Surgical Management in a Paediatric Case of Endobronchial Mucoepidermoid Carcinoma Involving the Carina.

Although mucoepidermoid carcinoma (MEC) is the most diagnosed malignancy of the salivary gland, it rarely localises to the bronchus, accounting for only 0.1-0.2% of all primary lung malignancies. Of those pulmonary MECs, most are found in segmental or lobar bronchi, and they are rarely found in mainstem bronchi, highlighting the novelty of this presentation for thoracic specialists. We present a case report of a seven-year-old female who underwent a carinal resection and a right upper lobectomy for the management of an endobronchial MEC causing right middle lobe (RML) obstruction. Intraoperatively, an exophytic mass originating from the junction of the right main bronchus and bronchus intermedius was identified, causing a partial obstruction of the RML bronchus. Frozen sections demonstrated clear margins and follow-up bronchoscopies have been unremarkable. Given their rarity, endobronchial MECs can be diagnostically difficult and cause uncertainty with respect to their management. Low-grade tumours have a much more favourable prognosis than their high-grade counterparts, with surgical resection being the gold standard of care. Therefore, the index of suspicion, time to diagnosis, and definitive treatment are critical to the outcome.

Improving Thoracic Surgery Ward Round Quality and Enhancing Patient Safety in a Referral Centre.

Introduction Ward rounds are vital clinical processes that facilitate an opportunity for daily review and management of thoracic surgery inpatients. The aim of this study was to compare thoracic surgery ward round documentation against locally agreed standards and design a template to improve the detail and uniformity of this process to enhance patient care. Materials and methods Data for this audit was collected retrospectively and prospectively. Data was collected during three auditing periods and managed on Microsoft Excel. Descriptive statistics were used for its analysis. Chi-square and Fisher's Exact tests were used to test for differences in reporting rates. Results and discussion Initially, a total of 199 ward round notes were reviewed. Imaging results (19%) and discharge planning (23%) were not reported. eCARE (electronic Clinical Assessment for Round Evaluation) was developed to ensure that all aspects of patient evaluation recommended by the guidelines were included. Reporting rates significantly improved after such changes. We analysed the effect of the new ward round note on discharge planning (23.3 vs 41%, p<0.001), complication rates (32.6 vs 21.9%, p=0.03), post-surgical length of stay (LOS) (7.0 vs 5.0, p<0.001). Conclusion Over a year, we audited the Thoracic Surgery Department's ward round documentation against locally agreed standards in line with national recommendations. Several important items were not regularly reported. Using closed-ended questions improved reporting rates, and patient care was optimised. Further research should explore the impact of this new documentation method on patient care and postoperative outcomes in our Trust as well as other cardiothoracic centres.

The effects of ischaemic conditioning on lung ischaemia-reperfusion injury.

Ischaemia-reperfusion injury (IRI) encompasses the deleterious effects on cellular function and survival that result from the restoration of organ perfusion. Despite their unique tolerance to ischaemia and hypoxia, afforded by their dual (pulmonary and bronchial) circulation as well as direct oxygen diffusion from the airways, lungs are particularly susceptible to IRI (LIRI). LIRI may be observed in a variety of clinical settings, including lung transplantation, lung resections, cardiopulmonary bypass during cardiac surgery, aortic cross-clamping for abdominal aortic aneurysm repair, as well as tourniquet application for orthopaedic operations. It is a diagnosis of exclusion, manifesting clinically as acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Ischaemic conditioning (IC) signifies the original paradigm of treating IRI. It entails the application of short, non-lethal ischemia and reperfusion manoeuvres to an organ, tissue, or arterial territory, which activates mechanisms that reduce IRI. Interestingly, there is accumulating experimental and preliminary clinical evidence that IC may ameliorate LIRI in various pathophysiological contexts. Considering the detrimental effects of LIRI, ranging from ALI following lung resections to primary graft dysfunction (PGD) after lung transplantation, the association of these entities with adverse outcomes, as well as the paucity of protective or therapeutic interventions, IC holds promise as a safe and effective strategy to protect the lung. This article aims to provide a narrative review of the existing experimental and clinical evidence regarding the effects of IC on LIRI and prompt further investigation to refine its clinical application.

Outcomes of robotic esophagectomy.

Esophagectomy has long been considered the standard of care for early-stage (≤ T2N0) esophageal cancer. Minimally invasive esophagectomy (MIE), using a combined laparoscopic and thoracoscopic approach, was first performed in the 1990s and showed significant improvements over open approaches. Refinement of MIE arrived in the form of robotic-assisted minimally invasive esophagectomy (RAMIE) in 2004. MIE is a challenging procedure for which consensus on optimal technique is still elusive. Although nonrobotic MIE confers significant advantages over open approaches, MIE remains associated with stubbornly high rates of complications, including pneumonia, aspiration, arrhythmia, anastomotic leakage, surgical site infection, and vocal cord palsy. RAMIE was envisioned to improve operative-associated morbidity while achieving equivalent or superior oncologic outcomes to nonrobotic MIE. However, owing to RAMIE's significant upfront costs, steep learning curve, and other requirements, adoption remains less than widespread and convincing evidence supporting its use from well-designed studies is lacking. In this review, we compare operative, oncologic, and quality-of-life outcomes between open esophagectomy, nonrobotic MIE, and RAMIE. Although RAMIE remains a relatively new and underexplored modality, several studies in the literature show that it is feasible and results in similar outcomes to other MIE approaches. Moreover, RAMIE has been associated with favorable patient satisfaction and quality of life.

Three-dimensional virtual and printed models for planning adult cardiovascular surgery.

BACKGROUND: The objective of this study was to explore the usefulness of virtual models and three-dimensional (3D) printing technologies for planning complex non-congenital cardiovascular surgery. METHODS: Between July 2018 and December 2019, adult patients with different cardiovascular structural diseases were included in a clinical protocol to explore the usefulness of Standard Tessellation Language (STL)-based virtual models and 3D printing for prospectively planning surgery. A qualitative descriptive analysis from the surgeon's viewpoint was done based on the characteristics, advantages and usefulness of 3D models for guiding, planning and simulating the surgical procedures. RESULTS: A total of 14 custom 3D-printed heart and great vessel replicas with their corresponding 3D virtual models were created for preoperative surgical planning. Six of 14 models helped to redefine the surgical approach, 3 were useful to verify device delivery, while the rest did not change the surgical decision. In all open surgery cases, cardiac and vascular anatomy accuracy of virtual and physical 3D replicas was validated by direct visualisation of the organs during surgery. Printing was achieved through an external provider associated with the Hospital, who printed the final prototype in 5-7 days. Printed production cost was between 100 and 500 USD per model. CONCLUSIONS: In the current study, the selected 3D printed models presented different advantages (visual, tactile, and instrumental) over the traditional flat anatomical images when simulating and planning some complex types of surgery. Notwithstanding 3D printing advantages, STL-based virtual models were pre-printing useful tools when instrumentation on a physical replica was not required.

Long-term outcomes of symptomatic and asymptomatic patients undergoing carotid endarterectomy in an average-volume community hospital.

BACKGROUND: Long-term benefit of carotid endarectomy has not yet been fully investigated in average volume centers. Thus our purpose is to evaluate long-term results of carotid endarterectomies at a medium-volume hospital. METHODS: A retrospective analysis of carotid artery stenosis operated between 2008 and 2017 in a community hospital was done. Demographic and postoperative outcomes were evaluated in short and long-term by Kaplan-Meier survival analysis. RESULTS: 167 procedures in 159 patients were included. Average age was 72 years, and 65% were men. Twenty-nine percent of the patients were symptomatic and the rest asymptomatic. Median hospitalization was 3 (IQR 3-4) days and the mean follow-up was 56 months. No hospital mortality was recorded. At 120-month follow-up, freedom of stroke was 97.4%, death 97.3%, restenosis, 98.7% and all combined events 92.9% (log rank p = .042) Combined event-free survival was 84.4% in symptomatic patients, and 96.1% in asymptomatic patients (log rank p = .025). CONCLUSIONS: In a medium-volume hospital combined event-free survival was 84.4% in symptomatic patients and 96.1% in asymptomatic at a 10-year follow-up.

Remote ischaemic conditioning in patients with ST-elevation myocardial infarction treated with percutaneous coronary intervention: an updated meta-analysis of clinical outcomes.

BACKGROUND: All previous meta-analyses including clinical outcomes after remote ischaemic conditioning (RIC) in patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) demonstrated that RIC significantly reduced all-cause mortality and major adverse cardiovascular events (MACE). Following the publication of these meta-analyses, three new randomised controlled clinical trials (RCT) including 5712 patients were reported. The objective of this study was to perform an updated meta-analysis about the effectiveness of RIC in reducing MACE in patients with STEMI undergoing PCI. METHODS: The search strategy included only RCT identified in MEDLINE, Embase, SCOPUS, and Cochrane (up to February 2020). Eligible studies included any type of RIC. The study adhered to the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) statement. The studies quality was evaluated with Cochrane Risk of Bias tool and Jadad score. RESULTS: Twelve RCT were included in the analysis (Q = 18.8, p = 0.065, I2 = 41.5%, 95%CI 0.0-70.3). Globally, 8239 STEMI patients with 816 MACE were reported with follow-ups between 1 and 45 months. Random effects model showed no significant effect of RIC on composite clinical endpoints (OR = 0.77, 95%CI 0.59-1.01, p = 0.105). Sensitivity analysis demonstrated that only the exclusion of CONDI-2/ERIC PPCI trial modified the significance of the global effect (OR 0.66, 95%CI 0.47-0.93), favouring RIC intervention. CONCLUSIONS: The current updated meta-analysis showed that use of RIC around the time of PCI for STEMI treatment added no significant benefit for clinical outcomes assessed between 6 and 45 months after the procedure. These conclusions are in direct contrast to previously published meta-analyses.

What patients consider to be a good doctor, and what doctors consider to be a good patient / Cómo definen los pacientes a un buen médico, y cómo definen los médicos a un buen paciente

ABSTRACT Background: From a patient's point of view, an 'ideal' doctor could be defined as one having personal qualities for interpersonal relationships, technical skills and good intentions. However, doctors' opinions about what it means to be a 'good' patient have not been systematically investigated. Aim: To explore how patients define the characteristics of a 'good' and a 'bad' doctor, and how doctors define a 'good' and a 'bad' patient. Material and Methods: We surveyed a cohort of 107 consecutive patients attending a community teaching hospital in February 2019, who were asked to define the desirable characteristics of a good/bad doctor. Additionally, a cohort of 115 physicians working at the same hospital was asked to define the desirable characteristics of a good/bad patient. Responses were subjected to content analysis. Simultaneously, an algorithm in Python was used to automatically categorize responses throughout text-mining. Results: The predominant patients' perspective alluded to desirable personal qualities more importantly than proficiency in knowledge and technical skills. Doctors would be satisfied if patients manifested positive personality characteristics, were prone to avoid decisional and personal conflicts, had a high adherence to treatment, and trusted the doctor. The text-mining algorithm was accurate to classify individuals' opinions. Conclusions: Ideally, fusing the skills of the scientist to the reflective capabilities of the medical humanist will fulfill the archetype of what patients consider to be a 'good' doctor. Doctors' preferences reveal a "paternalistic" style, and his/her opinions should be managed carefully to avoid stigmatizing certain patients' behaviors.

Antecedentes: Desde la perspectiva del paciente, un médico "ideal" podría definirse como aquel que tiene cualidades para las relaciones interpersonales, habilidades técnicas y buenas intenciones. Sin embargo, las opiniones de los médicos sobre lo que significa ser un "buen" paciente no se han investigado sistemáticamente. Objetivo: Explorar cómo los pacientes definen las características de un "buen" y "mal" médico, y cómo los médicos definen un "buen" y "mal" paciente. Material y Métodos: Encuestamos a una cohorte de 107 pacientes consecutivos que asistieron a un hospital comunitario en febrero de 2019, a quienes se les pidió que definieran las características deseables de un médico bueno/malo. Además, se pidió a una cohorte de 115 médicos que trabajaban en el mismo hospital que definieran las características deseables de un paciente bueno/malo. Las respuestas se sometieron a un análisis de contenido. Simultáneamente, se utilizó un algoritmo en Python para clasificar automáticamente las respuestas mediante minería de texto. Resultados: Los pacientes aludieron que las cualidades personales del médico eran más importantes que la competencia en conocimiento y las habilidades técnicas. Los médicos estarían satisfechos si los pacientes mostraran características positivas de personalidad, fueran propensos a evitar conflictos, tuvieran una alta adherencia al tratamiento y confiaran en el médico. El algoritmo de minería de texto clasificó las opiniones de los encuestados en forma precisa. Conclusiones: Idealmente, fusionar las habilidades del científico con las capacidades reflexivas del médico humanista cumplirá con el arquetipo de lo que los pacientes consideran un "buen" médico. Las preferencias de los médicos revelan un estilo "paternalista", y sus opiniones deben manejarse con cuidado para evitar estigmatizar los comportamientos de ciertos pacientes.

Supervivencia de la cirugía coronaria de múltiples vasos en el seguimiento hasta 20 años / Long-term survival of multi-vessel coronary surgery bypass grafting up to 20 years of follow-up

RESUMEN Introducción: Los resultados del seguimiento a largo plazo constituyen uno de los mejores parámetros para evaluar la calidad de una intervención médica. Objetivos: Analizar la supervivencia global y la supervivencia libre de eventos cardiovasculares a 20 años de la cirugía coronaria en un hospital de comunidad con historia clínica electrónica de larga data. Métodos: Se estudiaron en forma retrospectiva los resultados alejados de las cirugías coronarias aisladas efectuadas en pacientes con enfermedad de múltiples vasos o tronco de coronaria izquierda entre 1999 y 2003 en un hospital de comunidad. El seguimiento hasta 20 años se realizó a través de la historia clínica electrónica. Resultados: Se logró un tiempo de seguimiento medio de 125 meses (rango: 6-268) en 254 pacientes de los 272 operados en ese período (93,4%). El número promedio de puentes fue 3,3 (desvío estándar: 0,97); en 97,6% se usó al menos una arteria mamaria y 59,4% recibieron un puente con arteria radial. Se obtuvo un seguimiento de 2646 pacientes-años, con un riesgo anual de muerte por toda causa de 2,5%. La supervivencia global al seguimiento medio fue de 0,806 (error estándar, EE: 0,03), y la supervivencia libre de eventos cardiovasculares fue de 0,826 (EE: 0,03). Conclusiones: El registro electrónico completo de los afiliados a un hospital de comunidad operados hace más de 15 años permitió analizar la supervivencia global y libre de eventos a largo plazo. Estos resultados servirán como estándar al momento de elegir entre la cirugía y la angioplastia de múltiples vasos.

ABSTRACT Background: The outcomes of long-term follow-up constitute one of the best parameters to assess the quality of a medical intervention. Objectives: To analyze the overall and the free-of-cardiovascular events 20-year survival after coronary surgery in a community hospital with a long-standing electronic medical records. Methods: The results of coronary surgeries in patients with multi-vessel or trunk disease operated between 1999 and 2003 in a community hospital were retrospectively studied. The follow-up up to 20 years was carried out through the electronic medical record. Results: Of 272 patients operated, a mean follow-up of 125 months (range 6-268) was achieved in 254 (93.4%). The average number of bypasses was 3.3 (standard deviation 0.97); in 97.6%, at least one internal mammary artery was used and 59.4% received a radial artery graft. A follow-up of 2646 patient-years was obtained with an annual risk of death from all causes of 2.5%. The overall survival at the mean follow-up time was 0.806 (standard error (SE) 0.03), and the cardiovascular event-free survival 0.826 (SE 0.03). Conclusions: The complete electronic registration of affiliates to a community hospital operated more than 15 years ago allowed us to analyze the overall survival and the freedom of long-term events. These results will serve as a standard when choosing between surgery and multi-vessel angioplasty.

What patients consider to be a 'good' doctor, and what doctors consider to be a 'good' patient.

BACKGROUND: From a patient's point of view, an 'ideal' doctor could be defined as one having personal qualities for interpersonal relationships, technical skills and good intentions. However, doctors' opinions about what it means to be a 'good' patient have not been systematically investigated. AIM: To explore how patients define the characteristics of a 'good' and a 'bad' doctor, and how doctors define a 'good' and a 'bad' patient. MATERIAL AND METHODS: We surveyed a cohort of 107 consecutive patients attending a community teaching hospital in February 2019, who were asked to define the desirable characteristics of a good/bad doctor. Additionally, a cohort of 115 physicians working at the same hospital was asked to define the desirable characteristics of a good/bad patient. Responses were subjected to content analysis. Simultaneously, an algorithm in Python was used to automatically categorize responses throughout text-mining. RESULTS: The predominant patients' perspective alluded to desirable personal qualities more importantly than proficiency in knowledge and technical skills. Doctors would be satisfied if patients manifested positive personality characteristics, were prone to avoid decisional and personal conflicts, had a high adherence to treatment, and trusted the doctor. The text-mining algorithm was accurate to classify individuals' opinions. CONCLUSIONS: Ideally, fusing the skills of the scientist to the reflective capabilities of the medical humanist will fulfill the archetype of what patients consider to be a 'good' doctor. Doctors' preferences reveal a "paternalistic" style, and his/her opinions should be managed carefully to avoid stigmatizing certain patients' behaviors.

Self-estimation of surgical skills and competencies based on the learning curve theory in medical residents and fellows.

OBJECTIVE: The aim was to explore how in-training junior physicians perceive their surgical performance compared with the one externally rated by their senior surgeon trainers, using a general learning curve model. METHODS: Between April and June 2018, a prospective study was conducted at a community hospital associated with a school of medicine. To assess how in-training physicians estimated their surgical performance, 48 surgical residents and fellows were invited to choose one among six options using a scale ranging from "novice" to "automatic expert." In addition, five senior surgeons who supervised the residents/fellows were asked to give their own opinions on each surveyed physician's expertise level, according to the same categories. Concordance analysis was done to compare residents' and fellows' self-perceived skills and their actual performance as estimated by senior surgeons. RESULTS: Self-assessments tended to overestimate residents' and fellows' position on the learning curve; particularly for "proficient" over "competent," and for "automatic expert" over "expert" categories (p = 0.025). The average degree of agreement among senior physicians was 50.0%. Comparison between residents' and fellows' perceived skills and their performances as estimated by senior surgeons showed a weak concordance (kappa = 0.494, 95% confidence interval 0.359-0.631, p < 0.0001). CONCLUSIONS: Nearly 51% of the residents/fellows included in some surgical specialty training program overestimated his/her actual performance as evaluated by classical learning curve categories. Underestimation of self-assessed performance was also observed in 17% of respondents. A better feedback from expert observers to in-training surgeons could result in a more accurate self-perception of their real surgical skills and competencies.

OBJETIVO: Evaluar cómo los médicos en formación (juniors) perciben su propio desempeño quirúrgico en comparación con la calificación otorgada por sus instructores (seniors) según un modelo de curva de aprendizaje. MÉTODOS: Entre abril y junio de 2018 se realizó un estudio prospectivo en un hospital comunitario. Para evaluar cómo los médicos juniors estimaban su propio desempeño, 48 residentes/becarios de especialidades quirúrgicas eligieron una entre seis opciones excluyentes en una escala entre «novicio¼ y «experto automático¼. Además, cinco cirujanos que supervisaban a los residentes/becarios dieron sus propias opiniones sobre el nivel de desempeño de cada médico encuestado, usando las mismas categorías. Se realizó un análisis de concordancia para comparar las habilidades autopercibidas y el desempeño real según lo estimado por los cirujanos seniors. RESULTADOS: Cuarenta y siete juniors y 50 seniors completaron la encuesta. El 51% sobrestimó y el 17% subestimó su ubicación en la curva de aprendizaje con respecto a los observadores externos (p = 0.025). El grado promedio de acuerdo entre seniors fue del 50%. La comparación entre la autopercepción de los juniors con respecto a sus observadores seniors mostró una concordancia pobre (kappa = 0.494; intervalo de confianza del 95% [IC 95%]: 0.359-0.631; p < 0.0001; sesgo promedio de Bland-Altman: 0.40; IC 95%: 0.11-0.70). CONCLUSIONES: La mitad de los residentes/fellows sobrestimó, y uno de cada seis subestimó, su verdadera ubicación en la curva de aprendizaje en comparación a la opinión de los seniors. Un mejor conocimiento de la existencia de este sesgo de estimación del propio desempeño podría redundar en una mejor confiabilidad del juicio médico.

[Melanoma behavior according to age]. / Comportamiento del melanoma según la edad.

In recent years the incidence of melanoma in elderly patients has increased with an unfavorable oncologic outcome due not only to immune deterioration but also to greater aggressiveness of the tumor. The aim of this study was to evaluate the behavior of cutaneous melanoma in relation to age. A consecutive series of cases with melanoma operated in a reference center in the period 2001-2013 was included. The sample was divided into two groups according to the age. Group 1 (G1): under 65 years and Group 2 (G2): over 65 years. Histopathological variables and oncologic outcomes were compared between the two groups. Three hundred and eighty eight patients were operated. They belonged to G1 241 (62%) and to G2 147 (38%). Both groups were homogeneous with respect to the histological type of melanoma. Group 2 had thicker melanomas (Breslow > 4 mm 19% vs. 7%, p < 0.005) and higher rates of ulceration (37% vs. 20%, p: 0.007) and distant metastases (stage IV 11% vs. 3%, p 0.01). There was no difference between groups regarding nodal involvement. With a mean follow up of 45 (6-98) months throughout the series, recurrence of disease was higher in group 2 (26% vs. 17%, p: 0.03), but the specific mortality showed no significant difference (9.5% vs. 5.3%, p: 0.12). In conclusion, cutaneous melanoma in patients over 65 years is more aggressive with higher rates of local recurrence and distant metastases.