Prostate cancer brachytherapy: SFRO guidelines 2021.

Prostate brachytherapy techniques are described, concerning both permanent seed implant and high dose rate brachytherapy. The following guidelines are presented: brachytherapy indications, implant procedure for permanent low dose rate implants and high dose rate with source projector, as well as dose and dose-constraints objectives, immediate postoperative management, post-treatment evaluation, and long-term follow-up.

Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study.

OBJECTIVES/HYPOTHESIS: To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN: Cohort study. METHODS: A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS: Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS: The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1676-1682, 2021.

An infection-oriented approach for thoracic endovascular aortic repair in a SARS-CoV-2 positive patient. A case report.

CASE REPORT: A 64-year-old woman presented to our emergency department during the outbreak of the covid-19 emergency in Italy with syncope, anosmia, mild dyspnoea and atypical chest and dorsal pain. A chest CT scan showed an acute type B aortic dissection (ATBAD) and bilateral lung involvement with ground-glass opacity, compatible with interstitial pneumonia. Nasopharyngeal swabs resulted positive for SARS-CoV-2. For the persistence of chest pain, despite the analgesic therapy, we decided to treat her with a TEVAR. Patient's chest and back pain resolved during the first few days after the procedure. No surgical or respiratory complications occurred and the patient was discharged 14 days after surgery. DISCUSSION: By performing the operation under local anesthesia, it was possible to limit both the staff inside the operatory room and droplet/aerosol release. Since we had to perform the operation in a hemodynamics room, thanks to the limited extension of the endoprosthesis and the good caliber of the right vertebral artery we were able to reduce the risk of spinal cord ischemia despite the lack of a revascularization of the left subclavian artery. CONCLUSIONS: A minimally invasive total endovascular approach allows, through local anesthesia and percutaneous access, to avoid surgical cut down and orotracheal intubation. This, combined with a defined management protocol for infected patients, seems to be a reasonable way to perform endovascular aortic procedures in urgent setting, even in a SARSCoV- 2 positive patient. KEY WORDS: COVID-19, Dissection, TEVAR.

[Pulmonary rehabilitation in the in-hospital and outpatient phases]. / Rehabilitación pulmonar en fase hospitalaria y ambulatoria.

Pulmonary rehabilitation programmes aim to improve aerobic capacity and enhance quality of life in patients with chronic pulmonary disease, facilitating their participation and integration in different areas and activities of daily living, through the prescription and performance of physical exercise, as well as education on risk factors and healthy living. In multidisciplinary processes, various health professionals work together to support patients through the rehabilitation process, guiding lifestyle changes to improve their level of physical activity, nutritional factors, smoking cessation, diabetes management, medication adherence and weight loss, based on theories of behavioural change. The main objective of pulmonary rehabilitation programmes is to empower users in self-care and facilitate long-term management of chronic lung disease.

Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures.

BACKGROUND: Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG. METHODS: A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics. RESULTS: Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively. CONCLUSION: There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.

Photobiomodulation Therapy in Oral Medicine: A Guide for the Practitioner with Focus on New Possible Protocols.

Photobiomodulation (PBM) is the term to define the wide range of laser applications using low-energy densities and based on photochemical mechanisms where the energy is transferred to the intracellular mitochondrial chromophores and respiratory chain components. In literature, a great number of works are reported showing the advantages of PBM use in many oral diseases such as recurrent aphthous stomatitis, herpes infections, mucositis, and burning mouth syndrome. Different factors may explain the increasing reported use of PBM in oral medicine: the absence of side effects, the possibility of safely treating compromised patients such as oncologic patients, the possibility of a noninvasive approach not associated with pain or discomfort, and the possibility of performing short sessions. The review's aim is to describe the possible applications of PBM in oral medicine, giving practitioners simple guide for practice together with the information of a new treatment possibility "at home" performed by the patient himself under supervision.

Neuromuscular Development in Neonates and Postnatal Infants: Implications for Neuromuscular Electrical Stimulation Therapy for Dysphagia.

Purpose The aim of the current study was to review neuromuscular development, summarize the current body of evidence describing the use of neuromuscular electrical stimulation (NMES) therapy in infants, and identify possible contraindications for the use of NMES in the neonate and young infant. Method After a review of the literature describing neuromuscular development, we created a timeline of the developmental processes. Key milestones were determined, and a literature search was conducted to identify potential effects of electrical stimulation on this process. Results Current evidence supporting the use of NMES in the pediatric population is limited and of poor quality. Contraindications of the use of NMES in the neonate and young infant were identified, including (a) inhibited expression of the neural cell adhesion molecule that is vital for neuromuscular development, (b) alteration of muscle fiber type metabolic profile away from intended muscle fiber type morphology, and (c) interruption of postsynaptic acetylcholine receptor synthesis during neuromuscular junction development. Conclusion The use of NMES for the treatment of dysphagia in the neonate and young infant may influence early neuromuscular development in a manner that is not currently well understood. Future research is needed to further understand the effects of NMES on the developing neuromuscular system.

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

Myofascial trigger points are not an isolated neuromusculoskeletal phenomenon and have been implicated in systemic, visceral, and metabolic pathology, as a side effect of some medications and in the presence of psychological risk factors. This complexity can complicate adequate screening of patients prior to choosing dry needling as a treatment intervention. Regardless of whether clinicians practice in a direct access setting, they should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dry-needling appropriateness, technique chosen, and potential adverse responses to treatment. Of primary concern are conditions that can either manifest with myalgia and/or myopathy or masquerade as a more common musculoskeletal condition. This clinical commentary reviews system-specific considerations and other common disorders that should be screened for and discusses not only whether dry needling is appropriate but comments on technique and dosage considerations when initiating dry needling.

Novel Technique for Toe-to-Hand Transplantation: The Fourth-toe as an Alternative Option for Toe-to-Hand Transplantation for Pediatric Patients.

The first toe-to-hand transplantation was done in 1898 by Nicoladoni. It was a staged procedure and the toe flap was based on a pedicle. With advancement of optical instruments and microsurgeons' skills in 1964 the first microvascular toe-to-hand transplantation on a rhesus monkey was done. The technique's development has not stopped, many authors have modified it to achieve better outcomes for both traumatic and congenital hand defects. The most commonly used toes for transplantation are first, second, and second to third toe block. Well described plantar and dorsal vascular systems for first web space vessels as well as possibility to perform successful perforator anastomosis allows us to improve toe-to-hand transplantation further. There is a paucity of studies on single fourth toe-to-hand transplantation. We performed fourth-toe transplantation for three pediatric patients (mean age, 73 mo) with congenital (n=2) and traumatic (n=1) hand defects. Common plantar digital arteries were used for blood supply to the transplanted toes. No vascular problems occurred, and all transplanted toes survived. Patients and parents are satisfied with functional and esthetic outcomes. Early podometry results show insignificant changes which should not harm the foot in the long-term. We believe the fourth-toe transplantation is a promising method to use to reconstruct congenital or traumatic absence of digits for pediatric population.

Wide Awake Secondary Tendon Reconstruction.

The wide awake anesthesia technique is a useful tool in secondary tendon reconstruction. With active participation of the patient, the tendon repair can be adjusted appropriately to prevent repairs that are too tight or too loose. Areas of tendon scarring or triggering can be identified and released. Other advantages of active participation include reduction of gapping, ensuring adequate strength of repair, and avoiding tendon imbalances. Last, it allows intraoperative patient education and may therefore increase patient satisfaction. This article discusses how the technique can be applied to tenolysis, 2-stage tendon reconstruction, and tendon transfer.

Aplicaciones médicas de las cámaras de oxigenación hiperbárica de nueva generación / Medical applications of new generation hyperbaric oxygenation chambers

El uso clínico de la terapia de oxigenación hiperbárica (TOHB) consiste en respirar oxígeno en una concentración cercana al 100% en una cámara presurizada al menos a 1,4 atmósferas absolutas (atm). TOHB actúa produciendo hiperoxia y especies reactivas del oxígeno que desencadenan mecanismos bioquímicos variados. Se presenta una revisión de todas las nuevas aplicaciones emergentes de TOHB en varias especialidades médicas debido a que alcanza beneficios en la cicatrización de heridas, enfermedades inflamatorias y con componente neurológico o isquémico. Las nuevas cámaras realizan el tratamiento a presiones más seguras y con la misma eficiencia demostrada por métodos matemáticos y bioquímicos. El Grupo BioBárica Clinical Research presenta la estadística de las indicaciones en 559 pacientes tratados con estas cámaras en algunos centros médicos y las especialidades médicas implicadas. El uso de TOHB a media presión está en emergencia y podría proveer a futuro evidencia de su efectividad en otras especialidades médicas. (AU)

The clinical use of Hyperbaric Oxygen Therapy (HBOT) consists in breathing oxygen (O2) near to 100% in a pressurized chamber of at least at 1.4 absolute atmospheres (ATA). HBOT acts producing both hyperoxia and reactive oxygen species (ROS) and triggers others biochemical events. The BioBarica Clinical Research Group is developing clinical evidence in diverse pathologies because of accessibility and safety of the new Revitalair hyperbaric oxygen chamber. Because of working at "mild pressure", HBOT performed by these chamber are safer demonstrated by mathematical and biochemical methods. The BioBarica Clinical Research Group presents the statistics of the indications in 559 patients treated with these cameras in some medical centers and the medical specialties involved. Their accessibility to the physicians would become mild pressure HBOT used more frequently proving its effectiveness in other clinical specialties. (AU)

Neurostimulation for drug-resistant epilepsy: a systematic review of clinical evidence for efficacy, safety, contraindications and predictors for response.

PURPOSE OF REVIEW: Neurostimulation is becoming an increasingly accepted treatment alternative for patients with drug-resistant epilepsy (DRE) who are unsuitable surgery candidates. Standardized guidelines on when or how to use the various neurostimulation modalities are lacking. We conducted a systematic review on the currently available neurostimulation modalities primarily with regard to effectiveness and safety. RECENT FINDINGS: For vagus nerve stimulation (VNS), there is moderate-quality evidence for its effectiveness in adults with drug-resistant partial epilepsies. Moderate-to-low-quality evidence supports the efficacy and safety of deep brain stimulation (DBS) and responsive neurostimulation (RNS) in patients with DRE. There is moderate-to-very low-quality evidence that transcranial direct current stimulation (tDCS) is effective or well tolerated. For transcutaneous vagus nerve stimulation (tVNS), transcranial magnetic stimulation (TMS) and trigeminal nerve stimulation (TNS), there are insufficient data to support the efficacy of any of these modalities for DRE. These treatment modalities, nevertheless, appear well tolerated, with no severe adverse events reported. SUMMARY: Head-to-head comparison of treatment modalities such as VNS, DBS and RNS across different epileptic syndromes are required to decide which treatment modality is the most effective for a given patient scenario. Such studies are challenging and it is unlikely that data will be available in the near future. Additional data collection on potentially promising noninvasive neurostimulation modalities like tVNS, TMS, TNS and tDCS is warranted to get a more precise estimate of their therapeutic benefit and long-term safety.

Chiropractic student choices in relation to indications, non-indications and contra-indications of continued care.

Background: The quality of health care provider clinical decisions has long been recognized as variable. Research has focused on clinical decision making with the aim of improving patient outcomes. No studies have looked at chiropractic students´ abilities in this regard. Method: In 2016, advanced students from two Australian chiropractic programs (N = 444) answered a questionnaire on patient case scenarios for neck and low back pain (LBP). We selected 7 scenarios representing the three categories; continuing care, non-indicated care, and contraindicated care. This represented a total of 21 tested scores. Comparisons of correct answers were made a) for program years 3, 4 and 5, and b) between the three categories of care. Results: In almost 1/3 of scenarios, correct scores were 70% or greater. Best results were for two neck pain cases (simple and with spinal cord involvement). Continued care showed most improvements with study year. However, the scenarios that reflected non-indication for continued care had much worse results and did not improve in higher years. For the obvious contraindicated neck scenario, the results were good from the beginning and progressively improved and for a contraindicated LBP scenario the results started poorly in year 3 but improved over the program years. Conclusions: Although student responses were generally good, there is still room for improvement, especially for non-indicated care. The quality of students' clinical decisions can be measured and thus has the potential to be used by chiropractic educators and regulatory bodies to identify student's in need of assistance as well as to monitor chiropractic programs in relation to student competence. Trial registration: Not applicable.

The 'ins' and 'outs' of intussusception: Where best practice reduces the need for surgery.

Intussusception may be difficult to diagnose because the classical triad of symptoms is evident at the time of presentation in only about 20% of cases. This may lead to delays in making the correct diagnosis. The most common presenting features are colicky abdominal pain, vomiting, pallor, lethargy and listlessness. In recent years, the algorithms of management of intussusception have changed significantly: a routine plain abdominal X-ray has been replaced by ultrasonography, previously perceived contraindications to attempting an enema reduction no longer apply, gas has largely replaced barium for enema reduction, incomplete initial reduction is an indication for a delayed repeat enema if the child is stable clinically and partial reduction has been achieved, the indications for surgery have been tightened and laparoscopy affords an alternative surgical approach. This commentary expands on the rationale behind some of the recent advances in the management of children who present with suspected intussusception.

Surgical ultrasound-guided carpal tunnel release.

Ultrasound-guided surgery is a new trend stemming from the introduction of high-frequency linear probes and better quality screens. Surgical treatment of carpal tunnel syndrome is increasingly being performed under ultrasound guidance. Knowledge of musculoskeletal ultrasonography is obviously mandatory. Several types of cutting instruments (miniature knife, Gigli saw or hook) and surgical approaches (wrist or palm) have been described. Ultrasonography allows the wide-awake and local anesthesia with no tourniquet (WALANT) technique to be used in the context of ambulatory patient care. The practitioner must be aware of all the possible intraoperative and postoperative complications, and be able to treat them. The aim of this review is to analyze the literature on the feasibility and outcomes of surgical ultrasound-guided carpal tunnel release, and to compare it to the other validated techniques.

Endometrial Biopsy: American College of Nurse-Midwives.

Endometrial biopsy can be used to diagnose endometrial hyperplasia, endometrial cancer, and uterine infections. This cost-effective procedure has minimal side effects, and complications are rare. The purpose of this clinical bulletin is to provide clinicians with guidance about endometrial biopsy including the procedure's advantages and disadvantages, indications and contraindications, and side effects. In addition, step-by-step instructions for performing endometrial biopsy, the equipment required, selection of sampling devices, and care before and after the procedure are discussed.