Mechanical Ventilation Associated Pneumomediastinum - A Rising Incidence of Cases in an Emergency Hospital During the COVID-19 Pandemics.

Introduction: Mechanical ventilation is a last resort solution for patients presenting with acute respiratory distress syndrome produced by SARS-CoV-2. Spontaneous pneumomediastinum is a rare pathology associated with invasive mechanical ventilation. The objective of our research was to highlight the increased incidence of spontaneous pneumomediastinum during the COVID-19 pandemics in our hospital. Material and method: A retrospective review of the cases in our hospital requiring surgical evaluation was performed. Electronic health records from our institution were searched for nontraumatic pneumomediastinum from October to November 2021. All patients that were identified with pneumomediastinum were included in the review. Results: We identified 12 mechanical ventilated patients that presented with free air in the mediastinum on a computed tomography during the study period. All of the patients had SARS-CoV-2 bronchopneumonia with extensive pulmonary involvement. The mortality rate among these patients was 58.33%. Conclusions: The main take-home message of our study is that the incidence of mechanically ventilation-associated pneumomediastinum was exponentially higher during the fourth wave of COVID-19. There is a need for multicenter data in this pathology for a better approach and to define surgical management options for these patients.

Surgical Stasis: Anomalies Scarcities in Surgical Residents Training in the Covid-19 Period.

Introduction: The COVID-19 pandemic has led to a marked decrease in surgical procedures performed worldwide and to numerous other changes in medical practice. We investigated the effect of these changes on surgical trainees. Method: We searched medical records and asked a total of 67 surgical residents from different specialities (general surgery, obstetrics-gynecology, orthopedics-traumatology, neurosurgery) to answer a questionnaire investigating how the total number of surgical procedures and operative role varied for each respondent during the pandemic, the number of medical congresses and handson courses they attended during this time, how much study time was available to them and how the changes in their training modules affected them. Results: Most respondents reported a marked decrease in the number of surgical procedures performed, performing key operative steps with a lower frequency. Most of them believed that their training stagnated or suffered a setback. However, most residents consider the changes in their training during the pandemic a useful experience. Conclusion: The real effect of the COVID-19 pandemic on surgical training should be further studied. Future prospective studies should identify threshold values for each surgical procedure and the most effective compensatory strategies.

Prediction and Management of Surgical Site Infections in Hybrid Vascular Surgery for Peripheral Artery Disease.

OBJECTIVES: Postoperative complications are an important problem that all surgeons face. Among all possible complications, local and systemic infections are one of the most prevalent postprocedural adverse events. It is difficult to assess whether or not a patient will develop a surgical site infection (SSI), but there are certain basic investigations that can suggest the probability of such an event. We also investigated some clinically assessable signs to help us better predict the occurrence of SSIs. Every bit of information brings us closer to an ideal where we can bring postoperative complications to a minimum. Close examination and attention to detail is crucial in the prediction and prevention of SSIs. Methods: A multicenter, retrospective and prospective observational study was carried out between 01.01.2019 â?" 01.09.2021. All adult patients with peripheral artery disease (PAD) who had disabling intermittent claudication or rest pain, were included in this study. We excluded minor or vascular surgery emergencies (ruptured aneurysms, acute ischemia or vascular trauma). We followed the postoperative complications as well as their management with an emphasis on surgical site infections (SSIs). Receiver Operating Characteristic (ROC) curves were used to determine key values of statistical relevance by calculating the Area Under the Curve (AUC). Multivariate analysis was used to assess the statistical relevance of our data. Results: The study evaluates 128 patients diagnosed with PAD, aged between 47 and 97, with a mean age of 71.26 Ã+- 10.8 years. There were significantly more male than female patients 71.09% vs. 28.91% (p 0.01). All patients were treated using hybrid vascular techniques. All complication rates were recorded but we focused on SSIs, which was the most prevalent complication (25%). C-Reactive Protein with values higher than 5 mg/dl, was confirmed as a positive predictive factor for postoperative surgical site infections (AUC = 0.80). Another positive predictive factor for SSIs is hyperglycemia. Glycemic values higher than 140mg/dl are more frequently associated with postoperative infections (p = 0.02), a predictability curve of statistical significance was also obtained (AUC = 0.71). Postoperative SSIs were more prevalent in patients with preoperative distal trophic lesions (p 0.01). The presence of other complications such as edema and lymphoceles were also linked to SSIs (p 0.01). Nevertheless, patients who underwent surgery over negative wound pressure therapy (NWPT) for infection management had significantly shorter hospital stays (p 0.01). Conclusions: There are multiple clinical or paraclinical predictors of SSIs. The coexistence of several such factors can carry an additional risk of developing a SSI and should be evaluated and controlled separately in the preoperative phase as much as possible. Admission to a diabetes center and regulation of glycemic values prior to elective vascular surgery, for patients who can be surgically postponed is an effective method of preventing infections. Surgical management remains the most reliable form of treatment of SSIs, being the most efficient therapy and offering immediate results, while simultaneously shortening hospital stays.

Current Management of Colon Trauma at a Level II Trauma Center - A Single Center Review of Cases from the Last Two Decades.

Introduction: The large bowel is the second most commonly injured hollow viscus in penetrating abdominal trauma following the small bowel. Injuries to the colon are fairly common in times of war and the lessons learned in these instances have historically guided management. The objective of our research is to highlight current management principles as they are applied in a single trauma centre during the last two decades. Material and Method: retrospective review of our clinical experience was performed. Electronic health records from our institution were searched for injuries caused by external forces from January 2003 - October 2021. All patients that were identified with colon injuries were included in the review. Results: We identified 11 male patients with colon injuries during the study period. Repair options used were primary suture or colostomy formation with no anastomoses and no damage control procedures. Mortality was 27.2%, relatively high when compared with contemporaneous studies. Conclusions: The main take home message of our research is that the epidemiology of colon trauma is very different in a civilian environment that has a low caseload of penetrating injury compared to wartime injuries. There is a clear need of prospective multicentre data in this type of trauma cohorts to better define management options and not base our approach on wartime data or data from communities where the rate of penetrating injuries is high.

Acute Colonic Pseudoobstruction (Ogilvie Syndrome) - A Severe Complication in the Evolution of the Hospitalized or Institutionalized Patients.

Introduction: Ogilvie syndrome, or acute colonic pseudo-obstruction (ACPO), represents a pathological entity, potentially with a severe outcome, due to the acute important dilation of the large bowel, in the absence of a mechanical luminal obstruction. Usually, it occurs in patients admitted in intensive care unit, that associate severe surgical or medical pathologies. The mechanism of the ACPO has not been completely explained, but it is assumed that the motor function of the colon may be affected, as a result of autonomic regulation disturbance. Early diagnosis and treatment help reduce the risk of severe outcome, such as ischemia or perforation. Material and Method: In addition to our experience, a literature search was elaborated in order to evaluate the incidence, the etiology, the clinical presentation and the diagnosis of the ACPO. Results and Conclusions: The present study may be of help in the process of guiding the optimal management of a critically ill patient is at high risk of developing colonic pseudo-obstruction.

The Current Surgical Managemnt of the Parietal Deffects in Patients with Liver Cirrhosis - Options and Limits. Our Experience and Review of Literature.

Introduction: The abdominal wall hernias in patients with liver cirrhosis have a significant higher prevalence than those in non- cirrhotic patients. The best surgical treatment option and the optimal operative time still represent a subject of debate. Material and method: We have retrospectively analyzed the cases of abdominal wall hernias in patients with liver cirrhosis admitted in the Surgical Department of the Sfantul Pantelimon Clinical Emergency Hospital from Bucharest, undergoing surgical treatment between January 2012 and December 2016. Data regarding the laboratory results (the serum albumin and bilirubin levels, the Prothrombin Time) and the clinical aspects (the presence of ascites or encephalopathy) that helped establish the grade of the disease according to Child classification system, and, also, the information regarding the type of hernia, the character of the surgical indication (emergency or elective), the surgical technique and the postoperative evolution have been collected from the medical documents of the patients included in the present study. The statistical analysis has been made using the chi- square test. Results: 32 cases out of the total 65 patients included in the study, that underwent surgical intervention for the treatment of the abdominal wall defects, had umbilical hernia (49,23%), 18 cases presented with inguinal hernia (27.69%), 11 with incisional hernia (16.92%) and 4 with epigastric hernia (6.15%). 29 patients were subjected to elective surgery (44.6%) and 36 to emergency surgery (55,4%). Regarding the Child classification system used in the present study, 24 patients presented with Child A grade of cirrhosis (36.92%), 30 with Child B (46.15%) and 11 with Child C (16.92%). The postoperative morbidity rate was 45,83% in Child A group, 56,66% in Child B group and 81,8% in Child C group. The mortality rate was 4,16% in the Child A group (one death), 13.33% in the Child B group (4 deaths) and 72.72% in Child C group (8 cases). The highest mortality rates have been registered in patients that underwent emergency surgical intervention. Conclusions: The parietal defects in patients with liver cirrhosis can be surgically treated with satisfactory outcomes. The best results have been registered in patients with compensated form of the cirrhosis or in cases undergoing elective surgery. The methods used for the surgical treatment of the abdominal wall defects vary from herniorrhaphy to alloplastic techniques. For patients with ascites, a good control of this complication represents an important factor for the favourable postoperative evolution. The emergency surgical interventions are associated with greater risks of morbidity and mortality.

Appendiceal Diverticulitis - A Case Report.

Appendiceal diverticulitis is a very rare cause for pain in the right iliac fossa. Whether it is simptomatic or discovered randomly during an appendectomy or barium enema, understanding its clinical evolution is important for having a good management. In this report we present the case of a 50 year old female who underwent an open appendectomy during which we discovered appendiceal diverticulitis.

Morphometric study in thyroid tumors.

Various morphonuclear studies using digital image analysis have been taken into account in order to establish the malignancy of thyroid lesions based on their size and on the chromatographic characteristics of tumor cell nuclei. Nuclear morphometry involves the measurement of nuclear parameters to obtain diagnostically important information in an objective and reproducible manner. The aim of the present study was to evaluate the detailed morphometric analysis of histopathological preparations with lesions of the thyroid gland and to investigate its role in differentiating between benign and malignant thyroid lesions. The present study included 10 benign and 26 malignant thyroid cases with different selected thyroid lesions. Using a microscope connected to a computerized video system, nuclear morphometric parameters including the nuclear area, perimeter, average intensity, red average, width and roundness, were measured and analyzed. The main parameters used in the statistical calculation were significant in distinguishing between benign and malignant thyroid lesions. The association of morphometry in cytological smears for suspected malignant follicular lesions led to increased accuracy in establishing a suspicious malignant diagnosis for follicular lesions. Nuclear morphometry provides an unbiased point of view that increases diagnosis accuracy. Computerized morphometry can positively influence diagnostic accuracy, allowing for a better correlation with clinical and imaging data.

Burnout syndrome in Romanian medical residents in time of the COVID-19 pandemic.

Burnout is a state of physical or mental collapse caused by overwork or stress. Burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. The new COVID-19 pandemic has raised public health problems around the world and required a reorganization of health services. In this context, burnout syndrome and physical exhaustion have become even more pronounced. Resident doctors, and especially those in certain specialties, seem even more exposed due to the higher workload, prolonged exposure and first contact with patients. This article is a short review of the literature and a presentation of some considerations regarding the activity of the medical residents in a non-Covid emergency hospital in Romania, based on the responses obtained via a questionnaire. Burnout prevalence is not equal in different specialties. We studied its impact and imagine the potential steps that can be taken in order to reduce the increasing rate of burnout syndrome in the pandemics.

Traumatic abdominal wall hernia associated with small bowel injury-case report.

Traumatic abdominal wall hernias (TAWHs) are rare. Their diagnosis is mostly clinical and can be overlooked in the setting of trauma and distracting injuries or they can be misinterpreted as parietal hematomas. Associated lesions can influence decision making regarding time of operation and surgical technique. Our case highlights the management of a high-energy TAWH that associates a small bowel traumatic lesion. Surgical repair of TAWHs should follow general hernia repair principles. Further exploration of surgical options is necessary for a consensus to be reached.

A histopathological and immunohistochemical approach of surgical emergencies of GIST. An interdisciplinary study.

The tailored approach to gastrointestinal stromal tumors (GISTs) has led to better prognosis for these types of tumors. Also, finding out GIST's pathology has led to a better understanding of oncogenesis and cancer therapy in general. The rapid expansion of molecular and pathological knowledge of GISTs has given this disease a promising future. We analyze 30 cases of GISTs operated on in our clinic with confirmed diagnosis by immunohistochemistry. Most of the cases were acute cases that required urgent surgical therapy. An extended analysis of these cases is performed in order to underline their special features. We recorded 17 GISTs of the stomach, 12 GISTs of the small bowel and one esophageal GIST. Of the 30 cases, 15 cases required urgent surgery presenting with GI bleeding or shock following intraperitoneal rupture and bleeding or intestinal obstruction. Of the 15 cases that required urgent surgery 12 cases presented with serosal involvement. Twenty-four cases presented spindle cell histology, four cases were epithelioid and two cases presented mixed cellularity. Although acute presentation of GISTs is not the rule, 15 of 30 of our cases required immediate surgery and a high proportion of them (12/15) presented with serosal involvement. Serosal involvement may warrant the need for a macroscopic classification of GISTs and correlation to therapy. While overall mortality was not high in our series, morbidity is affected by acute presentation, though not specifically pertaining to the diagnosis of GIST. Acute presentations were more frequent, in our series, for small bowel GISTs, compared to gastric GISTs. Serosal involvement was more frequent in the group with acute presentation compared with non-acute GISTs and was present at the most cases of small bowel GISTs with acute onset. The Ki-67 index showed no difference between acute and non-acute onset of GISTs.