The COVANOS trial - insight into post-COVID olfactory dysfunction and the role of smell training

BACKGROUND

Olfactory dysfunction is a cardinal symptom of COVID-19 infection, however, studies assessing long-term olfactory dysfunction are limited and no randomised-controlled trials (RCTs) of early olfactory training have been conducted.

METHODOLOGY

We conducted a prospective, multi-centre study consisting of baseline psychophysical measurements of smell and taste function. Eligible participants were further recruited into a 12-week RCT of olfactory training versus control (safety information). Patient-reported outcomes were measured using an electronic survey and BSIT at baseline and 12 weeks. An additional 1-year follow-up was open to all participants.

RESULTS

218 individuals with a sudden loss of sense of smell of at least 4-weeks were recruited. Psychophysical smell loss was observed in only 32.1%; 63 participants were recruited into the RCT. The absolute difference in BSIT improvement after 12 weeks was 0.45 higher in the intervention arm. 76 participants completed 1-year follow-up; 10/19 (52.6%) of participants with an abnormal baseline BSIT test scored below the normal threshold at 1-year, and 24/29 (82.8%) had persistent parosmia.

CONCLUSIONS

Early olfactory training may be helpful, although our findings are inconclusive. Notably, a number of individuals who completed the 1-year assessment had persistent smell loss and parosmia at 1-year. As such, both should be considered important entities of long-Covid and further studies to improve management are highly warranted.

High Grade Penetrating Pancreatic Trauma - Case Report and Review of the Literature

INTRODUCTION

The pancreatic injuries have fortunately a low frequency, but when present associate multiple intraabdominal lesions, and carry a significant morbidity and mortality. The aim of this study is to underline the significant morbidity associated with high grade pancreatic injuries.

CASE REPORT

Female patient, 36 years old, with penetrating abdominal trauma due to domestic violence was referred to our center from a regional county hospital, after multiple laparotomies, hemodynamically unstable, with multiple organ failure. Abdominal clinical exam revealed evisceration, with massive pancreatic leakage at the level of the median laparotomy and through the stabbing wounds from the right flank. Emergency Computed Tomography showed multiple intraabdominal collections, with laceration of the liver, right kidney and pancreatic head. Abdominal exploration was decided. After a thorough abdominal debridement was revealed a deep laceration of the pancreatic head, with active extravasation of pancreatic secretion, correlating with a grade IV injury. Peritoneal lavage and large drainage of the lesser and greater peritoneal cavity was performed. The postoperative recovery was uneventful, with progressive decrease in pancreatic fistula output and discharge after 35 days.

CONCLUSIONS

High grade pancreatic traumas associate a significant morbidity. Efficient drainage of the pancreatic head injuries and patients management in high volume centers for pancreatic surgery maximize the survival rate.

Traumatic Tricuspid Valve Rupture after Blunt Chest Trauma - A Case Report and Review of the Literature

INTRODUCTION

Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare.

METHOD

Case report and review of the literature using PubMed/MEDLINE and EMBASE databases.

RESULT

A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days.

CONCLUSION

Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting.

Splenic implant assessment in trauma

Trauma is a global health issue, being the 4th death cause after cardio-vascular disease, malignancies and chronic pulmonary diseases and the main death cause among young people, under 45 years (1). The frequency of abdominal trauma is 10-12% of all polytrauma, and from all abdominal organs, the spleen and liver are the most often involved in polytraumatized patients case (2). The first purpose of a successful operational management is the control of active bleeding, and the second is preserving as much as possible of the destroyed organs. Over the last decades, the treatment of spleen traumas had been diversified,from nonsurgical treatment to surgical, also complex and diversified: from conservative treatment to splenectomy.Currently, from a therapeutic standpoint, the trends in spleen trauma are orientated towards conservative methods as the clinical and experimental data have shown that €œit is better with the entire spleen than part of it, and better with a part of it than with none at all (Raymond Hinshaw) (3).

Prehospital trauma care: a clinical review

INTRODUCTION

There are many controversies related to the trauma patient care during the pre-hospital period nowadays. Due to the heterogeneity of the rescue personnel and variability of protocols used in various countries, the benefit of the prehospital advanced life support on morbidity and mortality has been not established.

METHOD

Systematic review of the literature using computer search of the Library of Medicine and the National Institutes of Health International PubMed Medline database using Entre interface.We reviewed the literature in what concerns the basic and advanced life support given to the trauma patients during the prehospital period.

RESULTS

Although the organization of the medical emergency system varies from a country to another, the level of patient'scare can be classified into two main categories: Basic Life Support (BLS) and Advanced Life Support (ALS).There are many studies addressing what to be done at the scene.The prehospital care can be divided into two extremes: stay and play/treat then transfer or scoop and run/load and go.

CONCLUSIONS

A balance between "scoop and run" and "stay and play" is probably the best approach for trauma patients. The chosen approach should be made according to the mechanism of injury (blunt versus penetrating trauma), distance to the trauma center (urban versus rural) and the available resources.

Surgical treatment of parietal defects with "da Vinci" surgical robot

The robotic surgery has come through the development of telemedicine and minimally invasive surgery concepts, being developed in the military medicine by NASA during the years 1970-1980. The purpose of this paper is to briefly present our experience in the new field of the robotic surgery, by analyzing the results obtained over a lot of 20 patients operated with the "da Vinci" robot within the last 5 years in the Clinical Emergency Hospital Bucharest for various abdominal defects.

Open to laparoscopic conversion in hemoperitoneum of unknown origin

PURPOSE

Demonstrating the potential, in spite of the current trend, of closing an open emergency surgical procedure and to convert it to a minimally invasive approach.

METHODS

Case report of an open converted to a laparoscopic approach in an emergency setting for hemoperitoneum of unknown origin.

RESULTS

A 28-year-old-female patient was transported to the operating room for suspected acute appendicitis. Through McBurney's incision, hemoperitoneum was found. She was hemodynamically stable. The open incision was closed and a laparoscopic approach established. The diagnosis was a ruptured right ectopic pregnancy with mild hemoperitoneum. After a laparoscopic salpingectomy, her recovery was uneventful.

CONCLUSIONS

For selected cases, the conversion of an open procedure to a laparoscopic approach offers a real benefit for the patient, avoiding a large laparotomy and its associated morbidity.

[Mechanism of injury--trauma kinetics. What happend? How?]

INTRODUCTION

Understanding the mechanism of injuries represents a key element in blunt and penetrating trauma management.

METHOD

Systematic review of the main types of the modem trauma mechanisms, using Medline, Cochrane Library and Embase databases.

RESULTS

To properly understand the road car accident injuries, trauma surgeon should know as many details from the scene: the speed of cars, impact direction, if the car rolled over, if occupants were restrained, if airbags exploded, vehicle telemetry, extrication time. Motorcyclists are 20 to 30 times more at risk for severe injuries or death than the four-wheel vehicle occupants. Current evidence shows a significant decrease in injuries severity by increasing use of seat-belts, motorcycle helmets, childrestrains and speed limit. Despite this, few countries around the world have road safety laws relating to key factors that can be considered sufficiently comprehensive in scope. Many modern trauma systems use for prehospital triage mechanism of injury criteria.

CONCLUSIONS

The trauma surgeon should know the mechanism of injury. This allows a high suspicion for potential injuries, their early diagnosis and increased quality in the care of trauma patients.

Adrenalectomy by laparoscopic anterolateral transperitoneal approach for patients with previous abdominal surgery

Adrenal surgery has been radically changed by laparoscopic approach and we wonder whether the increase in the number of adrenalectomies is entirely justified by better understanding of the pathology and a developed diagnosis methods. The type of approach (transabdominal/retroperitoneal) remains a matter of the surgeon's experience. Method: In the past 8 years, we have performed more than 200 laparoscopic adrenalectomies by transperitoneal approach, 24 of them having previously significant abdominal surgery (cholecistectomy, gastric surgery, colectomy, bowel obstruction, exploratory laparoscopy, and adrenalectomy). The patients had a variety of adrenal pathologies such as Cushing disease, Cushing syndrome, Conn syndrome, incidentaloma, pheochromocytoma and even carcinoma. Results: 3 cases were converted to open approach, only one because of the adhesions. Reasons for conversion were also: spleen intarctisation and a difficulty in mobilizing the tumor. Operating time was not significantly prolonged because of the adhesions (40-360 min, median time 127 min). Postoperative evolution was simple with no morbidity or mortality and a fast recovery was recorded. Conclusions: Choosing the type of approach is related to surgeon experience, although 79-94% of the surgeons prefer the transabdominal lateral approach. We believe that with an experienced surgical team, there is no difficulty in performing adrenalectomy by transabdominal approach, with no significantly prolonged operating time, even though the patient has previously had abdominal surgery.

[History of trauma care]

BACKGROUND

Since its inception, the man suffered injuries through falls, fire, drowning and interpersonal conflict. While the mechanism and frequency of different specific injuries has changed passing of millennia, trauma remains an important cause of mortality and morbidity in modern society. Although the war is presented as one of the four knights of the Apocalypse, we must emphasize the important developments of surgical experience during war. The purpose of this study is to highlight the lessons learned during the history and how they changed the modern trauma care.

METHOD

Systematic review of English language literature using computer searching of Library of Medicine and the National Institutes of Health International MEDLINE database using PubMed Entre interface.

RESULTS

The first historical record of a trauma medical care is 3605 years ago. Over the past decades, one of the most important changes in trauma patient care is the selective nonoperative management (SNOM) of significant abdominal visceral injuries. SNOM was first described in 1968, for splenic trauma, by Upadhyay and Simpson. It was accepted much later for liver injuries. Beginning from 1960 - 1970, SNOM was introduced for abdominal stab wounds. Exploratory laparotomy remains the standard approach for abdominal gunshot wounds until 1990, when centers from United States and South Africa first reported cases successfully managed nonoperatively.

CONCLUSIONS

The trauma surgery has evolved continuously over the centuries, according to more and more severe modem injuries.

Giant adrenal cyst: case study

One of the rarest situations regarding an adrenal incidentaloma is an adrenal cyst. We present the case of a 61Z–year old male patient diagnosed with peritonitis. During surgery, a right adrenal tumor of 2 cm is discovered. The patient was referred to endocrinology. 6 months later the diameter of the tumor is 7 times bigger than the initial stage. It has no secretory phenotype, except for the small increase of serum aldosterone and the 24–h 17–ketosteroids. Open right adrenalectomy is performed and a cyst of 15 cm is removed. The evolution after surgery is good. The pathological exam reveals an adrenal cyst with calcifications and osteoid metaplasia. The immunohistochemistry showed a positive reaction for CD34 and ACT in the vessels and VIM in the stroma. The adrenal cysts are not frequent and represent a challenge regarding the preoperative diagnostic and surgical procedure of resection. The pathological exam highlights the major aspects.

Helicobacter pylori infection in surgical personnel

Helicobacter pylori can be isolated from oro-gastric secretions. Surgical personnel through their clinical practice are exposed to oro-gastric secretions either directly or in aerosolized form during oro-gastric examination and are at an increased risk of this occupationally acquired infection. The sero-prevalence of Helicobacter pylori antibodies in 70 surgical personnel was examined and found to be higher than a published control group. This may suggest that surgical personnel, through their practice, are at increased risk of infection, which poses important public and occupational health problems and may call for precautionary guidelines in clinical practice to prevent occupational infection and vector carriage.

The disinfection of flexible fibre-optic nasendoscopes out-of-hours: confidential telephone survey of ENT units in England

We present the results of a confidential telephone survey of ENT units in England on the disinfection of flexible fibre-optic nasendoscopes out-of-hours. The on-call residents of 124 units were contacted and questioned. In 35.1 per cent of units surveyed, the on-call resident was primarily responsible for cleaning the scopes after use. Only 46 per cent of these junior doctors had access to a chemical sterilant to allow for high-level disinfection of these scopes. Provision for disinfection of scopes was poorer in teaching hospitals and in units that served inner city populations. Only 12.1 per cent of Senior House Officers (SHOs) received any training in disinfection techniques and only 25.5 per cent of units kept a register of patients nasendoscoped out-of-hours for purposes of contact tracing.

Laser Assisted Uvulopalatoplasty: an objective evaluation of the technique and results

The operation of Laser Assisted Uvulopalatoplasty (LAUP) as described by Kamami is now becoming more commonly used in the treatment of snoring and obstructive sleep apnoea. The authors have treated 95 snoring patients, varying the lengths of the soft palate incisions and percentage of uvula excised. All operations were carried out under general anaesthesia using a CO2 laser. Pilot studies showed incisions that are 25% of the distance between the free edge of the soft palate to the hard palate junction and excision of 50% of the uvula give good results with minimal complications. A further study using these parameters was conducted and postoperative evaluation including polysomnography confirmed this procedure to be effective in reducing snoring levels both subjectively and objectively.