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.

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.

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.

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.

Platelet function defects in adolescents with heavy menstrual bleeding.

Platelet function defects (PFD) are reported to occur frequently in adult women with heavy menstrual bleeding (HMB). Few studies on adolescent HMB report varying incidence rates (2-44%) for PFD. We reviewed our institutional experience in detecting and managing PFD in adolescent HMB. Postmenarchial girls and adolescents with HMB seen at our institution undergo a comprehensive bleeding disorder work-up by paediatric haematology and paediatric gynaecology providers. Whole blood platelet aggregometry (WBPA) is performed as a second tier test after excluding thrombocytopaenia, coagulation factor deficiencies and Von Willebrand disease (VWD). We retrospectively reviewed the medical records of adolescents with HMB seen between June 2009 and November 2010, as approved by the Institutional Review Board. Patient demographics, clinical features, laboratory results, therapy details and patient outcome information were analysed. Overall, 114 postmenarchial girls and adolescents with HMB were evaluated; 68 patients (59%) had WBPA study performed. Nineteen patients (28%) had at least one aggregation or secretion defect; 12 (18%) had two or more such defects. Treatment included hormonal therapy (13/19; 68%), antifibrinolytic agents (8/19; 42%) and intra-nasal DDAVP (3/19; 16%). Thirteen patients (81%) had improved outcome (median follow-up--15.6 months; range of 1-66 months). In this study, PFD were identified in nearly one-third of girls with HMB, with the majority of these having two or more defects as identified by WBPA. Further prospective studies are needed to better define the prevalence and address appropriate management of HMB and other bleeding complications of PFD in adolescents.

Hyperglycemia is a predictor of mortality and morbidity in low birth weight newborn.

Early onset of hyperglycemia is common among low birth weight neonates. Increased risk for death and major morbidities has been observed among hyperglycemic low birth weight infants. This prospective observational study was done to find out hyperglycemia as a predictor of increased morbidity and mortality in the low birth weight sick newborn and was conducted among the hospitalized newborn of Special Care Baby Unit (SCABU), BIRDEM hospital, Dhaka, Bangladesh from July 2009 to December 2009. A total of 198 LBW neonates were included in this study. One third (30.8%) LBW neonates were found hyperglycemic. The mean gestational age was 33.2±3.6 weeks and mean birth weight was 1535.8±780gm in the hyperglycemic neonates. In this study, highest prevalence of hyperglycemia was observed in birth weight <1000gm (38.46%) and in gestational age ≤28 weeks (46.15%). Apnoea, confirmed sepsis and suspected sepsis, confirmed necrotizing enterocollitis (NEC) and neonatal jaundice showed statistically significant association with hyperglycemia than that of non hyperglycemic group. Mortality of neonates in hyperglycemic group was higher (31.15%) than that of non hyperglycemic neonates (10.22%) and the difference in mortality between two groups were found statistically significant (p<0.002). From this study it can be concluded that hyperglycemia in early neonatal period is related to increased morbidity and mortality in low birth weight newborn.

The end of tracheostomal stenosis? Introducing the fish mouth technique.

BACKGROUND: Post-laryngectomy tracheostomal stenosis is common and often results in an inadequate airway. Several techniques have been described to minimise tracheostomal stenosis. The star technique involves an 'X' incision with four flaps sutured into the trachea. The petal technique involves two inferior flaps on either side being sutured into the trachea. The authors combined the star and petal techniques, resulting in an innovative fish mouth technique. METHODS AND RESULTS: This innovation involves two lateral skin flaps being sutured into an incision on either side of the lateral wall of the trachea. This results in an elongated, broadened and elliptical tracheostoma, mimicking that of a fish mouth. CONCLUSION: Benefits of the fish mouth technique include adequate stoma size for respiration, easier clearing of secretions, self-sufficiency without a stent, easier cleaning of a tracheoesophageal voice prosthesis, and stoma occlusion for voice production. The fish mouth technique is easily reproducible and suitable for those with a voice prosthesis.

The impact of article processing charge waiver on conducting research in low-income countries.

Health sciences research is a major tool in exchanging publications and knowledge between the various countries of the world. Researchers in developing countries barely have any financial funding from governmental or educational institutes to support their research. In low-income countries such as Syria, With less than 30$ per month and almost no financial support, Syrian residency doctors are fighting to push the scientific research reality of this ongoing crisis country forward and without a doubt, APC waiver plays a crucial role in this continuing mission.

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.

Technique of laser calibration for wavelength-modulation spectroscopy with application to proton exchange membrane fuel cell measurements.

A diode laser sensor was developed for partial pressure and temperature measurements using a single water vapor transition. The Lorentzian half-width and line intensity of the transition were calibrated for conditions relevant to proton exchange membrane (PEM) fuel cell operation. Comparison of measured and simulated harmonics from wavelength-modulation spectroscopy is shown to yield accuracy of +/-2.5% in water vapor partial pressure and +/-3 degrees C in temperature despite the use of a single transition over a narrow range of temperatures. Collisional half-widths in air or hydrogen are measured so that calibrations can be applied to both anode and cathode channels of a PEM fuel cell. An in situ calibration of the nonlinear impact of modulation on laser wavelength is presented and used to improve the accuracy of the numerical simulation of the signal.

Maximum vocal intensity as a primary outcome measure in unilateral vocal fold paralysis patients.

OBJECTIVE: To evaluate voice intensity as the primary outcome measurement when treating unilateral vocal fold paralysis patients. METHODS: This prospective observational study comprised 34 newly diagnosed unilateral vocal fold paralysis patients undergoing surgical interventions: injection laryngoplasty or medialisation thyroplasty. Voice assessments, including maximum vocal intensity and other acoustic parameters, were performed at baseline and at one and three months post-intervention. Maximum vocal intensity was also repeated within two weeks before any surgical interventions were performed. The results were compared between different time points and between the two intervention groups. RESULTS: Maximum vocal intensity showed high internal consistency. Statistically significant improvements were seen in maximum vocal intensity, Voice Handicap Index-10 and other acoustic analyses at one and three months post-intervention. A significant moderate negative correlation was demonstrated between maximum vocal intensity and Voice Handicap Index-10, shimmer and jitter. There were no significant differences in voice outcomes between injection laryngoplasty and medialisation thyroplasty patients at any time point. CONCLUSION: Maximum vocal intensity can be applied as a treatment outcome measure in unilateral vocal fold paralysis patients; it can demonstrate the effectiveness of treatment and moderately correlates with self-reported outcome measures.

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.

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.

Patient perception of a randomised, controlled trial of laryngeal reinnervation versus thyroplasty for unilateral vocal fold paralysis.

OBJECTIVES: To explore unilateral vocal fold paralysis patients' perception of a proposed randomised, controlled trial of laryngeal reinnervation versus thyroplasty, and to identify patients' concerns regarding their voice. METHODS: Seventeen patients from five voice clinics in London were identified as being eligible for the randomised, controlled trial. Eleven of these patients (9 females and 2 males; age range, 18-65 years) were interviewed using a semi-structured topic guide (they were given a minimum of 2 weeks to read through the study information sheet). The interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: The patients were satisfied with the clarity of the information sheet. Most of them perceived that reinnervation was a more 'attractive' option than thyroplasty. This may have been the result of certain phraseology used in the information sheet and by recruiters. Patients' main concern was reduced voice strength and the effects of this on work and social life. CONCLUSION: Phraseology that needed changing was identified; these changes may optimise the recruitment process for a trial. We propose using the voice handicap index 10 as the primary measure of outcome in the proposed randomised, controlled trial.

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.

Thoracic surgery of testicular cancer patients.

Between 1 January 1980 and 31 December 1991 the authors treated 1450 patients with malignant testicular tumours. Out of them, in 42 patients aged 18-43 years with stage III non-seminoma germ cell testicular cancer, thoracic surgical interventions took place on 44 occasions since the combined cytostatic treatment did not result in a sufficient regression, or disease progression occurred. In one case the lesion was inoperable. In 43 cases successful resection was performed. In 27 cases unilateral, in two cases bilateral thoracotomy and in 15 cases median sternotomy took place. Solitary lesions were found in 26 and multiple ones in 18 cases, respectively. Two patients died in the direct postoperative phase. Forty patients were followed up for 4 to 130 months. Due to disease progression four and seven patients were lost within 12 and 12-24 months, respectively. Currently, 31 patients are alive 4 to 130 months following surgery (29 of them tumour-free, two with tumour). Based on adequate indications the thoracic surgery is justified both from diagnostic and therapeutic points of view. The metastasectomy might offer an advance in the management of these patients.