A two-stage stochastic optimization framework to allocate operating room capacity in publicly-funded hospitals under uncertainty.

Surgery demand is an uncertain parameter in addressing the problem of surgery block allocations, and its typical variability should be considered to ensure the feasibility of surgical planning. We develop two models, a stochastic recourse programming model and a two-stage stochastic optimization (SO) model with incorporated risk measure terms in the objective functions to determine a planning decision that is made to allocate surgical specialties to operating rooms (ORs). Our aim is to minimize the costs associated with postponements and unscheduled demands as well as the inefficient use of OR capacity. The results of these models are compared using a case of a real-life hospital to determine which model better copes with uncertainty. We propose a novel framework to transform the SO model based on its deterministic counterpart. Three SO models are proposed with respect to the variability and infeasibility of the measures of the objective function to encode the construction of the SO framework. The analysis of the experimental results demonstrates that the SO model offers better performance under a highly volatile demand environment than the recourse model. The originality of this work lies in its use of SO transformation framework and its development of stochastic models to address the problem of surgery capacity allocation based on a real case.

The effect of remaining trapezial space on outcomes after trapeziectomy with ligament reconstruction tendon interposition for trapeziometacarpal osteoarthritis.

Ligament reconstruction and tendon interposition (LRTI) procedures for trapeziometacarpal osteoarthritis aim to prevent proximal metacarpal migration to improve thumb function. We sought to evaluate the effect of the remaining trapezial space on outcomes after trapeziectomy with LRTI. Forty-seven patients were included in this study. Patients were evaluated clinically and radiologically. They were divided into two groups according to the remaining trapezial space at last follow-up. Postoperative to preoperative trapezial space ratio was >50% in group 1 and <50% in group 2. Mean follow-up was 30.8 months. Mean age, sex, dominant side, preoperative stage, and follow-up were similar in both groups. The mean QuickDASH scores were significantly better in group 1 than group 2. Mean tip and key pinch were significantly stronger in group 1, than group 2. Trapeziectomy with LRTI is the most used surgical technique and it produces satisfactory results. Improved clinical outcomes can be achieved when more than 50% of the preoperative trapezial space remains.

On-Pump Beating Heart Versus Conventional Coronary Artery Bypass Grafting Early After Myocardial Infarction: A Propensity-Score Matched Analysis From the ANZSCTS Database.

BACKGROUND: Coronary artery bypass grafting (CABG) performed early after acute myocardial infarction (AMI) carries a high risk of mortality. By avoiding cardioplegic arrest and aortic cross-clamping, on-pump beating heart CABG (ONBEAT) may benefit patients requiring urgent or emergency revascularisation in the setting of AMI. We evaluated the early and long-term outcomes of ONBEAT versus conventional CABG (ONSTOP) utilising the ANZSCTS National Cardiac Surgery Database. METHODS: Between 2001 and 2015, 5,851 patients underwent non-elective on-pump CABG within 7 days of AMI. Of these, 77 patients (1.3%) underwent ONBEAT and 5774 (98.7%) underwent ONSTOP surgery. Propensity-score matching (with a 1:2 matching ratio) was performed for risk adjustment. Survival data were obtained from the National Death Index. RESULTS: Before matching, the unadjusted 30-day mortality was ONBEAT: 9/77 (11.7%) vs. ONSTOP: 256/5,774 (4.4%), p<0.001. Preoperative factors independently associated with the ONBEAT were: septuagenarian age, peripheral vascular disease, redo surgery, cardiogenic shock, emergency surgery and single-vessel disease. After propensity-score matching, 30-day mortality was similar (ONBEAT: 9/77 (11.7%) vs. ONSTOP: 16/154 (10.4%), p=0.85), as was the rate of major adverse cardiac and cerebrovascular events (ONBEAT: 17/77 (22.1%) vs. ONSTOP: 38/154 (24.7%), p=0.84). ONBEAT patients received fewer distal anastomoses and were more likely to have incomplete revascularisation (ONBEAT: 15/77 (19.5%) vs. ONSTOP: 15/154, (9.7%), p=0.03). Despite this, 12-year survival was comparable (ONBEAT: 64.8% (95% CI 39.4-82.4%) vs. ONSTOP: 63.6% (95% CI 50.5, 74.3%), p=0.89). CONCLUSIONS: ONBEAT can be performed safely in high-risk patients requiring CABG early after AMI with similar short and long-term survival compared to ONSTOP.

Immediate selective laryngeal reinnervation in vagal paraganglioma patients.

OBJECTIVE: This prospective case series aimed to present the outcomes of immediate selective laryngeal reinnervation. METHODS: Two middle-aged women with vagal paraganglioma undergoing an excision operation underwent immediate selective laryngeal reinnervation using the phrenic nerve and ansa cervicalis as the donor nerve. Multidimensional outcome measures were employed pre-operatively, and at 1, 6 and 12 months post-operatively. RESULTS: The voice handicap index-10 score improved from 23 (patient 1) and 18 (patient 2) at 1 month post-operation, to 5 (patient 1) and 1 (patient 2) at 12 months. The Eating Assessment Tool 10 score improved from 20 (patient 1) and 24 (patient 2) at 1 month post-operation, to 3 (patient 1) and 1 (patient 2) at 12 months. There was slight vocal fold abduction observed in patient one and no obvious abduction in patient two. CONCLUSION: Selective reinnervation is safe to perform following vagal paraganglioma excision conducted on the same side. Voice and swallowing improvements were demonstrated, but no significant vocal fold abduction was achieved.

Scheduling elective surgeries: the tradeoff among bed capacity, waiting patients and operating room utilization using goal programming.

Scheduling of surgeries in the operating rooms under limited competing resources such as surgical and nursing staff, anesthesiologist, medical equipment, and recovery beds in surgical wards is a complicated process. A well-designed schedule should be concerned with the welfare of the entire system by allocating the available resources in an efficient and effective manner. In this paper, we develop an integer linear programming model in a manner useful for multiple goals for optimally scheduling elective surgeries based on the availability of surgeons and operating rooms over a time horizon. In particular, the model is concerned with the minimization of the following important goals: (1) the anticipated number of patients waiting for service; (2) the underutilization of operating room time; (3) the maximum expected number of patients in the recovery unit; and (4) the expected range (the difference between maximum and minimum expected number) of patients in the recovery unit. We develop two goal programming (GP) models: lexicographic GP model and weighted GP model. The lexicographic GP model schedules operating rooms when various preemptive priority levels are given to these four goals. A numerical study is conducted to illustrate the optimal master-surgery schedule obtained from the models. The numerical results demonstrate that when the available number of surgeons and operating rooms is known without error over the planning horizon, the proposed models can produce good schedules and priority levels and preference weights of four goals affect the resulting schedules. The results quantify the tradeoffs that must take place as the preemptive-weights of the four goals are changed.

Myeloid sarcoma: An unusual and rare laryngeal presentation.

INTRODUCTION: Myeloid Sarcoma (MS) or Granulocytic Sarcoma is an uncommon laryngeal malignancy. It may arise from myelodysplastic syndromes, malignancy or de novo. Presentation in the larynx is rare and some may present with Acute Myeloid Leukaemia (AML) whereby the later may be asymptomatic. CASE PRESENTATION: A 44-year-old South East Asian lady presented with a six months history of hoarseness, shortness of breath, reduced exercise tolerance, weight loss and laryngeal irritation. Symptoms progressed to coughing with liquids two months prior. On examination, she had a resting biphasic stridor and laryngoscopy revealed right immobile vocal cord with a firm right ventricle mass extending into the right paraglottic space. She was pale and haematology investigations revealed microcytic hypochromic anaemia. Magnetic Resonance Imaging (MRI) of the neck and thorax showed thickening of the right false cord, true cord and aryepiglottic fold. A biopsy taken during endolaryngeal microsurgery (ELMS) confirmed myeloid sarcoma of the right ventricle and para glottic mass. Further investigation revealed a background of AML and she then underwent chemotherapy. DISCUSSION: MS is a rarity with only nine reported cases between the years of 1954 until 2015. Immunohistochemistry and immunophenotyping are definite for diagnosis confirmation as MS cells often exhibit myeloperoxidase (MPO), lymphocyte common antigen (LCA) and CD117 markers. MS is treated with are chemotherapy (either systemic or intrathecal), radiotherapy, surgical excision or in combination. Systemic chemotherapy has better efficacy and prognosis as compared to localised treatment of radiotherapy or surgical excision. However, there has yet to be a definitive chemotherapy protocol. Prognosis is poor with a 5-year survival rate of 48%. CONCLUSION: Although laryngeal MS is a rare phenomenon, early recognition is key and patients should always be investigated for an underlying myeloproliferative or dysplastic disease.

CyberKnife stereotactic radiotherapy for isolated recurrence in the prostatic bed.

PURPOSE: To report a clinical experience of stereotactic body radiation therapy (SBRT) for isolated recurrence in the prostatic bed from prostate cancer. MATERIALS AND METHODS: Between November 2011 and November 2013, 16 patients were treated with SBRT for a macroscopic isolated recurrence of prostate cancer in the prostatic bed. All patients were initially treated with radical prostatectomy, and half of them also received radiotherapy. Two schedules of SBRT were used: 30 Gy in 5 fractions in previously irradiated patients, 35 Gy in five fractions in radiotherapy-naïve patients. RESULTS: At a median follow-up of 10 months (range 2-21 months), a significant biochemical response was found in all but one patient. At imaging evaluation, no local progression was noted: 10 patients showed partial response while four stable disease. At the moment of analysis, all 16 patients were alive. Seven of them experienced distant relapse, while nine maintained biochemical control, with no further therapy. Median time to relapse was 9.3 months (range 3-15.2 months). The treatment was well tolerated: One patient experienced G2 acute genitourinary and gastrointestinal toxicity. CONCLUSIONS: Our experience shows that SBRT with CyberKnife for isolated nodal relapse is a safe and well-tolerated treatment.

Triple pelvic osteotomy for the treatment of symptomatic acetabular dysplasia in adolescents and adults : A review of 42 hips.

We treated 42 hips with symptomatic acetabular dysplasia using triple pelvic osteotomy. The mean age of the patients was 20.7 years (12-47). The median follow-up was 50.3 months. The average Harris hip score improved from 74 to 92 points. Significant improvement from the preoperative to the latest follow-up evaluation was seen radiologically with reference to the center-edge angle, the anterior center-edge angle, the acetabular index and the femoral head extrusion index. Shenton's line was intact in 9 hips before the operation and it was intact in 40 hips at the latest follow-up. The cross-over sign was present in 15 hips before the operation and it was present in one hip after the operation. The results of this study demonstrated that triple pelvic osteotomy provides improved radiographic results and good symptomatic relief in acetabular dysplasia.

Cyberknife treatment for low and intermediate risk prostate cancer.

Cyberknife is an emerging treatment for early stage prostate cancer. Between October 2012 and January 2014, 32 patients were treated in our institution. Prescribed dose was 35-36.25 Gy in five fractions. Biochemical response was observed in 22 patients. Four patients experienced G2 acute genitourinary toxicity and in two cases we recorded G3 acute GU toxicity. 5 patients experienced G2 acute proctitis. At last follow up visit, all patients were still alive. 29 remained free of disease at last follow up appointment, while three developed a biochemical recurrence. Our experience confirms the efficacy and safety of Cyberknife for localized prostate cancer.

Reliability of OperaVOX against Multidimensional Voice Program (MDVP).

OBJECTIVE: To evaluate the agreement between OperaVOX and MDVP. DESIGN: Cross sectional reliability study. SETTING: University teaching hospital. METHODS: Fifty healthy volunteers and 50 voice disorder patients had supervised recordings in a quiet room using OperaVOX by the iPod's internal microphone with sampling rate of 45 kHz. A five-seconds recording of vowel/a/was used to measure fundamental frequency (F0), jitter, shimmer and noise-to-harmonic ratio (NHR). All healthy volunteers and 21 patients had a second recording. The recorded voices were also analysed using the MDVP. The inter- and intrasoftware reliability was analysed using intraclass correlation (ICC) test and Bland-Altman (BA) method. Mann-Whitney test was used to compare the acoustic parameters between healthy volunteers and patients. RESULTS: Nine of 50 patients had severe aperiodic voice. The ICC was high with a confidence interval of >0.75 for the inter- and intrasoftware reliability except for the NHR. For the intersoftware BA analysis, excluding the severe aperiodic voice data sets, the bias (95% LOA) of F0, jitter, shimmer and NHR was 0.81 (11.32, -9.71); -0.13 (1.26, -1.52); -0.52 (1.68, -2.72); and 0.08 (0.27, -0.10). For the intrasoftware reliability, it was -1.48 (18.43, -21.39); 0.05 (1.31, -1.21); -0.01 (2.87, -2.89); and 0.005 (0.20, -0.18), respectively. Normative data from the healthy volunteers were obtained. There was a significant difference in all acoustic parameters between volunteers and patients measured by the Opera-VOX (P < 0.001) except for F0 in females (P = 0.87). CONCLUSION: OperaVOX is comparable to MDVP and has high internal consistency for measuring the F0, jitter and shimmer of voice except for the NHR.

Afro Middle East Asian symposium on cancer cooperation.

This manuscript captures the discussion and recommendations that came out of a special Afro Asian symposium involving 13 countries. Unmet needs and cost-effective solutions with special emphasis on training form the backbone of practical next steps.

Changes in apoptotic and mitotic index, bcl2, and p53 expression in rectum carcinomas after short-term cytostatic treatment.

Twenty patients with rectal adenocarcinoma were endoscopically biopsied and given short-term cytostatic therapy [5-fluorouracil (5-FU) (600 mg/m(2)) and Ca-folinate (60 mg/m(2)) for 2 days]. Seven days later, the tumor was resected or a second biopsy was performed. Apoptotic and mitotic indices as well as (mutant) p53 and bcl(2) expression were determined in the tumor tissue before and after the short-term chemotherapy. The patients were treated thereafter with long-term, intermittent 5-FU administration and followed up clinically for 7-26 months. Six patients showed progression of the disease and died, whereas 14 improved or showed no tumor progression. Significant increase of the apoptotic index and nonsignificant decrease of the mitotic index after the short-term cytostatic treatment were seen in the tumor tissue of responder cases. Nonresponders showed no change in both mitotic activity and apoptotic activity. Both survivors and deceased showed high mutant p53 expression, and the changes after short-term 5-FU treatment were not significant. Expression of bcl(2) was present in only 5 cases, with the postchemotherapy changes being not significant. These findings suggest that apoptotic response to short-term cytostatic therapy may be an additional predictive factor in rectal adenocarcinoma.

Changes in apoptosis, mitosis, Her-2, p53 and Bcl2 expression in breast carcinomas after short-term tamoxifen treatment.

The short-term (7 days) effect of tamoxifen on apoptosis and mitosis index, p53, Bcl2 and Her-2/neu/c-erb2 expression in invasive ductal mammary carcinoma was studied histologically in the diagnostic biopsy and surgically removed tumor tissue of 10 patients. Following tamoxifen treatment expression of HER-2 and p53 decreased but Bcl2 remained unchanged. Mitotic activity decreased slightly, but not significantly. Apoptotic activity increased in six cases in the second sample compared to the values measured of the first biopsy. These changes may be attributed to the effect of antiestrogen therapy.

High frequency of metastatic Leydig cell testicular tumours.

690 patients were treated for testicular tumour in the course of 18 years. The histology of 7 cases showed Leydig cell tumour. In 4 of the 7 cases, a metastatic process leading to death was observed. At the time of diagnosis, 5 patients were found to have low stage, whereas 2 of the patients had advanced lymphatic involvement. The hematogenous and lymphatic metastases proved to be resistant to chemotherapy. Contrary to the major part of the literature, retroperitoneal lymphadenectomy should be performed with this histological type for the exact pathological staging immediately following orchiectomy.

Interleukin-4, immunoglobulin E and immunoglobulin A and resistance to re-infection with Schistosoma haematobium before and after chemotherapy.

The role of serum IL-4, IgE and IgA in protective immunity had been determined in 88- S. haematobium infected-individuals before and 3, 6, 9 and 12 months after treatment with a single dose of praziquantel. Before treatment, IL-4 level was found to be highly significant in all stages of infection, there was a positive correlation between IL-4 levels and egg count. Whereas serum IgE and IgA levels were significantly high in late infected group showing a negative correlation with egg count. After praziquantel treatment, IL-4 levels decreased gradually while IgE and IgA levels were significantly increased in all patients. At 9 and 12 months, viable ova were detected in 11 cases (12.5%), they were re-infected after treatment showing an increase in IL-4 levels, and a decrease in both serum IgE and IgA. These results indicate that IL-4 plays an important role in suppression of severe inflammatory responses associate with persistence of the parasitic stages. Also, serum IgE and IgA participate in protective immunity against S. haematobium infection. It may be essential to administer a second dose of praziquantel to all persons living in endemic areas who are likely to be in contact with infested water.

An enzyme-linked immunosorbent assay for detection of IgG1 antibodies specific to human cystic echinococcosis in Egypt.

Human cystic hydatidosis (cystic echinococcosis) is a chronic zoonotic disease that results from infection with the dog tapeworm Echinococcus granulosus. In Egypt, cystic echinococcosis (CE) is recognized in slaughtered livestock by veterinarians, however, there is little information about human CE infection rates. We describe an immunological assay useful for the diagnosis of human cystic hydatidosis. Sera were collected from surgically confirmed hydatid cases (34), nonendemic subjects free from parasitic infection (20) and from subjects (109) infected with other helminths (Hymenolepis nana, Schistosoma mansoni, Fasciola hepatica and Ancylostoma duodenale). Hydatid cyst fluid (HCF) of camel origin was used as antigen in an ELISA format to measure total E. granulosus specific IgG antibodies and IgG subclasses. Sensitivity measurements of total IgG, and IgG1-4 were 100, 100, 79.4, 61.8 and 55.9%, respectively, whereas respective specificity reached 65.1, 97.7, 98.4, 96.1 and 83. 7%. The diagnostic value of measuring IgG1 (97.7%), as assessed by a rating index (J) for combined sensitivity and specificity, was superior to total IgG (65.1%) and IgG2-4 (77.8, 57.9 and 39.6%, respectively). These findings set the stage for field evaluation of the IgG1 assay in areas endemic with human cystic hydatidosis.

Human cystic echinococcosis: diagnostic value of different antigenic fractions of hydatid cyst fluid with different specific immunoglobulin G subclasses by enzyme linked immunoelectrotransfer blot.

The present study intended to evaluate the usefulness of immunoblot analysis of hydatid cyst fluid (HCF) for diagnostic verification of human cystic echinococcosis (CE). HCF of camel origin was resolved by SDS-PAGE gel electrophoresis and transblotted on nitrocellulose membrane. Immunoglobulin G (IgG) subclass-specific antibody responses in 25 sera from surgically confirmed CE cases, 44 persons with other parasitic infections and 20 normal controls were analyzed. Total IgG and IgG subclass1-4 in CE sera preferentially recognized several polypeptide bands in the range of 14-200 kDa. The most predominant band recognized by total IgG antibodies was at 21 kDa (sensitivity, 96%; specificity, 98.5%; J index, 94.5%), by IgG1 at 38 kDa (sensitivity, 92%; specificity, 100%; J index, 92%) and by IgG3 at 60 kDa (sensitivity, 96%; specificity, 100%; J index 96%). Sera from the normal controls did not recognize any of these polypeptides. These data suggest that detection of any of these polypeptides bands could be used for confirmation of human cystic echinococcosis in Egypt.