Hospital-at-Home Expands Hospital Capacity During COVID-19 Pandemic

A Coronavirus Disease 2019 (COVID-19)–specific Hospital-at-Home was implemented in a 400-bed tertiary hospital in Barcelona, Spain. Senior or immune-compromised physicians oversaw patient care. The alternative to inpatient care more than doubled beds available for hospitalization and decreased the risk of transmission among patients and health care professionals. Mild cases from either the emergency department or after hospital discharge were deemed suitable for admission to the Hospital-at-Home. More than half of all patients had pneumonia. Standardized protocols and management criteria were provided. Only 6% of cases required referral for inpatient hospitalization. These results are promising and may provide valuable insight for centers undertaking Hospital-at-Home initiatives or in the case of new COVID-19 outbreaks.     

Results and indications of lateral ileostomy functionally terminated in colorectal surgery

Loop ileostomy (LI) ensures fecal diversion to protect an anastomosis or anatomic colorectal or ano-perineal damage. The aim of this retrospective study was to evaluate loop ileostomy morbidity in emergency and planned colorectal surgery. PATIENTS AND METHODS: From 1991 to 1996, 145 loop ileostomies were performed in 139 patients, 77 men and 62 women with a mean age of 48.7 years (15-82). The etiology was a rectal tumor (cancer or large villous tumor n = 47), inflammatory bowel disease (n = 47, ulcerative colitis = 37 and Crohn's disease = 10) Familial Adenomatous Polyposis (n = 13) and other diseases (n = 32). 80% LI (n = 116) protected ileo-anal anastomoses (n = 46) colo-anal anastomoses (n = 45, 26 with colonic pouch), ileo-rectal anastomoses (n = 11) and other anastomoses (n = 15). 20% LI (n = 29) dysfunctional ano-perineal lesions (n = 8), anastomosis leak (n = 4) or distal bowel without intestinal resection (n = 17). RESULTS: 7 deaths were not stoma-related. 91% LI were closed after a mean diversion time of 3.6 months. LI closure was performed by a parastomal (n = 128) or laparotomy procedure (n = 4). Morbidity during LI diversion was observed in 24 patients (16.5%) 12 of whom (8.3%) were operated for small bowel obstruction (n = 6; 4.2%) stoma revision (n = 5; 3.5%) and prolapse (n = 1; 0.7%). 2 patients had peristomal skin excoriations, and 5 patients required readmission for dehydration due to high LI output. Morbidity after LI closure was observed in 12 patients (8.6%) 5 of whom were operated for anastomotic leak (n = 4) or small bowel obstruction (n = 1). Low morbidity and defunctioning efficiency confirm the indications for LI. LI is our first-line stoma in planned or emergency colorectal surgery.     

EEG and cardiac activation during periodic leg movements in sleep: support for a hierarchy of arousal responses

OBJECTIVE: To investigate other physiologic changes that occur with periodic leg movements during sleep (PLMS) that might be considered to be more sensitive indices of sleep fragmentation. BACKGROUND: Although PLMS are associated with recurrent microarousals (MA), the frequency of PLMS with MA does not correlate with objective daytime sleepiness. It is postulated that the lack of correlation results from the low sensitivity of the standard criteria used to score MA. METHODS: Ten drug-free patients with a polygraphic and clinical diagnosis of restless legs syndrome (RLS) and PLMS were examined. The EEG correlates of PLMS were analyzed by visual scoring and spectral analysis during PLMS that ended in a visible microarousal (PLMS with MA) or not (PLMS without MA). The R-R interval in the EKG signal was also examined. RESULTS: A total of 34% of PLMS were associated with MA lasting >3 seconds, and 3% of PLMS were associated with MA lasting <3 seconds. Although PLMS with MA were associated with an increase in alpha activity, for PLMS without MA a significant increase in delta and theta activity was present. Both types of PLMS induced a shortening of the R-R interval; this was particularly more marked for PLMS with MA. CONCLUSIONS: First, visual scoring of MA that include a duration of less than 3 seconds has little effect on the detection of PLMS with MA. Second, EEG activation and tachycardia are present during both types of PLMS. Third, a hierarchy in the arousal response is present-going from autonomic activation to bursts of delta activity to alpha activity to a full awakening.     

Sequential changes in the synaptic structural profile following long-term potentiation in the rat dentate gyrus: I. The intermediate maintenance phase

Changes in synaptic structure have been reported following the induction of long-term potentiation (LTP). The structure of synapses during the intermediate maintenance of LTP has yet to be fully characterized in chronically implanted freely moving animals. The present study examined synapses in the middle third of the molecular layer (MML) of the rat dentate gyrus following repeated high frequency tetanization of the perforant path. Synapses from both 1) the ipsilateral inner third of the dentate molecular layer (IML), which was not directly stimulated during the induction of LTP, as well as 2) implanted, nonstimulated animals, served as controls. LTP was induced over a 4-h period, and the animals were sacrificed 24 h after the final stimulation of the LTP group. Ultrastructural quantification included the total number of synapses, synaptic curvature, the presence of synaptic perforations, and the maximum length of the synaptic contact. Although LTP was not associated with an overall increase in synaptic number, there was a significant increase in the proportion of presynaptically concave-shaped synapses. Further, the concave synapses in the LTP tissue were found to be significantly smaller than control concave synapses. There was also a significant increase in the number of perforated concave synapses which exceeded the overall increase in concave synapses, and occurred despite the lack of a general increase in perforated synapses. It was concluded that this specific structural profile, observed at 24 h postinduction, may help support the potentiated response observed at this stage of LTP maintenance.     

Who are the French plastic surgeons?

Based on data from the national advice of the Conseil National de l'Ordre des Médecins (French Medical Board), the author found 654 plastic surgeons in France and classified them into five categories, demonstrating the increasing proportion of females in this specialty.     

Hemorrhagic fevers: few clues after 25 years

There is a high prevalence of Ebola antibodies found in the Kenya population, related to geographical area and season, although the clinical disease was never found and the virus was not isolated. A field study was carried out in 7 hospitals in western Kenya, 1986 -1987 (including surveillance studies in suspect areas), to intensify collection and transport of samples, testing facilities, patient observation with record keeping and follow-up. This study involved 1109 admitted patients with fever and/or bleeding, 155 contacts of haemorrahagic fever antibody (Hfab) patients, and 916 people in suspect areas. Respectively 160,44 and 80 persons were found Hfab positive mainly to Ebola, using an indirect immunofluorescent assay. From 676 viral cultures no virus was isolated. A relationship between antibody titres and ecological factors, social habitat, age, sex or season was not found. The non-specificity of IF testing was demonstrated by: 1) the disagreement between the results of two reference laboratories; 2) the unpredictability of the titre conversation course; and 3) by proving a significant cross-reactivity with Borrelia burgdorferii antibodies, Plasmodium falcparum antibodies and Salmonella typhi antibodies. Renewed testing in 1995 of 90 positive sera (with low titres) showed 19 sera to be positive by Elisa (2 in Zaire, 1 in Sudan, 9 in Reston and 7 in Cote d'Ivoire) from which 4 were confirmed by IFI 2 in Reston and 2 in Cote d'Ivoire. These findings are more proof that non-human virulent strains of Filoviridae, especially Ebola virus, are around in Kenya.     

Physeal and epiphyseal extent of primary malignant bone tumors in childhood

Twenty-two patients with metaphyseal primary malignant bone tumors (17 osteosarcomas, 5 Ewing's tumors) occurring before closure of the growth plate were examined with plain radiographs and MRI in order to determine the physeal or epiphyseal extent of the tumor. Results were correlated with the pathologic examination. Transphyseal spread was pathologically proven in 13 cases (59%): 12 cases of osteosarcoma and 1 case of Ewing's tumor (70% and 20%, respectively). There was no significant relation between epiphyseal invasion, age of patient, length of tumor or, in the cases of osteosarcoma, response to chemotherapy. Plain radiographs showed epiphyseal involvement in 4 cases and there were 10 false negatives. MRI revealed epiphyseal involvement in all cases; there were no false positives or false negatives. T1-weighted images in coronal or sagittal planes appeared to be sufficient. These findings are very useful in planning surgical limb salvage procedures and stress the ineffectiveness of the barrier effect of the growth plate against tumor spread.     

Patterns of the coronary artery irrigation in the left ventricle

Summary Nowadays, the classifications of coronary arterial preponderance (Schlesinger, Baroldi, Gensini) do not provide the necessary information for a good systematization of coronary arterial irrigation. Based on segmental analysis (Selvester's method) an alternative classification of the arterial distribution of the left ventricle is presented. One thousand eighty ventricle segments corresponding to 90 human hearts (age range from 4 days to 94 years) are studied, using microdissection techniques. In order to obtain segmental arterial patterns, a cluster analysis was used. The alternative classification is based on the predominance of the segments irrigated by: the anterior interventricular artery (Type I; 31% of cases), the circumflex artery (Type II; 37% of cases), or a balance between both arteries (Type III; 32% of cases). Each group can be divided into two subgroups (A and B), according to the existence or not of a balance between the territories of anterior interventricular and circumflex arteries. This classification allows as a more realistic approach to the subject of arterial dominance, given that the left ventricle always presents a predominant irrigation from the anterior interventricular, the circumflex or both arteries.

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Essai de classification de l'irrigation artérielle coronaire du ventricule gauche

Résumé La classification en dominance artérielle coronaire, actuellement utilisée (Schlesinger, Baroldi, Gensini) ne donne pas toutes les informations nécessaires à une bonne systématisation de la distribution des artères coronaires. Nous présentons ici une classification alternative, basée sur la segmentation des parois du ventricule gauche à la manière de Selvester. 1080 segments ventriculaires gauches de 90 coeurs humains prélevés sur des sujets de 4 jours à 94 ans ont été analysés en utilisant les techniques de microdissection. La présente classification est basée sur — la prédominance de segments irrigués par l'artère interventriculaire antérieure (IVA) : type I, par l'artère circonflexe (CX) : type II, — ou sur l'existence d'un équilibre entre ces deux artères : type III. Le pourcentage de distribution de ces groupes est le suivant : type I : 31 % ; type II : 37 % ; type III : 32 %. Chacun de ces groupes peut-être divisé en deux sous-groupes A et B selon — la prédominance du nombre de segments irrigués exclusivement ou en partage par l'IVA, — ou l'existence d'un équilibre entre l'IVA et la CX. Cette classification permet une approche plus réaliste du problème de dominance artérielle, étant donné que le ventricule gauche est toujours irrigué en prédominance par l'IVA, par la CX ou à la fois par les deux.

     

Surgical management of isolated multiple ventricular septal defects. Logical approach in 130 cases.

From January 1980 through September 1990, 130 children underwent surgical closure of isolated multiple ventricular septal defects (mean age 14 +/- 18 months, mean weight 7.0 +/- 4.4 kg). Sixty-one were less than 1 year of age. Sixty-one children had pulmonary protection, 51 had pulmonary artery banding, and 10 had pulmonary valve stenosis. All other patients had severe pulmonary hypertension (mean systolic pressure 75.7 +/- 20.5 mm Hg and already disabling heart failure (New York Heart Association classes III and IV). The surgical management was based on the location of the defects and the ventricular dominance that were assessed preoperatively and intraoperatively. Midtrabecular ventricular septal defects were always centered by the moderator band and were therefore divided into low trabecular, midtrabecular, and high trabecular defects. The perimembranous septum was involved in 102 patients, the trabecular in 121, the inlet septum in 12, and the infundibular septum in 9. Fifty patients had the "Swiss cheese" form of the lesion. Closure of the ventricular septal defects included Dacron patch and mattress sutures. They were always first approached through a right atriotomy, which was sufficient for complete repair in 82 patients. In midtrabecular ventricular septal defects, section of the moderator band (n = 24) allowed closure of all the defects with a single Dacron patch. In 48 patients a right atriotomy and a right (n = 32) or left (n = 14) (particularly for low trabecular ventricular septal defects) or both right and left (n = 2) ventriculotomies were necessary to secure the repair. The hospital mortality rate was 7.7% (10 patients). The causes of deaths were residual ventricular septal defect (n = 5), pulmonary hypertension (n = 2), hypoplastic right ventricle (n = 1) and left ventricle (n = 1), and myocardial infarction (n = 1). Among eighteen survivors with residual ventricular septal defect, six were reoperated on; there were two deaths. A permanent pacemaker was necessary in four patients. Low trabecular ventricular septal defects and left ventriculotomy were significant risk factors for morbidity (death, residual ventricular septal defect), p less than 0.01. At 7 years of follow-up, 90% of survivors were in New York Heart Association class I. Actuarial survival and freedom from reoperation at 7 years were 89.6% and 87.5%, respectively.