OBJECTIVES:Deep inspiration breath-hold (DIBH) is commonly used in breast cancer radiotherapy to reduce radiation exposure to the heart and lungs. Recent techniques incorporating oxygen supplementation and hyperventilation have enabled DIBHs exceeding 2.5 minutes. However, data on internal organ stability during prolonged breath-holds (L-DIBH) remain limited. METHODS:In this prospective observational physiological study, 10 healthy female volunteers performed 2 L-DIBHs (2 minutes 8 seconds each) in both prone and supine positions, following a validated hyperventilation and oxygenation protocol. Serial 3D MRI scans were acquired every 16 seconds during each L-DIBH to assess positional stability of the heart, lungs, and left-sided breast. Cumulative distance-volume histograms (cDiVHs) were used to evaluate spatial relationships between organs and quantify internal displacement over time. RESULTS:A total of 319 high-quality 3D MRI series were analysed. cDiVHs demonstrated consistent organ positions across timepoints and sessions. While left breast position remained stable throughout all L-DIBHs, minor but statistically significant heart displacement was observed during each L-DIBH increasing over time, more pronounced in the prone position than supine. CONCLUSIONS:L-DIBHs of 2 minutes and 8 seconds are achievable and demonstrate stability in left breast positioning, with minimal movement of adjacent internal organs. Small but progressive shifts of the portion of the heart nearest the breast were detected, particularly in prone positioning. ADVANCES IN KNOWLEDGE:To account for these minimal displacements during L-DIBH, asymmetrical safety margins around the heart of 3 mm in prone and 2 mm in supine positions may be appropriate.

OBJECTIVE:This study investigates whether total laparoscopic hysterectomy in trans men can be safely performed as an ambulatory procedure without negatively impacting patient satisfaction with length of stay compared to inpatient surgery. DESIGN:Single-centre non-inferiority randomised controlled trial. SETTING:Ghent University Hospital, Belgium. POPULATION:Trans men scheduled for total laparoscopic hysterectomy. METHODS:Participants were randomly allocated to ambulatory surgery (intervention) or overnight stay (comparator). MAIN OUTCOME MEASURES:The main outcome was satisfaction with the length of hospital stay, measured on Day 7 postoperatively. Secondary outcomes were pain scores, analgesics use, quality of recovery, hospital anxiety and depression, complications, and readmission. RESULTS:One hundred trans men gave informed consent. Ninety-four underwent surgery (50 allocated inpatient and 44 ambulatory). The non-inferiority margin for the primary outcome was -20 on a 100-point VAS. Total laparoscopic hysterectomy as an ambulatory procedure was non-inferior to the inpatient setting regarding satisfaction with length of hospital stay after 1 week (mean difference 1.45; 95% CI: -6.71 to 9.61). There were lower pain scores in the ambulatory group, along with significantly more use of moderate analgesics on Days 1, 2, and 3 (resp. risk difference 0.35 (95% CI: 0.17-0.53), 0.32 (95% CI: 0.10-0.54), 0.31 (95% CI: 0.10-0.52)). The quality of recovery and hospital anxiety and depression scores were comparable between both groups. The readmission and postoperative complication rates were higher in the inpatient group. CONCLUSIONS:This study shows non-inferiority for patient satisfaction with length of hospital stay after hysterectomy in the ambulatory versus inpatient setting in a transgender population. TRIAL REGISTRATION:ClinicalTrials.gov: NCT05393583.

Objectives: Deep inspiration breath-holds (DIBHs) reduce heart and lung toxicity during breast cancer radiotherapy. Consecutive DIBHs are stressful, time-consuming, and leads to position changes. To facilitate the introduction of pre-oxygenation using high-flow nasal oxygen (HFNO) and hyperventilation to prolong DIBHs (L-DIBHs), we examined the effect of hyperventilation time on the duration of L-DIBHs. Additionally, to minimize total treatment time, the feasibility of several successive L-DIBHs was examined. Methods: Our previous protocol imposed 3 min of hyperventilation at 16 breaths per minute with pre-oxygenation using HFNO, in prone position. In the first phase, the effect of hyperventilation time on the length of the L-DIBH was investigated. The aim of the second phase was to investigate the feasibility of shorter preparation times before the second and third L-DIBH in the case of 3 consecutive L-DIBHs of at least 2 minutes. Results: There is a positive but weak correlation between preparation time and L-DIBH duration. With either 3 minutes 30 seconds or 6 minutes 20 seconds (depending on fitness) of voluntary hyperventilation duration, 93% of subjects could hold 3 consecutive L-DIBHs for over 2 minutes. The median duration of the third and last L-DIBH was 3 minutes 17 seconds (SD 1 min 4 seconds). Conclusion: A weak relationship exists between the hyperventilation time and L-DIBH duration. Repeating L-DIBHs with shorter preparations is achievable, resulting in a shorter total treatment time required. Advances in knowledge: It is possible to perform repeated L-DIBHs for breast cancer irradiation using HFNO and hyperventilation.

Background: Several regional anesthesia (RA) techniques have been described for distal upper limb surgery. However, the best approach in terms of RA block success rate and safety is not well recognized. Objective: To assess and compare the surgical anesthesia and efficacy of axillary brachial plexus block with other RA techniques for hand and wrist surgery. The attainment of adequate surgical anesthesia 30 min after block placement was considered a primary outcome measure. Additionally, successful block outcomes were required without the use of supplemental local anesthetic injection, systemic opioid analgesia, or the need to convert to general anesthesia. Methods: We performed a systematic search in the following databases: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and CENTRAL. RCTs comparing axillary blocks with other brachial plexus block techniques, distal peripheral forearm nerve block, intravenous RA, and the wide-awake local anesthesia no tourniquet (WALANT) technique were included. Results: In total, 3070 records were reviewed, of which 28 met the inclusion criteria. The meta-analysis of adequate surgical anesthesia showed no significant difference between ultrasound-guided axillary block and supraclavicular block (RR: 0.94 [0.89, 1.00]; p = 0.06; I2 = 60.00%), but a statistically significant difference between ultrasound-guided axillary block and infraclavicular block (RR: 0.92 [0.88, 0.97]; p < 0.01; I2 = 53.00%). Ultrasound-guided infraclavicular blocks were performed faster than ultrasound-guided axillary blocks (SMD: 0.74 [0.30, 1.17]; p < 0.001; I2 = 85.00%). No differences in performance time between ultrasound-guided axillary and supraclavicular blocks were demonstrated. Additionally, adequate surgical anesthesia onset time was not significantly different between ultrasound-guided block approaches: ultrasound-guided axillary blocks versus ultrasound-guided supraclavicular blocks (SMD: 0.52 [−0.14, 1.17]; p = 0.12; I2 = 86.00%); ultrasound-guided axillary blocks versus ultrasound-guided infraclavicular blocks (SMD: 0.21 [−0.49, 0.91]; p = 0.55; I2 = 92.00%). Conclusions: The RA choice should be individualized depending on the patient, procedure, and operator-specific parameters. Compared to ultrasound-guided supraclavicular and infraclavicular block, ultrasound-guided axillary block may be preferred for patients with significant concerns of block-related side effects/complications. High heterogeneity between studies shows the need for more robust RCTs.

Background:The events during acute HIV infection (AHI) set the stage for the subsequent course of the disease. Early initiation of antiretroviral therapy (ART) has been associated with favorable immunovirological outcomes, yet the precise impact of ART timing during AHI remains unclear, particularly on lymphoid tissues. Materials and methods:The ACS cohort is a prospective cohort study in Belgium, collecting longitudinal clinical data and human bodily material (HBM) from people diagnosed and treated during AHI. The aim of the cohort is to study the impact of ART initiation during AHI on HIV reservoir and immune dysfunction in peripheral blood and anatomical sanctuary sites, as well as its effect on the gut microbiome. The cohort consists of two HBM sampling trajectories: one limited (blood, stool and leukapheresis) and a more extensive one (blood, stool, leukapheresis, colonoscopy, inguinal lymph node excision and lumbar puncture). Here we describe the baseline characteristics, immunovirological outcomes, safety and tolerability of HBM sampling. Results:Between March 2016 and April 2024, 47 participants were enrolled, predominantly men who have sex with men (MSM), with a median age of 36 years [IQR 30-43.5]. Almost 90 % of participants initiated ART within 72 h after study inclusion, irrespective of HBM sampling trajectory. The timing of ART initiation according to the Fiebig stage did not significantly impact immune recovery (CD4/CD8 ratio ≥1) or the time to viral suppression. Approximately 40 % of participants opted for the extensive HBM sampling trajectory during AHI. However, the participation rate for the extensive trajectory decreased by nearly half at the longitudinal follow-up timepoint. In general, study-related procedures were safe and well-tolerated, with limited procedure-related adverse events (AEs). Inguinal lymph node excision was associated with the highest AE rate, in line with previous reports. Conclusions:Our findings reaffirm the beneficial effect of ART initiation during AHI on long term immunovirological outcomes, regardless of Fiebig stage at treatment initiation. Additionally, we demonstrate that the collection of HBM during and longitudinally after AHI is safe and feasible, without compromising time to ART initiation. Cohorts that integrate comprehensive clinical data with high-quality HBM samples are essential to longitudinally study the impact of early ART on reservoir dynamics and immune responses across various anatomical sites after AHI.

Aim Bag-mask ventilation (BMV) is often applied during advanced cardiopulmonary resuscitation (CPR). Lay rescuers usually apply mouth-to-mouth ventilation, which is contraindicated in case of potential disease transmission (e.g., during the COVID-19 pandemic). This study evaluates the influence of rescuers' before BMV training in following the correct BMV procedures during adult and infant CPR. Methods Medical students ( n = 112) were enrolled in a randomized cross-over manikin study: 60 first-year students (53.6%) (untrained, without any prior knowledge of CPR) and 52 fourth-year students (46.4%) (BLS-trained, with three consecutive years of basic CPR training), excluding Basic Life Support (BLS) certificate holders or lifeguards. Student-formed duos (i.e., two students from the same year working together) received a 15-min just-in-time onsite training in full CPR cycle using BMV and were tested during five cycles of 2-person CPR following the European Resuscitation Council (ERC) guidelines with the inclusion of BMV. Tidal volumes of 300–600 ml (adults) and 20–60 ml (infants) were considered as correct ventilations. Results From the initial 56 duos, 17 (30.4%) were excluded after applying incorrect numbers of ventilation or uninterpretable values. In adult CPR, comparing BLS-trained rescuers to untrained ones in correctly administrating ventilations using BMV after a 15-min just-in-time onsite training revealed no statistically significant difference [first years: 63.0% ( n = 136 out of 216 ventilations); fourth years: 59.5% ( n = 119 out of 200 ventilations); with a proportional difference of −3.5% (−12.8; 5.9)]. In infant CPR, a significant difference was observed in effective ventilations [first years: 55.5% ( n = 120 out of 216 ventilations); fourth years: 72.3% ( n = 133 out of 184 ventilations); with a proportional difference of 16.8 (7.25; 26.21)]. Conclusion Two-person BMV is a complex skill to perform both in adults and children, requiring sufficient and regular training. Lay rescuers receiving a 15-min just-in-time onsite BMV training could perform decent BMV in an adult CPR setting. BMV during infant CPR requires more extensive prior training and should not be entrusted to lay rescuers, even after a 15-min just-in-time onsite training.

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

Abstract Introduction Recent guidelines advocate a preoperative fasting interval of 6 h for solid food, 4 h for breast milk and 2 h for clear fluids. Long nil per mouth intervals give rise to complications and discomfort in the perioperative period. Gastric ultrasound is easily accessible and generates reliable information about gastric content. Patients and methods One hundred patients were offered a questionnaire regarding preoperative fasting. Important outcome measures were hour of last meal, last clear fluids intake, the source of preoperative information. Gastric ultrasound was performed in prone position and lateral decubitus. Results The mean duration of fasting for solid food was 13h29 and 9h51 for clear fluids. 48% of patients were well aware of the correct fasting guidelines. The most frequent source of information was the preoperative phone call. Gastric ultrasound only found insignificant amounts of gastric content. Discussion Too few patients are aware of the correct guidelines or fear complications and therefore adhere to the nil per mouth from midnight as most conservative measure. A phone call informing patients about the hour of surgery and allowing clear fluid intake until 2 h before surgery, is still not convincing enough. Some health care providers advise their patients the nil per mouth from midnight rule, due to risk of interfering with the operating room schedule. Conclusion It is still difficult to implement liberal intake of clear fluids according to current guidelines. Ambulatory surgery patients have long fasting intervals with decrease of subjective well-being and increased incidence of hunger and thirst.

Background and objectives Children are more likely to suffer a hypoxic-ischaemic cause for cardiac arrest. Early ventilation may provide an advantage in outcome during paediatric cardiopulmonary resuscitation [CPR]. European Resuscitation Council guidelines recommend five initial rescue breaths [IRB] in infants, stemming from the hypothesis that rescuers might need 5 attempts in order to deliver 2 effective ventilations. This study aimed to verify this hypothesis. Methods Participants (n = 112, convenience sample) were medical students from the Faculty of Medicine and Health Sciences Ghent University, Belgium. Students were divided into duos and received a 15 min just-in-time training regarding the full CPR-cycle using BMV. Participants then performed five cycles of 2-person CPR. The IRB were given by 1-person BMV, as opposed to a 2-persons technique during the further CPR-cycle. Correct ventilations for the infant were defined as tidal volumes measured (Laerdal® Q-CPR) between 20 and 60 ml, with n = 94 participants included in the analysis. The primary outcome consisted of the difference in the % of medical student duos providing at least 2 effective IRB between 2 and 5 attempts. Results Off all duos, 55,3% provided correct volumes during their first 2 initial ventilations. An increase up to 72,4% was noticed when allowing 5 ventilations. The proportional difference between 2 and 5 IRB allowed was thus significant [17,0%, 95% confidence interval (5.4; 28.0)]. Conclusion In this manikin study, 5 IRB attempts during infant CPR with BMV increased the success rate in delivering 2 effective ventilations. Besides, students received training emphasizing the need for 5 initial rescue breaths. This study provides evidence supporting European Resuscitation Council guidelines.

Purpose: As more complex surgery is performed in 1-day admissions there is a growing demand for appropri-ate postoperative follow-up. A digital patient portal (DPP) is a promising tool to support this and increase patients' quality of recovery. However, both patients and health care professionals have not fully embraced this eHealth technology. This study investigates the extent to which a patient portal is used in a tertiary ambulatory surgical care unit and assesses usability, applicability and user-friendliness both for the patient and health care worker.Design: Mixed method research design combining qualitative and quantitative methods.Methods: Four hundred and fifteen patients undergoing knee arthroscopic surgery or endonasal sinus surgery were included. Quantitative log data from the patient platform, clinical outcome measures and a patient questionnaire were used. Additionally, qualitative data was collected through interviews (with patients, n = 13; involved caregivers and physicians, n = 7) and observations (first introduction to patient with plat-form and team meetings, n = 15). Findings: Forty percent of the included patients effectively used the patient platform (>= 1 login). The patients mainly used the platform for gathering information; 62% of the active patients on the platform registered questionnaires initiated from the surgery center (eg, preoperative questionnaire) or diaries (e.g, daily follow-up using the Quality of Recovery Scale). Different barriers and facilitators toward DPP implementation were noted. Attention should be paid to the intrinsic and extrinsic motivation for using the portal and to the added value of the portal for the patient and health care professionals.Conclusions: Patients' perceptions of the DPP were positive and an increase in DPP use was observed during the study due to adjustments (eg, technical adjustments). However, a decline over time was noticed. The role of intrinsic and extrinsic motivation of all included parties needs to be further corroborated. (c) 2021 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Implementation of the Guidelines - How do we put the new ERC Guidelines into practice? On 16 and 17 June, we are organising our first-ever hybrid congress. You will be able to join us live at the beautiful conference venue in Antwerp, Belgium and present your Poster. We are happy to welcome you to Resuscitation 2022!

Purpose of review To give an overview of the impact of different forms of telehealth that are currently used in ambulatory anesthesia and surgery. Telehealth is applicable during the early recovery and intermediate recovery period (e.g. monitoring of quality of recovery), and as a tool for postoperative check-up during the late recovery phase. Recent findings Postoperative follow-up after ambulatory surgery is still crucial to maintain quality of care as pain and postoperative nausea and vomiting remain common adverse events. There is a surge of telehealth applications from procedure-specific commercial smartphone apps (mHealth) to complete digital patient platforms instituted by the government. However, patient and healthcare provider engagement is not universal. Usability of these applications is mandatory as well as identifying and overcoming the barriers to its use. Summary Telehealth gives many opportunities for postoperative follow-up of ambulatory surgery patients. Clear evidence on the benefits of telehealth in ambulatory surgery is however still sparse. Future research should focus on telehealth for improving quality and safety of postoperative recovery, convincing policymakers for reimbursement encouraging healthcare providers and patients to engage in telehealth.

BACKGROUND AND PURPOSE:Deep inspiration breath-hold is an established technique to reduce heart dose during breast cancer radiotherapy. However, modern breast cancer radiotherapy techniques with lymph node irradiation often require long beam-on times of up to 5 min. Therefore, the combination with deep inspiration breath-hold (DIBH) becomes challenging. A simple support technique for longer duration deep inspiration breath-hold (L-DIBH), feasible for daily use at the radiotherapy department, is required to maximize heart sparing.MATERIALS AND METHODS:At our department, a new protocol for multiple L-DIBH of at least 2 min and 30 s was developed on 32 healthy volunteers and validated on 8 breast cancer patients during radiotherapy treatment, using a pragmatic process of iterative development, including all major stakeholders. Each participant performed 12 L-DIBHs, on 4 different days. Different methods of pre-oxygenation and voluntary hyperventilation were tested, and scored on L-DIBH duration, ease of use, and comfort.RESULTS:Based on 384 L-DIBHs from 32 healthy volunteers, voluntary hyperventilation for 3 min whilst receiving high-flow nasal oxygen at 40 L/min was the most promising technique. During validation, the median L-DIBH duration in prone position of 8 breast cancer patients improved from 59 s without support to 3 min and 9 s using the technique (p < 0.001).CONCLUSION:A new and simple L-DIBH protocol was developed feasible for daily use at the radiotherapy center.

Background and Aims: The Laryngeal Mask Airway (LMA) Protector™ is one of the latest introduced supraglottic airway devices. It provides access and functional separation of the respiratory and digestive tracts. Compared to the LMA Supreme™, it has two digestive ports, one to provide suction in the pharyngeal region and one for gastric tube insertion. High oropharyngeal leak pressure is a marker for safe ventilation when using LMA devices. We hypothesized that oropharyngeal leak pressure of the LMA Protector™ is 5 cm H2O higher than the oropharyngeal leak pressure of the LMA Supreme™ at various cuff volumes. Secondary outcome measures were ease of insertion of both masks, fiberoptic confirmation of correct positioning, failures of insertion, presence of blood staining, sore throat, presence of air leak and insertion time. < Material and Methods: American Society of Anesthesiologists (ASA) I-III patients aged >18 years, scheduled for elective minor ambulatory surgery under general anesthesia with a LMA were included. Patients were randomized in the LMA Protector™ or LMA Supreme™ group based on a computer-generated random sequence table. After general anesthesia induction, oropharyngeal leak pressures were measured. < Results: Oropharyngeal leak pressures were significantly higher (P < 0.0001) for LMA Protector™ compared to LMA Supreme™ at different cuff volumes and a cuff pressure of 65 cm H2O. Insertion time was significantly higher for the LMA Protector™ (29 sec) [interquartile range (IQR) 23, 35] compared to the LMA Supreme™ (19 sec) (IQR 16, 22) (P < 0.0001). There were no statistically significant differences in ease of insertion (number of attempts for succesful positioning), failures of insertion, presence of blood staining, sore throat or presence of air leak. Conclusion: Oropharyngeal leak pressures were consistently higher (>5 cm H2O) for LMA Protector™ compared to LMA Supreme™. LMA Protector™, therefore, allows effective ventilation at higher airway pressures than LMA Supreme™. Trial Registration: http://clinicaltrials.gov.NCT03462550.

INTRODUCTION:The incidence of adverse events in day surgery is an important quality indicator. This retrospective study investigated factors independently associated with unanticipated admission of pediatric patients after ambulatory surgery. PATIENTS AND METHODS:Ambulatory pediatric patients requiring unanticipated admission between January 2016 and December 2018 were compared to ambulatory pediatric patients who were discharged home after a planned surgery. Demographic data, organizational data, American Society of Anesthesiologists (ASA) classification, type of surgery, type of anesthesia, length of surgery, time of completion of the surgery, campus site, and season were collected in both groups. The reason for unexpected admission was classified according to four subtypes: anesthetic, medical, social/organizational and surgical reason, respectively. Multivariate logistic regression was used to identify independent factors associated with unanticipated admission. RESULTS:From a total of 4235 pediatric patients, 78 children (1.9%) required unanticipated admission. The reasons for admission were anesthetic n = 29 (37.3%), surgical n = 20 (25.6%), medical n = 16 (20.5%) and social/organizational n = 13 (16.6%). Age <2 years (odds ratio [OR] 3.005, 95% confidence interval (CI) 1.500-6.018; ASA class 2 (OR 2.144; 95% CI 1.193-3.852); ASA class 3 (OR 11.617; CI 5.698-23.685); length of surgery >2 h (OR 3.056; CI 1.829-5.107); completion of surgery > 2:30 PM (OR 3.507; CI 1.854-6.633) and campus site (OR 3.628; CI 1.991-6.610) were factors significantly associated with unanticipated admission. CONCLUSION:Children are less likely to be admitted after ambulatory surgery when preoperatively carefully selected and when prioritized considering age, general health condition and invasiveness of the surgery.

INTRODUCTION:This systematic review aimed to give an overview of the current evidence surrounding the aetiology and management in terms of treatment and prevention of syncope in dental practices. Alongside the occurrence, the practitioner's competence, and the association between syncope and local anaesthetics were discussed. METHODS:An electronic search in EMBASE, Web of Science, PubMed, Cochrane databases and a hand search were performed by 2 independent reviewers to identify studies up to November 2019. Eligibility criteria were applied and relevant data was extracted. Inclusion criteria covered all types of dental treatment under local anaesthesia or conscious sedation performed by a wide range of oral health care workers in their practices. Risk of bias of the included studies was assessed using the methodological tools recommend by Zeng et al.1 No restrictions were made to exclude papers from qualitive analysis based on risk of bias assessment. RESULTS:The search yielded a total of 18 studies for qualitative analysis. With the exception of one prospective cohort study, all articles were considered having a high risk of bias. Meta-analysis showed that dentists encountered on average 1.2 cases of syncope per year. The male gender (RR = 2.69 [1.03, 7.02]), dental fear (RR = 3.55 [2.22, 5.70]), refusal of local anaesthesia in non-acute situations (OR = 12.9) and the use of premedication (RR = 4.70, [1.30, 16.90]) increased the risk for syncope. Treatment and prevention were underreported as both were solely discussed in one study. The supine recovery position with raised legs and oxygen administration (15l/min) was presented as an effective treatment. The Medical Risk-Related History (MRRH) system was proposed as prevention protocol, yet this protocol was ineffective in reducing incidence rates (p = 0.27). The majority of dentists (79.2%) were able to diagnose syncope, yet most (86%) lacked the skills for appropriate treatment. Only 57,6% of dental practices were equipped with an oxygen cylinder. CONCLUSIONS:Syncope is the most common emergency in dental practices. Nonetheless, the vast majority of dentists do not seem competent nor prepared to manage this emergency. Psychogenic factors seem to play an important role in provoking syncope. Placing the patient in a supine reclined position with raised legs in combination with the administration of oxygen seems effective for regaining consciousness. Although valuable in many aspects, risk assessment by medical history taking is not proven to result in fewer episodes. The strength of these conclusions is low based on GRADE guidelines.2.

The actual severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic highlights the need for advanced care planning (ACP) in patients affected with coronavirus disease of 2019 (COVID-19) in need for cardiopulmonary resuscitation (CPR) in case of sudden cardiac arrest (SCA).1De Filippis E.M. Ranard L.S. Berg D.D. Cardiopulmonary resuscitation during the COVID-19 pandemic: a view from trainees on the frontline.Circulation. 2020; https://doi.org/10.1161/CIRCULATIONAHA.120.047260Crossref Scopus (57) Google Scholar Primary care physicians (PCP) and specialists with trust bonds with their patients should encourage completion of physician order for life-sustaining treatments (POLST) forms to respect one's wish in the face of death.1De Filippis E.M. Ranard L.S. Berg D.D. Cardiopulmonary resuscitation during the COVID-19 pandemic: a view from trainees on the frontline.Circulation. 2020; https://doi.org/10.1161/CIRCULATIONAHA.120.047260Crossref Scopus (57) Google Scholar These official "Do Not Resuscitate (DNR)" codes are not always respected: a 9.42% rate of delivered CPR despite a DNR code (52 out of 552 SCA patients) was reported by the National Confidential Enquiry into Patient Outcome and Death in 2012 in the UK. Another study conducted in 2014 in an older and frailer patient population in the UK reported an outcome of 6.06% (8 out of 132 SCA patients).2Wong J. Duane P.G. Ingraham N.E. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation.Resuscitation. 2020; 146: 145-146Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 3Baxter L. Hancox J. King B. Powell A. Tolley T. STOP! patients receiving CPR despite valid DNACPR documentation.Eur J Palliative Care. 2018; 25: 125-127Google Scholar, 4National confidential enquiry into patient outcome and death. Time to intervene?. NCEPOD, London2012Google Scholar Reasons for unwanted CPR (uCPR) consist of absence of recording of patient's DNR status in nurses' notes, of DNR decision discussions with patient and relatives in medical files and failure to communicate the patient's wish between teams.2Wong J. Duane P.G. Ingraham N.E. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation.Resuscitation. 2020; 146: 145-146Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 3Baxter L. Hancox J. King B. Powell A. Tolley T. STOP! patients receiving CPR despite valid DNACPR documentation.Eur J Palliative Care. 2018; 25: 125-127Google Scholar Resuscitation teams arriving at the in-hospital setting, the emergency department, in homes, at home or on the street, generally do not know the patient and start immediately upon arrival after checking for absence of responsiveness and normal breathing.2Wong J. Duane P.G. Ingraham N.E. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation.Resuscitation. 2020; 146: 145-146Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Here, we explore the idea of an international symbol printable on patients' wristbands next to their personal identification, without using any acronym and making it usable everywhere (Fig. 1). The universal "STOP" symbol is drawn over a heart receiving CPR and/or defibrillation. It would be important to foresee a plastic flap with a pression button to cover the symbol to respect patient's privacy. The bracelet should not be easily removable as to not be exchanged between people.5Sanger Kelly L.J. Can color-coded bracelets help prevent medical errors?.Health Law Perspect. 2008; Google Scholar This idea could also be extended to nursing and retirement homes. The latter house elder populations where DNR codes should be known for each inhabitant. This could also be applied to each person chosing for DNR, independable of their actual health condition. Upon hospital intake, the symbol should be printed based on the global medical record (GMR) as established by the PCP. If the DNR code is established in-hospital by a medical doctor, the GMR should be updated, automatically informing the PCP and a new bracelet should be foreseen. This procedure could also be considered in nursing and retirement homes. For DNR codes in the general population (elderly living in their own house for example), this bracelet could be provided by the PCP. These combined strategies could help reduce the amount of uCPRs. Implementation could be discussed by the International Liaison Committee on Resuscitation (ILCOR), the European Resuscitation Council (ERC), the American Heart Association (AHA) and all other resuscitation organisations wordwide, in a meeting between world specialists in the field with medical ethical and law specialists to avoid any misuse, exploring potential ethical grey zones and discussing solutions.5Sanger Kelly L.J. Can color-coded bracelets help prevent medical errors?.Health Law Perspect. 2008; Google Scholar Part of the visuals were purchased from Shutterstock.com. None.

Viral rebound upon stopping combined antiretroviral therapy poses a major barrier toward an HIV cure. Cellular and anatomical sources responsible for reinitiating viral replication remain a subject of ardent debate, despite extensive research efforts. To unravel the source of rebounding viruses, we conducted a large-scale HIV-STAR (HIV-1 sequencing before analytical treatment interruption to identify the anatomically relevant HIV reservoir) clinical trial. We collected samples from 11 participants and compared the genetic composition of (pro)viruses collected under treatment from different cellular and anatomical compartments with that of plasma viruses sampled during analytical treatment interruption. We found a remarkably heterogeneous source of viral rebound. In addition, irrespective of the compartment or cell subset, genetically identical viral expansions played a significant role in viral rebound. Our study suggests that although there does not seem to be a primary source for rebound HIV, cellular proliferation is an important driver of HIV persistence and should therefore be considered in future curative strategies.