Novices were successfully trained to proficiency skill level. Although fiberoptic bronchoscopy skills started to decay within 2 months, the re-training time was shorter.

Objectives: Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke. Design: Retrospective observational cohort study. Setting: Academic comprehensive stroke center. Patients: Elderly acute stroke patients—2005–2009 (n = 462), 2010–2012 (n = 122), and 2016–2017 (n = 123). Interventions: None. Measurements and Main Results: After institutional review board approval, we retrospectively queried elderly stroke patients’ data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016–2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50–1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40–2.49]), year (1.01 [0.66–1.53]), age (1.78 [1.20–2.65] per 10 yr), smoking (8.0 [2.4–26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67–5.67]), Glasgow Coma Scale (0.73 [0.66–0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16–0.60]), creatinine (1.76 [1.17–2.64] for 2 vs 1), congestive heart failure (2.49 [1.06–5.82]), and warfarin (2.29 [1.17–4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79–0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71–0.87) and scaled Brier’s score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75–0.91) and scaled Brier’s score of 0.27. Conclusions: Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.

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Background Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. Methods We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. Results 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: 22 ± 6 days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, P = 0.77). The relationship did not differ for trauma and nontrauma patients (P = 0.75). Results were similar after adjusting for multiple potential confounders. Conclusions Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage.

We report 2 cases of successful treatment of neck and back pain with bipolar radiofrequency ablation (RFA) of the cervical and lumbar facet joints in patients with an automatic implantable cardioverter defibrillator (AICD). Two patients with complex cardiac histories and AICD devices were treated with bipolar RFA of the facet joints. One presented with axial neck pain and the other with axial back pain. The histories and physical examinations were consistent with facetogenic pain. Diagnostic medial branch block resulted in more than 70% pain relief lasting for several days, allowing patients to perform routine daily activities without significant pain. However, we were concerned about the use of conventional RFA of the medial branches of nerves for the fear of interference with the function of AICD by the RF currents and energy. We took advantage of the localized and limited current of bipolar RFA to perform this procedure for the cervical or lumbar facet joints avoiding any interference with the function of AICD. The procedures provided long-term pain relief to the patients, and marked improvement in their functional status without any evident complications related to the function of their AICD. This case report describes the safe and successful completion of bipolar RFA of the medial branch nerves to treat cervical and lumbar facetogenic pain in patients with AICD. This modality of treatment may be considered in patients with AICD. We are finding it to be increasingly common that patients who present with chronic neck and back pain have AICDs in place. Key words: Back pain, neck pain, facet, AICD, radiofrequency neurotomy, bipolar lesioning