The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England.

BACKGROUND: Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. METHODS: Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure. RESULTS: Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied. CONCLUSIONS: A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

Computational modelling of an aerosol extraction device for use in COVID-19 surgical tracheotomy.

In view of the ongoing COVID-19 pandemic and its effects on global health, understanding and accurately modelling the propagation of human biological aerosols has become crucial. Worldwide, health professionals have been one of the most affected demographics, representing approximately 20% of all cases in Spain, 10% in Italy and 4% in China and US. Methods to contain and remove potentially infected aerosols during Aerosol Generating Procedures (AGPs) near source offer advantages in reducing the contamination of protective clothing and the surrounding theatre equipment and space. In this work we describe the application of computational fluid dynamics in assessing the performance of a prototype extraction hood as a means to contain a high speed aerosol jet. Whilst the particular prototype device is intended to be used during tracheotomies, which are increasingly common in the wake of COVID-19, the underlying physics can be adapted to design similar machines for other AGPs. Computational modelling aspect of this study was largely carried out by Barcelona Supercomputing Center using the high performance computational mechanics code Alya. Based on the high fidelity LES coupled with Lagrangian frameworks the results demonstrate high containment efficiency of generated particles is feasible with achievable air extraction rates.

Skull base surgery for malignant tumors: The 2nd international collaborative study (1995-2015).

BACKGROUND: The current study presents the effort of a global collaborative group to review the management and outcomes of malignant tumors of the skull base worldwide. PATIENTS AND METHODS: A total of 28 institutions contributed data on 3061 patients. Analysis evaluated clinical variables, survival outcomes, and multivariable factors associated with outcomes. RESULTS: The median age was 56 years (IQR 44-67). The open surgical approach was used in 55% (n = 1680) of cases, endoscopic resection was performed in 36% (n = 1087), and the combined approach in 9.6% (n = 294). With a median follow-up of 7.1 years, the 5-year OS DSS and RFS were 65%, 71.7% and 53%, respectively. On multivariable analysis, older age, comorbidities, histology, dural/intracranial involvement, positive margins, advanced stage, and primary site were independent prognostic factors for OS, DSS, and RFS. Adjuvant RT was a protective prognostic factor. CONCLUSION: The progress across various disciplines may have contributed to improved OS and DSS in this study compared to previous reports.

A novel technique to repair orbital roof defects: irradiated homologous cadaveric rib (Tutoplast ®) graft in a recurrent frontal sinus ossifying fibroma.

Ossifying fibroma in the fronto-ethmoidal sinuses is a rare, benign condition. In symptomatic cases, surgical excision is often undertaken and bony defects may be repaired using alloplastic grafts. We present a novel method of repairing an orbital roof defect using irradiated homologous cadaveric rib (Tutoplast ®) graft, overlaid with a pericranial flap. The patient made an excellent recovery, concluding that it is a viable and safe option with lower morbidity.

European Reference Network for Rare Vascular Diseases (VASCERN): When and how to use intravenous bevacizumab in Hereditary Haemorrhagic Telangiectasia (HHT)?

Hereditary haemorrhagic telangiectasia (HHT) is a rare vascular multisystemic disease that leads to epistaxis, anaemia due to blood loss, and arteriovenous malformations (AVMs) in organs such as the lungs, liver and brain. HHT prevalence is estimated at 1/6000, i.e. around 85,000 European citizens, and is served by the European Reference Network for Rare Multisystemic Vascular Diseases (VASCERN). HHT treatments depend on clinical manifestations, and span multiple different medical, surgical and interventional disciplines. Separate to local treatments in the nose, in severe settings, intravenous bevacizumab has been proposed as treatment option, and the purpose of the current article is to assess the use of intravenous bevacizumab in patients with HHT in 2022 according to available data.

Multi-Disciplinary Simulation Training for Surgical Tracheostomy in Patients Mechanically Ventilated Secondary to Severe Acute Respiratory Syndrome Coronavirus-2.

Objective: A proportion of COVID-19 patients with severe respiratory manifestations of disease will require admission to intensive care for intubation and ventilation. When anticipating prolonged ventilation, the patient may proceed to surgical tracheostomy to afford safe respiratory wean. As surgical tracheostomy is an aerosol-generating procedure, it poses a high risk of viral transmission and ultimately may prompt anxiety and caution in participating staff members. We aimed to mitigate these risks by providing staff with appropriate training and experience to improve their confidence as well as practical ability. Methods: We developed a multi-disciplinary simulation training experience and checklist in order to optimize team performance during the high-stakes procedure. We evaluated staff confidence before and after the training with questionnaires. Results: Post-simulation, surgeons were more confident with donning the high-level personal protective equipment, and nurses were more confident in performing their role. Conclusions: Simulation allows the multi-disciplinary team an opportunity to practise high-risk procedures and prompts the team to assess staff knowledge base, troubleshoot queries, and teach roles and responsibilities in a safe environment. In the context of COVID-19, simulation encourages the staff's sense of preparedness and protection for true participation during a high-risk procedure.

European Reference Network for Rare Vascular Diseases (VASCERN) position statement on cerebral screening in adults and children with hereditary haemorrhagic telangiectasia (HHT).

Hereditary haemorrhagic telangiectasia (HHT) is a multisystemic vascular dysplasia inherited as an autosomal dominant trait. Approximately 10 % of patients have cerebral vascular malformations, a proportion being cerebral arteriovenous malformations (AVMs) and fistulae that may lead to potentially devastating consequences in case of rupture. On the other hand, detection and treatment related-risks are not negligible, and immediate. While successful treatment can be undertaken in individual cases, current data do not support the treatment of unruptured AVMs, which also present a low risk of bleeding in HHT patients. Screening for these AVMs is therefore controversial.Structured discussions, distinctions of different cerebrovascular abnormalities commonly grouped into an "AVM" bracket, and clear guidance by neurosurgical and neurointerventional radiology colleagues enabled the European Reference Network for Rare Vascular Disorders (VASCERN-HHT) to develop the following agreed Position Statement on cerebral screening:1) First, we emphasise that neurological symptoms suggestive of cerebral AVMs in HHT patients should be investigated as in general neurological and emergency care practice. Similarly, if an AVM is found accidentally, management approaches should rely on expert discussions on a case-by-case basis and individual risk-benefit evaluation of all therapeutic possibilities for a specific lesion.2) The current evidence base does not favour the treatment of unruptured cerebral AVMs, and therefore cannot be used to support widespread screening of asymptomatic HHT patients.3) Individual situations encompass a wide range of personal, cultural and clinical states. In order to enable informed patient choice, and avoid conflicting advice, particularly arising from non-neurovascular interpretations of the evidence base, we suggest that all HHT patients should have the opportunity to discuss knowingly brain screening issues with their healthcare provider.4) Any screening discussions in asymptomatic individuals should be preceded by informed pre-test review of the latest evidence regarding preventative and therapeutic efficacies of any interventions. The possibility of harm due to detection of, or intervention on, a vascular malformation that would not have necessarily caused any consequence in later life should be stated explicitly.We consider this nuanced Position Statement provides a helpful, evidence-based framework for informed discussions between healthcare providers and patients in an emotionally charged area.

Nasal inspiratory flow: at rest and sniffing.

BACKGROUND: This study quantifies the time-varying flow rate during inspiration at rest and in sniffing, both predecongestion and postdecongestion. It aims to provide a better understanding of nasal airflow mechanics, for application to the physiological modeling of nasal respiration and to therapeutic drug delivery. METHODS: The temporal profiles of nasal inspiration were measured at high fidelity in 14 healthy individuals using simultaneous bilateral hot-wire anemometry. Peak nasal inspiratory flow (PNIF) rate, acoustic rhinometry (AR), and the sinonasal outcome test (SNOT) provided complementary clinical measurements. The impact of decongestion was also investigated. RESULTS: In the initial phase of inspiration, a rapid rise in flow rate was observed. Flow first exceeded 150 mL/second in either passage within a median time of approximately 120 ms for inspiration at rest and approximately 60 ms in sniffing (∼20 ms in the fastest sniffs). The mean sustained flow rate attained and the overall period of each measured inspiratory profile were analyzed. AR showed a significant change in nasal volume with decongestion, although these change were not manifest in the temporal profiles of inspiratory flow (barring a weak effect associated with the most vigorous sniffs). CONCLUSION: Novel methods were applied to investigate the temporal profiles of nasal inspiration. Characteristic features of the profile were identified and found to be significantly different between inspiration at rest and sniffing. Decongestion was found to have little effect on the temporal profiles for the flow regimes studied.

Comprehensive review of small bowel metastasis from head and neck squamous cell carcinoma.

Secondary tumours of small intestine account for 10% of all small bowel cancers. The most common sites of primary tumour metastasizing to small bowel are uterus, cervix, colon, lung, breast and melanoma. The majority of these metastatic tumours come from adenocarcinoma primaries; squamous cell carcinoma constitutes a very small proportion of all metastatic small intestinal lesions. Metastasis to small bowel by head and neck squamous cell carcinoma is extremely rare and carries an unfavourable prognosis. Owing to the limited number of published studies, its characteristic features, clinical presentation and outcomes are poorly described. This work aims at specifying these characteristics by reviewing, compiling, analysing and reporting all published cases in the published literature on small bowel metastasis secondary to head and neck squamous cell carcinoma. To the best of our knowledge, this is the first comprehensive review article on the small intestinal metastasis from head and neck squamous cell carcinoma.

Inhibition of in vitro angiogenesis by 2-methoxy- and 2-ethyl-estrogen sulfamates.

Sulfamoylation of 2-methoxyestrone (2-MeOE1) was shown previously to enhance its potency as an anti-proliferative agent against breast cancer cells. We have examined the ability of a series of 2-methoxyestradiol (2-MeOE2) and 2-ethylestradiol (2-EtE2) sulfamates to inhibit angiogenesis in vitro. 2-MeOE2 bis-sulfamate and 2-EtE2 sulfamate were potent inhibitors of human umbilical vein endothelial cell (HUVEC) proliferation with IC(50) values of 0.05 microM and 0.01 microM, respectively. A novel co-culture system, in which endothelial cells were cultured in a matrix of human dermal fibroblasts, was also used to assess the anti-angiogenic potential of these drugs. In this system endothelial cells proliferate and migrate through the culture matrix to form tubule structures. Whereas 2-MeOE2 (1.0 microM) caused a small reduction in tubule formation, both 2-MeOE2 bis-sulfamate (0.1 microM) and 2-EtE2 sulfamate (0.1 microM) almost completely abolished tubule formation. 2-MeOE2 bis-sulfamate and 2-EtE2 sulfamate both induced BCL-2 phosphorylation, p53 protein expression and apoptosis in HUVECs. Microarray analysis of a limited number of genes known to be involved in the angiogenic process did not show any gross changes in cells treated with the 2-substituted estrogens. The sulfamoylated derivatives of 2-MeOE2 and 2-EtE2 are potent inhibitors of in vitro angiogenesis and both compounds should have therapeutic potential.