Unresolved issues on the antenatal use of corticosteroids for fetal lung maturation

Antenatal corticosteroids (ACS) for fetal lung maturation is celebrating the 50th anniversary. The most recent Cochrane review concluded that there is robust evidence that a single course of ACS reduces the risk of perinatal death and respiratory distress syndrome. Some aspects of ACS remain unresolved, including variations in the steroids regimen, effectiveness in certain groups, long-term effects, optimal timing of ACS administration in elective cases. it is well established that a single course of betamethasone or dexamethasone is beneficial in cases of anticipated preterm birth and delivery eventually occurs between two and seven days from administration. The main focus for future research should be on limiting the unnecessary exposure in low-risk pregnancies and investigating the effect in specific groups, periviable and late preterm fetuses

Case Report Miller-Fisher Syndrome: Are Anti-GAD Antibodies Implicated in Its Pathophysiology?

Miller-Fisher syndrome (MFS) is considered as a variant of the Guillain-Barre syndrome (GBS) and its characteristic clinical features are ophthalmoplegia, ataxia, and areflexia. Typically, it is associated with anti-GQ1b antibodies; however, a significant percentage (>10%) of these patients are seronegative. Here, we report a 67-year-old female patient who presented with the typical clinical features of MFS. Workup revealed antibodies against glutamic acid decarboxylase (GAD) in relatively high titers while GQ1b antibodies were negative. Neurological improvement was observed after intravenous gamma globulin and follow-up examinations showed a continuous clinical amelioration with simultaneous decline of anti-GAD levels which finally returned to normal values. This case indicates that anti-GAD antibodies may be associated with a broader clinical spectrum and future studies in GQ1b-seronegative patients could determine ultimately their clinical and pathogenetic significance in this syndrome

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Defining the causes of sporadic Parkinson's disease in the global Parkinson's genetics program (GP2)

The Global Parkinson’s Genetics Program (GP2) will genotype over 150,000 participants from around the world, and integrate genetic and clinical data for use in large-scale analyses to dramatically expand our understanding of the genetic architecture of PD. This report details the workflow for cohort integration into the complex arm of GP2, and together with our outline of the monogenic hub in a companion paper, provides a generalizable blueprint for establishing large scale collaborative research consortia

Multi-ancestry genome-wide association meta-analysis of Parkinson?s disease

Although over 90 independent risk variants have been identified for Parkinson’s disease using genome-wide association studies, most studies have been performed in just one population at a time. Here we performed a large-scale multi-ancestry meta-analysis of Parkinson’s disease with 49,049 cases, 18,785 proxy cases and 2,458,063 controls including individuals of European, East Asian, Latin American and African ancestry. In a meta-analysis, we identified 78 independent genome-wide significant loci, including 12 potentially novel loci (MTF2, PIK3CA, ADD1, SYBU, IRS2, USP8, PIGL, FASN, MYLK2, USP25, EP300 and PPP6R2) and fine-mapped 6 putative causal variants at 6 known PD loci. By combining our results with publicly available eQTL data, we identified 25 putative risk genes in these novel loci whose expression is associated with PD risk. This work lays the groundwork for future efforts aimed at identifying PD loci in non-European populations

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Amniotic band syndrome

A 30-year-old primiparous woman underwent routine nuchal translucency scan at 12+1 weeks of gestation. A possible amniotic band with entrapment of the upper limbs and the umbilical cord was noted. Amniotic bands or constriction rings may obstruct vascular and lymph supply and cause deformity, amputation or even intrauterine death. The exact etiology is unknown but they may be the result of rupture of the amnion without rupture of the chorion. In some cases, a fetoscopic intrauterine procedure may release the entangled limb, thus avoiding amputation. In this case, a follow up scan was scheduled at 14 gestational weeks to reassess and plan possible treatment, however, at that time a missed miscarriage was diagnosed, probably due to constriction of the umbilical cord. Following medical management, the abortus showed an amniotic band that caused amputation of both hands and constriction of the umbilical cord, as sonographically suspected

Prevalence of Cannabis Use Among Medical Students: A Systematic Review and Meta-analysis

Objective: Cannabis is reported to be the most common illicit substance used among medical students; however, the number of related studies is limited and their results are not systematically reviewed. The aim of our study was to analyze the prevalence of lifetime and current use of cannabis among medical students worldwide. Methods: A systematic review and meta-analysis was performed with adherence to the PRISMA guidelines. The electronic databases PubMed, Scopus, and Cochrane library were searched for studies on the prevalence of cannabis use among medical students. Prevalence of lifetime, past-year, and past-month cannabis use was extracted. Pooled prevalence and relative risk for sex were calculated using the random effects model and subgroup analyses were conducted. Results: A total of 38 observational (cross-sectional and cohort) studies were included (total number of participants 19 932), and most of them were conducted in Europe, Central and Southern America, and the United States. Overall pooled prevalence of lifetime cannabis use was 31.4% (95% confidence interval [CI]: 23.7%-39.6%), past-year use was 17.2% (95% CI: 10.8%-24.6%), and past-month use was 8.8% (95% CI: 5.6%-12.5%). Men displayed higher rates of cannabis use with a pooled relative risk of 1.55 (95% CI: 1.32-1.81). Heterogeneity was high ( I 2  > 75%) and there were differences among continents in all outcomes ( P  < .001). Conclusions: In conclusion, 1 in 3 medical students has used cannabis, whereas 8.8% were current users. Significant differences among continents were observed, but common finding was that male students tend to consume cannabis more often than female students