COPD Imaging on a 3rd Generation Dual-Source CT: Acquisition of Paired Inspiratory-Expiratory Chest Scans at an Overall Reduced Radiation Risk

As stated by the Fleischner Society, an additional computed tomography (CT) scan in expiration is beneficial in patients with chronic obstructive pulmonary disease (COPD). It was thus the aim of this study to evaluate the radiation risk of a state-of-the-art paired inspiratory-expiratory chest scan compared to inspiration-only examinations. Radiation doses to 28 organs were determined for 824 COPD patients undergoing routine chest examinations at three different CT systems–a conventional multi-slice CT (MSCT), a 2nd generation (2nd-DSCT), and 3rd generation dual-source CT (3rd-DSCT). Patients examined at the 3rd-DSCT received a paired inspiratory-expiratory scan. Organ doses, effective doses, and lifetime attributable cancer risks (LAR) were calculated. All organ and effective doses were significantly lower for the paired inspiratory-expiratory protocol (effective doses: 4.3 ± 1.5 mSv (MSCT), 3.0 ± 1.2 mSv (2nd-DSCT), and 2.0 ± 0.8 mSv (3rd-DSCT)). Accordingly, LAR was lowest for the paired protocol with an estimate of 0.025 % and 0.013% for female and male patients (50 years) respectively. Image quality was not compromised. Paired inspiratory-expiratory scans can be acquired on 3rd-DSCT systems at substantially lower dose and risk levels when compared to inspiration-only scans at conventional CT systems, offering promising prospects for improved COPD diagnosis

Perioperative non-invasive versus semi-invasive cardiac index monitoring in patients with bariatric surgery - a prospective observational study

Results Sixty patients (mean BMI 49.2 kg/m2) were enrolled into the study and data from 54 patients could be entered in the final analysis. Baseline CI was 3.2 ± 0.9 and 3.3 ± 0.8 l/min/m2, respectively. Pooled absolute CI values showed a positive correlation (rs = 0.76, P  92%). Conclusion Non-invasive as compared to semi-invasive CI measurements did not reach criteria of interchangeability for monitoring absolute and trending values of CI in morbidly obese patients undergoing bariatric surgery. Trial registration The study was registered retrospectively on June 12, 2017 with the registration number NCT03184272

Protein intake and outcome of critically ill patients: analysis of a large international database using piece-wise exponential additive mixed models

BACKGROUND Proteins are an essential part of medical nutrition therapy in critically ill patients. Guidelines almost universally recommend a high protein intake without robust evidence supporting its use. METHODS Using a large international database, we modelled associations between the hazard rate of in-hospital death and live hospital discharge (competing risks) and three categories of protein intake (low: 1.2~g/kg per day) during the first 11~days after ICU admission (acute phase). Time-varying cause-specific hazard ratios (HR) were calculated from piece-wise exponential additive mixed models. We used the estimated model to compare five different hypothetical protein diets (an exclusively low protein diet, a standard protein diet administered early (day 1 to 4) or late (day 5 to 11) after ICU admission, and an early or late high protein diet). RESULTS Of 21,100 critically ill patients in the database, 16,489 fulfilled inclusion criteria for the analysis. By day 60, 11,360 (68.9%) patients had been discharged from hospital, 4,192 patients (25.4%) had died in hospital, and 937 patients (5.7%) were still hospitalized. Median daily low protein intake was 0.49~g/kg IQR 0.27-0.66, standard intake 0.99~g/kg IQR 0.89- 1.09, and high intake 1.41~g/kg IQR 1.29-1.60. In comparison with an exclusively low protein diet, a late standard protein diet was associated with a lower hazard of in-hospital death: minimum 0.75 (95{\%} CI 0.64, 0.87), and a higher hazard of live hospital discharge: maximum HR 1.98 (95{\%} CI 1.72, 2.28). Results on hospital discharge, however, were qualitatively changed by a sensitivity analysis. There was no evidence that an early standard or a high protein intake during the acute phase was associated with a further improvement of outcome. CONCLUSIONS Provision of a standard protein intake during the late acute phase may improve outcome compared to an exclusively low protein diet. In unselected critically ill patients, clinical outcome may not be improved by a high protein intake during the acute phase. Study registration ID number ISRCTN17829198

Video-based, student tutor- versus faculty staff-led ultrasound course for medical students - a prospective randomized study

Background Ultrasound education is propagated already during medical school due to its diagnostic importance. Courses are usually supervised by experienced faculty staff (FS) with patient bedside examinations or students among each other but often overbooked due to limited FS availability. To overcome this barrier, use of teaching videos may be advantageous. Likewise, peer teaching concepts solely with trained student tutors have shown to be feasible and effective. The aim was to evaluate 1) objective learning outcomes of a combined video-based, student-tutor (ViST) as compared to a FS-led course without media support, 2) acceptance and subjective learning success of the videos. Methods Two ultrasound teaching videos for basic and advanced abdominal ultrasound (AU) and transthoracic echocardiography (TTE) were produced and six students trained as tutors. Fourth-year medical students (N = 96) were randomized to either the ViST- or FS course (6 students per tutor). Learning objectives were defined equally for both courses. Acquired practical basic and advanced ultrasound skills were tested in an objective structured clinical examination (OSCE) using modified validated scoring sheets with a maximum total score of 40 points. Acceptance and subjective learning success of both videos were evaluated by questionnaires based on Kirkpatrick's evaluation model with scale-rated closed and open questions. Results 79 of 96 medical students completed the OSCE and 77 could be finally analyzed. There was no significant difference in the mean total point score of 31.3 in the ViST (N = 42) and 32.7 in the FS course (N = 35, P = 0.31) or in any of the examined basic or advanced ultrasound skill subtasks. Of the 42 ViST participants, 29 completed the AU and 27 the TTE video questionnaire. Acceptance and subjective learning success of both videos was rated positively in 14-52% and 48-88% of the rated responses to each category, respectively. Attendance of either the student or faculty tutor was deemed necessary in addition to the videos. Conclusions A ViST versus FS teaching concept was able to effectively teach undergraduate students in AU and TTE, albeit acceptance of the teaching videos alone was limited. However, the ViST concept has the potential to increase course availability and FS resource allocation

Early modern human behavioural responses to marginal landscapes : Middle Stone Age geoarchaeology in Highland Lesotho

Figure S6. Effect of geographic representation of study patients on outcomes: mortality. Figure S7. Effect of geographic representation of study patients on outcomes: infections. (DOCX 190 kb

Lymphoid organisation in labial salivary gland biopsies is a possible predictor for the development of malignant lymphoma in primary Sjögren's syndrome

Objective The development of non-Hodgkin's lymphoma (NHL) confers a high risk of mortality in primary Sjogren's syndrome (pSS) patients, but the sensitivity and specificity of proposed lymphoma predictors are insufficient for practical use. The performance of lymphoid organisation in the form of germinal centre (GC)-like lesions was evaluated in labial salivary gland biopsies taken at pSS diagnosis as a potential lymphoma-predicting biomarker. Methods Labial salivary gland tissue biopsies available from two Swedish pSS research cohorts (n = 175) were re-evaluated by light microscopy in a blind study in order to identify GC-like structures as a sign of ectopic lymphoid tissue formation and organisation. A linkage study was performed with the Swedish Cancer Registry for lymphoma identification. The risk of developing NHL in GC-positive patients in comparison with GC-negative patients was evaluated using Kaplan-Meier statistics and log-rank test. Associations between GC-like structures and clinical and/or laboratory disease markers were also determined using. 2 or Fisher's exact tests. Results At diagnosis, 25% of pSS patients had GC-like structures in their salivary glands. Seven of the 175 patients studied (14% GC+ and 0.8% GC-) developed NHL during 1855 patient-years at risk, with a median onset of 7 years following the initial diagnostic salivary gland biopsy. Six of the seven patients had GC-like structures at diagnosis; the remaining patient was GC negative at the time of diagnosis (p=0.001). Conclusions The detection of GC-like structures by light microscopy in pSS diagnostic salivary biopsies is proposed as a highly predictive and easy-to-obtain marker for NHL development. This allows for risk stratification of patients and the possibility to initiate preventive B-cell-directed therapy