from review of reference lists and input of content experts. MeSH , Boolean operators and all fields within records were used to search in the advanced PubMed search engine. Search terms or phrases used were: children, child, pediatrics, treatment failure, antiretroviral therapy, prevalence, and associated factors.The advanced PubMed database search strategy was performed using the following key terms (((((((Children(tw) OR child(tw) OR pediatrics(tw))) OR (("child"[MeSH Terms] OR "child"[All Fields] OR "children"[All Fields]) AND tw[All Fields] OR ("child"[MeSH Terms] OR "child"[All Fields]) AND tw[All Fields] OR ("paediatrics"[All Fields] OR "pediatrics"[MeSH Terms] OR "pediatrics"[All Fields]) AND tw[All Fields]))) AND (((Treatment failure(tw) OR immunological failure(tw) OR clinical failure(tw) OR virological failure(tw))) OR (("treatment failure"[MeSH Terms] OR ("treatment"[All Fields] AND "failure"[All Fields]) OR "treatment failure"[All Fields]) AND tw[All Fields] OR  AND tw[All Fields] OR  AND tw[All Fields] OR  AND failure[All Fields]) AND tw[All Fields]))) AND (((ART(tw) OR antiretroviral therapy(tw) OR ARV(tw) OR antiretroviral(tw) OR HAART(tw))) OR (("art"[MeSH Terms] OR "art"[All Fields]) AND tw[All Fields] OR  OR "anti-retroviral agents"[All Fields] OR "antiretroviral"[All Fields]) AND ("therapy"[Subheading] OR "therapy"[All Fields] OR "therapeutics"[MeSH Terms] OR "therapeutics"[All Fields])) AND tw[All Fields] OR "arv"[All Fields] AND tw[All Fields] OR  OR "anti-retroviral agents"[All Fields] OR "antiretroviral"[All Fields]) AND tw[All Fields] OR  OR "highly active antiretroviral therapy"[All Fields] OR "haart"[All Fields]) AND tw[All Fields]))) AND  OR proportion(tw) OR magnitude(tw) OR risk factors (tw) OR associated factors(tw) OR predictors(tw))) OR  AND tw[All Fields] OR proportion[All Fields] AND tw[All Fields] OR magnitude[All Fields] AND tw[All Fields] OR ("risk factors"[MeSH Terms] OR ("risk"[All Fields] AND "factors"[All Fields]) OR "risk factors"[All Fields]) AND tw[All Fields] OR (associated[All Fields] AND factors[All Fields]) AND tw[All Fields] OR predictors[All Fields] AND tw[All Fields]))) AND ((Ethiopia(tw)) OR (("ethiopia"[MeSH Terms] OR "ethiopia"[All Fields]) AND tw[All Fields])). The search was done between March 3 and April 27, 2021. All papers published up to April 27, 2021 were included. Endnote X8 software manager was used to cite references and manage the searched literatures.This review has two main outcome variables. The first outcome is HIV/AIDS treatment failure which was defined as immunological, clinical, and virological treatment failure . The secStudy area: Only studies conducted in Ethiopia were included to produce single estimate of common effects.Study design: All observational study designs reporting the prevalence of TF were eligible for this meta-analysis.Population: All HIV-positive children on antiretroviral treatment.Language: Only articles reported in English language were incorporated.Publication condition: Both published and unpublished studies were considered.Conference reports and articles without full text access were excluded. Exclusion of these studies is because of the inability to check the quality of articles in the absence of full text.The required data from included articles were extracted by two authors (BG and LD) using a standardized data extraction format, adapted from the Joanna Briggs Institute (JBI). Any disagreements during screening were undertaken through discussion. The reviewer contacted the first author(s) of primary research for additional information. The first author name, follow up years, publication year, region, study area, study design, sample size, response rate, and prevalence with 95% CI were included the data selection form.The qualities of included articles were evaluated by four investigators  using Newcastle-Ottawa Scale quality assessment tool for observational studies . The too2 = 94.7%, p<0.001), hereafter, a random-effects meta-analysis model was performed to estimate the pooled prevalence. Subgroup analysis was conducted to adjust random variation between point estimates of original study and investigate how failure fluctuates across subgroup participants. Outlier within the included articles was checked using sensitivity analysis. Publication bias across studies was assessed using funnel plot and egger’s regression test. The Begg’s regression test results at 5% significance level were not statistically significant for publication bias https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  2 Dec 2021Reviewer #1 Comments to the AuthorThe authors of this systematic review and meta-analysis have presented useful data to determine the pooled national burden of childhood HIV/AIDS treatment failure as well as its associated factors in Ethiopia. Conversely, there are specific comments that the reviewer would like the authors to address so as to further improvement of the manuscript.Authors’ response: we are very glad to the reviewer’s appreciation of our efforts; and we have just given our respective responses to each of the specific reviewer comments as detailed below.1. Is the manuscript technically sound, and do the data support the conclusions?Thank you very much for your insightful comment. Yes. We have a conclusion which is supported by the data analysed and presented in this study . 2. Has the statistical analysis been performed appropriately and rigorously?We acknowledge the reviewer’s concern regarding to statistical analysis for this study. Yes. We have carried out all the necessary statistical analysis properly and presented our finding accordingly in the main documents of this study.3. Have the authors made all data underlying the findings in their manuscript fully available?Yes. Comments have been taken and we have made the necessary correction accordingly . For detail please see the supporting information file.4. Is the manuscript presented in an intelligible fashion and written in standard English?Great thanks. We have carefully reviewed the manuscript based on your suggestion and some typographic error has been also updated .5. It will be worthwhile to do a subgroup/sensitivity analysis of cohort and cross-sectional analysis. As, in you may exclude cross-sectional studies and check for the estimates in cohort studies. Repeat it for cross-sectional and compare whether there is a difference. You may also look at Urban/rural population. Any variable for meta-regression?Absolutely! We have taken the given comment and sensitivity analysis was already done accordingly. However, the result indicated that there is no single study unduly influenced the overall estimates of treatment failure and there is no significant variability for meta-regression. We have done subgroup analysis based on study design, and giving a prevalence of 12.14 in cohort which is nearly the same in cross-sectional study 13.43  . NB. Generally, we have tried to revise our manuscript according to the requirement of PLOS ONE template.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 7 Dec 2021Prevalence and associated factors of treatment failure among children on ART in Ethiopia: a systematic review and meta-analysisPONE-D-21-32599R1Dear Dr. Gelaw,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Frank T. SpradleyAcademic EditorPLOS ONE 10 Jan 2022PONE-D-21-32599R1 Prevalence and associated factors of treatment failure among children on ART in Ethiopia: a systematic review and meta-analysis Dear Dr. Gelaw:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofDr. Frank T. 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Acute myocardial injury is common after noncardiac surgery and associated with mortality. Impaired intraoperative cardiovascular dynamics are a risk factor for acute myocardial injury. Optimizing intraoperative cardiovascular dynamics may thus reduce acute myocardial injury. We aimed to investigate the effect of intraoperative personalized goal-directed hemodynamic management on the incidence of acute myocardial injury. We hypothesized that personalized goal-directed hemodynamic management reduces the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. We performed a post-hoc secondary analysis of a randomized clinical trial including 180 high-risk major abdominal surgery patients that were randomized to personalized goal-directed hemodynamic management or routine hemodynamic management. We compared the incidences of acute myocardial injury—defined according to the Fourth Universal Definition of Myocardial Infarction (2018)—between patients randomized to personalized goal-directed hemodynamic management or routine hemodynamic management by calculating the relative and absolute risk reduction together with 95% Wald confidence intervals and P values. Acute myocardial injury occurred in 4 of 90 patients (4%) in the personalized goal-directed hemodynamic management group and in 12 of 90 patients (13%) in the routine hemodynamic management group . In this post-hoc secondary analysis, intraoperative personalized goal-directed hemodynamic management reduced the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. This needs to be confirmed in larger prospective trials.The online version contains supplementary material available at 10.1007/s10877-022-00826-0. Acute myocardial injury is common in patients having noncardiac surgery and associated with postoperative mortality –5. AcuteIntraoperative hypotension—reflecting impaired intraoperative cardiovascular dynamics —is a modIn a recent randomized controlled clinical trial, we showed that intraoperative personalized goal-directed hemodynamic management reduces the incidence of postoperative clinical complications compared to routine hemodynamic management in high-risk patients having major abdominal surgery . HoweverWe thus now conducted a post-hoc secondary analysis of the original trial  to invesThe original trial and the present study were approved by the ethics committee  on 4 August 2015 and 2 December 2020 and all patients provided written informed consent.We performed a post-hoc secondary analysis of a randomized clinical trial  that wasAdult high-risk patients scheduled for major abdominal surgery expected to last at least 90 min or cause blood loss exceeding 1000 ml were enrolled into the original trial . PatientPatients were randomized to intraoperative personalized goal-directed hemodynamic management (targeting baseline cardiac index measured non-invasively one day before surgery) or to routine hemodynamic management . In patiBlood samples were collected before the induction of general anesthesia and three days after surgery. After centrifugation, serum aliquots were separated into Eppendorf tubes and stored at − 80 °C until transfer to our central laboratory for batched analysis. Serum troponin I was measured using the Siemens Atellica IM High-Sensitivity Troponin I Assay . The 99th percentile of a reference population for this assay is 38.6 ng/l for women and 53.5 ng/l for men . Serum NWe defined acute myocardial injury according to the definition of “myocardial injury and infarction associated with non-cardiac procedures” set forth in the Fourth Universal Definition of Myocardial Infarction (2018)  as a posDescriptive results are presented as medians with 25th percentiles and 75th percentiles for continuous data and as absolute frequencies and percentages for categorical data.Incidences of acute myocardial injury in the personalized goal-directed hemodynamic management and the routine hemodynamic management group are illustrated using stacked bar charts. We compared the incidences of acute myocardial injury between patients randomized to personalized goal-directed hemodynamic management or routine hemodynamic management by calculating the relative risk  and the absolute risk reduction together with 95% Wald confidence intervals (CI) and P values (Chi-squared test).To illustrate preoperative and postoperative troponin I and NT-proBNP concentrations in patients randomized to personalized goal-directed hemodynamic management and routine hemodynamic management we computed spaghetti plots and violin plots with overlaying boxplots. We compared relative changes in troponin I and NT-proBNP concentrations in patients randomized to personalized goal-directed hemodynamic management and routine hemodynamic management using the Wilcoxon rank-sum test with continuity correction.We used R version 3.5.3  for statistical analyses.We excluded 8 of the 188 patients included in the original trial because blood samples were missing. Therefore, we included 180 patients  in this post-hoc secondary analysis  in the personalized goal-directed hemodynamic management group and in 12 of 90 patients (13%) in the routine hemodynamic management group   relative change in postoperative NT-proBNP concentrations compared to baseline NT-proBNP concentrations was 227% (96% to 664%) in patients in the personalized goal-directed hemodynamic management group and 430% (143% to 851%) in patients in the routine hemodynamic management group (P = 0.046) Below is the link to the electronic supplementary material.