Knowledge, Attitude, and Perception on Bequeathing of Bodies for Medical Education and Research among Health Science Students of the University of Health and Allied Sciences.

Abstract Background: Cadaveric dissection is an established effective teaching method in anatomical science education. Cadaver acquisition for dissection is however based on voluntary body bequeathment. As a result of the increasing numbers of medical schools and students intake, the challenges of inadequate bodies for education became visible in most parts of the world as the main cadaver source remains anonymous corpses in the custody of the state. Cultural and religious beliefs or commercial purposes are among several factors that influence the decision about body donations. This study investigates the knowledge, attitude and perception of body bequeathing among health science students who benefitted or are potential beneficiary of cadaveric studies and identified factors influencing the bequest of bodies in Ghana for educational purposes among students in University of Health and Allied Sciences. Method: This was a cross-sectional descriptive study. The study recruited 513 students in the bachelor programmes for medicine, physician assistantship, nursing, midwifery, pharmacy and allied sciences at various levels. Both closed-and open-ended questions contained in a designed Questionnaire were administered. Result: About Seventy-four percent (74.1%) of respondents had heard of body bequeathal. Majority (98.3%) agreed body bequeathal was important. However, only 39.6% knew the requirements and processes of body bequeathal. Most (>90%) had a negative attitude towards body bequeathal. Conclusion: The study concluded that there was a high awareness of the importance of body bequeathal for medical education and research but very low procedural knowledge on bequeathing a body among health science students. Also most were unwillingness to donate their body or even encouraging others to donate their body. It is therefore recommended that the medical schools should set up accessible body bequeathal programmes that provides opportunities for interested individuals to be readily assisted through the process of body bequeathal. Keywords: Body Bequeathal, Medical Science Education, Cadaveric Dissection, Anatomical education

Obesity as a mortality risk factor in the medical ward: a case control study

Background Research regarding the association between severe obesity and in-hospital mortality is inconsistent. We evaluated the impact of body mass index (BMI) levels on mortality in the medical wards. The analysis was performed separately before and during the COVID-19 pandemic. Methods We retrospectively retrieved data of adult patients admitted to the medical wards at the Mount Sinai Health System in New York City. The study was conducted between January 1, 2011, to March 23, 2021. Patients were divided into two sub-cohorts: pre-COVID-19 and during-COVID-19. Patients were then clustered into groups based on BMI ranges. A multivariate logistic regression analysis compared the mortality rate among the BMI groups, before and during the pandemic. Results Overall, 179,288 patients were admitted to the medical wards and had a recorded BMI measurement. 149,098 were admitted before the COVID-19 pandemic and 30,190 during the pandemic. Pre-pandemic, multivariate analysis showed a “J curve” between BMI and mortality. Severe obesity (BMI > 40) had an aOR of 0.8 (95% CI:0.7–1.0, p = 0.018) compared to the normal BMI group. In contrast, during the pandemic, the analysis showed a “U curve” between BMI and mortality. Severe obesity had an aOR of 1.7 (95% CI:1.3–2.4, p < 0.001) compared to the normal BMI group. Conclusions Medical ward patients with severe obesity have a lower risk for mortality compared to patients with normal BMI. However, this does not apply during COVID-19, where obesity was a leading risk factor for mortality in the medical wards. It is important for the internal medicine physician to understand the intricacies of the association between obesity and medical ward mortality.

The Attitudes, Perspectives, and Barriers Among Primary Care Physicians Towards Addressing Sexual Health of Perimenopausal-Aged Women

Background/Objective: Menopause is the natural cessation of menstruation that typically occurs in women between ages 45 and 50. Menopause can lead to numerous issues regarding sexual health such as vulvovaginal atrophy, low desire, issues with vaginal lubrication, and an inability to achieve climax. Despite these issues, very few physicians initiate conversations about sexual health. Female patients generally feel uncomfortable bringing up the topic without first being asked by their physicians, so it is imperative to assess the reasons why physicians rarely discuss the topic. Methods: Sixteen semi-structured interviews were conducted with family medicine physician faculty and residents regarding barriers to discussing sexual health with their patients. Interviews were transcribed, reviewed, and coded for common themes. Generalizable categories were identified from these themes. Results: Patient embarrassment and cultural/religious norms were the most stated barriers to discussing sexual health. Adherence to norms and the lack of sexual education among patients were the most stated potential reasons for these barriers. The use of standardized questions and increasing efforts to directly discuss sexual dysfunction were the most stated potential solutions to these barriers. Better medical education regarding female sexual health and developing routines to ask about sexual health were the most stated strategies to help family medicine physicians to better serve this population. Conclusion and Potential Impact: This study established, from a family medicine perspective, the barriers and respective potential solutions towards improving the sexual health of women of menopausal age. Patients with suboptimal sexual health can affect other aspects of their health. If barriers to discussing this topic with patients can be reduced, more sexual dysfunction diagnoses can be made, and family medicine physicians can better guide and treat patients to resolve these issues and improve overall quality of life.

Personalized Approach for Obese Patients Undergoing Endoscopic Sleeve Gastroplasty

Obesity is a chronic, relapsing disease representing a major global health problem in the 21st century. Several etiologic factors are involved in its pathogenesis, including a Western hypercaloric diet, sedentariness, metabolic imbalances, genetics, and gut microbiota modification. Lifestyle modifications and drugs often fail to obtain an adequate and sustained weight loss. To date, bariatric surgery (BS) is the most effective treatment, but only about 1% of eligible patients undergo BS, partly because of its negligible morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive, endoscopic, bariatric procedure, which proved to be safe and effective. In this review, we aim to examine evidence supporting the role of a personalized and multidisciplinary approach, guided by a multidisciplinary team (MDT), for obese patients undergoing ESG, from patient selection to long-term follow-up. The cooperation of different health professionals, including an endocrinologist and/or obesity medicine physician, a bariatric surgeon, an endoscopist experienced in bariatrics, a registered dietitian, an exercise specialist, a behaviour coach, a psychologist, and a nurse or physician extender, aims to induce radical and sustained lifestyle changes. We also discussed the relationship between gut microbiota and outcomes after bariatric procedures, speculating that the characterization of gut microbiota before and after ESG may help develop new tools, including probiotics, to optimize weight loss outcomes.

When Minutes Matter: Rapid Infusion in Emergency Care

Purpose of Review This review provides historical context and an update on recent advancements in volume resuscitation for circulatory shock. Emergency department providers who manage critically ill patients with undifferentiated shock will benefit from the insights of early pioneers and an overview of newer techniques which can be used to optimize resuscitation in the first minutes of care. Recent Findings Rapid infusion of fluids and blood products can be a life-saving intervention in the management of circulatory and hemorrhagic shock. Recent controversy over the role of fluid resuscitation in sepsis and trauma management has obscured the importance of early and rapid infusion of sufficient volume to restore circulation and improve organ perfusion. Evidence from high-quality studies demonstrates that rapid and early resuscitation improves patient outcomes. Summary Current practice standards, guidelines, and available literature support the rapid reversal of shock as a key priority in the treatment of hypotension from traumatic and non-traumatic conditions. An improved understanding of the physiologic rationale of rapid infusion and the timing, volume, and methods of fluid delivery will help clinicians improve care for critically ill patients presenting with shock. Clinical Case A 23-year-old male presents to the emergency department (ED) after striking a tree while riding an all-terrain vehicle. On arrival at the scene, first responders found an unconscious patient with an open skull fracture and a Glasgow coma scale score of 3. Bag-valve-mask (BVM) ventilation was initiated, and a semi-rigid cervical collar was placed prior to transport to your ED for stabilization while awaiting air transport to the nearest trauma center. You are the attending emergency medicine physician at a community ED staffed by two attending physicians, two physicians assistants, and six nurses covering 22 beds. On ED arrival, the patient has no spontaneous respiratory effort, and vital signs are as follows: pulse of 140 bpm, blood pressure of 65/30 mmHg, and oxygen saturation 85% while receiving BVM ventilation with 100% oxygen. He is bleeding profusely through a gauze dressing applied to the exposed dura. The prehospital team was unable to establish intravenous access. What are the management priorities for this patient in shock, and how should his hypotension best be addressed?

Lesion Dissemination in Baseline PET/CT (D-MAX) and IPS Score Predict ABVD Treatment Outcome in PET-2 Negative Advanced-Stage Hodgkin Lymphoma Patients Enrolled in the Prospective GITIL/FIL HD0607 Trial

Background: Despite its high overall accuracy in predicting ABVD outcome in advanced stage Hodgkin Lymphoma (HL), interim PET performed after 2 chemotherapy cycles (PET-2) showed a sub-optimal negative predictive value (PV) on treatment response. In fact, PET-2 negative patients (p.) treated with six ABVD cycles in four prospective trials (RATHL, GITIL/FIL HD 0607, SWOG 0816 and Echelon-1), showed a 3-Y PFS ranging between 79% to 87%, even declining to 74% after a 5-year follow-up (Stephens 2019). A high Total Metabolic Tumor Volume (TMTV) calculated in baseline PET (cutoff value 471 ml.) , along with a high IPS (≥2) proved able to identify a small p. subset (7%) of PET-2 neg. p. with a 3-Y PFS of only 56% (Gallamini 16° ICML, 2021). A new TMTV-derived parameter aimed to image tumor spread, the tumor distance (DMAX), proved able to predict ABVD outcome in a retrospective series of HL p. from a single center (Durmo, 16° ICML 2021). We report here the PV on ABVD outcome of DMAX combined with IPS in a large cohort of PET-2 negative p. prospectively enrolled in the HD0607 clinical trial. Methods: Out of 783 p. with advanced HL (IIB-IVB) included in the HD0607 clinical trial (NCT00795613), 630 (81%) of them with both negative PET-2 and end-of therapy PET, were randomly assigned to no further therapy or consolidation radiotherapy over the area of a large nodal mass detected at baseline. A single experienced nuclear medicine physician calculated DMAX and TMTV in 331 out of 630 (52%) PET-2 negative p. in which the baseline PET images were available for review. Three different tumor segmentation methods for TMTV computing were chosen, with (1) a relative threshold of 41% of SUVmax in each lesion, (2) a fixed threshold of SUV=2.5 or (3) of SUV=4. DMAX was calculated as the maximum distance among any pixel of the tumor belonging to any lesions in the body. Results: The demographics of the 331 p. included in the present study and of the overall cohort of 630 PET-2 negative p. were: median age 31 (14-60) Vs. 31 (14-60), M/F ratio 0.86 Vs. 0.89; WHO Performance Status 0-1 91.5% Vs. 91.4%; B-symptoms 81.8 Vs. 81.1%; Stage IIB, III and IV 35.0, 35.0, 29.9, Vs.36.3, 33.0 and 30.0%; IPS 0-1 39.3 Vs. 39.8%, IPS 2-3 48.3 Vs. 49.4%, IPS &gt;3 12.4 Vs. 10.6%, Bulky 18.1 Vs. 17.9%. No difference in 6-y PFS was found for p. randomized to NFT or cRT (p=.48; Gallamini JCO 2020). After a median follow-up of 40.6 (4.8-87.2) months, the 3-Y PFS for the 331 p. included in the present analysis and for all the 630 PET-2 negative p. was 84% (95% CI 81% to 87%) and 87% (95% CI, 84% to 89%), respectively. Treatment failure was recorded in 51/331 (15.4%) and 81/627 (12.9%), respectively. Based on a ROC analysis the three different segmentation methods for MTV computing proved to be equivalent (AUC values 0.620-0.525) and hence the 41% threshold was chosen for consistency with previous works. Median and average DMAX values were 12.5 cm. and 15.3 cm. The most accurate cutoff value for DMAX to predict treatment outcome (3-Y PFS) was 16.2 cm., with an AUC of 0.62 (95% CI 0.53-0.70). With this cutoff value DMAX was able to identify two cohorts of patients with a statistically different 3y-PFS: 90% (CI 85-93%) and 76% (95% CI 69-85%), p &lt; 0.001. In multivariate analysis (Cox regression model) including all the above demographics and clinical parameters, as well as TMTV and DMX, only DMAX turned out significant in predicting relapse, with a HR of 1.46 (95% CI1.06-2.01), p=0.02. Upon combining DMAX (higher or lower than 16.2 cm.) and IPS (0-1 Vs. ≥2) in a two-factor predictive model, three categories of p. with a statistically different treatment outcome (P &lt; 0.0001) have been identified: (1) both low DMAX and low IPS, N =30 (9%), 3-Y PFS 100% (95% CI 96-100); (2) either high DMAX and low IPS or high IPS and low DMAX, N= 198 (60%); 3-Y PFS 88% (95% CI 83-93), and (3) both high DMAX and IPS, N= 103 (31%); 3-Y PFS 72% (95% CI 65-82), p&lt;0.0001. Conclusions: DMAX and IPS combined in a predictive model were able to single out three classes of PET-2 negative p. with a statistically different ABVD outcome. P. with a high MTV and a high DMAX, accounting for nearly one-third of p. included in the study, showed the highest risk of failing ABVD, with only 72% of them sustaining a long-term disease control at three years, thus deserving a more aggressive or innovative treatment. The remaining two-thirds had a very good outcome, with a 3-y PFS of 90%, thus stressing that ABVD could remain the standard of care for most PET-2 negative p. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

The Second Heart Program—A multidisciplinary team supporting people who inject drugs with infective endocarditis: Protocol of a feasibility study

Introduction Infective endocarditis (IE) is a severe and highly prevalent infection among people who inject drugs (PWID). While short-term (30-day) outcomes are similar between PWID and non-PWID, the long-term outcomes among PWID after IE are poor, with 1-year mortality rates in excess of 25%. Novel clinical interventions are needed to address the unique needs of PWID with IE, including increasing access to substance use treatment and addressing structural barriers and social determinants of health. Methods and analysis PWID with IE will be connected to a multidisciplinary team that will transition with them from hospital to the community. The six components of the Second Heart Team are: (1) peer support worker with lived experience, (2) systems navigator, (3) addiction medicine physician, (4) primary care physician, (5) infectious diseases specialist, (6) cardiovascular surgeon. A convergent mixed-methods study design will be used to test the feasibility of this intervention. We will concurrently collect quantitative and qualitative data and ‘mix’ at the interpretation stage of the study to answer our research questions. Ethics and dissemination This study has been approved by the Hamilton Integrated Research Ethics Board (Project No. 7012). Results will be presented at national and international conferences and submitted for publication in a scientific journal. Clinical trail registrarion Trial registration number: ISRCTN14968657 https://www.isrctn.com/ISRCTN14968657.

Complete molar pregnancies with a coexisting fetus: Pregnancy outcomes and review of literature

To review obstetric outcomes of complete hydatidiform molar pregnancies with a coexisting fetus (CHMCF), a rare clinical entity, we performed a retrospective case series of pathology-confirmed HMCF. The cases were collected via a private Maternal-Fetal Medicine physician group on social media. Each contributing institution from across the United States obtained informed consent and institutional data transfer agreements as required, then transmitted the data using a HIPAA-compliant modality. Data collected included maternal, fetal/genetic, placental and delivery characteristics. Nine institutions contributed 14 cases. We found that the median gestational age at diagnosis was 12 weeks 2 days (9w0d - 19w4d), and over half were diagnosed in the first trimester. Sixty-four percent of CHMCF cases were a product of assisted reproductive technology. Placental mass size universally enlarged over the surveillance period. When invasive testing was performed, insufficient sample or no growth was noted in 40% of the sampled cases. Antenatal complications occurred in all delivered patients. Four patients developed gestational trophoblastic neoplasia. This is the largest reported series of obstetric outcomes for CHMCF, and highlights the need to counsel patients about the severe maternal and fetal complications in continuing pregnancies, including progression to gestational trophoblastic neoplastic disease.

18 F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography imaging for the diagnosis of immune checkpoint inhibitors associated myocarditis

Immune-checkpoint inhibitors (ICI) have profoundly improved the prognosis of cancer patients but are associated with life-threatening myocarditis (incidence≤1%).The diagnosis of ICI-myocarditis remains challenging necessitating the need for novel diagnostic strategies.This single center cohort included 61 consecutive patients referred to our cardio-oncology unit for a suspicion of ICI-myocarditis with a positive troponin, between March 2019 and March 2021. In the 31 patients with suspected ICI-myocarditis with available FDG-PET, the median delay between admission and the first available FDG-PET performed was 12 days [interquartile-range:9-30]. Patients received ICI (ICI-monotherapy: 24/31, 77% and ICI-combination therapy: 7/31, 23%), mainly for lung cancer (n=10), melanoma (n=5), and kidney cancer (n=3). FDG-PET was performed using a standardized protocol involving dietary measures prior to PET, including fasting of at least 6h and a fat enriched diet without carbohydrates for 24h. FDG-PET platforms included Biograph-mCT-Flow Siemens (n=9/34, 26%) or Discovery-MI-5-Ring General Electric (n=25/34, 74%) devices and analysed using Singo.via Workstation (Siemens) by a nuclear medicine physician blinded to patients’ medical records. Interpretation of FDG-PET was based on the following classification: 1/No FDG uptake, 2/Diffuse FDG uptake, 3/Focal FDG uptake, 4/Focal on diffuse FDG uptake.An abnormal cardiac fixation on FDG-PET suggestive of myocarditis was observed in only 2/21 (9.5%) patients with otherwise definite ICI-myocarditis (1 diffuse, 1 focal), not different in proportion versus 1/7 (14.3%, 1 focal) patient without ICI-myocarditis (p>0.99). The sensitivity, specificity, positive predictive and negative predictive values (with their 95% confidence-interval) of FDG-PET for ICI-myocarditis was 9.5% (1.2-30.4%), 85.7% (42.1-99.6%), 66% (17.5-95%), 24% (18.5-30.6%), respectively. Only 2/14(14.2%) FDG-PET were positive despite being performed at a time in which ICI-myocarditis was fully active with troponin levels over ten-times the normal values versus 0/6(0%,p>0.99) for FDG-PET performed when troponin levels were abnormal but below ten-times the upper limit. Similarly, there was no difference in FDG-PET positivity rate for exams performed within 14 days (1/7, 14.3%; plus 3 inconclusive exams) versus those performed after 14 days (1/14, 7.2%; no inconclusive exams; p>0.99) of hospital admission.Altogether, our study suggests that FDG-PET has a limited diagnostic value for the diagnosis of ICI-Myocarditis.