Overlapping stent insertion for a treatment-resistant seroma after arteriovenous fistulation using prosthetic grafts

An arteriovenous fistula was required for permanent vascular access in a patient undergoing hemodialysis due to progressive chronic kidney disease associated with short bowel syndrome. In the present report, we discuss the case of a patient who underwent arteriovenous grafting because there was no proper native vein as a route, following which a seroma developed near the arterial anastomosis. Despite several surgical treatments, seroma not only recurred but also affected dialysis by compressing the graft. A stent was inserted into the graft to withstand the pressure from the seroma, and because one stent could not withstand the pressure, the stent overlapped where it received the most compression. Since then, the patency of graft has been well maintained for more than 2 years. Increasing the radial force of overlapping stents would be an alternative plan to help solve the problematic repeated compressible seroma despite multiple surgical treatments.

An audit assessing the monitoring of SSRIS after initiation in children and adolescents

AimsTo identify children and adolescents started on SSRIs to see if they are being followed up in accordance to NICE and Maudsley guidelinesObjectivesHas the patient been followed up after a week to check for adverse effects or improvement in their mental state?Has the patient been re-evaluated every 4-6 weeks, if not is there an alternative plan?If there is no improvement has the dose been increased?If there is an adverse effect has the dose been lowered or the medication stopped?MethodPaper case notes including clinic letters and handwritten notes were reviewed on the 19/10/2020. The following data were collected anonymously.AgeGenderDate seen / Date medication startedName of medicationDate medication startedDate of Follow-upMonitoring of improvementMonitoring of adverse effectsOutcome of monitoringResultA total of 18 sets of cases were identified.Follow-up occurred in 17 of the 18 cases.The one case that had not been followed up had started the medication 8 weeks before the audit. The median follow-up time was 42 days (6 weeks). No cases were followed up within a week.Monitoring of improvement was recorded in 88% of case notes reviewed.Monitoring for adverse effects occurred in 36% of case notes and none of these patients had reported any side effects. 53% of cases did not have monitoring of adverse effects documented. There were two patients (11%) who did not take the medication as prescribed. One out of choice and one their parent had not collected it.The medication dose was increased in 22% of patients without clear documentation of monitoring for adverse effects.ConclusionAfter discussion with the clinical lead it was decided it is impractical to follow up patients a week after starting medication. However, patients and their carers should be informed of the side effects and advised to contact CAMHS if adverse effects occur.The area of practice that can be improved is the documentation of adverse effects at follow-up.Recommendations:All patients to be informed of the common side effects of the medication before it is initiated and advised to contact the CAMHS team if they have concernsAll CAMHS patients started on SSRIs should be followed up within 4-6 weeksAt follow-up any adverse events and clinical response should be discussedAn accurate record of the exchanges of the above information should be documented in the notesRe-audit

Pakistan specific COVID-19 overview and recommendations

Soon after its emergence in Wuhan, China in late December, the novel coronavirus (SARS-CoV-2) spread rapidly to the other parts of the world and acquired a pandemic status. Pakistan reported its first case of SARS-CoV-2 on February 26, 2020, in Karachi. Since then, a higher prevalence of COVID-19 was reported from almost all major cities of Pakistan. Owing to the high rate of COVID-19, Pakistan enforced a lockdown across the whole country on March 24, 2020. This lockdown controlled the SARS-CoV-2 successfully; however, severe economic losses were observed in the lockdown Standard Operating Procedure (SOP) guidelines. We, therefore, proposed an alternative plan termed as “regulated reverse lockdown” which will help decrease the burden of COVID-19 without having a negative effect on the economy. The present editorial will address the potential flaws in the already imposed lockdown and will propose an alternative plan to make the lockdown more effective in terms of COVID-19 prevalence and economic growth of Pakistan.

Derailed Cardiac Surgical Practice during COVID-19 Pandemic: Concerns and Proposed Solution Strategy

The current ongoing novel corona virus disease 2019 (COVID 19) pandemic has led to reallocation of substantial hospital resources and workforce depriving the institution’s ability to handle the routine caseload. The sustenance of health care would require a comprehensive management plan and focused strategy. The cardiac surgical department would consume majority of critical care resources, hence, a balance should be sought between the resumption of routine surgeries and the emergency unavoidable ones. We have proposed an alternative plan to guide the formulation of a strategic comeback.

Italy’s coalition faces important election tests

Significance This is mostly thanks to the significant decrease in COVID-19 cases in Italy and Rome obtaining relatively low-risk financial support from the EU to reboot the economy. Also, League party leader Matteo Salvini has been unable to offer a convincing alternative plan to handle COVID-19. Impacts The elections would be postponed only if there was a substantial surge in COVID-19 cases in the six regions due to vote. The upcoming elections will be the first major test of support for the far right since the COVID-19 outbreak. Business confidence is likely to suffer if coalition instability increases speculation of early national elections.

An areal openness model (AOM) for quantifying the “openness” of floor plans

PurposeThis paper aims to describe and demonstrate a quantitative areal openness model (AOM) for measuring the openness of floor plans. Creation of the model was motivated by the widely reported but rarely quantified link between openness and adaptability.Design/methodology/approachThe model calculates values for three indicators: openness score (OS), weighted OS (WOS) and openness potential (OP). OS measures the absence of obstructions (walls, chases, columns) that separate areas in a floor plan. WOS measures the number of obstructions while also accounting for the difficulty of removing them. OP measures the potential of a floor plan to become more open. Indicators were calculated for three demolished case study buildings and for three adapted buildings. The case study buildings were selected because openness – or lack thereof – contributed to the owners' decisions to demolish or adapt.FindingsOpenness indicators were consistent with the real-world outcomes (adaptation or demolition) of the case study buildings. This encouraging result suggests that the proposed model is a reasonable approach for comparing the openness of floor plans and evaluating them for possible adaptation or demolition.Originality/valueThe AOM is presented as a tool for facility managers to evaluate inventories of existing buildings, designers to compare alternative plan layouts and researchers to measure openness of case studies. It is intended to be sufficiently complex as to produce meaningful results, relatively simple to apply and readily modifiable to suit different situations. The model is the first to calculate floor plan openness within the context of adaptability.