Tight glycemic control: what do we really know, and what should we expect?

Tight glycemic control has engendered large numbers of investigations, with conflicting results. The world has largely embraced intensive insulin as a practice, but applies this therapy with great variability in the manner of glucose control and measurement. The present commentary reviews what we actually know with certainty from this vast sea of literature, and what we can expect looking forward

The development of dynamic noise perimetry

This thesis describes the developm ent o f Dynamic Noise Perimetry (DNP), a novel method based on the equivalent noise input technique. The method, specifically targeted to an early stage o f OAG, used a 0.5 cycle per degree sine-wave grating presented at 8Hz in conjunction with an external noise m ask that was optimised for the stimulus. Equivalent noise and sampling efficiency w ere determ ined at various locations within the visual field to identify a stage o f the disease that was analogous to ganglion cell shrinkage, a stage which is believed to precede conventional methods o f detection. A pilot study initially determ ined w hether the spatial parameters o f the mask, in terms o f noise check size, were dependent on the spatial and temporal param eters o f the grating stimulus. The results show ed that the m axim al dimensions o f each check, i.e. the critical check size, were correlated w ith the drift frequency o f the stimulus. In a second and preliminary study, the variation in the critical check size with grating spatial and temporal frequency was investigated as a function o f eccentricity. Critical noise check size, in terms o f noise checks per cycle, decreased w ith increasing spatial frequency and drift frequency o f the stimulus, and with eccentric viewing. These results were used to optim ise the critical parameters for the noise mask. Temporal contrast sensitivity, equivalent noise and sampling efficiency were determined at various locations in the visual field, in 20 normal individuals and in 10 individuals with OAG. Temporal contrast sensitivity was reduced, and equivalent noise levels were elevated in early OAG, w hen com pared with normal individuals. Derivative measures o f sampling efficiency and equivalent noise declined with glaucomatous field loss. DNP was able to identify individuals w ith OAG, at locations which exhibited abnormal Pattern Deviation values and/ or abnorm al retinal nerve fibre layer thickness. DNP clearly warrants further developmen

Outcomes in patients with gunshot wounds to the brain.

Introduction:Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods:We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results:825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion:We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence:Level II

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study.

Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Cholera in Haiti: informing health policies

The worst cholera epidemic in recent history began in Haiti in October, 2010. By August 2012, more than 7500 people had died and almost 600 000 cases were recorded. Published research and a UN investigation suggest that the UN military mission, MINUSTAH, was the most likely source, caused by failures in medical screening and waste management. The UN has not used these findings to update its policy. We postulate that this was partly because UN officials might be unable to understand the data. Helping UN officials to comprehend the data could enable quick, evidence-based protocol reform. We investigated knowledge and interpretation of scientific reports by UN officials. We searched PubMed for articles published between October 2010, and June 2012, with the terms “Haiti” and “cholera”. Only original research about the origins of cholera in Haiti were included. Of 103 articles found, seven met this inclusion criterion. We also included data from the UN report. We supplemented our PubMed search with discussions with the authors of the identified reports. We provided scientific briefs to UN officials who responded to the cholera epidemic. We met with 23 UN officials, including permanent mission representatives. We asked officials if they saw a need for translation of scientific findings, found briefings helpful in shaping policy, and could foresee briefings influencing policy recommendations. 21 officials expressed difficulty understanding the scientific data and said that they would appreciate help interpreting results. All asked questions about the published research that they felt were not answered by lay media reporting. None had read any original articles, although 20 had read excerpts from or all of the UN report. Every official reported an improved understanding of the origin of cholera in Haiti after a briefing. 16 officials thought that our briefings could help shape policy. All officials felt that regular communication between scientists and policy makers was essential to inform policy changes. 21 officials stated that they had not been previously approached by the scientific community to assist them with interpretation of the data to help guide policy reform. A comprehensive response to and prevention of epidemics requires collaboration between researchers and policy makers. In the Haiti cholera epidemic, the scientific community and UN officials were addressing a common crisis but working independently. Partnership between science and policy needs proactive, independent researchers who seek out policy makers and help them to interpret scientific data. Almost 2 years into the cholera epidemic, the UN has not updated any of its medical or waste policies. If more people can help UN officials to understand scientific findings, the UN might speed up updating its protocols, which could save the lives of UN staff and the people they serve. None