With limited healthcare resources, it is important to provide the right level and form of care. The aim of this study was to determine whether selected single-jaw orthognathic surgery in outpatient care (OPC) generates lower healthcare costs than in inpatient care (IPC). The costs of surgically assisted rapid maxillary expansion (SARME), Le Fort I osteotomy (LFI), and bilateral sagittal split osteotomy (BSSO) were calculated for 165 patients, 107 treated in OPC and 58 in IPC. Additionally, costs for revisits, emergency visits, emergency phone calls, re-operations, and plate removal during the first 12 months postoperatively were recorded. The total mean costs of the different operations including revisits, emergency visits, and phone calls were 34.2-48.8% lower in OPC than in IPC at 12 months postoperatively. Operation costs were lower for LFI in OPC (P = 0.009) and for SARME in IPC (P = 0.007). Anaesthesia costs were lower for LFI (P < 0.001) and BSSO (P < 0.001) in OPC, and there were fewer revisits (P = 0.001) and lower costs (P = 0.002) after LFI in OPC compared to IPC. This study showed that selected single-jaw orthognathic surgeries in outpatient care are associated with lower healthcare costs compared to inpatient care.

Orthognathic surgery is traditionally performed in inpatient care. The question is whether patient safety is maintained when orthognathic surgery is performed in outpatient care. This retrospective cohort study was conducted to investigate patient safety in selected single-jaw orthognathic surgeries performed in outpatient care compared to inpatient care. Postoperative infection, postoperative bleeding, postoperative pain, plate removal, and re-operation, as well as emergency visits/phone calls and postoperative admission during the first 12 months after surgery were recorded. Predictor variables were sex, age, smoking, general disease, antibiotics, operation type, and operation time. Of the 165 patients included, 58 were treated in inpatient care and 107 in outpatient care. No significant difference was found between the groups regarding postoperative bleeding, pain, plate removal, re-operation, or emergency visits/ phone calls. Ninety-four percent of outpatients (n = 101) were able to leave the hospital on the day of surgery as planned. There was an increased risk of postoperative infection in the outpatient care group (odds ratio 2.46, P = 0.049). Selected single-jaw orthognathic surgery can be performed in the outpatient setting, with maintained patient safety. The reason for the increased risk of postoperative infection among patients operated in outpatient care should be investigated in further studies.

Background TAFRO syndrome is a rare clinical subtype of idiopathic multicentric Castlemans disease characterised by thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly. Renal involvement is common, sometimes requiring temporary renal replacement therapy. Due to the associated thrombocytopenia, renal biopsies are rarely performed limiting descriptions of the renal histopathology in this condition. This case describes a patient with TAFRO syndrome and the associated renal histology. Case presentation A 49-year-old Caucasian man presented to a tertiary hospital in Sydney with a six- week history of malaise, non-bloody diarrhoea, progressive shortness of breath, and drenching night sweats. A progressive bicytopenia and renal function decline necessitating temporary dialysis prompted a bone marrow aspirate and trephine, as well as a renal biopsy respectively. This noted a hypercellular bone marrow with increased granulopoiesis, reduced erythropoiesis, and fibrosis, with renal histology suggesting a thrombotic microangiopathic-like glomerulopathy. Alternate conditions were excluded, and a diagnosis of TAFRO syndrome was made. Glucocorticoids and rituximab were initiated with rapid renal recovery, and normalisation of his haematologic parameters achieved at six months. Conclusion This case describes an atypical thrombotic microangiopathy as the predominant histologic renal lesion in a patient with TAFRO syndrome. This was responsive to immunosuppression with glucocorticoids and rituximab, highlighting the importance of early recognition of this rarely described condition.

A cost-effectiveness analysis, considering both costs and health outcomes of interventions, are important for decision-making and implementation in the health care. Exercise during oncological treatment is beneficial for health and have been found to counteract side effects of treatment. The Swedish Phys-Can RCT compared a six-month exercise program combining supervised resistance training and homebased endurance training of high-intensity ( HI ) versus low-to-moderate intensity (LMI), with or without additional behaviour change support. At post intervention, HI yielded small improvements of fitness and physical fatigue compared with LMI. At 18 months, no differences were found in total costs between the intensities. However, knowledge of the cost effectiveness in exercise interventions with regard to intensity is limited. In this study, we aimed to evaluate the long-term cost-effectiveness of an exercise program at HI versus LMI during oncological treatment. A cost-effectiveness analysis was undertaken from a societal perspective for 18 months. 189 (n=99 HI and n=90 LMI) participants with breast, colorectal, or prostate cancer were included from the Phys-Can RCT. Health outcomes were measured as quality-adjusted life years (QALYs), using EQ-5D-5L at baseline, six months and 18 months. Costs included the exercise intervention, health care utilisation and productivity loss. At 18 months, the total cost per participant did not differ significantly between HI (€27,314) and LMI exercise (€29,788). There was no significant difference in health outcome between the intensities. On average HI generated 1.190 (SD = 0.223) QALYs and LMI 1.185 (SD = 0.211) QALYs for 18 months, meaning HI led to an additional 0.005 QALYs. The incremental cost-effectiveness ratio (ICER) indicates that HI was more effective and saved costs compared with LMI. The uncertainty around the ICER was large, however our results indicates that HI exercise was cost-effective compared to LMI exercise at longer term since there was lower total costs per QALY gained. Thus, we suggest that exercise with its health benefits may be implemented regardless of intensity.

Abstract Background The discovery of new markers for acute kidney injury (AKI) in acute decompensated heart failure (ADHF) has been hampered by an incomplete understanding of the pathological processes underlying AKI in ADHF. Purpose In a sheep model of ADHF, we investigated changes in kidney gene expression in response to the development of, and recovery from, ADHF. Methods We collected serial kidney biopsies from 6 sheep prior to rapid cardiac pacing (day 0), after development of ADHF (pacing @220bpm for 14 days), and at the end of a 25-day (non-pacing) recovery period. Serial biopsies were supplemented with kidney samples collected post-mortem from animals undergoing a similar pacing/recovery protocol, giving a total of 11 “baseline” (B), 13 “heart failure” (HF) and 8 “recovery” (R) samples. We prepared RNA-Sequencing libraries using total RNA and Illumina TruSeq stranded mRNA library kits. Hormonal, haemodynamic, biochemical and urine measurements were also performed in all sheep before, during, and after development of ADHF. The study followed the principles of laboratory animal care and was approved by our institution's Animal Ethics Committee. Results We observed profound changes in hormonal, haemodynamic, biochemical and urine measures of cardio-renal injury in all sheep, confirming simulation of the peripheral consequences of ADHF, including clinically-relevant kidney dysfunction. This occurred in conjunction with altered kidney expression of 982 genes during ADHF development and 1,807 genes during ADHF recovery (p adj.<0.05, Fig 1). During ADHF development, changes in kidney gene expression were associated with activation of the pro-inflammatory p38 MAPK pathway and repression of several anti-inflammatory and reno-protective pathways, including eNOS signalling (all p adj.<0.001). In contrast, during ADHF recovery, changes in kidney gene expression were associated with reactivation of reno-protective pathways repressed during ADHF development, activation of anti-fibrotic pathways (including PTEN signalling) and repression of pathways that mediate inflammation and renal injury (including NF-kB signalling, all p adj.<0.001). Among 431 ADHF “responsive” genes (i.e. those that increased during ADHF development and decreased during ADHF recovery, or vice versa, Fig. 1), 37 genes encoded proteins detectable in plasma or urine and may represent markers of kidney repair in ADHF. Although most gene expression changes were transient, 192 genes remained altered after 4-weeks recovery (p adj.<0.05, Fig 1). Of these, 13 genes were predicted to encode proteins detectable in plasma or urine and may represent persistent markers of kidney injury in ADHF. Conclusion Our data provide the first insight into the gene pathways associated with kidney injury and repair in ADHF, in an established ovine model. Understanding the pathological processes underlying AKI in ADHF may enable discovery of novel markers for monitoring kidney injury and repair in ADHF. Figure 1. Genes altered in the kidney in ADHF Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Health Research Council of New Zealand, Heart Foundation of New Zealand

The purpose of this prospective controlled intervention study was to evaluate an Early Childhood Caries (ECC) prevention program from pregnancy to 12 months of age. Pregnant women living in socioeconomically disadvantaged areas in Sweden received an individual interdisciplinary ECC prevention program consisting of oral health promoting talks using motivational interviewing technique. Findings show a tendency towards a decrease in the proportion of children with high risk of ECC in the intervention group, although nonsignificant. The program reached a higher proportion of mothers, whose children had increased risk of ECC, with an oral health message during pregnancy compared to ordinary routines.

Background: Syphilis is a rare sexually transmitted infection caused by the spirochete, Treponema pallidum, however, there is increasing prevalence amongst HIV-infected individuals. Late (tertiary) syphilis typically manifests as cutaneous, cardiovascular or neuro-syphilis. Cutaneous tertiary syphilis presents clinically as annular plaques and/or nodules with raised borders and central depression. Microscopic features may vary, but typically there is a rich, deep dermocutaneous plasma cell inflammatory cell infiltrate with necrotising granulomas and dense lymphohistiocytic inflammation. Immunohistochemical staining (IHC) for Treponema pallidum can detect spirochetes with high sensitivity and specificity.

BACKGROUND:Damage biomarkers may identify mechanisms and sites of acute kidney injury (AKI). However, the utility of novel AKI biomarkers differs by context, and their utility for monitoring treatment of AKI is unknown. We hypothesized that selected AKI biomarkers would facilitate monitoring of mechanism-specific treatment. We examined this using a panel of biomarkers to monitor cisplatin-induced AKI treatment with alpha-lipoic acid (α-LA) that has previously been demonstrated to ameliorate cisplatin induced AKI. METHODS:AKI was induced in male Sprague Dawley rats using cisplatin (6mg/kg) in the presence or absence of a single dose of α-LA (100mg/kg). A panel of 12 urinary kidney damage biomarkers (CystatinC, NGAL albumin, alpha-1-acid glycoprotein, clusterin, KIM-1, osteopontin, total protein, cytochrome C, epidermal growth factor, interleukin-18 and malondialdehyde was examined as well as histological injury, serum creatinine and cystatin C, and clinical parameters. RESULTS:Cisplatin treatment modified all parameters, except interleukin-18 and malondialdehyde, with each parameter demonstrating a different temporal profile. α-LA treatment attenuated renal tubular injury scores (P <0.05), decreased peak serum creatinine (p=0.004) and cystatin C (p=0.04), and urinary damage biomarkers of proximal tubular injury (CystatinC, NGAL, albumin, and alpha-1-acid glycoprotein). Other urinary biomarkers were not modified. Neither α-LA alone, nor the cisplatin vehicle (DMSO) modified biomarker profiles. CONCLUSIONS:α-LA treatment ameliorated cisplatin-induced AKI. Protection was demonstrated by reduced structural damage, improved glomerular filtration and reduced excretion of urinary biomarkers of proximal tubular damage. Effective treatment of AKI can be monitored by site and perhaps by mechanism-specific kidney damage biomarkers.

Non-invasive prenatal testing (NIPT) is a method that is based on small portions of cell-free fetal DNA (cffDNA) that is present in the woman’s blood during pregnancy. Analysis of cffDNA in a blood sample can be used for different types of prenatal diagnosis. The use of NIPT to detect trisomies has developed rapidly over the past four years. The aim of this study was to examine the costs and cost effectiveness of NIPT to detect trisomy 21 (T21, Down’s syndrome) in Sweden. The procedures of a cost-analysis and a cost-effectiveness analysis were followed using true number of detected T21 as outcome. The main comparator was the 1st trimester combined test (nuchal translucency (NT) in combination with levels of free-β-hCG and PAPP-A). For the estimation of sensitivity and specificity of T21 using NIPT, a meta-analysis using data from 32 studies were used. Calculations were performed for 10 000 pregnancies with an average age of the women at 30 years, tested in week 12, and with an average risk of having trisomy 21 (1:526). The price of NIPT was set to €542 (no price is yet available in Sweden). Costs and quality of life related to living with T21 were not included. Using NIPT as a first line procedure increases the costs from about €2 M to more than €5 M and its cost-effectiveness ratio become about €2 M per extra true detected T21 compared to the combined test. Using NIPT as a second line procedure (following the combined test with a cut-off risk at 1:200) leads to reduced costs and fewer procedure-related miscarriages, but with 0.04 fewer T21 detected. The use of NIPT to test for T21 increases the number of detected T21. It is not possible to clarify what testing strategy (if any) that would be considered cost-effective.

Dynamic Circuit Specialization (DCS) optimizes a Field-Programmable Gate Array (FPGA) design by assuming a set of its input signals are constant for a reasonable amount of time, leading to a smaller and faster FPGA circuit. When the signals actually change, a new circuit is loaded into the FPGA through runtime reconfiguration. The signals the design is specialized for are called parameters. For certain designs, parameters can be selected so the DCS implementation is both smaller and faster than the original implementation. However, DCS also introduces an overhead that is difficult for the designer to take into account, making it hard to determine whether a design is improved by DCS or not. This article presents extensive results on a profiling methodology that analyses Register-Transfer Level (RTL) implementations of applications to check if DCS would be beneficial. It proposes to use the functional density as a measure for the area efficiency of an implementation, as this measure contains both the overhead and the gains of a DCS implementation. The first step of the methodology is to analyse the dynamic behaviour of signals in the design, to find good parameter candidates. The overhead of DCS is highly dependent on this dynamic behaviour. A second stage calculates the functional density for each candidate and compares it to the functional density of the original design. The profiling methodology resulted in three implementations of a profiling tool, the DCS-RTL profiler. The execution time, accuracy, and the quality of each implementation is assessed based on data from 10 RTL designs. All designs, except for the two 16-bit adaptable Finite Impulse Response (FIR) filters, are analysed in 1 hour or less.

Dynamic Circuit Specialization (DCS) is an optimization technique used for implementing a parameterized application on an FPGA. The application is said to be parameterized when some of its inputs, called parameters, are infrequently changing compared to the other inputs. Instead of implementing these parameter inputs as regular inputs, in the DCS approach these inputs are implemented as constants and the design is optimized for these constants. When the parameter values change, the design is re-optimized for the new constant values by reconfiguring the FPGA. It has been investigated that run-time reconfiguration speed is the limiting factor of the DCS implementations on Xilinx FPGAs. We propose an idea to constrain the design's placement and use the custom Xilinx HWICAP driver to improve reconfiguration speed at the cost of a small reduction in design performance. We use Xilinx Virtex-5 and Zynq-SoC as experimental platforms and we have used an 8-bit FIR filter with different tap configurations as our parameterized design whose filter coefficient values are infrequently changing inputs. A drastic improvement in the reconfiguration speed with a factor of 14 is achieved with only a ≈ 6% decrease in performance.

Dynamic Circuit Specialization (DCS) is a technique used to optimize FPGA applications when some of the inputs, called parameters, are infrequently changing compared to other inputs. For every change of parameter input values, a specialized FPGA configuration is generated during run time and the FPGA is reconfigured with a specialized bitstream. We examine how the performance of the DCS technique evolves with the advent of newer Xilinx FPGA architectures. The performance of the DCS technique is evaluated on three different Xilinx FPGA architectures: Virtex-II Pro, Virtex-5 and Zynq SoC. We have used a 16-tap, 8-bit FIR filter as a parameterized design, with the filter coefficients as the parameters of the FIR design.

Dynamic Circuit Specialisation (DCS) is a method that exploits the reconfigurability of modern FPGAs to allow the specialisation of FPGA circuits at run-time. Currently, it is only explored as part of Register-transfer level design. However, at the Register-transfer level (RTL), a large part of the design is already locked in. Therefore, maximally exploiting the opportunities of DCS could require a costly redesign. It would be interesting to already have insight in the opportunities for DCS from the higher abstraction level. Moreover, the general design trend in FPGA design is to work on higher abstraction levels and let tool(s) translate this higher level description to RTL. This paper presents the first profiler that, based on the high-level description of an application, estimates the benefits of an implementation using DCS. This allows a designer to determine much earlier in the design cycle whether or not DCS would be interesting. The high-level profiling methodology was implemented and tested on a set of PID designs.

Introduction Considerable disparity has been noticed in macrosomic deliveries due to lack of recognised guideline in the management of macrosomia. In this study, we determined risk factors predicting macrosomia and associated complications. We analysed variations in management of macrosomia in a large teaching hospital. Method This study was done by retrospective analysis of case notes of 45 women who delivered macrosomic babies from January 2010 to June 2010 in university hospitals of Leicester NHS trust. Results Incidence of macrosomia was highest in the age group 30–40 years (46%). About 71% of babies with macrosomia in our analysis occurred in women with BMI < 30. Eighty % of macrosomic babies were born to non-diabetic mothers. Prior incidence of macrosomia occured in 17.9% of multiparous women in our sample. Our analysis highlighted the variations in management of macrosomia, typically in mode of delivery (Table 1). Abstract PL.53 Table 1 Antenatal care/delivery/complications associated with macrosomia Factor Incidence Antenatal clinical suspicion 40% Macrosomia missed on scan 16.6% Spontaneous Vaginal Deliveries 48.8% Induction of Labour 33.3% Elective Caesarean section 17.7% Postpartum haemorrhage 44.4% Anal Sphincter Injury 6.6% Shoulder Dystocia 0.49% Poor Apgar score/NNU admission 0% Conclusion In our analysis, we concluded that it is difficult to anticipate macrosomia based on risk factors. Also, there is a high incidence of complications associated with macrosomic deliveries. This highlights need for regular obstetric emergency ‘skills and drills’. There is a need for standardised guidelines on management of macrosomia.