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Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...

Background: Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented. Aims: As Ž . Ž part of an ongoing randomized study on the value of multidisciplinary care in a high risk NYHA Class IV , elderly mean age . Ž . 69 years heart failure population, we examined the effects of this intervention on previously high 20% 1-month readmission Ž . Ž . rates. Methods: Unlike previous studies of this approach, both multidisciplinary MC and routine care RC populations were Ž . cared for by the cardiology service, complied with adherence to clinical stability criteria prior to discharge 100% of patients Ž . Ž and received at least target dose angiotensin-converting enzyme ACE inhibition with perindopril prior to discharge 94% of . indicated patients . We analysed death and unplanned readmission for heart failure at 1 month. Results: This early report Ž . from the first 70 patients 67% male, 71% systolic dysfunction with a mean ejection fraction of 31.0" 6.7% enrolled in this study demonstrates elimination of 1-month hospital readmission in both RC and MC groups. This unexpected result Ž represents a dramatic improvement both for this patient cohort 20% 30-day readmission rate prior to enrolment reduced to . 0% following the index admission in both care groups and in comparison with available data. Conclusions: Critical contributors to this improvement appear to be specialist cardiology care, adherence to clinical stability criteria prior to discharge and routine use of target or high-dose ACE inhibitor therapy prior to discharge. Widespread application of this approach may have a dramatic improvement in morbidity of CHF while limiting the escalating costs of this condition. ᮊ

This article describes the development, field testing, and evaluation of an interactive computer program, "Life Challenge," developed by the New York State Department of Health as a tool for enhancing adolescents' sense of self-efficacy in HIV/AIDS prevention programs. The computer kiosks were field tested in 13 sites serving high-risk adolescents. The program uses a time travel adventure game format to provide information and nonthreatening skill practice. Users record and play back their responses as they "negotiate" with their chosen partners. A proof of concept evaluation with analysis of 211 audio responses found that users took negotiating tasks seriously; statistically significant learning gains were achieved on knowledge items and in self-efficacy scores (greatest improvement for those with low baseline self-efficacy levels). Challenges and problems encountered in implementing the project are described, and the potential of using computers for skill practice and educational interventions in health education is explored.

Background: Multidisciplinary care (MDC) of heart failure (HF) can significantly reduce rates of unplanned hospitalisation, the major cost component of HF care. Aims: This prospective, randomised, controlled study examines the cost-benefits of MDC of HF in the setting of optimal medical care. Methods: 98 NYHA class IV HF patients (mean age 70.8"10.5 years) were randomised to MDC (ns51) or routine care (RC; ns47) of HF. A direct intervention cost was calculated from contact time (scheduled and unscheduled) spent by the MDC team. Unplanned hospitalisation costs for HF were calculated at a daily rate of 7242. Outcomes were determined in monetary terms, i.e. the cost of the service per hospitalisation prevented and net costsy savings at 3 months. Results: The direct intervention cost of the MDC team was 75860, with an average cost per patient of 7113 (95% Cl: 97-128). At 3 months, there were a total of 12 unplanned HF readmissions in the RC group (25.5% rate, 195 days) compared to 2 in the MDC group (3.9% rate, 17 days). The number needed to treat to prevent one hospitalisation for HF was 6 over 3 months. The cost of the service per hospitalisation prevented was 7586. The intervention produced a net cost saving of 737,216 for 51 patients treated over 3 months. Sensitivity analyses using 50% variation in costs and lower relative risk reductions confirmed the cost-benefits of the intervention. Conclusion: MDC of HF remains cost-beneficial when combined with optimal, medical care. The significant clinical and cost-benefits suggest that this intensive approach to MDC and medical management should become the standard of care for HF.

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Iodine-131 SPECT/CT is useful for accurate evaluation of regional and distant activity in characterization of foci as residual thyroid tissue or nodal, pulmonary, or osseous metastasis. Suspected physiologic mimics of disease can be confirmed with increased reader confidence.

The effects of short-term (2.5 wk) and long-term (10 wk) testosterone propionate (2.5 mg/day; 5 days/wk) treatment on diaphragm contractility, fatigue resistance, and fiber type proportions were studied in male and female rats. Contractility and fatigue resistance indexes were measured in an in vitro diaphragm costal strip preparation by direct stimulation at 37 degrees C. The fatigue paradigm consisted of 30 trains/min at 5 Hz (50% duty cycle) for 10 min. Fatigue resistance indexes were calculated as postfatigue divided by baseline forces. In females but not males, testosterone treatment produced significant increases in body weight, costal diaphragm weight, and contractility and significant decreases in fatigue resistance indexes. The interaction between testosterone treatment and the duration of treatment was significant, with the increase in contractility (females) being significant after short-term but not long-term treatment. No significant difference in fiber type proportions or areas was observed, regardless of treatment duration or the preexperimental, basal circulating level of androgen.