BackgroundAmyotrophic lateral sclerosis (ALS) is a disease characterized by a progressive degeneration of motor neurons leading to paralysis. Our previous MRI diffusion tensor imaging studies detected early white matter changes in the spinal cords of mice carrying the G93A-SOD1 mutation. Here, we extend those studies using ultra-high field MRI (17.6 T) and fluorescent microscopy to investigate the appearance of early structural and connectivity changes in the spinal cords of ALS mice.MethodsThe spinal cords from presymptomatic and symptomatic mice (80 to 120 days of age) were scanned (ex-vivo) using diffusion-weighted MRI. The fractional anisotropy (FA), axial (AD) and radial (RD) diffusivities were calculated for axial slices from the thoracic, cervical and lumbar regions of the spinal cords. The diffusion parameters were compared with fluorescence microscopy and membrane cellular markers from the same tissue regions.ResultsAt early stages of the disease (day 80) in the lumbar region, we found, a 19% decrease in FA, a 9% decrease in AD and a 35% increase in RD. Similar changes were observed in cervical and thoracic spinal cord regions. Differences between control and ALS mice groups at the symptomatic stages (day 120) were larger. Quantitative fluorescence microscopy at 80 days, demonstrated a 22% reduction in axonal area and a 22% increase in axonal density. Tractography and quantitative connectome analyses measured by edge weights showed a 52% decrease in the lumbar regions of the spinal cords of this ALS mice group. A significant increase in ADC (23.3%) in the ALS mice group was related to an increase in aquaporin markers.ConclusionsThese findings suggest that the combination of ultra-high field diffusion MRI with fluorescent ALS mice reporters is a useful approach to detect and characterize presymptomatic white matter micro-ultrastructural changes and axonal connectivity anomalies in ALS.
OBJECTIVES Shortening hospital length of stay after lobectomy for stage I non-small-cell lung cancer (NSCLC) remains a challenge, and the literature regarding factors associated with safe early discharge is limited. We sought to evaluate the safety of postoperative day (POD) 1 discharge after lobectomy and its correlation with institutional caseload using the National Cancer Database, jointly sponsored by the American College of Surgeons and the American Cancer Society. METHODS We identified patients with stage I NSCLC (tumour ≤4 cm, clinical N0, M0) in the National Cancer Database who underwent lobectomy from 2010 to 2015. Hospital surgical volume was assigned based on total surgical volume for lung cancer. The cohort was divided into 2 groups: POD 1 discharge [length of stay (LOS) ≤ 1] and the standard discharge (LOS > 1). Outcome variables were compared in propensity matched cohorts, and the multivariable regression model was created to assess factors associated with LOS ≤ 1 and the occurrence of adverse events (unplanned readmissions, 30- and 90-day deaths). RESULTS A total of 52 830 patients underwent lobectomy for stage I NSCLC across 1231 treating facilities; 3879 (7.3%) patients were discharged on day 1 (LOS ≤ 1), whereas 48 951 (92.7%) were discharged after day 1 (LOS > 1). Factors associated with LOS ≤ 1 included male sex, higher socioeconomic status, right middle lobectomy, minimally invasive surgery and high-volume centres. The risk of adverse events was higher for LOS ≤ 1 in low [odds ratio (OR): 1.913, 95% confidence interval (CI) 1.448–2.527; P < 0.001] and median quartiles (OR: 2.258; 95% CI 1.881–2.711; P < 0.001), but equivalent in high-volume centres (OR: 0.871, 95% CI 0.556–1.364; P = 0.54). CONCLUSIONS The safety and efficacy of early discharge on POD 1 following lobectomy are associated with lung cancer surgical volume. Implementation of ‘enhanced recovery’ protocols is likely related to safe early discharges from high-volume centres.
The US Agency for International Development (USAID) receives directives and funding through the appropriation process, though until recently, global surgery was not included in its mission. Nevertheless, an estimated five billion people lack access to safe, timely, and affordable surgical care, in large part due to lack of economic resources. Using coalition-based advocacy, the G4 Alliance successfully developed and submitted language that was incorporated into the 2020 Appropriations report language, directing USAID to financially support global surgery. This has significant implications for global surgical investment, yet few advocates are aware of the 2020 Appropriations language, let alone how they can utilize it now to advance global surgery in their respective countries. Here, we describe how advocates navigate the US appropriations process and the ways USAID funds are obtained for the purposes of global health. We also highlight the importance of coalition-based advocacy and provide guidance in how to increase success.
Safe surgical care, including anesthesia, obstetrics, and trauma, is an essential component of a functional health system, yet five billion people lack access to high-quality, timely and affordable surgical care. As health decision makers are grappling with how to make appropriate investments for crisis readiness and resilience, investments in surgical care should be considered for their compounding benefits to meet a country’s diverse health goals. National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) are developed through global partnerships and multi-stakeholder consensus and provide a dynamic framework for surgical scale-up that also improves the resilience of the larger health system. Our paper applies principles from the literature on health system resilience to surgical systems and examines the unique capabilities of the surgical workforce and infrastructure to be redeployed during times of crisis, using examples from the current pandemic.
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