Long survival after neoadjuvant and adjuvant camrelizumab plus chemotherapy and surgery in a patient with hepatoid adenocarcinoma of the lung: A case report

Hepatoid adenocarcinoma of the lung (HAL) is a rare and aggressive subtype of lung cancer. The prognosis for patients with HAL is generally poor and currently, there are only limited treatment options. Here, we present a case of a 47-year-old male diagnosed with locally advanced-stage HAL who achieved a remarkably long disease-free survival after receiving neoadjuvant and adjuvant camrelizumab plus chemotherapy and surgery. This case highlights the potential of immunochemotherapy plus surgery in improving outcomes for patients with HAL.

Integration of a deep learning basal cell carcinoma detection and tumor mapping algorithm into the Mohs micrographic surgery workflow and effects on clinical staffing: A simulated, retrospective study

Background

Artificial intelligence (AI) enabled tools have been proposed as 1 solution to improve health care delivery. However, research on downstream effects of AI integration into the clinical workflow is lacking.

Objective

We aim to analyze how integration of an automated basal cell carcinoma detection and tumor mapping algorithm in a Mohs micrographic surgery unit impacts the work efficiency of clinical and laboratory staff.

Methods

Slide, staff, and histotechnician waiting times were analyzed over a 20-day period in a Mohs micrographic surgery unit. A simulated AI workflow was created and the time differences between the real and simulated workflows were compared.

Results

Simulated nonautonomous algorithm integration led to savings of 35.6% of slide waiting time, 18.4% of staff waiting time, and 18.6% of histotechnician waiting time per day. Algorithm integration on days with increased reconstruction complexity resulted in the greatest time savings.

Limitations

One Mohs micrographic surgery unit was analyzed and simulated AI integration was performed retrospectively.

Conclusions

AI integration results in reduced staff waiting times, enabling increased productivity and a streamlined clinical workflow. Schedules containing surgical cases with either increased repair complexity or numerous tumor removal stages stand to benefit most. However, significant logistical challenges must be addressed before broad adoption into clinical practice is realistic.

A systematic review of combined surgery and brachytherapy approaches for children and young people with relapsed and refractory rhabdomyosarcoma (Local-REFoRMS)

Approximately one third of children with rhabdomyosarcoma relapse or have refractory disease. Treatment approaches include a combination of systemic therapies and local therapies, directed at tumour site(s). This review was conducted to evaluate the effectiveness and safety of the combination of surgery and brachytherapy as local therapy for treating children and young people with relapsed/refractory rhabdomyosarcoma. This review identified studies based on a previous systematic review looking at the treatments for children and young people under 18 years old with relapsed/refractory rhabdomyosarcoma. Studies conducted after 2000 were included. Survival outcomes, relapse rates, adverse events and functional outcomes were extracted. From 16,965 records identified in the baseline systematic review, 205 included the words 'AMORE' or 'brachytherapy', and were screened for eligibility in this substudy. Thirteen studies met the inclusion criteria for Local-REFoRMS, including over 55 relapsed and refractory rhabdomyosarcoma patients. Most studies were retrospective cohort studies conducted within Europe. Most patients had embryonal disease within the head and neck or bladder/prostate regions, and received local therapy for first relapse. Approximately one quarter of patients relapsed following surgery and brachytherapy, with local relapses occurring more than metastatic relapse. Adverse events and functional outcomes were infrequently reported, but related to the site of surgery and brachytherapy. Study quality was limited by inconsistent reporting and potential selection bias. Outcomes following surgery and brachytherapy for a selected group of relapsed and refractory rhabdomyosarcoma show reasonable benefits, but reporting was often unclear and based on small sample sizes.

Successful surgical management of a pyothorax in a Guinea baboon (Papio papio)

A 16-year-old male Guinea baboon (Papio papio) was evaluated for weakness and focal wet fur of 1-week duration. A pyothorax caused by Streptococcus anginosus was diagnosed. A surgical approach was chosen, combined with a systemic antibiotic therapy. Medical imaging and C-reactive protein follow-up revealed the resolution of the pyothorax.

Systematic review of nerves at risk at the wrist in common surgical approaches to the forearm: Anatomical variations and surgical implications

Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to nerves around the wrist. Preserving these nerves is important to prevent complications such as neuroma formation and motor and sensory changes to the hand. We conducted a review of the literature to assess the nerves at risk and whether 'safe zones' exist to avoid these nerves. An independent reviewer conducted searches in Embase and MEDLINE of the literature from 2010 to 2020. A total of 68 papers were identified, with 18 articles being included in the review. Multiple nerves were identified as being at risk for each of the approaches described. In the anterior approach, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury. An incision immediately radial to the flexor carpi radialis (FCR) or directly over the FCR is most likely to avoid injury to both superficial branch of the radial nerve (SBRN) and PCBMN. With Thompson's approach, the safest zone for an incision is directly over or slightly radial to Lister's tubercle to avoid injury to SBRN and lateral cutaneous nerve of the forearm. For the ulnar approach, a safe zone was shown to be on the ulnar side of the wrist around the ulnar styloid (US) when the forearm was in supination or a neutral position to avoid injury to the dorsal branch of the ulna nerve (DBUN). Care must be taken around the US due to the density of nerves and the proximity of the last motor branch of the posterior interosseous nerve to the ulnar head. This review highlighted the proximity of nerves to the three most common surgical incisions used to access the forearm. In addition, anatomical variations may exist, and each of the nerves identified as being at risk has multiple branches. Both factors increase the potential of intraoperative damage if the anatomy is not properly understood. The surgeon must adhere carefully to the established approaches to the wrist and distal forearm to minimize damage to nerves and optimize surgical outcomes for the patient.

Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors

BACKGROUND

Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods.

METHODS

This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression.

RESULTS

The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events.

CONCLUSIONS

In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.

International consensus is needed on a core outcome set to advance the evidence of best practice in cancer prehabilitation services and research

Prehabilitation aims to optimise patients' physical and psychological status before treatment. The types of outcomes measured to assess the impact of prehabilitation interventions vary across clinical research and service evaluation, limiting the ability to compare between studies and services and to pool data. An international workshop involving academic and clinical experts in cancer prehabilitation was convened in May 2022 at Sheffield Hallam University's Advanced Wellbeing Research Centre, England. The workshop substantiated calls for a core outcome set to advance knowledge and understanding of best practice in cancer prehabilitation and to develop national and international databases to assess outcomes at a population level.

Rising vasectomy volume following reversal of federal protections for abortion rights in the United States

In June 2022 the United States Supreme Court issued a ruling in the case Dobbs v. Jackson that overturned Roe v. Wade, the 1973 ruling establishing a federally protected right to abortion in the United States. Anecdotal reports suggested increased vasectomy volume following this event; however, no published data exist. We sought to describe trends in vasectomy consultation before and after the Dobbs v. Jackson ruling (referred to as pre- and post-Dobbs herein). Following IRB approval, we reviewed charts of all adults seeking vasectomy consultation in July-August 2021 and July-August 2022 at a large healthcare organization. We then aggregated vasectomy procedural billing data from 2018 to present. The primary outcome was volume of vasectomy consultation appointments and the secondary outcome was number of vasectomies performed. In July-August 2021 (Pre-Dobbs), 116 men attended vasectomy consultation versus 142 men in July-August 2022 (Post-Dobbs). Median age Post-Dobbs was significantly younger than Pre-Dobbs (35 vs 38 years, respectively, p = 0.01) with a significant increase in Post-Dobbs men under 30 seeking vasectomy (p = 0.005). A total of 16.9% (24/142) of Post-Dobbs men were childless, compared to 8.6% (10/116) of Pre-Dobbs men (p = 0.05). Of those with children, median number of offspring was unchanged at 2. Billing data showed a significant increase in vasectomy procedural volumes Post-Dobbs. While overturning Roe v Wade directly impacted female reproductive rights, number of vasectomy consultations and procedures increased significantly following this decision. Younger men, especially those under 30, as well as childless men were significantly more likely to seek consultation Post-Dobbs compared to the prior reproductive legal climate. While longer-term data are needed, findings indicate that men are invested in maintaining reproductive autonomy for themselves and their partners.

Clinical characteristics, molecular aberrations, treatments, and outcomes of malignant histiocytosis

Malignant histiocytosis (MH) is an extremely rare neoplasm of the macrophage-dendritic cell lineage. We report the clinical characteristics, molecular aberrations, treatments, and outcomes of patients with MH seen at two referral centers from January 2000 to May 2023. We identified 43 patients with MH, of which 26 had histiocytic sarcoma (MH-H), 9 interdigitating dendritic cell sarcoma (MH-IDC), and 8 Langerhans cell sarcoma (MH-LC). The median age at diagnosis was 61 years (range, 3-83). Thirty-three patients (77%) had multifocal disease, while 10 had unifocal involvement. Tumor specimens from 22 patients (51%) underwent targeted next generation sequencing, and 19 of 22 (86%) had at least one pathogenic mutation, including mutations in MAPK pathway genes (73%). The median overall survival (OS) among the entire cohort was 16 months (95% CI: 8-50). The outcomes of those with multifocal disease were significantly shorter than their unifocal counterpart: median OS of 10 months versus 50 months (p = .07). Patients with risk organ involvement (bone marrow, spleen, or liver) had significantly inferior outcomes. Chemotherapy and surgery were the most common first-line treatments for multifocal and unifocal disease, respectively. While the outcome for patients with multifocal disease was poor, there was a subset of patients who had durable responses to treatment. Our study highlights that MH has heterogeneous clinical presentation, frequent oncogenic mutations, and prognosis, which is strongly tied to disease extent and type of organ involvement.

Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review

BACKGROUND

Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs).

OBJECTIVES

This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers.

SEARCH STRATEGY

The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE.

SELECTION CRITERIA

Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included.

DATA COLLECTION AND ANALYSIS

Results were synthesized using narrative synthesis approach with emergence of key themes by frequency.

MAIN RESULTS

The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing.

CONCLUSIONS

A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.

A guide for addressing sexual health in breast cancer patients

PURPOSE

Sexual health concerns are common in breast cancer surgery but often overlooked. Yet, breast cancer patients want more sexual health information from their providers. We aimed to share ways for providers to address sexual health concerns with their breast cancer patients at different stages of the treatment process.

METHODS

Experts in breast cancer treatments, surgeries, and sexual health at Memorial Sloan Kettering Cancer Center assembled to review the literature and to develop the recommendations.

RESULTS

Providers should provide sexual health information for their breast cancer patients throughout the continuum of care. Conversations should be initiated by the providers and can be brief and informative. Whenever appropriate, patients should be referred to Sexual Medicine experts and/or psychosocial support. There are various recommendations and tools that can be utilized at diagnosis, endocrine and chemotherapy, and breast surgery to identify patients with sexual health concerns and to improve their sexual functioning.

CONCLUSION

In this paper, we sought to provide providers with some insights, suggestions, and tools to address sexual health concerns. We encourage healthcare providers to initiate the conversation throughout the continuum of care beginning as early as diagnosis and refer patients to additional services if available.

Seek and ye shall find: The utility of perioperative VTE screening in high-risk oncologic patients undergoing abdominopelvic surgery

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the prevalence and risk factors associated with perioperative venous thromboembolism (VTE) in patients undergoing major oncologic surgery using an epidural catheter (EC) for postoperative analgesia with mechanical prophylaxis and without chemoprophylaxis.

METHODS

Six hundred and twenty-six patients undergoing major oncologic surgery from 2009 to 2023 were evaluated. VTE was defined as deep vein thrombosis above the level of the knee. Lower extremity venous duplexes (LEVDs) were done preoperatively and postoperatively after the EC was removed. All patients received mechanical thromboprophylaxis, but not chemical prophylaxis, while the EC was in place. A generalized linear multivariable model was constructed to identify risk factors that predict pre and postoperative VTE.

RESULTS

29/626 patients (4.6%) were found to have preoperative VTE. 16/626 (2.6%) were found to have a postoperative VTE when their preoperative LEVD was negative. In comparison to patients without preoperative VTE, those with VTE were more likely to be male, anticoagulated, and have a history of coronary artery disease. Patients in the postoperative VTE group were older, male, anticoagulated, and had a history of VTE. On multivariable analysis, previous history of VTE was the risk factor most strongly associated with both pre and postoperative VTE.

CONCLUSION

Oncologic patients undergoing elective abdominopelvic surgery with epidural analgesia should be screened in the perioperative setting with LEVD to identify VTE and possibly prevent PE.

"Right Into the Center": A Semantic Analysis of Direction in Operating Room Instruction

OBJECTIVE

In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction.

DESIGN

We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR.

SETTING

Midwestern academic university teaching hospital.

PARTICIPANTS

Six attending and 6 resident surgeons.

RESULTS

Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech.

CONCLUSIONS

Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.

Genetics may affect the risk of undergoing surgery for rhizarthrosis

Osteoarthritis is a prevalent and severe disease. Involvement of the trapeziometacarpal joint is common and can lead to both pain and disability. Genetics are known to affect the risk of osteoarthritis, but it remains unclear how genetics affect disease trajectories. In this study, we investigated whether the genetic associations of trapeziometacarpal osteoarthritis (rhizarthrosis) vary with the need for surgical treatment. The study was conducted as a case-control genome-wide association study using individuals from the Copenhagen Hospital Biobank pain and degenerative musculoskeletal disease study and the Danish Blood Donor Study (N = 208,342). We identified patients diagnosed with rhizarthrosis and grouped them by treatment status, resulting in two case groups: surgical (N = 1083) and nonsurgical (N = 1888). The case groups were tested against osteoarthritis-free controls in two genome-wide association studies. We then compared variants suggestive of association (p < 10-6) in either of these analyses directly between the treatment groups (surgical vs. nonsurgical rhizarthrosis). We identified 10 variants suggestive of association with either surgical (seven variants) or nonsurgical (three variants) rhizarthrosis. None of the variants reached nominal significance in the opposite treatment group (p ≥ 0.14), and all 10 variants were significantly different between the treatment groups at a false discovery rate of 5%. These results suggest possible differences in the genetic associations of rhizarthrosis depending on surgical treatment. Clinical significance: Uncovering genetic differences between clinically distinct patient groups can reveal biological determinants of disease trajectories.

Perioperative methadone for posterior spinal fusion in adolescents: Results from a double-blind randomized-controlled trial

BACKGROUND

Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized-controlled trials are lacking in the pediatric literature.

AIMS

We conducted a single-center double-blind randomized-controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion.

METHODS

A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid-related side effects, and ratio of patient-controlled analgesia injections: attempts as a behavioral index of uncontrolled pain.

RESULTS

Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] -0.07 [-0.2 to 0.02]; (p = .026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p = .250). Groups did not differ on opioid-related side effects.

CONCLUSIONS

A two-dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid-related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion.

Management of intracranial cavernous malformations using conservative vs. surgical and/or radiosurgical treatment: A systematic review and meta‑analysis

Intracranial cavernous malformations (CMs) are vascular lesions with a high bleeding rate. At present, the debate regarding their treatment is still ongoing. The present systematic review and meta-analysis aimed to evaluate the safety of surgery or radiosurgery (SRS) for the management of CMs and to determine their potential outcomes compared with conservative treatment. The present systematic review and meta-analysis investigated the relative articles involving the management of intracranial CMs, namely their natural history (conservative treatment) vs. surgical/SRS treatment through electronic databases until June, 2023. The collected variables included the first author's name, the study period covered, the year of publication, the total number of patients examined and their age, and the number of males. In total, six articles met the eligibility criteria. The total number of patients was 399 (157 in the surgery/SRS group and 242 in the conservative treatment group). The results revealed that surgical or SRS management is a safe procedure for CMs compared with conservative treatment. Notably, the use of hemosiderin in the pre-MRI, the free of seizures parameter and the neurological deficit parameters were associated with improved outcomes in the surgical or SRS group of patients.

Primary Site Surgery in Distantly Metastatic Oropharyngeal Squamous Cell Carcinoma

OBJECTIVES

Determine if intensive local therapy (i.e., local surgery or radiation) has a survival benefit for patients presenting with distantly metastatic oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

Retrospective population-based cohort study of patients in the National Cancer Database presenting with distantly metastatic OPSCC. Overall survival (OS) was compared for patients receiving systemic therapy alone or in combination with local surgery or curative dose radiation, controlling for various clinicodemographic factors.

RESULTS

Between 2010 and 2015, 627 patients presented with newly diagnosed, metastatic OPSCC and an initial treatment course including systemic chemotherapy. Multivariable analysis demonstrated that local radiation therapy was independently associated with improved OS (OR 0.64, CI [0.51-0.81]); local surgery was not independently associated with improved OS (OR 0.99, CI [0.65-1.53]). Higher T stages were associated with worse OS (OR 1.69, CI [1.14-2.50] for T3 and OR 1.77, CI [1.22-2.58] for T4 compared to T1). HPV-positive (HPV+) tumors were associated with improved OS compared to HPV- (OR 0.79, CI [0.64-0.97]). Multiagent chemotherapy was associated with improved OS compared to single-agent (OR 0.78, CI [0.62-1.00]). The best survival for the entire cohort and for HPV+ patients was for radiation with systemic therapy and the worst survival for systemic therapy alone.

CONCLUSIONS

Curative dose local radiotherapy in addition to systemic therapy is associated with improved OS compared to systemic therapy alone in patients presenting with distantly metastatic OPSCC. There is not a significant survival benefit for local surgery in addition to systemic therapy in this patient population, regardless of HPV status.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2243-2251, 2024.

Contralateral Nodal Relapse in Well-lateralised Oral Cavity Cancers Treated Uniformly with Ipsilateral Surgery and Adjuvant Radiotherapy With or Without Concurrent Chemotherapy: a Retrospective Study

AIMS

To evaluate the incidence and pattern of contralateral nodal relapse (CLNR), contralateral nodal relapse-free survival (CLNRFS) and risk factors predicting CLNR in well-lateralised oral cavity cancers (OCC) treated with unilateral surgery and adjuvant ipsilateral radiotherapy with or without concurrent chemotherapy.

MATERIALS AND METHODS

Consecutive patients of well-lateralised OCC treated between 2012 and 2017 were included. The primary endpoint was incidence of CLNR and CLNRFS. Univariable and multivariable analyses were carried out to identify potential factors predicting CLNR.

RESULTS

Of the 208 eligible patients, 21 (10%) developed isolated CLNR at a median follow-up of 45 months. The incidence of CLNR was 21.3% in node-positive patients. CLNR was most common at level IB (61.9%) followed by level II. The 5-year CLNRFS and overall survival were 82.5% and 57.7%, respectively. Any positive ipsilateral lymph node (P = 0.001), two or more positive lymph nodes (P < 0.001), involvement of ipsilateral level IB (P = 0.002) or level II lymph node (P < 0.001), presence of extranodal extension (P < 0.001), lymphatic invasion (P = 0.015) and perineural invasion (P = 0.021) were significant factors for CLNR on univariable analysis. The presence of two or more positive lymph nodes (P < 0.001) was an independent prognostic factor for CLNR on multivariable analysis. CLNR increased significantly with each increasing lymph node number beyond two compared with node-negative patients.

CONCLUSION

The overall incidence of isolated CLNR is low in well-lateralised OCC. Patients with two or more positive lymph nodes have a higher risk of CLNR and may be considered for elective treatment of contralateral neck.

Attitudes and perceptions of cancer patients and healthcare providers towards prehabilitation: A thematic synthesis

PURPOSE

Prehabilitation, which is the process of enhancing functional capacity before undergoing surgery or other treatments, has been shown to improve cancer patients' outcomes. Patient and healthcare provider attitudes and perceptions are essential factors in the successful implementation of prehabilitation. The purpose of this systematic review is to synthesize qualitative evidence and explore the barriers and facilitators to prehabilitation implementation.

METHODS

From the earliest available date to October 2023, 7 databases (PubMed, Web of Science, Cochrane Library, Embase, CINAHL, PsycINFO, and MEDLINE) were searched for a systematic review. Data were extracted, thematically analysed, and mapped onto the Capability, Opportunity, and Motivation Model of Behaviour (COM-B). The Critical Appraisal Skills Programme (CASP) tool was used to assess the quality of the studies.

RESULTS

A total of 26 studies were included, involving 377 patients, 51 caregivers, and 156 healthcare providers. 16 factors were identified and mapped onto the COM-B model: reflective/automatic motivation, physical/social opportunity, physical/ psychological capability.

CONCLUSIONS

Patients and healthcare provides identified a lack of reflective motivation and physical opportunities as the most significant barriers to engagement in prehabilitation. Personalized approaches, social support, and healthcare providers' engagement are key factors for prehabilitation. Future research should focus on developing effective interventions to enhance the uptake and sustainability of prehabilitation.

A supervised machine learning model for identifying predictive factors for recommending head and neck cancer surgery

BACKGROUND

New patient referrals are often processed by practice coordinators with little-to-no medical background. Treatment delays due to incorrect referral processing, however, have detrimental consequences. Identifying variables that are associated with a higher likelihood of surgical oncological resection may improve patient referral processing and expedite the time to treatment. The study objective is to develop a supervised machine learning (ML) platform that identifies relevant variables associated with head and neck surgical resection.

METHODS

A retrospective cohort study was conducted on 64 222 patient datapoints from the SEER database.

RESULTS

The random forest ML model correctly classified patients who were offered head and neck surgery with an 81% accuracy rate. The sensitivity and specificity rates were 86% and 71%. The positive and negative predictive values were 85% and 73%.

CONCLUSIONS

ML modeling accurately predicts head and neck cancer surgery recommendations based on patient and cancer information from a large population-based dataset. ML adjuncts for referral processing may decrease the time to treatment for patients with cancer.

Free flap reconstruction at a rural-based tertiary medical college hospital: Barriers and outcomes

BACKGROUND AND OBJECTIVES

In a rural-based setting, providing optimal treatment is often difficult owing to the limited resources and financial constraints being rampant in cancer care delivery. Oncological resections often result in large, complex defects requiring free flap reconstruction to achieve cosmetic and/or functional goals. This article focuses on our experience of starting and promoting microvascular reconstruction in a rural tertiary medical college hospital.

METHODS

Retrospective observational study of patients undergoing free flap reconstruction for oncological indications was included. Standard oncological principles were followed for cancer extirpation. Free flap reconstruction was done using loupes of 4× magnification. Flap-related outcomes and barriers in doing free flap reconstruction were analysed.

RESULTS

A total of 56 patients were included. The most common free flap undertaken was free anterolateral thigh flap in 21 (37.5%) patients. The mean duration of reconstruction was 438 min. Re-exploration was undertaken in 17 patients (30.4%). Nonsalvageable flap loss was 19.64%. Adjuvant treatment was administered in all patients as per oncological indications, albeit with some delay in 12.5%. Barriers to reconstruction were noted in the pre-, intra- and postoperative periods.

CONCLUSION

Reconstruction with free flaps is feasible in a resource-constrained setup with careful planning and a multidisciplinary team approach to overcome the barriers.

Drainage fluid LDH and neutrophil to lymphocyte ratio as biomarkers for early detecting anastomotic leakage in patients undergoing colorectal surgery

OBJECTIVES

In this study, we investigated the role of several circulating and drainage fluid biomarkers for detecting postoperative complications (PCs) and anastomotic leakage (AL) in patients undergoing colorectal surgery.

METHODS

All consecutive patients undergoing colorectal surgery between June 2018 and April 2020 were prospectively considered. On postoperative days (POD) 1, 3, and 5, we measured lactate dehydrogenase (LDH) in drainage fluid, C-reactive protein (CRP) in serum and drainage fluid, and neutrophil to lymphocyte ratio (NLR).

RESULTS

We enrolled 187 patients. POD1 patients with AL had higher serum CRP levels, while on POD3 and on POD5 higher NLR and serum CRP. LDH and CRP in drainage fluid were also significantly higher at both time points. The area under the curves (AUCs) of serum and drainage fluid CRP were 0.752 (0.629-0.875) and 0.752 (0.565-0.939), respectively. The best cut-off for serum and drainage fluid CRP was 185.23 and 76 mg/dL, respectively. The AUC of NLR on POD3 was 0.762 (0.662-0.882) with a sensitivity and specificity of 84 and 63 %, respectively, at a cut-off of 6,6. Finally, drainage fluid LDH showed the best diagnostic performance for AL, with an AUC, sensitivity, and specificity of 0.921 (0.849-0.993), 82 %, and 90 % at a cut-off of 2,186 U/L. Trends in serum parameters between patients with or without PCs or AL were also evaluated. Interestingly, we found that NLR decreased faster in patients without PCs than in patients with PCs and patients with AL.

CONCLUSIONS

Drainage fluid LDH and NLR could be promising biomarkers of PCs and AL.

Return to Sports After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) tears are one of the most common orthopedic injuries among athletes. Although a small proportion of patients with isolated tears can return to sports after completing a nonsurgical rehabilitation program, ACL reconstruction is frequently recommended for young athletes, especially those with concomitant knee injuries or symptomatic knee instability. Alongside emerging evidence for the effect of prehabilitation, the current standard of care for postoperative ACL physical therapy includes pain control, range of motion, quadriceps strengthening, weight bearing, postoperative bracing, and dynamic limb stabilization and control. The early rehabilitation period includes non-weight-bearing exercises and passive range of motion, which is followed by a longer period of gradual strengthening focused on regaining preinjury strength, proprioception, and control with progressively more demanding dynamic movements. The total rehabilitation period is expected to take around 9 months, during which the patient should be evaluated at frequent intervals by a licensed physical therapist in addition to a daily home exercise program. Prior to discharge from the rehabilitation program, patients should be evaluated by both the surgeon and physical therapist. Patients are encouraged to return to sports once they meet a set of perceptual, subjective, objective, neuromuscular, functional, sport-specific drills, and load management testing criteria.

Sinonasal Angiomatous Polyp: A Case Report and Review of Literature

Sinonasal angiomatous polyp (SAP) is a benign pseudoneoplastic lesion rarely reported in the literature. It may be misdiagnosed as a malignant neoplasm due to its aggressive features of bone erosion clinically or on imaging. We report the case of a 43-year-old woman with a 3 month history of unilateral nasal obstruction with recurrent epistaxis. Nasal endoscopy showed polypoid nasal mass occupying the left nasal cavity. Imaging was suggestive of malignant vascular tumor. The patient underwent surgical excision after embolization. Histopathology concluded to the diagnosis of SAP.

Experimental evaluation of accuracy and efficiency of two control strategies for a novel foot commanded robotic laparoscope holders with surgeons

The implementation of a laparoscope-holding robot in minimally invasive surgery enhances the efficiency and safety of the operation. However, the extra robot control task can increase the cognitive load on surgeons. A suitable interface may simplify the control task and reduce the surgeon load. Foot interfaces are commonly used for commanding laparoscope-holding robots, with two control strategies available: decoupled control permits only one Cartesian axis actuation, known as decoupled commands; hybrid control allows for both decoupled commands and multiple axes actuation, known as coupled commands. This paper aims to determine the optimal control strategy for foot interfaces by investigating two common assumptions in the literature: (1) Decoupled control is believed to result in better predictability of the final laparoscopic view orientation, and (2) Hybrid control has the efficiency advantage in laparoscope control. Our user study with 11 experienced and trainee surgeons shows that decoupled control has better predictability than hybrid control, while both approaches are equally efficient. In addition, using two surgery-like tasks in a simulator, users' choice of decoupled and coupled commands is analysed based on their level of surgical experience and the nature of the movement. Results show that trainee surgeons tend to issue more commands than the more experienced participants. Single decoupled commands were frequently used in small view adjustments, while a mixture of coupled and decoupled commands was preferred in larger view adjustments. A guideline for foot interface control strategy selection is provided.

Top advances of the year: Cervical cancer

The year 2023 was an extraordinary year for the further development and expansion of novel treatments for all patients with cervical cancer, ranging from early stage to later stage and metastatic or recurrent disease. Individuals with early-stage disease will benefit from less invasive surgery with subsequent improvement in quality of life. The effectiveness of immunotherapy has been demonstrated in upfront, locally advanced cervical cancer and confirmed in advanced metastatic disease. Induction chemotherapy will play a role in some patients with locally advanced disease, particularly those in low resource areas of the world. Novel therapeutics including antibody-drug conjugates have shown efficacy even in pretreated patients. As we continue to explore innovative therapeutics in this space, however, we must also continue to improve the diversity of clinical trial accrual to allow for generalizable results. At the same time, we must focus on eradicating this disease with appropriate screening and vaccination.

The diagnostic, therapeutic, and ethical impact of artificial intelligence in modern medicine

In the evolution of modern medicine, artificial intelligence (AI) has been proven to provide an integral aspect of revolutionizing clinical diagnosis, drug discovery, and patient care. With the potential to scrutinize colossal amounts of medical data, radiological and histological images, and genomic data in healthcare institutions, AI-powered systems can recognize, determine, and associate patterns and provide impactful insights that would be strenuous and challenging for clinicians to detect during their daily clinical practice. The outcome of AI-mediated search offers more accurate, personalized patient diagnoses, guides in research for new drug therapies, and provides a more effective multidisciplinary treatment plan that can be implemented for patients with chronic diseases. Among the many promising applications of AI in modern medicine, medical imaging stands out distinctly as an area with tremendous potential. AI-powered algorithms can now accurately and sensitively identify cancer cells and other lesions in medical images with greater accuracy and sensitivity. This allows for earlier diagnosis and treatment, which can significantly impact patient outcomes. This review provides a comprehensive insight into diagnostic, therapeutic, and ethical issues with the advent of AI in modern medicine.

Soft and hard tissue evaluation of guided socket shield implant cases

BACKGROUND

The socket-shield (SS) technique results in long-term functional osseo- and dento-integration, preserving the dimensional stability of hard and soft tissues over time. This study aimed to describe the successful implementation of a surgical technique to facilitate "SS" cases.

METHODS

The cases included males and females aged 32-81 years consecutively treated between 2020 and 2023 (longest follow-up, 3.5 years). For each case, pre- and post-operative cone-beam computed tomography (Digital Imaging and Communications in Medicine files) and intraoral optical scans (IOS; STL files) were performed. Digital immediate implant placement and simultaneous tooth extraction and SS production were planned using an implant planning software. Implants were planned considering sagittal-ridge and tooth-root angular-configuration. Surgical guides were used to perform the digitally-supported SS technique. All cases were planned and surgically performed by one operator (Pedro M. Trejo). Preoperative digital IOS-models were superimposed to post-operative models to assess soft-tissue changes. Pre and post sagittal views were used to assess the radiographic buccal-plate thickness at various healing times. An investigator not involved with case planning or treatment performed measurements.

RESULTS

Results reflected soft-tissue stability with minimal mean thickness change at 0-, 1-, 2-, and 3-mm measurement levels of 0.03, -0.2, 0.14, -0.07, and 0.04 mm, respectively, with a mean gingival-margin change of 0.04 mm. The free gingival-margin change ranged from a 0.58-mm gain in height to a -0.57-mm loss. The mean radiographic buccal-plate thickness post-operatively was 2.04 mm (range, 0.7-2.9 mm).

CONCLUSION

The digitally-supported guided SS technique enables predictable immediate implant-placement positions and stable buccal peri-implant soft and hard tissues over time.

KEY POINTS

Why are these cases new information? The uniqueness of the surgical technique described herein is that it results in favorable positions of immediate, socket-shielded (SSed), implant placements, with soft- and hard-tissue stability as the byproduct. What are the keys to successful management of these cases? Digitally, plan for the best possible implant position within the alveolar housing to satisfy prosthetic requirements, and then adjust this position to accommodate the socket shield dimensions. Digitally, provide a space/gap between the future dentinal shield and the implant. Clinically, allow for time to carve the final position and dimensions of the shield. Plan ahead the extent of the apical third of the SS, and the removal of the apex, if dealing with a long root. What are the primary limitations to success in these cases? Inadequate use of digital technology; case-sensitive technique requires proper execution of each digital and technical clinical step.

Single Center Prospective Study of Cross-Clamp versus Balloon Occlusion in Robotic Mitral Surgery

BACKGROUND

Both transthoracic aortic cross-clamp and endoaortic balloon occlusion have been shown to have comparable safety profiles for aortic occlusion. Since most surgeons use only one technique, we sought to compare the outcomes when a homogeneous group of surgeons changed their occlusion technique from aortic cross-clamp to balloon occlusion.

METHODS

We changed our technique from aortic cross-clamp to balloon occlusion in November 2022. This allowed us to conduct a prospective treatment comparison study in the same group of surgeons. Propensity score matching (PSM) was used to match cases(balloon occlusion) 1:3 to controls (aortic cross-clamp) based on age, gender, body mass index, concomitant maze, and tricuspid valve repair.

RESULTS

Total of 411 patients underwent robotic mitral surgery from 2020 through 2023. Using PSM, 56 balloon occlusion patients were matched to 168 aortic cross-clamp patients. Median age was 65 years (interquartile range[IQR],55.6-70.0) and the majority were males(n=119,53%). All valves were successfully repaired. Balloon occlusion had a shorter median cardiopulmonary bypass (CPB) time compared to aortic cross-clamp (84.0 vs. 94.5 min,p=0.006). Median cross-clamp time (64.0 vs. 64.0 min,p=0.483) and total surgery time (5.9 vs. 6.1 hours,p=0.495) did not differ between groups. There was no in hospital death. There were five surgeons who performed various combinations of console and bedside roles. CPB, cross-clamp, and surgery durations were not significantly affected by the different surgeon combinations.

CONCLUSIONS

Compared to aortic cross-clamp, balloon occlusion has similar perioperative and early postoperative outcomes. Additionally, it likely introduces a 10-minute reduction in total CPB time.

The effect of socioeconomic status and training programmes on burnout in postgraduate trainees in the United Kingdom: a cross-sectional analysis

PURPOSE

Burnout is described as a state of mental exhaustion caused by one's professional life and is characterised by three domains: emotional exhaustion, depersonalisation, and a reduced sense of accomplishment. The prevalence of stress is high amongst doctors and varies by specialty, gender, trainee level, and socioeconomic status. The authors set out to examine the scale of the problem, as well as to determine the influence of both socioeconomic status and chosen training programme on burnout amongst postgraduate trainees. This would identify at-risk groups and aid in future targeted interventions.

METHODS

Cross-sectional data were obtained, following approval from the General Medical Council, from The National Training Survey, completed annually by all trainees in the United Kingdom. Data were then anonymised and analysed. Burnout scores were derived from the Copenhagen Burnout Inventory and are positively framed (higher scores equal lower burnout).

RESULTS

The questionnaire was completed by 63 122 participants from 2019 to 2020. Mean burnout amongst all trainees was 52.4 (SD = 19.3). Burnout scores from the most deprived quintile was significantly lower compared with those from the least deprived quintile: 51.0 (SD = 20.6) versus 52.9 (SD = 18.9), respectively (P < 0.001). The highest levels of burnout were reported in Internal Medical Training, Emergency Medicine, Obstetrics and Gynaecology, and Core Surgical Training, respectively.

CONCLUSION

Postgraduates from lower socioeconomic backgrounds are more likely to encounter burnout during training. At-risk groups who may also benefit from targeted intervention have been identified, requiring further examination through future studies.

A Survey of Demographics and Treatments in Melanoma Case Reports: Retrospective Bibliometric Analysis

Melanoma case reports show variations in treatment by age and sex.

3-Dimensional Pouchography: A Proof-of-Concept Study of a Novel Technique for Visualizing Ileoanal Pouch Anatomy & Morphology in Normal and Mechanical Pouch Complication Patients

BACKGROUND

Herein, we present a proof-of-concept study of 3-dimensional (3D) pouchography using virtual and printed 3D models of ileal pouch-anal anastomosis (IPAA) in patients with normal pouches and in cases of mechanical pouch complications.

MATERIALS & METHODS

We performed a retrospective, descriptive case series of a convenience sample of 10 pouch patients with or without pouch dysfunction who had CT scans appropriate for segmentation were identified from our pouch registry. The steps involved in clinician-driven automated 3D reconstruction are presented.

RESULTS

Three patients who underwent CT imaging and were found to have no primary pouch pathology, and seven patients with known pouch pathology identifiable with 3D reconstruction including pouch strictures, megapouch, pouch volvulus, and twisted pouches underwent 3D virtual modeling; one normal and one twisted pouch were 3D printed. We discovered that 3D pouchography reliably identified staple lines (pouch body, anorectal circular and transverse, and tip of J), the relationship between staple lines, and variations in pouch morphology, and pouch pathology.

CONCLUSIONS

Three-dimensional reconstruction of IPAA morphology is highly feasible using readily available technology. In our practice, we have found 3D pouchography to be an extremely useful adjunct to diagnose various mechanical pouch complications and improve planning for pouch salvage strategies. Given its ease of use and helpfulness in understanding the pouch structure and function, we have started to routinely integrate 3D pouchography into our clinical pouch referral practice. Further study is needed to formally assess to value of this technique to aid in the diagnosis of pouch pathology.

Emergency surgical decompression of the orbit may rescue impaired vision even in a patient presenting late with a retrobulbar haematoma: A case report from rural southwestern Uganda

Retrobulbar haematoma is a rare emergency that can potentially lead to blindness. Common causes include facial trauma and surgery. Timely surgical evacuation of the haematoma improves visual outcomes. In rural communities, patients often present to hospital after many hours and this increases the risk of poor visual outcomes. Radiological evaluation which is often not available in rural communities, results in further delay in surgical treatment. This case report highlights the need for urgent surgical intervention over radiological evaluation in patients with retrobulbar haematoma and orbital compartment syndrome.

A protocol for the conduct of a multicentre, prospective, randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures

Aims

Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures.

Methods

The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive.

Discussion

The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England - Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024.

Modern management of the axilla

Surgical management of the axilla has evolved considerably in recent years, with a strong focus on de-escalation to minimise morbidity whilst maintaining oncological outcomes. Current trials will focus on the omission of Sentinel node biopsy in select groups of patients, while axillary lymph node dissection will be reserved for those with more aggressive disease.

Associations of preoperative anaemia with healthcare resource use and outcomes after colorectal surgery: a population-based cohort study

BACKGROUND

Preoperative anaemia is common in patient undergoing colorectal surgery. Understanding the population-level costs of preoperative anaemia will inform development and evaluation of anaemia management at health system levels.

METHODS

This was a population-based cohort study using linked, routinely collected data, including residents from Ontario, Canada, aged ≥18 yr who underwent an elective colorectal resection between 2012 and 2022. Primary exposure was preoperative anaemia (haemoglobin <130 g L-1 in males; <120 g L-1 in females). Primary outcome was 30-day costs in 2022 Canadian dollars (CAD), from the perspective of a publicly funded healthcare system. Secondary outcomes included red blood cell transfusion, major adverse events (MAEs), length of stay (LOS), days alive at home (DAH), and readmissions.

RESULTS

We included 54,286 patients, with mean 65.3 (range 18-102) years of age and 49.0% females, among which 21 264 (39.2%) had preoperative anaemia. There was an absolute adjusted cost increase of $2671 per person at 30 days after surgery attributable to preoperative anaemia (ratio of means [RoM] 1.05, 95% confidence interval [CI] 1.04-1.06). Compared with the control group, 30-day risks of transfusion (odds ratio [OR] 4.34, 95% CI 4.04-4.66), MAEs (OR 1.14, 95% CI 1.03-1.27), LOS (RoM 1.08, 95% CI 1.07-1.10), and readmissions (OR 1.16, 95% CI 1.08-1.24) were higher in the anaemia group, with reduced DAH (RoM 0.95, 95% CI 0.95-0.96).

CONCLUSIONS

Approximately $2671 CAD per person in 30-day health system costs are attributable to preoperative anaemia after colorectal surgery in Ontario, Canada.

Towards global model generalizability: independent cross-site feature evaluation for patient-level risk prediction models using the OHDSI network

BACKGROUND

Predictive models show promise in healthcare, but their successful deployment is challenging due to limited generalizability. Current external validation often focuses on model performance with restricted feature use from the original training data, lacking insights into their suitability at external sites. Our study introduces an innovative methodology for evaluating features during both the development phase and the validation, focusing on creating and validating predictive models for post-surgery patient outcomes with improved generalizability.

METHODS

Electronic health records (EHRs) from 4 countries (United States, United Kingdom, Finland, and Korea) were mapped to the OMOP Common Data Model (CDM), 2008-2019. Machine learning (ML) models were developed to predict post-surgery prolonged opioid use (POU) risks using data collected 6 months before surgery. Both local and cross-site feature selection methods were applied in the development and external validation datasets. Models were developed using Observational Health Data Sciences and Informatics (OHDSI) tools and validated on separate patient cohorts.

RESULTS

Model development included 41 929 patients, 14.6% with POU. The external validation included 31 932 (UK), 23 100 (US), 7295 (Korea), and 3934 (Finland) patients with POU of 44.2%, 22.0%, 15.8%, and 21.8%, respectively. The top-performing model, Lasso logistic regression, achieved an area under the receiver operating characteristic curve (AUROC) of 0.75 during local validation and 0.69 (SD = 0.02) (averaged) in external validation. Models trained with cross-site feature selection significantly outperformed those using only features from the development site through external validation (P < .05).

CONCLUSIONS

Using EHRs across four countries mapped to the OMOP CDM, we developed generalizable predictive models for POU. Our approach demonstrates the significant impact of cross-site feature selection in improving model performance, underscoring the importance of incorporating diverse feature sets from various clinical settings to enhance the generalizability and utility of predictive healthcare models.

Knowledge, attitudes and practice towards postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses in Beijing: a cross-sectional survey

OBJECTIVE

To explore the knowledge, attitudes and practice (KAP) towards the postoperative nursing of patients with digit replantation and skin flap transplantation among new nurses.

DESIGN

Cross-sectional survey.

SETTING

Two tertiary medical centres in Beijing, China.

PARTICIPANTS

New nurses with working experience within 2 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The demographic characteristics of the nurses and their KAP towards the postoperative nursing of patients with digit replantation and skin flap transplantation were collected using a self-administered questionnaire. The primary outcome was the KAP scores towards the postoperative nursing of patients with digit replantation and skin flap transplantation. The secondary outcomes were the factors associated with the KAP scores and how the KAP dimensions interacted among them.

RESULTS

A total of 206 valid questionnaires were collected. The mean KAP scores were 7.72±3.28 (total score 13; 59.3%), 37.95±6.05 (total score 50; 75.9%) and 38.23±6.12 (total score 45; 84.9%), indicating poor knowledge, moderately favourable attitudes and active practice. The structural equation model analysis showed that knowledge directly influences attitudes (β=0.82, 95%CI 0.60 to 1.05, p<0.001) and that attitudes directly influence practices (β=0.72, 95%CI 0.62 to 0.83, p<0.001). Knowledge had no direct influence on practices (β=0.10, 95%CI -0.09 to 0.29, p=0.313), but the indirect influence was significant (β=0.60, 95%CI 0.41 to 0.78, p<0.001).

CONCLUSION

The lack of sufficient knowledge towards the postoperative nursing of patients with digit replantation and skin flap transplantation among nurses with <2 years of experience and the correlation among the KAP dimensions suggested the importance of proper training.

Bilateral spheno-orbital meningiomas: surgical management, progression, and recurrence

OBJECTIVE

Bilateral spheno-orbital meningiomas (bSOMs) are a rare entity among meningiomas. These tumors are benign and predominantly affect women. They represent 4% of spheno-orbital meningiomas (SOMs) and are poorly described in the literature. This study aimed to describe the characteristics, risk factors, evolution, and management of bSOMs.

METHODS

Twenty patients with bSOMs were enrolled in a multicentric descriptive study including 15 neurosurgical departments.

RESULTS

In this study, the authors found that bSOMs affected exclusively women, with a mean age of 50 years. Approximately 65% of patients were on progestin therapy. The mean follow-up in this series was 55 months. Clinically, visual symptoms were predominant: proptosis was present in 17 of 20 patients (85%; 7 unilateral, 10 bilateral), and a decrease in visual acuity was observed in 11 of 20 patients (55%; 6/10 to 9/10 in 6 patients, 3/10 to 5/10 in 1 patient, and < 3/10 in 4 patients). Contrary to unilateral SOMs, the authors identified that intracranial hypertension was a common presentation (25%) of bSOMs. Surgical management with gross-total resection was the gold standard treatment. Recurrences only occurred following subtotal resection in 36% to 60% of patients, with a median time of 50 to 54 months after surgery. Visual improvement or stability was observed in 75% of cases postoperatively. Progesterone receptor expression levels were 70% to 100% in 10 of 11 (91%) cases.

CONCLUSIONS

Bilateral SOMs are usually found in female patients and are strongly associated with hormone replacement therapy. Early surgical management with gross-total resection is the most effective treatment in terms of recurrence and improves visual acuity. Given the slow progressive nature of bSOMs and their time to recurrence, which can be up to 10 years, long-term follow-up of patients is essential.

Treatment strategies for pelvic organ prolapse and postoperative outcomes in older women with long-term care needs: A population-based retrospective cohort study

OBJECTIVE

The study aimed to investigate treatment options for older women with pelvic organ prolapse (POP) and postoperative outcomes based on their long-term care (LTC) status.

METHODS

We used the medical and LTC insurance claims databases of Tochigi Prefecture in Japan, covering 2014 to 2019. We included women 65 years and older with POP and evaluated their care status and treatment, excluding women with an observation period <6 months. Among women with a postsurgical interval ≥6 months, we compared care level changes and deaths within 6 months and complications within 1 month postoperatively between those with and without LTC using Fisher exact test.

RESULTS

We identified 3406 eligible women. Of the 447 women with LTC and 2959 women without LTC, 16 (3.6%) and 415 (14.0%), respectively, underwent surgery. Among 393 women with a postsurgical interval ≥6 months, 19 (4.8%) required LTC at surgery. Two of the 19 women with LTC (10.5%) and eight of 374 women without LTC (2.1%) experienced worsening care-needs level. No deaths were recorded. Urinary tract infection (UTI) was significantly more frequent in women with LTC than in women without LTC (36.8% vs 8.6%). Other complications were rare in both groups.

CONCLUSION

The proportion of patients who underwent surgery for POP was lower in women with LTC than in women without LTC. Postoperative UTI was common and 11% had a worsening care-needs level postoperatively, whereas other complications were infrequent. Further detailed studies would contribute to providing optimal treatment to enhance patients' quality of life.

Challenges in Diagnosing and Treating Subperiosteal Orbital Hematoma Secondary to Sinusitis: A Case

Subperiosteal orbital hematoma secondary to sinusitis is rare. Thus far, 19 cases of this disease have been reported, of which none involved postoperative skin anesthesia in the region innervated by the supraorbital nerve. In this article, for the first time we report a case of subperiosteal orbital hematoma secondary to sinusitis with skin anesthesia in the area innervated by the supraorbital nerve after surgery.

Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study

BACKGROUND

Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects.

METHODS

We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID).

RESULTS

Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034).

CONCLUSIONS

Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Perioperative management of a double valve replacement and coronary artery bypass graft in a patient with carcinoid syndrome; a case report and literature review

INTRODUCTION

Carcinoid tumors are rare neuroendocrine tumors; about 5% of patients develop the carcinoid syndrome. We present the case of a patient with carcinoid syndrome undergoing cardiac surgery.

CASE REPORT

A 74-year-old patient with carcinoid heart disease and hepatic metastases underwent double valve replacement and CABG. The patient was on octreotide therapy and antihypertensive medication. An octreotide infusion was commenced perioperatively. Pharmaceutical agents that could potentially precipitate histamine release or exacerbate catecholamine secretion and carcinoid crises were avoided. Postoperatively, recovery was complicated by atrial fibrillation, chest infection, pleural effusions, acute kidney injury and delirium.

DISCUSSION

Hepatic metastases cause systemic hormones' secretion, which cause a carcinoid crisis. Perioperative administration of octreotide is used, while vigilance is required to differentiate between hemodynamic effects related to the operation or disease specific factors.

CONCLUSION

No carcinoid crisis was evident perioperatively. High vigilance with appropriate monitoring, aggressive management combined with meticulous choice of pharmaceutical agents led to this outcome.

Comparative effectiveness of angioembolization versus open surgery in patients with blunt splenic injury

The effectiveness and safety of transcatheter splenic artery embolization (SAE) compared to those of open surgery in patients with blunt splenic injury (BSI) remain unclear. This retrospective cohort-matched study utilized data from the Japan Trauma Data Bank recorded between 2004 and 2019. Patients with BSI who underwent SAE or open surgery were selected. A propensity score matching analysis was used to balance the baseline covariates and compare outcomes, including all-cause in-hospital mortality and spleen salvage. From 361,706 patients recorded in the data source, this study included 2,192 patients with BSI who underwent SAE or open surgery. A propensity score matching analysis was used to extract 377 matched pairs of patients. The in-hospital mortality rates (SAE, 11.6% vs. open surgery, 11.2%, adjusted relative risk (aRR): 0.64; 95% confidence interval [CI]: 0.38-1.09, p = 0.10) were similar in both the groups. However, spleen salvage was significantly less achieved in the open surgery group than in the SAE group (SAE, 87.1% vs. open surgery, 32.1%; aRR: 2.84, 95%CI: 2.29-3.51, p < 0.001). Survival rates did not significantly differ between BSI patients undergoing SAE and those undergoing open surgery. Nonetheless, SAE was notably associated with a higher likelihood of successful spleen salvage.

Inferior Rectus Muscle Y-Split for Thyroid-Related Vertical Strabismus

Incomitant hypotropia in thyroid eye disease can be difficult to manage, especially in the presence of orthotropia with fusion in down gaze and reading position. Recessing the affected ipsilateral inferior rectus muscle may result in an undesirable downgaze diplopia secondary to a hypertropia in downgaze. Various surgical techniques have been described to manage this potential complication including asymmetric recession of both inferior rectus muscles, posterior myoscleropexy operation, and the Scott recess/resect procedure of the contralateral inferior rectus. In 2004, Hoerantner et al. introduced the y-split recession of the medial rectus muscle for near esotropic deviations. The anterior portion of muscle is split and secured in a y-shaped configuration, which reduces the muscle lever arm and helps minimize incomitance and muscle slippage. Unlike the traditional Cüppers Faden, a y-split recession results in torque reduction in all gaze positions. In addition, a y-split recession does not involve scleral passes posteriorly reducing the risk of globe perforation. We report a patient with incomitant strabismus secondary to thyroid eye disease who underwent a combination of traditional recession and y-splitting recession of the contralateral inferior rectus muscle, resulting in good functional alignment in primary gaze and in the reading position.

Clinical course of patients with conservatively managed cerebral cavernous malformations

INTRODUCTION

There is uncertainty whether patients with a cerebral cavernous malformation (CCM) should undergo conservative or surgical treatment, resulting in practice variation among hospitals. Our objective was to report clinical outcomes of patients with primarily conservatively managed CCMs.

PATIENTS AND METHODS

This single-center cohort study included consecutive adult CCM patients, diagnosed in 2000-2023, who underwent conservative management as primary treatment strategy. Data were extracted from medical records, and we systematically conducted telephone and questionnaire follow-up. Functional status was assessed on the modified Rankin Scale (mRS).

RESULTS

Of 345 patients, we included 265 patients with a CCM (median age 46 years; 45% male). At baseline, 131 (49%) patients presented with symptomatic hemorrhage (SH), and 134 (51%) with other symptoms or asymptomatically. During 58 months (IQR 35-94) median follow-up, 51 (19%) patients experienced a SH, 33 (12%) a seizure, and 13 (5%) focal neurological deficits. Fourteen (5%) patients underwent intervention (surgery n = 11, radiosurgery n = 4). Presentation with SH was associated with higher annual bleeding rates (6.0% vs 1.5%, p < 0.001), and higher cumulative 5-/10-year bleeding risks (31%/41% vs 7%, p < 0.001). Brainstem CCM was associated with higher cumulative 5-/10-year bleeding risks (27%/38% vs 17%/21%, p = 0.038). Nineteen (7%) patients died; two (0.8%) directly attributable to CCM. Of 246 surviving patients, 205 (83%) completed the questionnaire. At follow-up, 172/224 (77%) patients were functionally independent (mRS score ⩽2).

DISCUSSION AND CONCLUSION

The majority of conservatively managed CCM patients remained free of a SH during follow-up. Few patients required intervention, and death attributable to the CCM was rare. These data may help patient counseling and treatment decisions.

Validation of TRI-SCORE for Outcome Prediction After Isolated Tricuspid Valve Surgery in Asian Patients

BACKGROUND

TRI-SCORE was recently developed in Europe as a risk model for predicting in-hospital death after isolated tricuspid valve surgery. We aimed to validate TRI-SCORE in an Asian population and investigate its value for predicting long-term outcomes.

METHODS AND RESULTS

The TRI-SCORE was calculated for 202 patients (65±11 years, 61% women, 81% functional tricuspid regurgitation) who underwent isolated tricuspid valve surgery for severe tricuspid regurgitation at 2 Korean centers and was based on 8 parameters: age, New York Heart Association class, right-sided heart failure signs, furosemide daily dose, glomerular filtration rate, bilirubin, left ventricular ejection fraction, and moderate/severe right ventricular dysfunction. The primary outcome was all-cause death during follow-up; the secondary outcome was in-hospital death. During a median follow-up duration of 50 (interquartile range, 21-82) months after isolated tricuspid valve surgery, 23 (11.4%) patients experienced the primary outcome, and 7 (3.5%) patients experienced the secondary outcome. Observed all-cause death and in-hospital death increased by up to 50% in those with higher scores. Patients with the primary outcome had a higher TRI-SCORE (4.5±2.4 versus 2.9±2.1; P=0.001) than those without. The TRI-SCORE showed a significant association with the primary outcome (concordance index, 0.77, cutoff value, 4) and in-hospital death (area under the curve, 0.84; cutoff value, 3). Using the Kaplan-Meier analysis, patients with a high TRI-SCORE exhibited a poor outcome for all-cause death at follow-up (log-rank P<0.001) and in-hospital death (log-rank P=0.004).

CONCLUSIONS

TRI-SCORE was validated in an Asian population and helped predict long-term outcomes after isolated tricuspid valve surgery.