Chorioamnionitis is a leading cause of preterm birth worldwide, with higher incidence at lower gestational ages. An early and reliable diagnosis of histological chorioamnionitis (HCA) in preterm infants may be helpful in guiding postnatal management, especially the administration of prophylactic antibiotics to prevent early-onset sepsis. The main aim of this study was to investigate metabolomic analysis of urines collected in the first 24 hours of life as diagnostic tool of HCA.Gestational age-, birth weight-, delivery mode- and sex- matched (1:2) preterm neonates (< 35 weeks’ gestation) born to mothers with or without HCA were enrolled from an observational study. Gas chromatography-mass spectrometry (GC-MS)-based metabolomic analysis was performed on urine samples non-invasively collected in the first 24 hours of life. Univariate analysis, partial least square discriminant analysis (PLS-DA) and its associated variable importance in projection (VIP) score were performed. The most affected metabolic pathways were examined by Metabolite Sets Enrichment Analysis (MSEA).P < 0.01).Fifteen cases  and 30 controls  were enrolled. Following univariate analysis, 29 metabolites had a significantly different concentration between cases and controls. The supervised PLS-DA model confirmed a separation between the two groups. Only gluconic acid, an oxidation product of glucose, was higher in cases than in controls. All other VIP metabolites were more abundant in the control group. Glutamate metabolism, mitochondrial electron transport chain, citric acid cycle, galactose metabolism, and fructose and mannose degradation metabolism were the most significantly altered pathways (For the first time, urinary metabolomics was able to discriminate neonates born to mothers with and without HCA. The identification of specifically altered metabolic pathways may be helpful in understanding metabolic derangement following chorioamnionitis. Chorioamnionitis is a leading cause of preterm birth worldwide, with higher incidence at lower gestational ages . The terHistological examination of the placenta constitutes the gold standard for diagnosis, however the results are available only several days after birth . PrenataCertainly, an early, reliable diagnosis of IUI, before or immediately after birth, could improve the individualized care of the neonates. This appears particularly true for what concerns the management of postnatal antibiotic treatment for prevention of EOS. Currently, international guidelines recommend diagnostic evaluation, including blood culture, and administration of empiric antibiotic therapy for all term and preterm neonates born to mothers with clinically suspected chorioamnionitis to avoid possible occurrence of EOS, whose incidence is very high in the presence of chorioamnionitis ,15. GiveIn the last few years, a metabolomic approach was used by some authors to identify metabolic changes associated with early spontaneous preterm birth and to better understand the pathophysiological mechanism of chorioamnionitis ,22. In 2In the present study, gas chromatography-mass spectrometry (GC-MS)-based metabolomic analysis was performed on urine samples non-invasively collected in the first 24 hours of life from preterm neonates exposed or not exposed to histological chorioamnionitis (HCA), with a dual intent: first, to investigate the ability of urinary metabolomics to discriminate between neonates born to mothers affected by HCA and neonates born to mothers without HCA within the first 24 hours of life; second, to analyze neonatal urinary metabolic products altered by HCA, in order to understand the influence of chorioamnionitis on newborn’s metabolism.This was a pilot, nested case-control study in the context of a single-center observational prospective cohort study, performed to evaluate outcomes in neonates exposed to HCA. The observational study was conducted at the Neonatal Intensive Care Unit (NICU) of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Italy, from November 2011 to September 2015. The study protocol was approved by the Ethics Committee of the Hospital and a written informed consent was obtained from parents before inclusion in the study. All procedures were in accordance with the Helsinki Declaration of 1975, as revised in 2008.All inborn neonates with a gestational age (GA) < 35 weeks and/or a birth weight (BW) ≤ 1500 g admitted to the NICU were consecutively enrolled in the observational study. Exclusion criteria were being outborn, the presence of major congenital anomalies, lack of parental consent or a missing pathological examination of fetal adnexa.A group of neonates among those enrolled in the observational study was retrospectively selected for metabolomic analysis on the basis of histological examination of the placenta, in order to compare the metabolomic profile of urine collected from neonates born to mothers with HCA (cases) with that of a group of neonates born to mothers without HCA (controls). Cases were matched 1:2 with controls for GA at birth, BW, sex, and delivery mode. The sample size was established following the method reported by Julious et al. . HCA wasClinical data were prospectively collected from the electronic medical records for the entire birth cohort, including case-subjects and controls for the present study.Urine was collected within the first 24 h of life from all the neonates enrolled in the observational study until sample size for metabolomic analysis was obtained. Urine samples were collected using a cotton ball in the disposable diaper that was checked every 60–90 minutes for the presence of urine. Cotton balls contaminated by stools were discarded and replaced. Urines were squeezed from the cotton ball using a sterile 1 mL syringe and immediately frozen and stored at -80°C until analysis, conducted at the Department of Chemical and Geological Sciences of University of Cagliari, Italy.N-Methyl-N-trimethylsilyltrifluoroacetamide (MSTFA) were added, the mixture was vortex mixed for 1 min and then allowed to react for 1 h at room temperature. The derivatized samples were diluted with 600 μL of hexane containing tetracosane (0.01 mg/mL) as internal standard, just prior to GC-MS analysis.Urine samples were thawed at room temperature and vortexed to homogenize. 150 μL of urine were transferred in a 2 mL Eppendorf tube with 800 μL of urease solution (1 mg/mL), vortexed for 1 min, and sonicated for 30 min. 800 μL of cold methanol was added, the mixture was vortexed for 1 min, and centrifuged at 4°C, 14 000 rpm for 10 min. 1200 μL of supernatant were successively transferred in glass vials and evaporated to dryness in an Eppendorf vacuum centrifuge. 30 μL of a 0.24 M solution of methoxylamine hydrochloride in pyridine were added to each vial, samples were vortex mixed 1 min and left to react for 17 h at room temperature. 30 μL of http://chemdata.nist.gov/mass-spc/amdis). Successively, each peak was identified by comparing relative mass spectrum and retention time with those stored in an in-house made library including 296 metabolites. Other metabolites were identified using NIST08 , and Golm Metabolome Database . This strategy allowed for the detection of 131 compounds: 113 accurately identified, 8 unknown compounds matching equally unknown compounds contained in GMD, and 10 unknown molecules recurring in every sample. AMDIS analysis produced an electronic sheet data matrix  that was submitted to univariate and multivariate statistical analysis.Samples were analyzed using a MS Agilent 5975C interfaced to the GC 7820 equipped with a DB-5ms column (J & W); injector temperature at 230°C, detector temperature at 280°C, helium carrier gas flow rate of 1 mL/min. The GC oven temperature program was 90°C initial temperature with 1 min hold time and ramping at 10°C/min to a final temperature of 270°C with 7 min hold time. 1 μL of the derivatized sample was injected in split mode (1:20). After a solvent delay of 3 min mass spectra were acquired in full scan mode using 2.28 scans/s with a mass range of 50–700 Amu. Each acquired chromatogram was analysed using the free software AMDIS  or Mann-Whitney U test . Fisher's exact test was used for categorical variable. Data were analyzed using Excel Version 14.0 , and P values < 0.05 were considered as statistically significant. For the analysis of metabolomic data, the Excel data matrix containing 131 metabolites was processed using the integrated web-based platform MetaboAnalyst 3.0 [2) and the cross-validated R2 (Q2) were determined. The most affected metabolic pathways were examined by Metabolite Sets Enrichment Analysis (MSEA) in MetaboAnalyst 3.0. MSEA uses a set of predefined metabolic pathways to identify significant changes in functionally related metabolites. Data were input in MSEA as a list of 98 metabolites identified by their Human Metabolome Database (HMDB) ID [Continuous clinical and demographic data were tested for normality and compared between cases and controls using lyst 3.0 . UnivariHMDB) ID  and the HMDB) ID .A total of 15 cases (group 1) and 30 controls (group 2) underwent metabolomic analysis. The mean GA was 30.2 ± 3.8 weeks for neonates born to mothers with HCA and 30.2 ± 2.9 weeks for controls, while the mean BW was 1415 ± 471.9 grams for cases and 1426 ± 569.8 for controls.There was no significant difference between cases and controls in demographic characteristics, prenatal management or clinical indicators of adaptation to extra-uterine life , despiteBy means of GC-MS metabolomic analysis, urine samples collected during the first 24 hours of life from neonates born to mothers with HCA were compared with those of controls through univariate and multivariate analysis.Following univariate analysis, 29 metabolites had a significantly different concentration between cases and controls. As reported in Thirty-six samples (12 cases and 24 controls) underwent PLS-DA analysis . The supervised PLS-DA model showed a separation between cases and controls as reported in 2 (goodness of fit) = 0.87, and Q2 (goodness of prediction) = 0.39. The cross validation (CV) method applied was 10-fold CV and the corresponding performance measure resulted in P = 0.12, probably due to the low number of samples.This model was best described by the fourth principal component, showing accuracy = 0.79, RAmong the 131 detected metabolites, those most responsible for the discrimination between the two groups are reported, in order of importance, in N-acetylneuraminic acid), and amine derivatives . Only gluconic acid, an oxidation product of glucose, was higher in cases than in controls. All other VIP metabolites were more abundant in the control group.According to their chemical classification, VIP metabolites shown in P values and the bar length is proportional to the fold enrichment. Glutamate metabolism, mitochondrial electron transport chain, citric acid cycle , galactose metabolism, and fructose and mannose degradation metabolism were the most significantly altered pathways (P < 0.01)  .Chorioamnionitis is a prenatal condition that has been associated with different adverse neonatal outcomes . The strUnfortunately, no reliable early marker of HCA is currently available and risk stratification of neonates is based on clinical risk factors such as GA, the presence of preterm pre-labor rupture of membranes and/or of clinical signs of chorioamnionitis in the mother . This beThe objectives of the present study were: 1) to establish if metabolomic analysis of urines collected non-invasively during the first 24 hours of life was able to discriminate neonates born to mothers affected by HCA, in order to target more appropriately antibiotic prophylaxis not relying on a clinical diagnosis of chorioamnionitis that often yields false positive and negative results; 2) to characterize neonatal metabolic pathways specifically altered by the presence of HCA itself. Urinary metabolomics has been recently used, even by our group, to investigate several clinical conditions in neonates, such as intrauterine growth restriction, sepsis or cytomegalovirus infection –35. To tIn the study population, case-control matched by GA, BW and sex, no significant difference with regard to prenatal risk factors, obstetric perinatal management, and postnatal well-being was recorded. Nonetheless, twenty per cent of babies born to mothers with HCA developed EOS, confirming the strong link between HCA and EOS already underlined by many authors.As for the metabolomic analysis, metabolomics fingerprinting of urine was able to discriminate between neonates born to mothers with and without HCA. All identified metabolites, except for gluconic acid, had a lower concentration in urine from neonates born to mothers with HCA compared with controls, even if the statistical significance of the proposed model was affected by the low number of samples.Moreover, the two most affected metabolic pathways were correlated to the energy metabolism, including the citric acid cycle and the mitochondrial electron transport chain. Low concentrations of succinic, citric and malic acid in urine samples from neonates born to mothers with HCA could be related to neonatal mitochondrial dysfunction, possibly due to a systemic inflammatory status triggered by microbial antigens frequently responsible for HCA and similar to that seen in septic patients .N-acetylglucosamine, N-acetylneuraminic acid, 3,4-dihydroxybutyric acid, ethanolamine and arabinose, which were found decreased in pathological samples. N-acetylglucosamine is an amide formed by the condensation of glucosamine and acetic acid and it is a key component of cellular wall of both Gram-positive and Gram-negative bacteria. In particular, N-acetylglucosamine is a major component of cell wall peptidoglycan, which contains alternating residues of N-acetylglucosamine and N-acetylmuramic acid [N-acetylglucosamine may be related to the higher demand caused by bacterial growth. In addition, the alteration observed for the fatty acid 3,4-dihydroxybutyric acid and the monosaccharide arabinose seems to be a sign of dysbiosis, as was recently shown by De Angelis et al. [Furthermore, the influence of bacterial metabolism may be hypothesized. In our study, the observed metabolites that may be associated with bacterial metabolism include mic acid . Reduceds et al. .A lower concentration of the hexoses mannose and galactose  in urine samples from neonates born to mothers with HCA compared with controls may be attributed to the presence of bacteria in the amniotic cavity. In similar fashion, in a study by Romero et al. , the metMoreover, our results documented a significant activation of the glycerophospholipid metabolism in neonates born to mothers with HCA. This is in agreement with the results obtained in 2016 by Prince et al. , who stuFinally, the increase in gluconic acid in urine samples from neonates born to mothers with HCA could be related to the microbial activity and the pentose phosphate pathway . GlucoseA significant strength of this study is the use of a non-invasively collected biological sample such as urine to perform highly informative metabolomic analysis in the first 24 hours of life. This strategy may allow for the investigation of the metabolic derangement induced by prenatal conditions such as IUI with minimal influence on postnatal management. Nonetheless, we are aware of some weaknesses of our study. The sample size is small, but adequate for a pilot study; further investigations in large groups of neonates are needed to confirm our results. Another limitation may be the lack of microbiological analysis on placental tissues to identify a more reliable association between intrauterine infection, HCA and a subsequent neonatal metabolic fingerprint. However, especially in preterm pregnancies, it is known that most cases of HCA are a consequence of microbial invasion of the amniotic cavity and chorioamnionic membranes .To the best of our knowledge, this is the first time urinary metabolomics has been applied to identify neonates exposed to HCA. In this study, GC-MS-based metabolomic analysis of urine non-invasively collected in the first 24 hours of life from preterm neonates was able to distinguish those born to mothers with and without HCA. Furthermore, this particular approach may prove to be a powerful tool to better understand the altered metabolic pathways associated to chorioamnionitis.S1 File®, Microsoft Co, Redmond, WA, USA) containing the detected metabolites and their respective concentrations. First column contains metabolites names, first row samples identifier, second row class identifier, 1 defining chorioamnionitis samples and 2 control samples. Samples in this file are completely anonymized.Matrix spreadsheet (Microsoft Excel(XLSX)Click here for additional data file.


AbstractDeep Discoverer, we observed a large stylodactylid shrimp resting on a sedimented sea floor at 4826 m in the Marianas Trench Marine National Monument. The shrimp was not collected but most closely resembled Bathystylodactylusbathyalis, known previously only from a single broken specimen. Video footage shows the shrimp facing into the current and extending its upraised and fringed first and second pereopods, presumably capturing passing particles. The video footage is the first ever to show a living deep-sea stylodactylid and constitutes the deepest record for the family. We provide a list of the deepest reports of caridean shrimps world-wide.Using the remotely operated vehicle  Alvinocarididae) have been studied in detail Okeanos ExplorerShip (OkEx), administered through the Office of Exploration and Research. The ship is equipped with a 6,000 m-rated dual-body system comprising the remotely-operated vehicle (ROV)Deep Discoverer (D2) and Seirios camera sled. During operations, Seirios is tethered to the ship with a standard oceanographic armored, fiber-optic cable (1.73 cm diameter) and D2 is linked to Seirios with a neutrally buoyant tether, thus isolating the ROV from the OkEx surface motion to allow precise maneuvering and steady imaging of deep-sea communities.We obtained photographs and video of the shrimp from the ROVD2 is outfitted with two maneuverable and four fixed video cameras; scientific observations are made primarily using two high-definition video cameras. Light is supplied by 26 LED lamps , with eight of these on four hydraulically positioned booms. Paired lasers (10 cm apart) mounted on the fixed, high-definition video camera provide size scale in the imagery. The ROV traversed the seafloor at a speed of approximately ~ 0.1– 0.3 knots (1 knot = 0.514 m s-1) with the cameras generally set on wide-angle view, and zooms were initiated to obtain detailed imagery when objects of scientific or aesthetic interest were encountered. High-definition video was transmitted from the D2 in HD-SDI 1080i format. OkEx is equipped with high-speed communication capabilities to enable scientists on the shore to participate in ship operations in time via telepresence (see http://oceanexplorer.noaa.gov/okeanos/collaboration-tools/welcome.html). Scientists (and anyone with an Internet connection) are able to observe live video feeds from the ROVD2 and participate in real-time via a private Internet chat room and satellite teleconference line.The OkEx was engaged in the “2016 Exploration of the Marianas” Expedition, a baseline study of deep-water environments in and around the Commonwealth of the Northern Mariana Islands and the Mariana Trench Marine National Monument (MTMNM). D2 Dive 13 of Leg 3 (30 June 2016) of this expedition explored a site informally named “Twin Peaks” on a seamount in the MTMNM. The D2 spent 4 hours 48 min traversing the bottom, from 4840 meters depth upslope to 4787 m. The seafloor was mostly thickly sedimented with clay-like particles that were easily disturbed into clouds by the ROV thrusters; small outcroppings of sedimentary rocks were seen frequently as well as occasional large boulders.From 20 April to 10 July, 2016, the ROV reached the bottom and the benthic exploration began, an observation was made of a single individual stylodactylid shrimp  at 4826 m depth . No other stylodactylids were observed during the dive or on other dives during this expedition. Other benthic shrimps (Superfamily Penaeoidea) and thread-leg shrimps (Caridea: Nematocarcinidae) were observed on soft substrates, as well as other carideans associated with soft corals (Order Gorgonacea) and sponges (Hexactinellida). When initially observed, the shrimp was facing away from the ROV camera. Participating scientists noted this was an atypical shrimp species for the expedition, so the ROV settled to capture detailed images. After a couple of minutes the ROV was repositioned to get a lateral view of the shrimp. During the approximately 4 minutes of observation (including the ROV maneuver) the shrimp did not move from its initial position on the bottom, facing into the weak boundary layer current. The following environmental data were recorded during the observation: temperature 1.47236°C, salinity 34.69294 PSU, dissolved oxygen 4.96223 mg/L.Approximately 2 hours 17 min after the Stylodactylidae , an enteropneust (phylum Hemichordata), a swimming holothurian (Echinodermata), and a hermit crab PageBreak(Parapagurus sp.) with an associated commensal sea anemone (Actiniaria). The ROV was not equipped with collecting equipment that could capture any of these animals and so their species identification remains uncertain.With anterior legs upraised, the shrimp faced into the current, presumably using its legs as a net to capture passing particles. The shrimp had first and second pereopods fringed with setae and with extremely slender chelae, characteristic of the family ctylidae . The deespinules . The shroral Sea . The prePaguritta and the mole crabs, family Hippidae; or setose third maxillipeds, as in crabs of the family Porcellanidae (As in the euphausiaceans, the long, setose legs of the stylodactylid seem to form a “filter basket” that captures particles. The shrimp in the video was not seen to open and expel water by means of pumping, as can euphausiaceans, but instead relied on passive transfer of food particles by the boundary layer current. No other group of carideans is known to feed in this manner . Other dllanidae .Stylodactylidae, caridean shrimps reported from abyssal depths include species of the families Bythocarididae, Crangonidae, Disciadidae, Nematocarcinidae, Oplophoridae, Pandalidae and Pasiphaeidae (Table Bathystylodactylus sp. is the deepest report of a member of this family. The oplophorid Heterogenysmicrophthalma has been collected in trawls as deep as 5060 m (Acanthephyra sp.” from baited traps as deep as PageBreak6890 m in the Kermadec Trench, but their photographs (Fig. Heterogenysmicrophthalma. If confirmed this would be the deepest recorded caridean shrimp record, a record currently held by Glyphocrangonatlantica at 6364–6373 m (Relatively few caridean shrimps live at bathyal depths, i.e. greater than 1000 m, with far fewer recorded at abyssal depths of 3000 m and deeper. As well as species of the s 5060 m . Jamiesophs Fig.  show a s4–6373 m .http://oceanexplorer.noaa.gov/okeanos/explorations/ex1605/dailyupdates/media/video/0630-mudmonsters/0630-mudmonsters.htmlVideo link:


Globally, childhood undernutrition continues to be a major public health concern, with an estimated 165 million children classified as stunted and 51.5 million suffering from acute malnutrition. Childhood undernutrition increases the risk of childhood morbidity and mortality, impairs cognitive development and adult productivity, and may also increase the risk of certain diseases in adulthood. Approximately 875,000 deaths, or 12.6% of all deaths in children under the age of five, can be attributed to acute malnutrition [Achieving this ambitious target will require improving and expanding treatment programs for moderate and severe acute malnutrition. Over the last 15 years, there has been a paradigm shift in the treatment of severe acute malnutrition, from inpatient management to home-based therapy with ready-to-use therapeutic foods (RUTF). Community-based management of acute malnutrition (CMAM) is now considered to be the standard of care for uncomplicated severe acute malnutrition (SAM) . CMAM prNutrients entitled “Challenges in Implementing the Integrated Community-Based Outpatient Therapeutic Program for Severely Malnourished Children in Rural Southern Ethiopia”, Tadesse et al. critically examine the effectiveness of a community-based treatment program integrated into the local health care system in southern Ethiopia [In their recent report in Ethiopia . Study pStudies of CMAM programs which specifically evaluate scaled-up, operational treatment programs not affiliated with a non-governmental organization (NGO) are limited. In Ethiopia, other groups evaluating the C-OTP program have reported recovery rates as high as 79% in a much smaller study in southern Ethiopia and 62% in northern Ethiopia . Both ofNutrients. This rigorous design allowed for verification of the accuracy of recorded C-OTP data and did not limit the investigators to the information collected on patient cards. The authors are to be commended for critically examining the C-OTP program and for disseminating their results, for it is only through critical analysis that problems can be identified and solutions to these problems developed. For example, the authors identify a need for improved distribution of supplies such as RUTF and antibiotics, and for strategies to reduce sharing and selling of RUTF as specific areas to target for improvement. However, simply identifying this information is not enough: the next step must be using this knowledge to make substantive changes. Then, the process of evaluation can begin anew.Among these studies, the prospective design and verification of anthropometric measurements, RUTF distribution, and other metrics by independent data collectors is unique to Tadesse’s important study in Today, the question facing home-based therapies for acute malnutrition is no longer whether they are effective; it is how to best expand and integrate CMAM into the primary health care system so that every child has access to potentially life-saving care. The evidence presented by Tadesse et al.  shows th


Sideline video review has been increasingly used to evaluate risk of concussive injury during match play of a number of collision sports, with the view to reducing the incidence of match play concussion injuries. The purpose of this study was to evaluate the effectiveness of sideline video review for identifying and evaluating head impact events in Rugby Union.All Australian teams’ 2015 Super Rugby season matches were studied. Meaningful head impact events (HIEs) were identified, comprising events identified and acted upon during matches and events identified through a post-season retrospective review. Video footage of each HIE was coded by two experienced independent sports medicine clinicians to evaluate management decisions made by match-day (MDD) and team doctors (TD). HIE incidences for matches with and without sideline video were compared, and the agreement between game-day video interpretation and the independent clinician opinion calculated.κ = 0.49 .Seventy HIEs were identified in 83 matches (47 identified during matches and 23 identified post-season), equating to 42.5 HIEs per 1000 player match hours. When video review was available, an unnoticed HIE occurred once every 4.3 matches, compared to once every 2.3 matches when the sideline video review was unavailable. Of the 47 identified in-match HIEs evaluated by TD and MDD during the season, 18 resulted in an immediate and permanent removal, 28 resulted in temporary removal for an off-field assessment, and one resulted in the player continuing the game. Game-day head injury assessment process video decisions agreed with the independent clinician view in 72% of cases, These findings suggest that access to sideline video review is an important supplementary component to identify potential concussions; however, there is a critical need for improved systems and processes to reduce the likelihood of missing an incident. Video review available on the sideline for the match-day doctor (MDD)/team doctor (TD) improves the detection possible HIEs.Early post-match video review might be important to pick up ‘missed’ significant HIEs that could be subsequently evaluated on game day by the TD in a timely manner.Despite the use of MDDs, TDs, and video feed on the sideline, overt concussion signs can be subtle, or develop later, and so may not be detected during a match.κ = 0.49 (95% CI 0.38–0.59)].The level of agreement between the independent clinician consensus recommendation versus the (MDD) and (TD) in-match decision was weak [Rugby Union is a full-contact collision sport with one of the highest incidences of concussion of all contact sports . At the Video analysis has been used to evaluate risk of concussive injury during match play with the view to prevent or reduce the incidence of match play concussion injuries –9. Videon = 5), New Zealand (n = 5), and South Africa (n = 5). Participants for this study were all Australian Super Rugby franchise players involved in the 2015 Super Rugby season. All players sustaining a meaningful HIE  were included and identified, either by TD or independent MDD, or following post-season retrospective video review. This study was approved by the University of Newcastle Human Ethics Committee (reference no. H-2015-0352).The Super Rugby competition is the elite level state/provincial competition in the southern hemisphere. In 2015, the competition was made up of 15 franchises from Australia (The WR HIA process provides an advanced care pathway for concussion management at the elite level and consists of three stages delivered by TDs and independent MDDs. The first stage (HIA-1) involves in-match identification and management of meaningful HIEs with the potential to cause concussion. Briefly, players overtly demonstrating signs of concussion  are immediately and permanently removed from play. Where the consequences of a HIE are not clear, players undergo a standardised off-field screening assessment for suspected concussion (HIA-1 screening assessment) . A tempoAll MDD/TD’s in-match video and removal from play decision-making was recorded in writing using HIA forms. Data were subsequently stored in a secure World Rugby (WR) database. In addition to the match-day process, WR also have an independent video analyst review all professional matches to identify any potential missed HIE. Separate to the routinely collected WR data, a post-season retrospective video review of all matches involving the five Australian Super Rugby franchises from the 2015 Super Rugby season was conducted by two authors (RK and WM) to identify all possible HIEs. This review was conducted independent of the MDD and/or TD and blinded to the in-match HIA decisions that were made by the MDD and/or TD. Data pertaining to the total number of HIE incidents that did not meet threshold for Criteria 1 or off-field screening criteria was not recorded in this study.An independent evaluation was then conducted using the broadcaster’s video footage of (i) all MDD/TD-identified in-match HIEs and (ii) all incidents identified in the post-season retrospective video review. This evaluation was conducted by two clinicians (AG and RK) experienced in the video review of concussion. Both experienced clinicians independently provided an opinion on each incident  based on this video footage. In instances where the management opinions of the two independent clinicians differed, a discussion regarding the decision-making process was conducted to attempt to find agreement. Where it was not possible to reach an agreement, an opinion was obtained from a third clinician (MM), who is also experienced in the on-field management and video review of concussion.The analysis proceeded in three stages. Firstly, the epidemiology of HIEs in Super Rugby was described, including the number of HIEs detected, and the overall incidence of HIEs. Secondly, HIA process outcomes were described for all included HIEs. Thirdly, the effectiveness of sideline video review for identifying HIEs was evaluated by comparing the number of additional HIEs detected on retrospective post-season review between matches with and without the Hawk-Eye system available. Finally, the agreement between match-day TD/MDD video review decision and the consensus decision from the independent clinicians was compared .n) or a percentage of the total. Incidence rates are presented as incidences per 1000 player hours with 95% confidence intervals. Inter-rater agreement analyses used Cohen’s kappa (κ) statistics [κ coefficients are calculated by considering the proportion of rater agreement and the expected proportion [κ described by McHugh [κ agreement was categorised as almost perfect (> 0.90), strong (0.80–0.90), moderate (0.60–0.79), weak (0.40–0.59), minimal (0.21–0.39), and none (0–0.20). A census sample of all HIEs in a single season was analysed. All analysis was performed using IBM SPSS Statistics V.23.0 [Descriptive analyses are presented as frequencies . Overall, there were 34 diagnosed concussions; 25 players suffered one concussion, 3 players suffered two concussions, and one player suffered three concussions during the season. The incidence of diagnosed concussions for the Australian franchises during the 2015 Super Rugby season was 20.5 concussions per 1000 player match hours (95% CI 14.2–28.6). Figure Of the 47 HIEs identified by the MDD/TD on match day, 18 were deemed to meet Criteria 1  requirements and were permanently removed from play. Of these, 16 (89%) were ultimately diagnosed with concussion. Twenty-eight (60%) HIEs were assessed as requiring temporary removal and an HIA-1 off-field screening assessment. In 10 of these cases, the player was permanently removed after an abnormal off-field screen, with all 10 players ultimately diagnosed with concussion. The remaining 18 players were returned to play following normal screening assessments. However, 3 of these players were ultimately diagnosed with concussion. Finally, of the 47 HIEs identified by the MDD/TD on match day, one 2%) player was permitted to play on with further monitoring. Data pertaining to the total number of HIE incidents that did not meet threshold for Criteria 1 or off-field screening criteria was not recorded in this study. Of the 23 HIEs detected on post-season video review, 21 of these players entered stages 2 or 3 of the HIA process and 5 were ultimately diagnosed with concussion. HIA process and concussion outcomes for each HIE are summarised in Fig. % player p = 0.53. Overall, the TD/MDD missed HIEs at a rate of one every 2.3 matches when sideline video was not available, whereas this rate was one every 4.3 matches when sideline video was available (Tables n = 47). In 14 of the 18 immediate and permanent removal (78%) cases, the consensus opinion of the clinical post-season review agreed with the match-day management decision, whereas in 3/18 (17%) cases, the consensus opinion of the clinical post-match review was that the HIE were considered to meet criteria for an off-field assessment rather than permanent removal, and in 1/18 (6%) cases, the consensus independent evaluation was that incident did not meet criteria for removal and instead the player should have been able to play on with monitoring. In 19 of the 28 HIEs (67%) identified by MDD/TDs as requiring HIA-1 off-field screening assessment, the independent evaluation agreed with the match-day management decision. Whereas in 8/28 (29%) cases, the consensus opinion recommended permanent removal. In 6/8 (75%) of these cases, the HIEs occurred in matches where the MDD/TD did not have access to sideline video to review. In the other two cases, the post-season review recommended permanent removal on the basis of evidence of cervical hypotonia. In 1/28 (4%) case, the independent evaluation recommended play on rather than a HIA-1 temporary removal for the off-field screen.Overall 23 additional ‘missed’ HIEs were detected on the post-season retrospective video review . There were 15 missed HIEs in the 64 matches where sideline video review was available (11.7 HIEs per 1000 player match hours (95% CI 5.8–17.6), compared to 6 missed HIEs in 19 matches where sideline video was unavailable , incidence rate ratio = 1.8, 95% CI 0.66–4.5, κ = 0.88 (95% CI 0.85–0.91), which is considered to be strong agreement [κ = 0.49 (95% CI 0.38–0.59), which is considered to be weak agreement [The overall inter-rater agreement for the management decisions between the two independent raters (i.e. prior to discussion) was greement . The levgreement .To expand previous video analysis work in collision sports, this study explored the use of retrospective video evaluation of HIEs for Australian Super Rugby franchises to assess the live decision-making process of the TD/MDD. Forty-seven HIEs were evaluated by TD and MDD during the season, with a further 23 identified (i.e. a 49% increase in identified HIEs) through a post-season video review process. Of the additional 23 ‘missed’ HIEs, eight occurred in matches without sideline video review (21.1 HIEs per 1000 match hours) and 15 occurred where sideline video was available (11.7 HIEs per 1000 match hours).Collectively, these findings suggest that access to sideline video review is an important supplementary component to identify potential concussions, since they increase both the number of HIEs identified and the number of HIEs that are subsequently diagnosed as concussions either through meeting the Criteria 1 signs and symptoms for immediate and permanent removal or through indicating an off-field screen that subsequently confirms a concussion (see Table n = 3) or where the player might have been allowed to play on (n = 1). There were three players who were removed from play and diagnosed with concussion post-match after having been returned to play following normal screening assessments. The current study did not examine how or when the diagnosis was made post-match. However, the later stages of the HIA process (HIA-2 and HIA-3), which involves the serial post-match clinical follow-up and diagnostic assessment for concussion are routinely conducted on match day and this may have been when the diagnosis was made. It is unknown whether the players themselves acknowledged they had sustained a concussion despite denying it during the match, if the HIA-2 or HIA-3 assessments detected an abnormal performance, and/or if there was a delay in symptom onset. In addition, in 8/28 (29%) of cases that were considered by the MDD/TD as requiring a HIA-1 off-field screening assessment, and the consensus opinion of the clinicians on post-season review recommended permanent removal based on evidence of cervical hypotonia.Specifically, we found that retrospective analysis to identify all HIEs and to evaluate MDD and TD decisions identified 12 cases where Criteria 1 signs and symptoms indicated immediate and permanent removal. Eight of these HIEs had been identified during matches, but were assessed through the off-field assessment rather than immediate and permanent removal, while four were missed entirely (Table The inter-rater agreement of the post-season review decisions for the management of the identified cases was 0.88 (95% CI 0.85–0.91), strong agreement. The IRA between the MDD/TD game-day management decision and the consensus decision based on the expert reviewer’s post-season review was 0.49 (95% CI 0.38–0.59), weak agreement, suggesting that further education of TD/MDD in the recognition and significance of post-traumatic signs is required.The addition of sideline video assessment is a further important piece of the puzzle, but there is a critical need for improved systems and processes to reduce the likelihood of missing an incident. In the present study, expert clinicians were able to evaluate the MDD and TD decisions with greater time than is typically the case during matches, as well as to identify HIEs that may have been missed entirely. Such time is unavailable during matches, and so the current results may be viewed as ‘ideal’ scenario changes that video could produce.However, we do find a significant effect of video on the decisions made regarding removal, off-field screening, and continued play and so suggest that these processes may benefit from the use of ‘spotters’ on game day at various vantage points separate from the TD/MDD but with communication channels to alert the TD/MDD to a potential HIE. Ongoing education of TD/MDD about the early signs of concussion is also a critical point. Furthermore, the use of a post-game video review may be an important method for detecting any ‘missed’ head impact events.There are a number of ongoing challenges associated with in-match sideline identification of possible concussion, including (i) identification and management of brief early signs (that may have resolved completely by the time that the player is assessed), (ii) the potential evolution of symptoms and signs (including delayed presentation), and (iii) the failure of players to report symptoms on game day. These issues are not mutually exclusive, but the improved education and self-reporting by the player likely has the greatest potential for improving the early identification and on-going management. A growing literature  has examThere are a number of limitations associated with this study. Firstly, not all matches had video available on the sideline for the MDD/TD. While this enabled analysis, comparison, and comment on the matches with and without a sideline video review process, it is a limitation to the consistency of the data and generalisability of the results. If video review within professional sports is implemented, then access to high-quality reviews with the capability of multi-angle and slow motion replays to allow for close ups would be optimal  and woulAlthough the video reviewer was blinded to the sideline assessment results and the medical diagnosis of concussion for this study, they were only partially blinded to the use of the HIA. Given that the process for enacting a use of this rule requires the trainer to provide a signal to the sideline, and the official on the sideline identifies the interchange, the video reviewer was able to identify many instances where the HIA was used.The current study was a post-season review of teams from one of three countries in the tournament in question, and as such, a further limitation of the current study pertains to the generalisability of the current findings to the entire competition, or to other levels of rugby union, or to the modified game (i.e. Rugby 10s or Rugby 7s). Finally, only one reviewer completed the coding of the entire game, for every game in the season that the Australian franchises were involved in; the inter-rater reliability of that type of coding is unknown.Future studies may focus on the incidence, sensitivity, specificity, positive, and negative predictive power of the concussion signs proposed for the HIA criteria for permanent removal versus an off-field screen. Ascertaining the base rates of these signs during match play will assist in interpreting the video signs on the sideline when reviewing possible HIEs during a match.Concussion signs can be subtle, resolve quickly, or become apparent some time after the initial impact . For theIt is important to determine the reliability and validity of identifying the objective signs of concussion when using video analysis because not all instances of specific observed concussion signs occur as a result of the player having sustained a concussion  and not We found a strong agreement between experienced independent post-season video reviewers in the management decision of professional rugby players. The level of agreement between the independent reviewers’ post-season consensus opinion and the MDD/TD in-match decision was, however, weak. Video injury surveillance can be difficult to interpret but may provide a useful adjunct to the clinical assessment of potential concussion. With improved access to video replays and improved communication between video observers and sideline medical personnel, the detection of concussion may improve .


Oncological and functional results after colorectal cancer surgery vary considerably between hospitals and surgeons. At present, the only source of technical information about the surgical procedure is the operative note, which is subjective and omits critical information. This study aimed to evaluate the feasibility of operative video recording in demonstrating both objective information concerning the surgical procedure and surgical quality, as using a systematic approach might improve surgical performance.From July 2015 through November 2015, patients aged ≥18 years undergoing elective colorectal cancer surgery were prospectively included in a single-institution trial. Video recording of key moments was performed peroperatively and analyzed for adequacy. The study cases were compared with a historic cohort. Video was compared with the operative note using the amount of adequate steps and a scoring system.p = .024; p = <.001. Adequacy score: p = .039; p = <.001, both respectively).This study compared 15 cases to 32 cases from the historic control group. Compared to the written operative note alone, significant differences in availability of information were seen in favor of video as well as using a combination of video plus the operative note (N adequate steps Systematic video registration is feasible and seems to improve the availability of essential information after colorectal cancer surgery. In this respect, combining video with a traditional operative note would be the best option. A multicenter international study is being organized to further evaluate the effect of operative video capture on surgical outcomes. Over the past several years, laparoscopic surgery has become standard of care in the treatment of colorectal malignancies, resulting in similar oncological outcomes and improved short-term results compared with conventional open surgery.Although colorectal cancer treatment has improved dramatically, short- and long-term oncological and functional results in colorectal cancer patients with similar stage disease vary widely between different hospitals and surgeons.The importance of quality improvement programs to decrease operative variability is widely supported at this time. In 2009, Haynes et al. introduced the surgical safety checklist, used in the “Time-out-procedure,” cutting mortality in half after implementation.The aim of this study was to investigate the feasibility of operative video recording with the hypothesis that this may (1) increase the amount of critical information from the surgical procedure and (2) improve surgical quality due to a systematic approach using a checklist.All patients aged 18 years or older undergoing elective laparoscopic colorectal cancer resection  in Havenziekenhuis  were included from July 2015 through November 2015. During each surgical procedure, intraoperative video recordings of about 10 s length were made of predefined key moments, initiated and ceased by the primary surgeon. Patients with metastatic disease, unresectable tumor, or incomplete video recordings due to technical difficulties in the recording software were excluded from analysis. The primary and secondary outcomes were compared with a historical cohort, treated 1 year before implementation of the checklist, to avoid bias induced by the use of the checklist. The medical research and ethics committee of the Erasmus Medical Centre exempted this study from the Research Involving Human Subjects Act (WMO).Key moments in the studied surgical procedures were defined by experts in this field . A surgical checklist was compiled from these key moments and further transcribed into a case report form (CRF). During surgery, video fragments under direction of the leading surgeon were recorded according to the surgical checklist, and the corresponding steps were checked off on the CRF afterward. If a step was not relevant in a particular procedure, “n/a” was added next to the step in the CRF.Before reviewing the video recordings, requirements for adequacy were dictated . Then, the completed CRFs along with operative recordings and the operative notes were reviewed for adequacy . The CRFs and the requirements for an adequate recording can be found in the online supplementary material. Failure to comply with these requirements, or absence of a recording resulted in a step being labeled “not adequate.” In reviewing the operative note, a step would be labeled “not adequate” if there were either an incomplete description or a lack of description altogether.With respect to the primary outcome, the availability of essential information, according to the predefined checklist, was evaluated. This information was collected from the operative video recording of the study group and from the operative note from both the study group and historic control group. Subsequently, the availability of the essential information was compared between the video recordings alone vs the operative note of the historic control group, and between the combination of the video recordings and the operative note coming from the study group vs the operative note of the historic control.To assess the availability of information, two methods were used: (1) The adequacy of steps with adequate information was compared. (2) A scoring system was utilized. For the maximum amount of information, according to the critical steps described in the CRF, a maximum of 100 points could be obtained. These 100 points were divided by the number of applicable steps in that specific procedure, resulting in the amount of points per step. Finally, the factor of the amount of adequate steps and the amount of points per step was calculated, resulting in the total score for that specific procedure.With respect to the secondary outcome, surgical complications within 30 postoperative days were analyzed to assess any improvement in surgical quality, which was expected with the use of a predefined checklist according to our hypothesis. Surgical complications were graded according to the Clavien-Dindo classification. The following complications were included in analysis: surgical wound infection, intra-abdominal abscess, urinary tract infection, respiratory tract infection, cardiologic complication, neurologic complication (including delirium), postoperative ileus, postoperative bleeding, and anastomotic leakage. Furthermore, the postoperative length of stay was measured.High-definition images were captured using EndoEYE 30° videoscope connected to an EVIS EXERA II CLV-180 xenon light source and subsequently an EVIS EXERA II CV-180 video processor . The video feed was then recorded on a Microsoft Windows based computer system in MPEG-4 format using image storage software .t test was used. Otherwise, the Mann-Whitney U test was conducted. In analyzing the adequacy per step, the sum of all adequate steps was calculated, converting the range to continuous data. Subsequently the Mann-Whitney U test was used for comparison. A p value of less than .05 was considered statistically significant.Data was analyzed with IBM SPSS version 23.0 for Mac. Categorical data were presented as numbers and percentages. Continuous data were described by mean and standard deviation. Study population and historical control were compared using chi-square test or Fisher exact test in case of categorical data. Continuous data was tested for normality using the Shapiro-Wilk Test, and if normal distribution was present, an independent samples From July 2015 through November 2015, 20 patients meeting inclusion criteria were included in this study. All 20 patients underwent elective surgery for colorectal cancer with operative video recording according to the predefined checklist. A total of five patients were excluded from further analysis: two patients because of technical difficulties in the recording software resulting in loss of video fragments, two patients because of absence of malignancy, and one patient because of disseminated disease. As a result, the study population concerned 15 patients, who were was compared with 32 patients meeting inclusion criteria, which were retrospectively included in the period of July 2014 through January 2015. Patient characteristics are presented in Table The number of adequate and inadequate steps was compared between the two groups. Two comparisons were made: firstly, the video recordings of the study group versus the operative notes of the historic control group, and secondly, the video recordings and operative notes of the study cases combined versus the operative notes of the historic control cases Table . Respectp = .039; p = <.001, respectively).The average score for the amount of available information was 54.29 points (±15.42 SD) for the operative notes in the control group, 67.08 points (±13.81 SD) for the video recording alone, and 80.53 points (±11.72 SD) for the combination of video recording and operative note. Video recording alone and the combination of video recording and operative note scored significantly higher compared with the operative notes in the historic control group (p = .648), respectively, and the average score for the amount of available information was 54.29 points (±15.42 SD) and 53.24 points (±13.26 SD) (p = .705) respectively.When comparing the operative notes of the historic control cases to the operative notes of the study cases, the overall number of adequate steps were 185 (53.9 %) and 84 (53.2 %) (p = .016), there was no significant difference found between the study cases and the historic control.Postoperative outcomes within 30 days after surgery are summarized in Table Very few published studies analyzed the possible advantages of operative video recording prospectively. This pilot study is the first study evaluating operative video recording during colorectal cancer surgery. Our findings confirm the feasibility of systematic video registration in colorectal cancer surgery, as is shown in prior research.About half of the steps in the operative note were described in an adequate manner, which is in accordance with similar published findings in different fields of surgery.With regard to operative vascular control, a difference was found favoring the operative note over video. This is mainly due to atypical resections such as resection of the splenic flexure in which vascular control is at the level of peripheral vessels. Furthermore, especially in typical left-sided resections with central vascular control, it was sometimes difficult to assess the anatomy in the video without the explanation of the surgeon.There was no significant difference found between the operative notes of the historic control group and those of the study cases in both the number of adequate steps and the average score for the amount of available information, which would suggest that participation of the study and the knowledge of the checklist by the surgeons do not bias the increase in available information when operative note and video registration are combined.No significant difference was found in postoperative outcomes within 30 days, apart from postoperative length of stay. Because of the small sample size in the study group, this result should be considered thoughtfully.Although video recording during laparoscopy has minimal impact on the surgical procedure, it might be considered impractical if recording could only be started and stopped outside the sterile area . This problem can be avoided by using a laparoscope with a dedicated recording button, or by using a recording remote inside the sterile environment, thus giving complete control to the surgeon’s team.The video recordings in this study are fragments, aimed to capture the specific key moments in the surgical procedure instead of using a full-length recording. This results in a manageable amount of content and minimizes the required digital storage space. However, because of the fragmentation, it is sometimes difficult for reviewers to recognize certain structures in that particular fragment. A great improvement to this matter could be the addition of audio to the video recording, where the surgeon can verbally annotate the given procedure.In addition to the improvement in available operative information and possibly surgical outcomes, video recording might also be useful for patient and family information and education and research purposes regarding effects of specific surgical techniques, as well as situational team awareness in the operating room. Also, it can result in improved communication between physicians from the treating team .In conclusion, peroperative systematic video registration in colorectal cancer surgery is feasible and early results regarding an increase in available intraoperative information are promising. An international multicenter study is currently being organized to evaluate the effect of video capture on surgical quality and patient outcomes.


Neonatal mortality is a significant problem in many low-resource countries, yet for every death there are many more newborns who suffer a life-threatening complication but survive. These “near-misses” are not well defined, nor are they well understood. This study sought to explore how health care providers at three tertiary care centers in Ghana ) understand the term “near-miss.” Eighteen providers from the NICUs at three teaching hospitals in Ghana  were interviewed in depth regarding their perceptions of neonatal morbidity, mortality, and survival. Near the end of the interview, they were specifically asked what they understood the term “near-miss” to mean. Participants included nurses and physicians at various levels and with varying years of practice . Results indicate that the concept of “near-misses” is not universally understood, and providers differ on whether a baby is a near-miss or not. Providers disagreed on the utility of a near-miss classification for clinical practice, with some suggesting it would be helpful to draw their attention to those at highest risk of dying, with others suggesting that the acuity of illness in a NICU means any baby could become a ‘near-miss’ at any moment. Further efforts are needed to standardize the definitions of neonatal near-misses, including developing criteria that are able to be assessed in a low-resource setting. In addition, further research is warranted to determine the practical implications of using a near miss tool in the process of providing care in a resource-limited setting and whether it might be best reserved as a retrospective indicator of overall quality of care provided. Nearly 3 million newborn babies die every year, and one third of these deaths occur in the first 24 hours after delivery,2. The mWhile neonatal mortality is a significant problem in LMICs, for every death there are many more newborns who narrowly miss dying and may suffer long-term consequences as a result. Neonatal “near misses” are newborns who survive a life-threatening condition. One studUnlike maternal near misses, however, there is no standard definition and validated tool to identify neonatal near misses. Maternal near-misses have been studied repeatedly, such that there is a World Health Organization Maternal Near-Miss Tool that is commonly used to conduct near-miss assessments. Yet asseDespite the increasing use of neonatal near-miss assessments, it is not clear how clinicians in neonatal care units in low-resource settings might view this classification. Would knowing a newborn counted as a near-miss have any effect on subsequent care provided? Is ‘near-miss’ as a classification useful for clinicians? Or is it better reserved as an indicator of overall quality of care, given that reduced mortality makes it harder to see improvements in relatively rare events? This study sought to explore how health care providers understand the term ‘near-miss’, focusing on three neonatal intensive care units at three teaching hospitals across Ghana.This study was an exploratory, qualitative study, nested within a larger, prospective study of maternal and neonatal near-misses at three tertiary care centres in Ghana. Data presented here reflect qualitative data collected from a subset of the participants included in the larger study.Data were collected from April through August 2015 at the Cape Coast Teaching Hospital (CCTH), Komfo-Anokye Teaching Hospital (KATH), and Korle Bu Teaching Hospital (KBTH) in southern Ghana.CCTH is located in Cape Coast , which is the smallest district in Ghana in terms of land size, the poorest in Central Region, and the fourth poorest region in Ghana. ,10 It seKATH is a teaching hospital affiliated with the Kwame Nkrumah University of Science and Technology School of Medical Sciences (KNUST-SMS) located in Kumasi, the second largest city in Ghana, with a population of about 2 million. KATH serKBTH, the teaching hospital associated with the University of Ghana School of Medicine and Dentistry is located in the capital city of Accra, with a population of about 4 million. It is thSelected health care providers who work in the neonatal intensive care units (NICUs) at KATH, KBTH, and CCTH were asked to participate in this research. Eligible participants were physicians or nurses with experience working in the NICU who were working between April and August 2015. No limit on duration of experience in the NICU was specified. At each site, 3 doctors and 3 nurses were selected, each with a different level of experience . Participants were selected by site facilitators based on level of experience and availability. A total of 18 health care providers gave consent for participation, representing 11.8% of the 152 total providers on the employment roster across all three hospitals.Indepth interviews were conducted by a trained research assistant with several years’ experience in qualitative research methodology. Interviews, which typically lasted between 30 and 60 minutes, were conducted in English and transcribed verbatim.A brief questionnaire was developed to assess demographic information and training history for participating healthcare workers. The in-depth interview guide was developed using an iterative process amongst the investigators, eight of whom are clinicians  who have experience in the study sites. The tool was pilot tested among members of the target population and revised prior to study initiation. Ethical clearance was obtained from the institutional review boards at the Kwame Nkrumah University of Science and Technology for KATH, University of Cape Coast for CCTH, University of Ghana for KBTH, and the University of Michigan.Information about the objectives of the discussion and the purpose of the overall study were provided to each potential participant. Confidentiality with regard to their participation and anonymity with regard to their data were assured. Written informed consent was obtained from each participant. Permission to audio-record the interviews was obtained.Research assistants approached providers during their time in the NICU, explained the study, and scheduled interviews at a time that was convenient for the provider. Interviews took place in a staff room in the pediatric ward and ranged from 30–60 minutes.Demographic data were collected using the Qualtrics offline data collection application for Iphone before the start of each interview. Interviews were recorded on iGearPro Multifunctional Voice Recorder or via Smart record application on Iphone. Interviews were transcribed verbatim using Infinity Foot Control transcription pedal with Express Scribe software.Quantitative data on participant demographics were entered into Stata V 13.1 and analyzed for descriptive statistics such as mean, range, and distribution.All qualitative interviews were read by at least two of the investigators  and “in-vivo” coding was conducted to assist in the identification of main codes. In-vivo coding involves making written notes on hard copies of the transcripts and reviewing the notes together. This iterative process used in-vivo coding to develop a preliminary coding structure and supporting codebook. All transcripts were entered into NVivo 10.0, a qualitative software analysis package. Focused coding  was conducted by 4 separate coders . Coders held regular meetings to review and revise the codebook to reflect inclusion and exclusion criteria that may not have arisen previously.The concept of “near-misses” was not universally understood by healthcare providers, regardless of their level of training, and regardless of whether providers were doctors or nurses. Some providers said they had heard of near-misses before but couldn’t remember what they were, while others said they didn’t think providers understood what constituted a near-miss. Still others confused neonatal near-miss mortality with missed opportunities for immunizations.“It’s a near-miss if you don’t immunize them before they go .” At its most fundamental level, near-misses were described as “…if the baby that you think would die hasn’t died and the baby survives…. That’s near-miss.” Others describe near-misses as being inherently unpredictable:“…there are times you think… a baby is stable enough to leave but then suddenly it will die. Then there is somebody who is very ill, you think …tomorrow by the time you come in they will not be there. But he will be there and he will go home. So you can’t exactly say that you can distinguish between them.” “We call them miracle babies.” Other providers suggested that whether or not a baby was a ‘near-miss’ may be a matter of opinion:“It depends on how much effort is given to save the baby–one baby could be resuscitated and live and we call that a near-miss. Another baby could have arrived late, not gotten medicine in a timely way, and only later is it administered and the baby gets better. That could also be a near miss. I don’t think all of us will have the same point of view… It all depends on when you saw the baby (and) what you did to prevent the mortality.” When asked whether the classification of ‘near-miss’ was useful to clinical management, most providers (15 out of 18) indicated that they believed “near-miss” is a useful term.“I think it’s even going to enhance that child’s survival rate, ‘cause you know that … child can stop breathing at any time and we need (a) bag and mask, and so you have your resuscitation tools right …(at) arm’s length or at a point where you don’t have to go searching, where is this, where is that? I think it’s going to provide and enhance the care of those ones who are near misses to prevent us from missing them actually.” “…The fact that we can classify a baby as a near miss needing a lot of attention can help us in our day-to-day work so that we…take care of those who really need our attention, you know, earlier than those who can actually wait a bit.”But 3 of the 18 respondents said “near miss” was not a useful term because all babies in the NICU require attention and vigilance, and favoring some over others may not be ideal.“If you are thinking somebody is very stable, so perhaps you are giving your attention to the person you think is so ill, and then only for you to realize that the other person who…you thought was so stable rather turns bad and just dies…. So I don’t think it’s good for you to start distinguishing that this particular baby is ok, so let me turn all my attention to this one.” “I don’t think putting a label on them will make a difference.” Nonetheless, 16 out of 18 respondents said that the classification of “near-miss” might change how they managed the baby.“…If it’s a near miss, then you know that … there can be consequences so we have to look out for them.” This study suggests that few providers in Ghanaian NICUs had heard of neonatal near-misses or were familiar with what might constitute a near-miss. Most agreed that babies who survive a life-threatening event would warrant additional attention. While many providers expressed support for the use of a near-miss classification system to help them identify the newborns at greatest risk of dying shortly after birth, a vocal minority of providers felt that all newborns in a NICU have the potential to take an abrupt turn for the worse, and thus a near-miss classification may provide a false sense of security. Providers expressed concern that resources ought not be diverted for only a subset of newborns in the NICU.The findings of this study raise the question of whether a near-miss classification–which some posit is a retrospective diagnosis for cases that are identical to deaths in all but the outcome, which can only be determined in hindsight–is relevOne challenge with assessing neonatal near-misses is the difficulty in developing criteria that works for all settings, amid the wide variability of clinical, interventional and laboratory markers that have been considered as newborn scoring tools or neonatal near miss tools. These criteria would have to be simple, feasible to assess, meaningful for clinicians, managers and health care professionals, stable in terms of severity, and applicable to a variety of settings. Current This study has several notable strengths. First, it took place across three tertiary care centers  in different regions of Ghana, and it included health care providers of varying ages, backgrounds, and levels of experience in a NICU setting. Thus the findings reflect an extremely diverse group of participants, yet all work in high acuity settings with greater-than-average exposure to emerging trends in neonatal care as a function of being based at University teaching hospitals. Nonetheless, results were consistent: providers were not familiar with the concept of neonatal near-misses. In addition, this study used a semi-structured interview format with very little prompting, allowing providers to speak in their own words about how they perceived near-misses. This methodology was intentional: We did not want to bias responses through the use of structured questionnaires with multiple choice answers that might provide clues to how the authors conceptualized near-misses before respondents had a chance to provide their own opinions. Finally, this is the first study that we know of that asks providers what they think of the term ‘near-miss’ in the context of ill newborns in a resource-limited setting.Despite its strengths, this study’s qualitative methodology precludes generalization of the findings. Designed as an exploratory study, this research aimed to further our understanding of provider perceptions. Thus further research is warranted on the construct of ‘near-misses’ in a low resource setting. In particular, it is not clear whether the categorization of ‘near-miss’ is appropriate in low-resource NICUs, given that most babies who are admitted are extremely ill and may all classify as near-misses. Another limitation of this study relates to the differences in experiences between the doctors interviewed  and the nurses. We attribute this to the greater likelihood of more junior physicians spending more time at the hospital, while more senior physicians were less likely to be on-site and perceived as available for interviews. Nonetheless, our results may be different if more senior-level providers were included in our sample.This study explored the perceptions of healthcare providers with varying levels of experience in Ghana on the concept of a “neonatal near miss”. The majority of providers were relatively unfamiliar with the concept, although most acknowledged a baby who survived a life-threatening event warranted additional attention, thus agreeing a neonatal near-miss classification would be useful. However, further research is warranted to determine the practical implications of using a near miss tool in the process of providing care in a resource-limited setting and whether it might be best reserved as a retrospective indicator of overall quality of care provided.


Patients with combined pulmonary fibrosis and emphysema (CPFE) have been suggested to have an increased risk of lung cancer. We conducted a systematic review of all published data and performed a meta-analysis to define the characteristics of lung cancer that develops in CPFE.We searched Pubmed, Embase, and Cochrane to find original articles about lung cancer and CPFE published prior to September 2015. All titles/abstracts were reviewed by two radiologists to identify articles that used predefined selection criteria. Summary estimates were generated using a random-effect model and odds ratios (ORs) to develop squamous cell carcinoma (SqCC) were calculated. Kaplan–Meier survival curves were obtained for the survival of patients with CPFE and non-CPFE.Nine original articles that assessed 620 patients were included in this review. In the pooled data, patients were older age (70.4 years), almost all were heavy smokers (53.5 pack years), and males were predominant (92.6%). SqCC was the most common type (42.3%), followed by adenocarcinoma (34.4%). Compared with lung cancer population with an otherwise normal lung, the OR to develop SqCC in CPFE was 9.06 . The ORs in CPFE compared with lung cancers that developed in lungs with fibrosis or emphysema were also higher. The median survival for CPFE patients with lung cancer (19.5 months) was significantly shorter than in non-CPFE (53.1 months).Lung cancer in CPFE, most commonly SqCC, presents in elderly heavy smokers with a male predominance. The median survival for CPFE patients with lung cancer is 19.5 months. Patients with idiopathic pulmonary fibrosis (IPF) or chronic obstructive pulmonary disease (COPD) are at an increased risk of developing lung cancer, especially in the case of male smokers –3. The tThe coexistence of pulmonary fibrosis and emphysema has been suggested since 1990 . More rePrevious studies should be re-evaluated to clarify their inclusion criteria for CPFE, as it has not had a standardized definition and the characteristics of lung cancer in CPFE have not yet been fully evaluated. Herein, we conducted a systematic review and meta-analysis of all available studies to determine the risk of lung cancer in CPFE, to describe the histopathology of lung cancer in CPFE and to assess mortality after lung cancer diagnosis.This present study was conducted according to the guidelines suggested by the Meta-analysis of Observational Studies in Epidemiology group based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement  15]. We. We15]. Inclusion criteria were as follows: (1) population: cohort or case-control study of lung cancer patients with a group of patients with CPFE; (2) intervention: surgical resection or pathologically confirmed cancer; (3) comparison: cancer patients without CPFE, such as cancers that develop in a normal lung  or a lung with fibrosis or emphysema alone; and (4) outcome: median survival time and survival curves that include 1- to 3- or 5-year survival rates. Exclusion criteria were as follows: (1) case reports; (2) review articles, letters, comments, or conference proceedings; (3) studies of subjects other than lung cancer patients with CPFE; (4) studies with an overlapping population; and (5) non-English full text. In nine patients of a study , the diath edition [To identify relevant studies, two radiologists (K.H.D. and H.J.K.) independently reviewed all titles and abstracts. A full-text review was carried out using inclusion and exclusion criteria. The two reviewers independently retrieved information about the study design, year, country, number of patients, overall survival, and survival curves. Disagreements between the two reviewers were resolved by consensus. In all but two of the included articles, the definition of CPFE was based on a previous article : (a) upp edition . Patholoχ2 test, and significant heterogeneity was defined as a P-value <0.10. Values of I2 > 50% were deemed to indicate substantial heterogeneity. Publication bias was not evaluated because of the small number of included studies in this meta-analysis. Summary survival curve data were obtained using five studies from which Kaplan–Meier survival curves were available [χ2 test. All statistical analyses were performed using Comprehensive Meta-analysis (CMA) software, version 2.0  and R version 3.0.2 .Pooled data that was produced using the inverse variance method for calculating each weight, along with the calculated pooled proportion and its 95% confidence interval (CI) were obtained. Forest plots were generated by using random-effects models. Study heterogeneity was assessed using the vailable . Cancer After removing duplicate data between the three databases, 287 articles were identified from the literature search . After eP < 0.001) (P < 0.001). P = 0.08), 88.2% (P < 0.001) and 12.7% (P = 0.33). The ORs in the CPFE group were higher compared with lung cancers developing in lungs with fibrosis  or emphysema  alone, without statistical significance. The summed OR for the proportion of adenocarcinoma in patients with CPFE compared with that in non-CPFE were demonstrated in P < 0.001; In the studies that we included, pooled data showing the characteristics of the comparison groups are presented in < 0.001) . CompareIn four studies which were reported the outcomes of 429 CPFE with lung cancer, 20 (4.7%) patients (6 related to chemotherapy and 14 as postoperative complication) developed acute exacerbation of CPFE , 14, 20.P <0.001). The 1-, 3-, and 5-year survival rates of lung cancer patients with CPFE were 63.2%, 32.0%, and 17.6%, respectively . The early detection of lung cancer on chest radiographs can be difficult because tumors may be hidden by the involvement of CPFE. It can also be difficult to identify lung cancer on CT because of concomitant parenchymal fibrosis and emphysema. Thus, a diagnosis of lung cancer may be delayed. Misdiagnoses or delayed diagnoses could be a burden for CPFE patients who have reduced pulmonary function and for the surgeons who had planned to carry out a surgical resection.Regarding lung cancer staging, the CPFE group included more advanced stages compared with the non-CPFE group (P <0.001); this finding is consistent with those of previous studies [The median survival time for lung cancer patients with CPFE was shorter than for lung cancer patients with non-CPFE Click here for additional data file.S2 FigSummed odds ratios for the proportion of adenocarcinoma in patients with CPFE compared with (A) normal lungs or those with (B) fibrosis or (C) emphysema.(TIF)Click here for additional data file.S1 File(DOC)Click here for additional data file.S1 TableSearch terms and the number of studies identified from (A) Pubmed, (B) EMBASE and (C) Cochrane Library.(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.