The great pretender-Bell's palsy secondary to SARS-CoV-2?

This case series highlights a possible association between isolated facial nerve palsy and SARS-CoV-2. Caution should be exercised in the use of steroids in patients with COVID-19 as its impact is still not well established.

Randomized control trial comparing an Alvarado Score-based management algorithm and current best practice in the evaluation of suspected appendicitis.

BACKGROUND: An objective algorithm for the management of suspected appendicitis guided by the Alvarado Score had previously been proposed. This algorithm was expected to reduce computed tomography (CT) utilization without compromising the negative appendectomy rate. This study attempts to validate the proposed algorithm in a randomized control trial. METHODS: A randomized control trial comparing the management of suspected acute appendicitis using the proposed algorithm compared to current best practice, with the rate of CT utilization as the primary outcome of interest. Secondary outcomes included the percentage of missed diagnosis, negative appendectomies, length of stay in days, and overall cost of stay in dollars. RESULTS: One hundred sixty patients were randomized. Characteristics such as age, ethnic group, American Society of Anesthesiologist score, white cell count, and symptom duration were similar between the two groups. The overall CT utilization rate of the intervention arm and the usual care arm were similar (93.7% vs 92.5%, p = 0.999). There were no differences in terms of negative appendectomy rate, length of stay, and cost of stay between the intervention arm as compared to the usual care arm (p = 0.926, p = 0.705, and p = 0.886, respectively). Among patients evaluated with CT, 75% (112 out of 149) revealed diagnoses for the presenting symptoms. CONCLUSION: The proposed AS-based management algorithm did not reduce the CT utilization rate. Outcomes such as missed diagnoses, negative appendectomy rates, length of stay, and cost of stay were also largely similar. CT utilization was prevalent as 93% of the study cohort was evaluated by CT scan. TRIAL REGISTRATION: The study has been registered at ClinicalTrials.gov (NCT03324165, Registered October 27 2017).

Comparing the Utility and Surgical Outcomes of Harmonic Focus Ultrasonic Scalpel with Ligasure Small Jaw Bipolar Device in Thyroidectomies: A Prospective Randomized Controlled Trial.

BACKGROUND: Ultrasonic or bipolar radiofrequency energy devices are routinely used for dissection and hemostasis during thyroidectomy. We report a single-center, prospective, randomized controlled trial comparing the utility and outcomes of Harmonic Focus, an ultrasonic coagulating shear device (UCSD), versus Ligasure Small Jaw, an electrothermal bipolar vessel sealer (EBVS) in thyroidectomy (NCT01765686). METHODS: Between December 2012 to January 2016, eligible patients were randomized to undergo hemithyroidectomy using either a UCSD or an EBVS. The primary outcome was duration of surgery. Secondary outcomes included blood loss, postoperative complications, ease of device use, ease of device set-up, vocal cord function, postoperative wound drainage, pain score, and adverse events. RESULTS: Of 110 patients assessed for eligibility, 100 were randomly allocated (UCSD: 49 patients; EBVS: 51 patients) and analyzed by intention-to-treat. There were no differences in specimen delivery time, total duration of surgery, wound drainage, and adverse events between the two groups. The UCSD group had a greater proportion of patients with higher postoperative pain scores in the first 72 h (8.1% vs. 2.0%, p = 0.043). Surgeons reported greater ease of use for the UCSD (49% vs. 27%; p = 0.005), while operating room staff favored the EBVS (60% vs. 33%, p = 0.005). CONCLUSIONS: Energy devices are equally effective in reducing thyroidectomy operative times, with no differences in the duration of surgery, drainage, or adverse events. Use of the UCSD was associated with higher postoperative pain scores, but was favored by the surgeons, likely due to the ability to perform fine dissection with the device itself.

Transaxillary thyroidectomies: a comparative learning experience of robotic vs endoscopic thyroidectomies.

OBJECTIVE: Robotic and endoscopic approaches have become more accepted in thyroid surgery, with current literature documenting the experience of high-volume centers. We adopted both approaches concurrently, and this series presents our initial experience to assess the more practical option for low- to moderate-volume centers starting out with transaxillary thyroidectomies. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Over a period of 4 years, 101 patients underwent transaxillary thyroidectomies, of whom 48 underwent robotic thyroidectomy and 53 underwent endoscopic thyroidectomy. Data analysis includes patient characteristics, procedure time, thyroid pathology, and postoperative complications. A survey was conducted among surgeons to assess the subjective experience. RESULTS: Endoscopic hemithyroidectomies had a significantly shorter duration of operation (145.8 minutes) vs that of robotic hemithyroidectomies (193.6 minutes), P < .001. The mean time taken for the first 5 hemithyroidectomies vs the last 5 hemithyroidectomies showed a greater drop in the endoscopic group (49.1%) vs the robotic group (18.6%). There were 2 cases of transient recurrent laryngeal nerve injury. In the surgeon survey, the endoscopic technique was perceived to have less need for peripheral support, while the robotic technique was preferred for its shorter learning curve. CONCLUSION: In terms of outcome, both techniques are comparable at least in the initial phase. Based on our early experience, the endoscopic technique may be less intuitive with a longer learning curve, although at steady state, it may be the quicker procedure. This is relevant for low- to moderate-volume centers starting their transaxillary thyroidectomy program.