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To improve maternal and neonatal outcomes, Vietnam implemented early essential newborn care (EENC) using clinical coaching and quality improvement self-assessments in hospitals to introduce policy, practice and environmental changes. Da Nang Hospital for Women and Children began EENC with caesarean section births to inform development of national guidelines. This study compared newborn outcomes after caesarean sections pre/post-EENC introduction.

Maternity records of all live in-born hospital caesarean births and separate case records of the subpopulation admitted to the neonatal intensive care unit (NICU) were reviewed pre-EENC (November 2013-October 2014) and post-EENC (November 2014-October 2015) implementation. NICU admissions and adverse outcomes on NICU admission were compared using descriptive statistics.

A total of 16 927 newborns were delivered by caesarean section 7928 (46.8%) pre-EENC and 8999 post-EENC (53.2%). Total NICU admissions decreased from 16.7% to 11.8% (relative risk 0.71; 95% CI 0 rates of exclusive breast feeding and KMC in the NICU.

Junior doctors are working in an increasingly overstretched National Health Service. In 2018, Kettering General Hospital (KGH) was awarded £60 800 of government funds to create high-quality rest facilities and improve junior doctor well-being.

An audit and survey in KGH identified the structural and functional improvements needed. From November 2019 to June 2020, £47 841.24 was spent on creating new rest facilities. On completion, a postaction review assessed how the changes impacted morale, well-being and quality of patient care.

The majority of doctors were happy with the new rest areas (60%), a majority felt that they would use the on-call room area (63%) and the renovation improved morale and well-being. There was an increased ability to take breaks. However, the majority of doctors are not exception-reporting missing breaks 79% (2019), 74% (2020).

This report recommends the maintenance of increased staffing levels and rest facilities during the recovery phase of COVID-19. The remaining £12 958.76 should be directed at sustaining the quality of KGH rest facilities. Lastly, the rate of exception-reporting must be increased through improving awareness, exploring alternative methods and supporting the action when necessary. The continual investment into rest facilities ensures workforce well-being and translates into patient safety.

This report recommends the maintenance of increased staffing levels and rest facilities during the recovery phase of COVID-19. The remaining £12 958.76 should be directed at sustaining the quality of KGH rest facilities. Lastly, the rate of exception-reporting must be increased through improving awareness, exploring alternative methods and supporting the action when necessary. The continual investment into rest facilities ensures workforce well-being and translates into patient safety.

The incidence of early onset colorectal cancer (eoCRC) diagnosed among individuals under age 50 has been rising. However, risk factors for eoCRC are unclear. We investigated whether metabolic abnormalities are risk factors for eoCRC adenocarcinoma.

Invasive colorectal adenocarcinoma cases diagnosed between ages 15-49 from 2008-2018 at Kaiser Permanente Southern California (KPSC) were identified. Those with a history of inflammatory bowel disease were excluded. Non-cancer controls were selected 51 for each case matched by age, sex, and length of membership prior to index date. Data were collected from KSPC's electronic medical records. The exposures of interest included obesity, type 2 diabetes, hypertension, and dyslipidemia, assessed from greater than or equal to 1 year prior to eoCRC diagnosis/index date. Conditional logistic regressions were used to evaluate the associations between these metabolic risk factors and risk of eoCRC adenocarcinoma, adjusting for race/ethnicity, smoking, family history, neighborhood socioeconomic status and health care utilization.

A total of 1,032 cases and 5,128 controls were included. Risk of colorectal adenocarcinoma was significantly associated with obesity [odds ratio (OR)= 1.41 (95% confidence interval 1.14-1.74)], but not diabetes, hypertension or dyslipidemia. ML324 research buy In analysis stratified by tumor location, obesity was significantly associated with risk of colon adenocarcinoma [OR=1.57 (1.18-2.09)] but its association with rectal adenocarcinoma was less clear [OR=1.17 (0.84-1.64)]. No significant interaction was detected between obesity and age (greater than or equal to40 vs. <40), and obesity and sex.

Obesity was associated with risk for eoCRC adenocarcinoma.

This finding could help inform early-onset colorectal adenocarcinoma screening and prevention recommendations.

This finding could help inform early-onset colorectal adenocarcinoma screening and prevention recommendations.

Early onset colorectal cancer (EoCRC), diagnosed in those <50 years old, is increasing in incidence. We sought to differentiate characteristics and outcomes of EoCRC in patients with sporadic disease or preexisting conditions.

We evaluated 2135 patients with EoCRC in a population-based cohort from the Canadian province of British Columbia. Patients were identified based on presence of hereditary syndromes (n=146) or IBD (n=87) and compared to patients with sporadic EoCRC (n=1902).

Proportions of patients with preexisting conditions were highest in the youngest decile of 18-29 (34.3%, P<0.0001). Patients with sporadic EoCRC were older, more likely female, and had increased BMI (P<0.05). IBD-related EoCRC had the highest rates of metastatic disease, poor differentiation, adverse histology, lymphovascular and perineural invasion (P<0.05). Survival was lower in patients with IBD (HR1.80, 95%CI 1.54-3.13, P<0.0001) and higher in hereditary EoCRC (HR0.47, 95%CI 0.45-0.73, P<0.0001) compared to sporadic. Prognosis did not differ between ulcerative colitis or Crohn's disease but was lower in those with undifferentiated-IBD (HR1.87, 95%CI 1.01-4.05, P=0.049). Lynch syndrome EoCRC had improved survival over familial adenomatous polyposis (HR0.31, 95%CI 0.054-0.57, P=0.0037) and other syndromes (HR0.43, 95%CI 0.11-0.99, P=0.049). In multivariate analysis controlling for prognostic factors, hereditary EoCRC was unchanged from sporadic, however, IBD-related EoCRC had worse overall survival (HR2.21, 95%CI 1.55-3.16, P<0.0001).

EoCRC is heterogenous and patients with preexisting conditions have different characteristics and outcomes compared to sporadic disease.

Prognostic differences identified here for young patients with CRC and predisposing conditions may help facilitate treatment planning and patient counselling.

Prognostic differences identified here for young patients with CRC and predisposing conditions may help facilitate treatment planning and patient counselling.Overview of Gomm W, Röthlein C, Bowl K, et al Valsartan contaminated with N-nitrosodimethylamine and cancer risk a longitudinal cohort study with German health insurance data. Dtsch Arztebl Int 2021; 118357-62. doi 10.3238/arztebl.m2021.0129.

Patients with COVID-19 can present to the emergency department (ED) without immediate indication for admission, but with concern for decompensation. Clinical experience has demonstrated that critical illness may present later in the disease course and hypoxia is often the first indication of disease progression. The objectives of this study are to (a) assess feasibility and describe a protocol for ED-based outpatient pulse-oximetry monitoring with structured follow-up and (b) determine rates of ED return, hospitalisation and hypoxia among participants.

Prospective observational study of patients presenting to a single academic ED in Boston with suspected COVID-19. Eligible patients were adults being discharged from the ED with presumed COVID-19. Exclusion criteria included resting oxygen saturation <92%, ambulatory oxygen saturation <90%, heart rate >110 beats per minute or inability to use the device. Study personnel made scripted phone calls on postdischarge days 1, 3 and 7 to review the pulse-firmed or suspected COVID-19.The capacity of human brain to sustain complex cortical dynamics appears to be strongly associated with conscious experience and consistently drops when consciousness fades. For example, several recent studies in humans found a remarkable reduction of the spatiotemporal complexity of cortical responses to local stimulation during dreamless sleep, general anesthesia, and coma. However, this perturbational complexity has never been directly estimated in non-human animals in vivo previously, and the mechanisms that prevent neocortical neurons to engage in complex interactions are still unclear. Here, we quantify the complexity of electroencephalographic (EEG) responses to intracranial electrical stimulation in rats, comparing wakefulness to propofol, sevoflurane, and ketamine anesthesia. The evoked activity changed from highly complex in wakefulness to far simpler with propofol and sevoflurane. The reduced complexity was associated with a suppression of high frequencies that preceded a reduced phase-locking, and disruption of functional connectivity and pattern diversity. We then showed how these parameters dissociate with ketamine and depend on intensity and site of stimulation. Our results support the idea that brief periods of activity-dependent neuronal silence can interrupt complex interactions in neocortical circuits, and open the way for further mechanistic investigations of the neuronal basis for consciousness and loss of consciousness across species.Astrocytes provide neurons with diffusible factors that promote synapse formation and maturation. In particular, glypican-4/GPC4 released from astrocytes promotes the maturation of excitatory synapses. Unlike other secreted factors, GPC4 contains the C-terminal GPI-anchorage signal. However, the mechanism by which membrane-tethered GPC4 is released from astrocytes is unknown. Using mouse primary astrocyte cultures and a quantitative luciferase-based release assay, we show that GPC4 is expressed on the astrocyte surface via a GPI-anchorage. Soluble GPC4 is robustly released from the astrocytes largely by proteolytic shedding and, to a lesser extent, by GPI-anchor cleavage, but not by vesicular release. Pharmacological, overexpression, and loss of function screens showed that ADAM9 in part mediates the release of GPC4 from astrocytes. The released GPC4 contains the heparan sulfate side chain, suggesting that these release mechanisms provide the active form that promotes synapse maturation and function. Overall, our studies identified the release mechanisms and the major releasing enzyme of GPC4 in astrocytes and will provide insights into understanding how astrocytes regulate synapse formation and maturation.Learning in sensorimotor adaptation tasks has been viewed as an implicit learning phenomenon. The implicit process affords recalibration of existing motor skills so that the system can adjust to changes in the body or environment without relearning from scratch. However, recent findings suggest that the implicit process is heavily constrained, calling into question its utility in motor learning and the theoretical framework of sensorimotor adaptation paradigms. These inferences have been based mainly on results from single bouts of training, where explicit compensation strategies, such as explicitly re-aiming the intended movement direction, contribute a significant proportion of adaptive learning. It is possible, however, that the implicit process supersedes explicit compensation strategies over repeated practice sessions. We tested this by dissociating the contributions of explicit re-aiming strategies and the implicit process in human participants over five consecutive days of training. Despite a substantially longer duration of training, the implicit process still plateaued at a value far short of complete learning and, as has been observed in previous studies, was inappropriate for a mirror-reversal task.