Chemical Angioplasty with Nitroglycerin for Vasospasm after Subarachnoid Hemorrhage: Case Series and Review

Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits. Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to perform a comprehensive review and analysis of aneurysmal vasospasm. Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both. Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty. Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.

The combined oral contraceptive pill

The combined oral contraceptive pill (COCP) has been a popular choice of contraception since it was first introduced in 1961. There are numerous varieties of COCP and tailored regimes allow patients more choice and opportunities to adapt contraception to suit individual needs. The pandemic has made it more difficult for patients to access long-acting reversible contraception support and many have been using interim methods of contraception, including the COCP. In this article we explore which pill to prescribe, developments in tailored regimes, guidance about changing pills when side effects arise, health risks and benefits, as well as best practice for remote assessments and prescribing.

Antipsychotic Use in Pregnancy: Patient Mental Health Challenges, Teratogenicity, Pregnancy Complications, and Postnatal Risks

Pregnant women constitute a vulnerable population, with 25.3% of pregnant women classified as suffering from a psychiatric disorder. Since childbearing age typically aligns with the onset of mental health disorders, it is of utmost importance to consider the effects that antipsychotic drugs have on pregnant women and their developing fetus. However, the induction of pharmacological treatment during pregnancy may pose significant risks to the developing fetus. Antipsychotics are typically introduced when the nonpharmacologic approaches fail to produce desired effects or when the risks outweigh the benefits from continuing without treatment or the risks from exposing the fetus to medication. Early studies of pregnant women with schizophrenia showed an increase in perinatal malformations and deaths among their newborns. Similar to schizophrenia, women with bipolar disorder have an increased risk of relapse in antepartum and postpartum periods. It is known that antipsychotic medications can readily cross the placenta, and exposure to antipsychotic medication during pregnancy is associated with potential teratogenicity. Potential risks associated with antipsychotic use in pregnant women include congenital abnormalities, preterm birth, and metabolic disturbance, which could potentially lead to abnormal fetal growth. The complex decision-making process for treating psychosis in pregnant women must evaluate the risks and benefits of antipsychotic drugs.

Prehospital Tourniquet Use Should be a Trauma Team Activation Criterion.

Purpose Prehospital tourniquet application is not a standard trauma team activation (TTA) criterion recommended by the ACS COT. Tourniquet use has seen a resurgence recently with associated risks and benefits of more liberal usage. Our institution added tourniquet application as TTA criterion in January 2019. This study aimed to evaluate the effect this would have on patient care and overtriage. Methods A prospective analysis was conducted for all TTA associated with tourniquets placed during 2019. An overtriage analysis was conducted utilizing a modified Cribari method as described in Resources for the Optimal Care of the Injured Patient, comparing patients that met standard TTA criteria (TTA-S), to those who met criteria due to tourniquet placement (TTA-T). Results During the study, there were 46 TTA with tourniquets. Mean prehospital tourniquet time was 80 minutes. Median ISS was 10, 8 (17%) had an ISS >15. Urgent operative intervention was needed in 74%, with 23% and 21% requiring orthopedic and vascular procedures, respectively. Tourniquets were correctly placed in 80% and clinically appropriate in 57%. Of these subjects, 25 (54%) were TTA-S and 21 TTA-T. Overtriage analysis was performed. Overtriage for TTA-T was 33.3%. Overtriage among TTA-S was 4%. Conclusion Patients with prehospital tourniquets are frequently severely injured. The immediate presence of a trauma surgeon can have significant impacts in these cases. This is particularly important in a rural environment with long tourniquet times. Prehospital tourniquet application as a TTA criteria does not result in excessive overtriage.

Companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19: a mixed-methods analysis of national and organisational responses and perspectives

ObjectivesTo explore stakeholders’ and national organisational perspectives on companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19, as part of the Achieving Safe and Personalised maternity care In Response to Epidemics (ASPIRE) COVID-19 UK study.SettingMaternity care provision in England.ParticipantsInterviews were held with 26 national governmental, professional and service-user organisation leads (July–December 2020). Other data included public-facing outputs logged from 25 maternity Trusts (September/October 2020) and data extracted from 78 documents from eight key governmental, professional and service-user organisations that informed national maternity care guidance and policy (February–December 2020).ResultsSix themes emerged: ‘Postcode lottery of care’ highlights variations in companionship and visiting practices between trusts/locations, ‘Confusion and stress around ‘rules’’ relates to a lack of and variable information concerning companionship/visiting, ‘Unintended consequences’ concerns the negative impacts of restricted companionship or visiting on women/birthing people and staff, ‘Need for flexibility’ highlights concerns about applying companionship and visiting policies irrespective of need, ‘‘Acceptable’ time for support’ highlights variations in when and if companionship was ‘allowed’ antenatally and intrapartum and ‘Loss of human rights for gain in infection control’ emphasises how a predominant focus on infection control was at a cost to psychological safety and human rights.ConclusionsPolicies concerning companionship and visiting have been inconsistently applied within English maternity services during the COVID-19 pandemic. In some cases, policies were not justified by the level of risk, and were applied indiscriminately regardless of need. There is an urgent need to determine how to sensitively and flexibly balance risks and benefits and optimise outcomes during the current and future crisis situations.

Analysis of teachers' ideas about the impact of digital educational products on the cognitive-personal and activity sphere of students

Introduction. The processes of digitalization of all spheres of society, including education, require a detailed analysis of their impact on the development of the personality of students. Practice shows the ambiguity of the impact of digital educational products on the development of the student: they are both a resource, a means of development, and at the same time, they are risky in nature for various spheres of personality: cognitive, emotional-volitional, value, communicative and educational activities. The purpose of the study is to analyze the parameters of the cognitive-personal and activity spheres of students, which are influenced by digital educational products. Materials and methods. The study involved 243 teachers of secondary schools in Moscow, Moscow region, Voronezh, Nizhny Novgorod, Samara (Russian Federation). To determine the risks and benefits of using digital educational products for the cognitive-personal and activity spheres of students, an author's questionnaire was used, with the help of which an anonymous online survey was conducted (using a google-form). Research results. Statistical analysis revealed correlations between the parameters "development" and "deformation" of the cognitive qualities of students "Attention" (rs = -0.905; p≤0.01) and "Memory" (rs = -0.833; p≤0.01), which indicates a significant discrepancy in the assessments of teachers. For most of the characteristics of the personal sphere and educational motivation, the correspondence in the assessments was determined between what “develops” and what “deforms” in students when learning with the help of digital educational products. Conclusion. The novelty of the study lies in identifying the ambiguity of the impact of the digital educational products used on the development of the personality of modern schoolchildren and in determining the areas of greatest risk. The obtained results can be used as recommendations for teachers and leaders of educational institutions in the development of digital educational products for secondary schools.

DEVELOPMENT OF MARKET THEORY: THE RELATIONSHIP BETWEEN COMPETITION RISK AND THE DIGITAL MARKET

The development of the Internet, big data, computer algorithms, artificial intelligence, selflearning robots and other areas of the digital economy contribute to improving life. At the same time, players with market power are emerging in the economy, based on the use of algorithms, big data, big analytics, the use of intellectual property rights, the widespread use of targeted marketing technologies on this basis, not only studying, but also forming consumer preferences. The consequences of digital transformation in the economy are significant, and symbolic changes in legislation and practice of its application cannot be dispensed with here. It is necessary to measure the risks and benefits of the digital economy for competition and public welfare. Risks need to be managed, and benefits need to be multiplied. It is necessary to evaluate the new situation in the markets based on the basic postulates, and also take into account that the dynamic nature of changes has become the main characteristic of the markets.