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A 48-year-old female, gravida 5, para 5, has abnormal uterine bleeding. Two years ago, when her symptoms started, her endometrial biopsy revealed simple endometrial hyperplasia without atypia and an ultrasound was normal. After progestin therapy, the hyperplasia and abnormal bleeding resolved. Recently her abnormal bleeding returned, and a current biopsy revealed a return of simple hyperplasia without atypia. The patient is finished having children and would like to pursue definitive treatment. Eight years ago, she was diagnosed with adult-onset diabetes, which has been controlled with an oral hypoglycemic (metformin). The patient’s BMI is 30 kg/m2. She has had no previous surgeries and has no other medical conditions.
Epithelial ovarian cancer is currently still treated with chemotherapy using carboplatin and paclitaxel in a 3-weekly regimen. Maintenance treatment is started, using targeted therapy with anti-VEGF bevacizumab or PARP inhibitor olaparib. In the recurrent setting the classical platinum-resistant or -sensitive cut-off has loosened and these days time to next subsequent treatment is increasingly used. New drugs are being investigated in ovarian cancer, mainly CDK4/5 inhibitors and checkpoint inhibitors.
The aim of this study is to evaluate clinical and surgical outcomes of children with subaortic stenosis, to determine the risk factors for surgery and reoperation and to compare isolated subaortic stenosis and those concomitant with CHDs.
The study involved 80 children with subaortic stenosis. The patients were first classified as isolated and CHD group, and the isolated group was further classified as membranous/fibromuscular group. The initial, pre-operative, post-operative and the most recent echocardiographic data, demographic properties and follow-up results of the groups were analysed and compared. The correlation of echocardiographic parameters with surgery and reoperation was evaluated.
There was a significant male predominance in all groups. The frequency of the membranous type was higher than the fibromuscular type in the whole and the CHD group. The median time to the first operation was 4.6 years. Thirty-five (43.7%) patients underwent surgery, 5 of 35 (14%) patients required reoperation. The rate of surgery was similar between groups, but reoperation was significantly higher in the isolated group. The gradient was the most important factor for surgery and reoperation in both groups. In the isolated group besides gradient, mitral-aortic separation was the only echocardiographic parameter correlated with surgery and reoperation.
Reoperation is higher in isolated subaortic stenosis but similar in membranous and fibromuscular types. Early surgery may be beneficial in preventing aortic insufficiency but does not affect the rate of reoperation. Higher initial gradients are associated with adverse outcomes, recurrence and reoperation.
Sacrococcygeal teratoma (SCT) is a common tumor of the neonatal period. Prenatal diagnosis of SCT carries a high mortality rate because of the potential for high output heart failure and hydrops. Tumors can also rupture, leading to severe anemia and death. The mother’s health is also at risk if maternal mirror syndrome develops. Prenatal evaluation includes high resolution ultrasound, fetal echocardiography, and magnetic resonance imaging. Pregnancy management includes frequent assessment of the tumor size, growth, and the effects on the fetal cardiovascular system. Treatment options depend on the tumor characteristics and cardiac function, as well as maternal health and support. Fetal therapy aims to debulk or devascularize the tumor, thereby alleviating high output failure and minimizing the risk of spontaneous rupture and hemorrhage. Decisions regarding a symptomatic fetus with SCT may include prenatal intervention or early delivery. Anesthetic management of fetal treatment for SCT is tailored to the mode of therapy chosen; this may include a minimally invasive approach, in-utero surgery, or an EXIT procedure. The nuances of management of this condition center on understanding of the pathophysiology of a hydropic fetus as a result of the SCT and being prepared for resultant cardiovascular instability and massive hemorrhage.
We discuss how music may play a role in confronting age-associated health and wellness concerns. Common age-associated illnesses such as diabetes, depression, and pain and the benefits of music therapy are noted. The central focus of this chapter is on resiliency, the capacity to recuperate quickly; recovery, the return to wellness; and, personal growth, the process of gaining new insight, understanding, and adapting. Embracing a humanistic orientation, we explore how music gives vital meaning to life, aids in the recovery from surgery, and assists in managing illnesses. Scientific as well as personal descriptions of how music musical activities may bolster well-being and provide a path to illness management and recovery are offered. Examples of therapeutic approaches used in areas of neurocognitive disorders and with US military veterans are noted.
This chapter offers a critical reading of Macbeth as a play preoccupied with war, including civil war and border warfare. Macbeth is arguably the greatest example of a character whose brutality is condemned so soon after being celebrated. There is an exploration of doublethink in a play that holds up savagery as heroism in its opening act in the shape of the severed head of a rebel and holds up the head of the executioner, a hero-turned-villain, in its closing scene. Working at the intersection of military history and medical humanities, this reading of the play tracks the effects and aftereffects of war and wounding, examines modern responses to the play by soldiers and psychiatrists that raise issues around care and control of veterans, addresses the politics of remembering and remembrance, and reflects on recent responses to Macbeth as a drama depicting the consequences of post–traumatic stress disorder.
The long-term prospective multi-centre nationwide (French) observational study FRANCISCO will provide new information on perimembranous ventricular septal defect with left ventricular overload but no pulmonary hypertension in children older than 1 year. Outcomes will be compared according to treatment strategy (watchful waiting, surgical closure, or percutaneous closure) and anatomic features of the defect. The results are expected to provide additional guidance about the optimal treatment of this specific population, which is unclear at present.
Little is known about the impact of COVID-19 on the outcomes of patients undergoing surgery and intervention. This study was conducted between 20 March and 20 May 2020 in six hospitals in Istanbul, and aimed to investigate the effects of surgery and intervention on COVID-19 disease progression, intensive care (ICU) need, mortality and virus transmission to patients and healthcare workers. Patients were examined in three groups: group I underwent emergency surgery, group II had an emergency non-operating room intervention, and group III received inpatient COVID-19 treatment but did not have surgery or undergo intervention. Mortality rates, mechanical ventilation needs and rates of admission to the ICU were compared between the three groups. During this period, patient and healthcare worker transmissions were recorded. In total, 1273 surgical, 476 non-operating room intervention patients and 1884 COVID-19 inpatients were examined. The rate of ICU requirement among patients who had surgery was nearly twice that for inpatients and intervention patients, but there was no difference in mortality between the groups. The overall mortality rates were 2.3% in surgical patients, 3.3% in intervention patients and 3% in inpatients. COVID-19 polymerase chain reaction positivity among hospital workers was 2.4%. Only 3.3% of infected frontline healthcare workers were anaesthesiologists. No deaths occurred among infected healthcare workers. We conclude that emergency surgery and non-operating room interventions during the pandemic period do not increase postoperative mortality and can be performed with low transmission rates.
Diagnosis of sinus venosus defects, not infrequently associated with complex anomalous pulmonary venous drainage, may be delayed requiring multimodality imaging.
Retrospective review of all patients from February 2008 to January 2019.
Thirty-seven children were diagnosed at a median age of 4.2 years (range 0.5−15.5 years). In 32 of 37 (86%) patients, diagnosis was achieved on transthoracic echocardiography, but five patients (14%) had complex variants (four had high insertion of anomalous vein into the superior caval vein and three had multiple anomalous veins draining to different sites, two of whom had drainage of one vein into the high superior caval vein). In these five patients, the final diagnosis was achieved by multimodality imaging and intra-operative findings. The median age at surgery was 5.2 years (range 1.6−15.8 years). Thirty-one patients underwent double patch repair, four patients a Warden repair, and two patients a single-patch repair. Of the four Warden repairs, two patients had a high insertion of right-sided anomalous pulmonary vein into the superior caval vein, one patient had bilateral superior caval veins, and one patient had right lower pulmonary vein insertion into the right atrium/superior caval vein junction. There was no post-operative mortality, reoperation, residual shunt or pulmonary venous obstruction. One patient developed superior caval vein obstruction and one patient developed atrial flutter.
Complementary cardiac imaging modalities improve diagnosis of complex sinus venosus defects associated with a wide variation in the pattern of anomalous pulmonary venous connection. Nonetheless, surgical treatment is associated with excellent outcomes.
Total rhinectomy is an invasive procedure that significantly impairs the intranasal turbulence, humidification and heating of inspired air. The use of uvulopalatopharyngoplasty for the treatment of sleep-disordered breathing disorders such as primary snoring and obstructive sleep apnoea has diminished over the past years because of the emergence of less invasive procedures and alternative therapeutic options. This clinical record presents the treatment of a long-term side effect of total rhinectomy using uvulopalatopharyngoplasty.
In 1997, a 62-year-old male underwent total rhinectomy for a nasal schwannoma, followed by rehabilitation with a nasal prosthesis. Twenty-one years later, he presented with severe complaints of nasal blockage and breathing difficulties during both daytime and night-time. Clinical examination revealed no major anomalies besides significant velopharyngeal narrowing. Thus, in 2019, uvulopalatopharyngoplasty was performed to re-establish velopharyngeal patency. Hereafter, the symptoms of nasal blockage disappeared, resulting in an improved quality of life.
Uvulopalatopharyngoplasty may prove useful to treat selected patients with daytime breathing difficulties due to velopharyngeal narrowing.
Female sexual dysfunction (FSD) can be overlooked. Different types of breast cancer surgery could have a different impact on the sexuality of women. Artificial intelligence (AI) could help to determine the relation between those conditions.
To investigate whether AI could predict FSD relying primarily on the time elapsed after treatment and the type of breast cancer surgery.
Data of age, time elapsed after treatment and type of surgery (breast-conserving therapy and mastectomy) were employed to predict FSD status in 128 subjects using an AI. Women with and without steady relations were included in the analysis. FSD prevalence was 27.3%. The AI was conservatively tuned to maximize the positive likelihood ratio considering predicted and real FSD statuses. The free and open source programming language R was used for all the analyses. Dataset source: Nowosielski, Krzysztof; Krzystanek, Marek; Kowalczyk, Robert; Streb, Joanna; Kucharz, Jakub; Głogowska, Iwona; Lew-Starowicz, Zbigniew; Cedrych, Ida (2018), “Data for: Factors affecting sexual function and body image of early stage breast cancer survivors in Poland: A short-term observation.”, Mendeley Data, V1, doi: 10.17632/948n98trm6.1
Predictions obtained a positive likelihood ratio of 5.314. The results were indicative of fair performance.
AI might be useful to predict FSD in women who undergo breast cancer surgery. Furthermore, the results of this study might indicate a moderate effect of age, time after treatment and type of surgery on the probability of FSD occurrence. Finally, the AI used in this study is freely available, allowing anyone to experiment.
Breast cancer is a severe pathology that once detected completely changes the patient’s perception of life.
Evaluating the relationship that is established between the level of stress, the type of surgery applied and, the instructive level of women.
We selected 67 patients which were divided into 2 groups: group I(31) women who benefited from immediate reconstruction and group II(36) subjects who benefited from a late reconstruction. We split each group into two subgroups: women with secondary education and women with higher education. A socio-demographic questionnaire and the DASS-21 scale were applied.
Comparing the two groups we noticed that stress level was more present in group I(38,7%) than in group II(25%). The differences were not statistically significant(p>0,05). In the subgroup of women with higher education in group I, high levels of stress were observed at 23,08% and, in the subgroup of patients with secondary education, 50% had high levels of stress. The differences were not statistically significant (p>0,05). We also analyzed the two subgroups of group II and we identified increased levels of stress in 20% of patients with higher education compared to those with secondary education where 26,93% had high levels of stress. Also, the differences were not statistically significant(p>0,05). A statistically significant difference(p<0,05) was found when we compared the level of stress between women with secondary education of group I and those of group II.
The study revealed that stress levels tend to be higher in women with immediate breast reconstruction and secondary education.
To explore the feasibility and superiority of applying the WeChat platform in a midterm follow-up of surgical repair for ventricular septal defects in infants.
Eighty-six infants with VSD who underwent surgical repair were divided into an outpatient follow-up group and a WeChat follow-up group. The clinical data, including complications, economic cost, time spent, loss to follow-up rate, and parents’ satisfaction at the 3-month and 1-year follow-ups, were recorded and analysed.
There was no significant difference in the incidence of post-operative complications between the two groups. Although the loss to follow-up rate in the WFU group was lower than that of the OFU group, the difference was not statistically significant. The economic cost and time spent in the 3 months and 1 year after discharge in the WFU group were significantly lower than those in the OFU group. One year after discharge, the PSQ-18 score of the WFU group was significantly higher than that of the OFU group.
Compared with outpatient follow-up, the WeChat platform at the midterm follow-up after surgical repair of VSDs in infants has the advantages of saving time and economic costs and improves parents’ satisfaction.
Equal to COVID-19 patients, non-COVID-19 patients are affected by the medical and social drawbacks of the COVID-19 pandemic. A significant reduction in elective life-changing surgeries has been witnessed in almost all affected countries. This study discusses an applicable and effective pre-operative assessment protocol that can be applied during the COVID-19 era.
Our study is a descriptive retrospective observational study that involves children with CHD requiring open-heart surgeries at our tertiary care centre between March and November, 2020. We reviewed the charts of eligible patients aged 18 years and below. We identified the total numbers of scheduled, performed, and postponed surgeries, respectively. A thorough description of the clinical and physical presentation of the postponed cases, who tested positive for SARS-CoV-2, is provided.
Sixty-eight open-heart surgeries were scheduled at our centre between March and November, 2020. Three surgeries (4%) were postponed due to COVID-19. The three patients were asymptomatic COVID-19 cases detected on routine SARS-CoV-2 polymerase chain reaction testing. No symptoms of cough, chest pain, dyspnea, rhinorrhea, diarrhea, abdominal pain, anosmia, and ageusia were reported by our patients. All patients were afebrile and hemodynamically stable. Owing to the pre-operative assessment protocol that was implemented after the first case was detected, only three healthcare workers were at risk of COVID-19 transmission and were imposed to infectious evaluation and home quarantine.
Adopting our discussed preoperative COVID-19 assessment protocol for CHD patients is an effective method to detect COVID-19 infections, optimise patient care, and ensure healthcare workers’ safety.
The application of a 4K display resolution three-dimensional exoscope system (Vitom 3D) was evaluated to determine the feasibility of adopting the system in ENT surgery in the coronavirus disease 2019 era and beyond.
Eighteen ENT surgeons performed structured otological tasks on fresh-frozen sheep heads using the Vitom 3D. Structured feedback of the participants’ experience was analysed.
Seventy-four per cent and 94 per cent of participants reported that the Vitom 3D was ergonomic and comfortable to use respectively. Whilst colour fidelity and image quality were very good, 50 per cent of participants reported image distortion and pixilation at the highest magnification. All participants agreed that there was an increased educational value to exoscope technology. Half the participants preferred the microscope over the Vitom 3D for fine otological work, which may reflect the learning curve.
The Vitom 3D exoscope is a promising and viable alternative for performing otological surgery when using full personal protective equipment in the coronavirus disease 2019 era.
To evaluate the circumstances in which recurrent laryngeal nerve palsy occurs after thyroid surgery.
This study assessed 1026 patients who underwent surgery for benign thyroid disease over a seven-year period in a retrospective, single-centre study.
With a total of 1835 recurrent laryngeal nerves at risk, there were 38 cases (2.07 per cent) of transient recurrent laryngeal nerve palsy and 8 (0.44 per cent) of permanent recurrent laryngeal nerve palsy. No explanation was found for 10 of the 46 cases of recurrent laryngeal nerve palsy. Among the 38 other cases, the probable causes included poor identification of the recurrent laryngeal nerve during surgery, involuntary resection of the nerve and several other factors.
Apart from accidental resection of the recurrent laryngeal nerve during thyroid surgery, the causes of post-operative recurrent laryngeal nerve palsy are often unclear and likely multifactorial. Poor identification of the recurrent laryngeal nerve during surgery is still the main cause of post-operative recurrent laryngeal nerve palsy, even when intra-operative neuromonitoring is used.
This is a case of an infant with unilateral discontinuous right pulmonary artery. Cardiac catheterisation with pulmonary wedge injection diagnosed the anomaly and aided in surgical planning. The patient underwent semi-autologous surgical repair utilising an autologous main pulmonary artery flap. One month following discharge, he underwent successful balloon dilation of the residual stenosis and was discharged the same day.
The impact of loco-regional treatment (LRT) with radiotherapy (RT) in patients presenting with metastatic breast cancer (MBC) has not been widely studied. The aim of this study was to review the treatment outcomes of LRT including RT in patients with MBC.
Materials and methods:
Patients who presented with MBC were included in this retrospective study. Analysis was undertaken to determine the difference in local disease control, overall survival (OS) and progression-free survival (PFS) with systemic treatment alone, surgery alone, surgery plus RT and RT alone with long-rank test. Multivariate analysis was done, using the cox regression for factors affecting PFS and OS.
From 2007 to 2014, data of 257 patients with MBC were collected. Totally, 185 patients received LRT and 72 did not. LRT was surgery plus RT, surgery only and RT only in 113, 47 and 25 patients, respectively. Cytotoxic chemotherapy and hormone therapy were received by 205 and 166 patients, respectively. Median follow-up was 36 months (6–120 months). PFS and OS at 3 years with and without LRT were 31% versus 6% (p < 0·001) and 41% versus 17% (p < 0·001), respectively. PFS at 3 years with surgery plus RT, RT alone and surgery was 40, 33 and 6%, respectively. OS at 3 years with surgery plus RT, RT alone and surgery was 50, 38 and 17%, respectively. Patients without LRT had worse PFS and OS, 6 and 17%, respectively. RT had significant impact on PFS and OS along with chemotherapy and hormone treatment.
In patients with MBC, improved local control, PFS and OS were achieved with loco-regional RT. Loco-regional RT along with chemotherapy and hormones were significant factors for PFS and OS irrespective of surgery.
This study aimed to evaluate the effect of resident involvement and the ‘July effect’ on peri-operative complications after parotidectomy.
The American College of Surgeons National Surgical Quality Improvement Program database was queried for parotidectomy procedures with resident involvement between 2005 and 2014.
There were 11 733 cases were identified, of which 932 involved resident participation (7.9 per cent). Resident involvement resulted in a significantly lower reoperation rate (adjusted odds ratio, 0.18; 95 per cent confidence interval, 0.05–0.73; p = 0.02) and readmission rate (adjusted odds ratios 0.30; 95 per cent confidence interval, 0.11–0.80; p = 0.02). However, resident involvement was associated with a mean 24 minutes longer adjusted operative time and 23.5 per cent longer adjusted total hospital length of stay (respective p < 0.01). No significant difference in surgical or medical complication rates or mortality was found when comparing cases among academic quarters.
Resident participation is associated with significantly decreased reoperation and readmission rates as well as longer mean operative times and total length of stay. Resident transitions during July are not associated with increased risk of adverse peri-operative outcomes after parotidectomy.