A comparison of technicques to disimpact the fetal head on a second stage caesearean simulator

Background The rate of second stage caesarean section (CS) is rising with associated increases in maternal and neonatal morbidity, which may be related to impaction of the fetal head in the maternal pelvis. In the last 10 years, two devices have been developed to aid disimpaction and reduce these risks: the Fetal Pillow (FP) and the Tydeman Tube (TT). The aim of this study was to determine the distance of upward fetal head elevation achieved on a simulator for second stage CS using these two devices, compared to the established technique of per vaginum digital disimpaction by an assistant. Methods We measured elevation of the fetal head achieved with the two devices (TT and FP), compared to digital elevation, on a second stage Caesearean simulator (Desperate Debra ™ set at three levels of severity. Elevation was measured by both a single operator experienced with use of the TT and FP and also multiple assistants with no previous experience of using either device. All measurements were blinded Results The trained user achieved greater elevation of the fetal head at both moderate and high levels of severity with the TT (moderate: 30mm vs 12.5mm p<0.001; most severe: 25mm vs 10mm p<0.001) compared to digital elevation. The FP provided comparable elevation to digital at both settings (moderate: 10 vs 12.5mm p=0.149; severe 10 vs 10mm p=0.44). With untrained users, elevation was also significantly greater with the TT compared to digital elevation (20mm vs 10mm p<0.01). However digital disimpaction was significantly greater than the FP (10mm vs 0mm p<0.0001). Conclusion On a simulator, with trained operators, the TT provided greater fetal head elevation than digital elevation and the FP. The FP achieved similar elevation to the digital technique, especially when the user was trained in the procedure.

Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.

Effects of systematization of public services on the example of a single provider of public services

Public services are one of the basic forms of interaction between the population and the state apparatus. Modern challenges require significant flexibility, focus on meeting the needs of citizens and the availability of a sufficient level of competence of employees and institutions involved in the provision of public services. The article describes the sphere of rendering public services in Kazakhstan, a conceptual business model of a single operator (provider) of public services. Using the example of the transformation of the activity of a public service provider (NJSC State Corporation “Government for Citizens”), the effects of application are shown, and the reserves of cost optimization are estimated as a result of the application of modeling of management processes based on ontologies. An important result of the study is the assessment of the possibility of digital transformation of the public services sector and replication of the results on the activities of the state apparatus.

Catheter ablation of Idiopathic Ventricular Arrhythmias in Nepal-5 Years Single Centre Experience

Background and Aims: Idiopathic ventricular arrhythmia (IVAs) is defined as premature ventricular complexes (PVCs), nonsustained ventricular tachycardia or sustained ventricular tachycardia (VT) in the absence of obvious structural heart disease. Catheter ablation has become an established treatment strategy for wide varieties of idiopathic ventricular arrhythmias. The aim of this study is to report the efficacy and safety of catheter ablation of idiopathic ventricular arrhythmias, for the first time in Nepal. Methods: This is a retrospective observational descriptive study of all patients who underwent electrophysiological study and radiofrequency catheter ablation for IVAs from March, 2015 to February 2020 at Shahid Gangalal National Heart center (SGNHC). Results: Altogether 101 patients underwent an EP study with intent to ablations for idiopathic ventricular arrhythmias. In 13 patients, ventricular arrhythmias were not present on the procedure day and also could not be induced in the lab, therefore ablation was performed in 88 patients only. RVOT was the most common site of these arrhythmias comprising 51% of all cases, followed by fascicular VT (34%) and basal left ventricular IVAs (15%). Out of 88 patients, the acute success of 7 patients could not be assessed because of very infrequent PVCs. Out of remaining 81 patients, acute success achieved in 77 patients (95%). Recurrence occurred in 9 patients (10.7%) and 4 patients underwent repeat ablation giving rise to over clinical success during follow up in 78 patients (88.7%). There were two major complications, one pulmonary embolism and another cardiac tamponade both managed successfully. Conclusion: This single-center single operator study demonstrates that catheter ablation of idiopathic ventricular arrhythmias has a high success and low complication rate

Clinical Characteristics and Outcomes Among Patients Undergoing High‐Risk Percutaneous Coronary Interventions by Single or Multiple Operators: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

Background High‐risk percutaneous coronary intervention (HR‐PCI) is increasingly common among contemporary patients with coronary artery disease. Experts have advocated for a collaborative 2‐operator approach to support intraprocedural decision‐making for these complex interventions. The impact of a second operator on patient and procedural outcomes is unknown. Methods and Results Patients who underwent HR‐PCI from 2015 to 2018 within the Veterans Affairs Healthcare System were identified. Propensity‐matched cohorts were generated to compare the outcomes following HR‐PCI performed by a single or multiple (≥2) operators. The primary end point was the 12‐month rate of major adverse cardiovascular events. We identified 6672 patients who underwent HR‐PCI during the study period; 6211 (93%) were treated by a single operator, and 461 (7%) were treated by multiple operators, with a nonsignificant trend toward increased multioperator procedures over time. A higher proportion of patients treated by multiple operators underwent left main (10% versus 7%, P =0.045) or chronic total occlusion intervention (11% versus 5%, P <0.001). Lead interventionalists participating in multioperator procedures practiced at centers with higher annual HR‐PCI volumes (124±71.3 versus 111±69.2; standardized mean difference, 0.197; P <0.001) but otherwise performed a similar number of HR‐PCI procedures per year (34.4±35.3 versus 34.7±30.7; standardized mean difference, 0.388; P =0.841) compared with their peers performing single‐operator interventions. In a propensity‐matched cohort, there was no significant difference in major adverse cardiovascular events (32% versus 30%, P =0.444) between patients who underwent single‐operator versus multioperator HR‐PCI. Adjusted analyses accounting for site‐level variance showed no significant differences in outcomes. Conclusions Patients who underwent multioperator HR‐PCI had similar outcomes compared with single‐operator procedures. Further studies are needed to determine if the addition of a second operator offers clinical benefits to a subset of HR‐PCI patients undergoing left main or chronic total occlusion intervention.

Clinical Longevity of Indirect Composite Resin Inlays and Onlays: An Up to 9-Year Prospective Study

Objective This clinical study evaluated the clinical performance of composite resin inlays and onlays over 9 years. Materials and Methods Sixty composite resin inlays and onlays were placed in 32 patients, aged 20 to 60 years, by a single operator using the same clinical procedure. The restorations were examined for fracture rate; esthetics; and patient acceptance and marginal integrity, including caries, marginal discoloration, tooth integrity, and surface texture. All restorations were evaluated at the time of placement and 3, 6, and 9 years after placement by using the modified U.S. Public Health Service criteria. Results At the 3-year follow-up, an Alpha score was given to 88.4% of restorations, while a Bravo score was given to the remaining 11.6%. There was not any failure. At the 6-year follow-up, the success rate of the restorations was 100% without failure. None of the restorations was scored with Delta (D). An Alpha score was given to 60% of the restorations, a Bravo score was assigned to 35%, and a Charlie score was 5% of the restorations. Overall, the success rate of the restorations at 9-year follow-up was 85% and the failure rate was 15%. An Alpha score was given to 15% of the restorations, a Bravo score was given to 50%, a Charlie score was assigned to 20%, and a D score was given to 15% of the restorations. Conclusion Indirect resin composite inlays and onlays showed acceptable long-term clinical results. The success rate of the restorations at 9-year follow-up was 85% and the failure rate was 15%.