A randomized controlled trial evaluating low-intensity shockwave therapy for treatment of persistent storage symptoms following transurethral surgery for benign prostatic obstruction.

BACKGROUND: Low-intensity shockwave therapy (Li-SWT) can improve bladder function through enhancement of angiogenesis and nerve regeneration and suppression of inflammation and overactivity. In this trial, we aimed to evaluate the efficacy of Li-SWT on persistent storage symptoms after transurethral surgery (TUS) for benign prostatic obstruction (BPO). METHODS: Between July 2020 and July 2022, 137 patients with persistent storage symptoms; urgency episodes/24 h ≥ 1 and daytime frequency ≥8, for at least three months after TUS for BPO were randomly allocated to Li-SWT versus sham versus solifenacin 10 mg/day in 3:1:1 ratio. The primary end point was the percent reduction from baseline in overactive bladder symptom score (OABSS) at 3-month follow-up. The changes in 3-day voiding diary parameters, quality of life (QoL) score, peak flow rate and residual urine at 3 and 6-month follow-up were compared. Treatment-related adverse effects were also evaluated. RESULTS: Baseline data were comparable between groups. The percent reduction from baseline in OABSS at 3-month follow-up was significantly higher in Li-SWT compared to sham (-55% versus -11%), and it was comparable between Li-SWT and solifenacin-10 (-55% versus -60%). Li-SWT achieved significant improvement like solifenacin-10 in 3-day voiding diary parameters and QoL score at 3-month follow-up. This improvement remained comparable between Li-SWT and solifenacin-10 at 6-month follow-up. No adverse effects related to Li-SWT were noted apart from tolerable pain during the procedure. Solifenacin-10 was associated with bothersome adverse effects in 73% of the patients with 11.5% discontinuation rate. CONCLUSIONS: Li-SWT ameliorates persistent storage symptoms and promotes QoL after TUS for BPO, with comparable efficacy and better tolerance compared to solifenacin.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND: Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients. METHODS: We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence. RESULTS: The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke. CONCLUSION: There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

Fungating and Ulcerating Breast Cancer: Wound Closure Algorithm, Complications, and Survival Trends.

Fungating breast cancer severely affects patients' daily lives, and patient management poses major oncology challenges. To present 10-year outcomes of unique tumor presentation, suggesting a focused algorithm for surgical management and providing deep analysis for factors affecting survival and surgical outcomes. Eighty-two patients with fungating breast cancer were enrolled in the period from January 2010 to February 2020 in the Mansoura University Oncology Center database. Epidemiological and pathological characteristics, risk factors, different surgical treatment techniques, and surgical and oncological outcomes were reviewed. Preoperative systemic therapy was used in 41 patients, with the majority (77.8%) showing progressive response. Mastectomy was performed in 81 (98.8%) patients, with primary wound closure in 71 (86.6%), and wide local excision in a single patient (1.2%). Different reconstructive techniques in non-primary closure operations were used. Complications were reported in 33 (40.7%) patients, of which 16 (48.5%) were of Clavien-Dindo grade II category. Loco-regional recurrence occurred in 20.7% of patients. The mortality rate during follow-up was 31.7% (n = 26). Estimated mean overall survival (with 95% CI) was 55.96 (41.98-69.9) months; estimated mean loco-regional recurrence-free survival (with 95% CI) was 38.01 (24.6-51.4) months. Surgery is a cornerstone fungating breast cancer treatment option, but at the expense of high morbidity. Sophisticated reconstructive procedures may be indicated for wound closure. A suggested algorithm based on the center's experience of wound management in difficult mastectomy cases is displayed.

Thermal performance enhancement of the wick-type solar still using titanium dioxide nanoparticles embedded in paraffin wax as a phase change material.

In this study, the performance of the wick-type solar still was investigated using phase change material (PCM) with titanium dioxide nanoparticles as a storage material. Therefore, two solar stills were fabricated one of which was operated with pure PCM and the other one was operated with PCM incorporated with Tio2 nanoparticles. The use of the nanoparticles was to enhance the thermal conductivity of the PCM and hence improve the productivity and the efficiency of the studied solar still. The proposed design was investigated with jute and cotton as wick materials. The results revealed that the addition of the nanoparticles increased the thermal conductivity of the PCM by 9.6%. Moreover, the daily productivity was found to be 1058 and 1226 ml/m2 day for cotton and jute, respectively in case of the presence of the PCM-nanocomposite.

Q-Switched 1064-nm Nd: YAG laser versus fractional carbon dioxide laser for post acne scarring: A split-face comparative study.

OBJECTIVES: Many treatment modalities are available for post acne scarring. However, the response to the treatment is extremely variable among patients. AIM: The aim of this study was to compare the efficacy and safety of Q-switched Nd: YAG (1064 nm) and fractional CO2 (10,600 nm) lasers in the treatment of atrophic post acne scars. METHODS: This study included 20 patients with atrophic facial post acne scars graded according to Sharquie's score. All subjects received four sessions of laser treatment with a 4-week interval between the sessions. The study was designed as a double-blinded, comparative, split-face study applying Q-switched 1064-nm Nd:YAG laser to the right side of the face and fractional CO2  laser to the left side. RESULTS: Q-switched 1064-nm Nd: YAG laser achieved significantly higher improvement percentage when compared to fractional CO2  lasers (33.33% versus 17.37% Sharquie's score reduction, respectively). There was a significant negative correlation between the percentages of improvement and the patients' age on both sides and a significant positive correlation with the baseline Sharquie scores on both sides. CONCLUSION: Q-Switched 1064-nm Nd: YAG laser could be a promising safe option for the management of atrophic post acne scars.

Ultrasound versus thoracoscopic-guided paravertebral block during thoracotomy.

BACKGROUND: Paravertebral block can be performed with the aid of surgical landmarks, ultrasound, or a thoracoscope. This study was designed to compare ultrasound-guided paravertebral block with the thoracoscopic technique. METHODS: This prospective randomized comparative study included 40 adults scheduled for elective thoracic surgery. Study participants were randomized to an ultrasound group or a thoracoscope group. A catheter for paravertebral block was inserted prior to thoracotomy with real-time ultrasound visualization in the ultrasound group, and under thoracoscopic guidance in the thoracoscope group. Total analgesic consumption, visual analogue pain score, technical difficulties, and complications were compared between the 2 groups. RESULTS: Total analgesic consumption in the first 24 hours was less in the ultrasound group than in the thoracoscope group (rescue intravenous fentanyl 121.25 ± 64.01 µg in the ultrasound group vs. 178.75 ± 91.36 µg in the thoracoscope group; p = 0.027). Total paravertebral bupivacaine consumption was 376.00 ± 33.779 mg in the ultrasound group and 471.50 ± 64.341 mg in the thoracoscope group (p < 0.001). Technical difficulties and complications in terms of time consumed during the maneuver, more than one needle pass, and pleural puncture were significantly lower in the ultrasound group than in the thoracoscope group. CONCLUSION: Ultrasound-guided paravertebral catheter insertion is more effective, technically easier, and safer than the thoracoscope-assisted technique.

Operative bleeding during thoracoscopic thymectomy: Causes and management strategies.

Bleeding during thoracoscopic thymectomy is a potentially critical complication that necessitates either immediate effective thoracoscopic control or conversion to an open approach. It can be difficult to manage and the surgeon must respond quickly in order to keep the patient safe . In this video tutorial we present various forms of intraoperative bleeding that can occur during thoracoscopic thymectomy and discuss how to manage them in patients with myasthenia gravis. Our management techniques include compression, clipping, stitching, and safe conversion to an open approach.

Effect of Adding Hydrocortisone to Intraperitoneal Bupivacaine in Laparoscopic Bariatric Surgery.

BACKGROUND: Bariatric surgery is the effective management of obesity; however, postoperative pain is associated with a great morbidity. The management of pain is important for the enhancement of patient recovery. Local anesthetics can be injected during laparoscopic surgery into the peritoneum throughout the ports produced either before the beginning of laparoscopy or before the closure of the wound to reduce postoperative pain. Our aim is to evaluate if there is an additive analgesic effect by the administration of intraperitoneal hydrocortisone with streamed intraperitoneal bupivacaine as a method of postoperative pain relief in laparoscopic bariatric surgeries. PATIENTS AND METHODS: One hundred patients listed for laparoscopic bariatric surgery were the subject of this study. Patients were randomly allocated into two groups: Group I received 100 mg of 0.5% isobaric bupivacaine plus 20 mL normal saline intraperitoneally and Group II received intraperitoneal 100 mg of 0.5% isobaric bupivacaine + 100 mg hydrocortisone + 20 mL of saline at the end of the laparoscopic procedure. The primary outcome was the Visual Analog Scale (VAS) score for pain. The secondary outcomes were the time of first analgesic request, total opioid requirement, heart rate, and mean blood pressure. RESULTS: VAS showed a significant decrease at 4, 6, and 12 h postoperative in Group II compared to Group I. There was a marked decrease in total meperidine requirement with prolonged time of the first analgesic request in Group II compared to Group I. CONCLUSION: Intraperitoneal hydrocortisone with bupivacaine had improved postoperative pain relief with a decrease in analgesic requirement.

Recurrent mandibular ameloblastoma in soft tissue and rib graft 17 years after initial presentation.

BACKGROUND: Ameloblastoma is the commonest odontogenic tumour of epithelial origin with a high incidence for developing local recurrence. We present a patient who developed local recurrence in both soft tissue and bone graft 17 years after the initial presentation. CASE PRESENTATION: A 75-year-old female with a previous history of right hemimandibulectomy and rib reconstruction for ameloblastoma in 1999 presented to our centre with a large cystic mouth floor swelling, biopsy from which revealed recurrent ameloblastoma. The patient underwent excision of the recurrent mass en bloc with the cystic swelling through oral and cervical approaches. The patient was discharged after 5 days with an uneventful postoperative course and with a free 2-year follow-up from further recurrence. CONCLUSION: Ameloblastoma is a locally aggressive tumour for which wide local excision with adequate margins is the best management approach. Recurrence of ameloblastoma even after adequate resection is not uncommon, and its management is considered a surgical challenge. A very long time may pass between the initial presentation and the development of recurrence.

Cardiac Preconditioning Effect of Ketamine-Dexmedetomidine versus Fentanyl-Propofol during Arrested Heart Revascularization.

BACKGROUND: Myocardial damage due to ischemia and reperfusion is still unavoidable during coronary surgery. Anesthetic agents have myocardial preconditioning effect. Ketamine has sympathomimetic effect, while dexmedetomidine has a sympatholytic effect in addition to anesthetic, analgesic, and anti-inflammatory properties of both the drugs. This study was carried out to compare ketamine-dexmedetomidine (KD) combination with fentanyl-propofol (FP) combination on the release of cardiac troponin T (cTnT) and outcome after coronary artery bypass graft. PATIENTS AND METHODS: Ninety adult patients who underwent coronary artery bypass grafting (CABG) were assigned to receive either KD base anesthesia (KD group) or FP anesthesia (FP group). Trends of high-sensitive cTnT, CK-MB, and serum cortisol were followed in the first postoperative 24 h. Other outcomes were vital signs, weaning from cardiopulmonary bypass, tracheal extubation time, and echocardiographic findings. RESULTS: There was a significant lower release of cTnT in KD group than FP group during its peak values at 6 h after aortic unclamping (92.01 ± 7.332 in KD versus 96.73 ± 12.532 ng.L-1 P = 0.032). significant lower levels of serum cortisol levels were noted KD group than in FP group at 6 and 12 h after aortic unclamping P < 0.001. As regard tracheal extubation time, patients assigned to KD group extubated earlier than whom in FP group 202.22 ± 28.674 versus 304.67 ± 40.598 min respectively P < 0.001. CONCLUSION: The use of KD during on-pump CABG confers better myocardial protective and anti-inflammatory effect than fentanyl propofol.

Volatile Anesthetics versus Total Intravenous Anesthesia for Cardiac Surgery.

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.).

Surgical approaches, anaesthetic management and outcome in pediatric superior mediastinal tumors.

BACKGROUND: Pediatric superior mediastinal tumors are a heterogeneous group of tumors with marked variation in pathology and extension. We reviewed our experience with different surgical approaches to tumors originating from or extending to superior mediastinum in pediatrics. PATIENTS AND METHODS: The medical records of all patients who had undergone resection for superior mediastinal tumors in Children's Cancer Hospital - Egypt, between January 2008 to December 2015, were reviewed for demographic data, clinico-pathological features, radiologic findings, operative techniques and outcome. RESULTS: The study included 20 patients. Diagnosis included: germ cell tumors (n=8), neuroblastoma (n=4), soft tissue sarcoma (n=3), thymolipoma (n=2), infantile fibromatosis (n=1), calcifying fibrous tumor (n=1), and thymic carcinoma (n=1). Tumor extension was divided into tumors extending unilaterally to one hemithorax (n=9), tumors extending bilaterally to both hemithoraces (n=4), and cervico thoracic junction tumors (n=7). Extended lateral thoracotomy was used in 8 patients. Other approaches included trapdoor (n=5), clamshell (n=4), cervical approach (n=2) and double level lateral thoracotomy (n=1). There was no perioperative mortality, and postoperative morbidity was 20%. At the end of December 2016, 15 patients were alive free of disease, 5 patients developed local and/ or distant relapse. CONCLUSION: Pediatric superior mediastinal tumors could be divided into 3 groups according to tumor extension. Each group has an optimum surgical approach that achieves the best exposure for adequate resection. However, further research is needed to confirm the conclusion as this was a descriptive study and the sample size was too small for valid statistical analysis.