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1.
Cureus ; 12(11): e11285, 2020 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-33274159

RESUMO

Purpose Radiotherapy to the pelvis and especially the anal sphincters can result in long-term faecal incontinence. The aim of this study was to assess the effectiveness of biofeedback anal strengthening exercises in radiotherapy-related faecal incontinence. Methods A retrospective cohort study was performed on seven patients with radiotherapy-related faecal incontinence. Education and biofeedback based anal strengthening exercises were provided. Baseline and follow-up measurements were performed assessing anal sphincter fatigue time, resting, squeeze, and cough pressure. Continence scores and quality of life measures were assessed. Patients were followed up at five months. Results The radiotherapy target varied between prostate, uterus, and rectum. Four of the seven patients were female. Pescatori (0-10) and St Mark's (0-10) continence scores had a median improvement of 2 (range 0-5) and 1 (range 0-8) respectively. Self-completed patient continence scores (0-10mm) had a median improvement of 2mm (1-6mm). Anal fatigue time measurements (Isotonic Fatigue Time (seconds) and Isometric Fatigue Time (Cycles)) showed a median improvement of three seconds (-4 - 36 seconds) and three seconds (-1 - 6 seconds), respectively. Resting Pressure (mmHg), Squeeze Pressure (mmHg) and Cough Pressure (mmHg) showed median improvement of 10mmHg (-10-21mmHg), 15mmHg (-16 - 100mmHg) and 21mmHg (-3 - 53mmHg), respectively. Patient-defined quality of life (QOL) measures showed a median change of 0.2 (range 0-0.5). Conclusion Patients in this pilot study with radiotherapy-related faecal incontinence had improved anal pressure metrics, continence, and QOL following biofeedback based anal strengthening exercises. These early results suggest a benefit for anal strengthening in patients undergoing pelvic radiotherapy.

2.
J Therm Biol ; 94: 102754, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33292995

RESUMO

In the face of climate change there is an urgent need to understand how animal performance is affected by environmental conditions. Biophysical models that use principles of heat and mass transfer can be used to explore how an animal's morphology, physiology, and behavior interact with its environment in terms of energy, mass and water balances to affect fitness and performance. We used Niche Mapper™ (NM) to build a vervet monkey (Chlorocebus pygerythrus) biophysical model and tested the model's ability to predict core body temperature (Tb) variation and thermal stress against Tb and behavioral data collected from wild vervets in South Africa. The mean observed Tb in both males and females was within 0.5 °C of NM's predicted Tbs for 91% of hours over the five-year study period. This is the first time that NM's Tb predictions have been validated against field data from a wild endotherm. Overall, these results provide confidence that NM can accurately predict thermal stress and can be used to provide insight into the thermoregulatory consequences of morphological (e.g., body size, shape, fur depth), physiological (e.g. Tb plasticity) and behavioral (e.g., huddling, resting, shade seeking) adaptations. Such an approach allows users to test hypotheses about how animals adapt to thermoregulatory challenges and make informed predictions about potential responses to environmental change such as climate change or habitat conversion. Importantly, NM's animal submodel is a general model that can be adapted to other species, requiring only basic information on an animal's morphology, physiology and behavior.

3.
JACC Case Rep ; 2(2): 309-311, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33215164

RESUMO

We describe the case of a degenerative, sutureless bioprosthetic valve (BPV) with deformation and stent infolding in a patient with elevated surgical risk. Following discussion among the heart team, balloon valve fracture was performed to facilitate deployment of an aortic valve-in-valve transcatheter heart valve. Post-procedural imaging demonstrated BPV frame protrusion and contained annular rupture, which required operative intervention. (Level of Difficulty: Intermediate.).

4.
BMC Surg ; 20(1): 296, 2020 Nov 24.
Artigo em Inglês | MEDLINE | ID: mdl-33234128

RESUMO

BACKGROUND: Parastomal hernia (PSH) management poses difficulties due to significant rates of recurrence and morbidity after repair. This study aims to describe a practical approach for PSH, particularly with onlay mesh repair using a lateral peristomal incision. METHODS: This is a retrospective review of consecutive patients who underwent PSH repair between 2001 and 2018. RESULTS: Seventy-six consecutive PSH with a mean follow-up of 93.1 months were reviewed. Repair was carried out for end colostomy (40%), end ileostomy (25%), ileal conduit (21%), loop colostomy (6.5%) end-loop colostomy (5%) and loop ileostomy (2.5%). The repair was performed either with a lateral peristomal incision (59%) or a midline incision (41%). Polypropylene mesh (86%), biologic mesh (8%) and composite mesh (6%) were used. Stoma relocation was done in 9 patients (12%). Eight patients (11%) developed postoperative wound complications. Recurrence occurred in 16 patients (21%) with a mean time to recurrence at 29.4 months. No significant difference in wound complication and recurrence was observed based on the type of stoma, incision used, type of mesh used, and whether or not the stoma was repaired on the same site or relocated. CONCLUSION: Onlay mesh repair of PSH remains a practical and safe approach and could be an advantageous technique for high-risk patients. It can be performed using a lateral peristomal incision with low morbidity and an acceptable recurrence rate. However, for patients with significant adhesions and very large PSH, a midline approach with stoma relocation may also be considered.

5.
World Neurosurg ; 2020 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-33065350

RESUMO

OBJECTIVE: To determine the impact of the 2019 novel coronavirus disease (COVID-19) pandemic on operative case volume in 8 U.S. neurosurgical residency training programs in early 2020 and to survey these programs regarding training activities during this period. METHODS: A retrospective review was conducted of monthly operative case volumes and types for 8 residency programs for 2019 and January through April 2020. Cases were grouped as elective cranial, elective spine, and nonelective emergent cases. Programs were surveyed regarding residents' perceptions of the impact of COVID-19 on surgical training, didactics, and research participation. Data were analyzed for individual programs and pooled across programs. RESULTS: Across programs, the 2019 monthly mean ± SD case volume was 211 ± 82; 2020 mean ± SD case volumes for January, February, March, and April were 228 ± 93, 214 ± 84, 180 ± 73, and 107 ± 45. Compared with 2019, March and April 2020 mean cases declined 15% (P = 0.003) and 49% (P = 0.002), respectively. COVID-19 affected surgical case volume for all programs; 75% reported didactics negatively affected, and 90% reported COVID-19 resulted in increased research time. Several neurosurgery residents required COVID-19 testing; however, to our knowledge, only 1 resident from the participating programs tested positive. CONCLUSIONS: This study documents a significant reduction in operative volume in 8 neurosurgery residency training programs in early 2020. During this time, neurosurgery residents engaged in online didactics and research-related activities, reporting increased research productivity. Residency programs should collect data to determine the educational impact of the COVID-19 pandemic on residents' operative case volumes, identify deficiencies, and develop plans to mitigate any effects.

6.
Artigo em Inglês | MEDLINE | ID: mdl-33058142

RESUMO

BACKGROUND: Obstetric anal sphincter injuries (OASIs) are a significant complication of vaginal delivery, and a leading cause of anal incontinence in women. AIMS: The aims were to explore the management of OASIs in Australia and New Zealand (ANZ) by colorectal surgeons and how this compares with current recommendations and international experience, and to identify the deterrents to the provision of best-practice care among colorectal surgeons. MATERIALS AND METHODS: Three hundred colorectal surgeons of the Colorectal Surgical Society of ANZ were mailed questionnaires. Areas of interest included: surgeon demographics; exposure to OASIs; understanding of current recommendations; and opinions regarding the importance of symptoms and assessment tools in OASIs. RESULTS: There were 94 completed questionnaires (response rate 31.3%). Fifty-seven surgeons (60.6%) reported low exposure to OASIs during their fellowship training. Greater than 90% believed patients with grade three tears and above should have anal sphincter assessment. Sixty-six (70.2%) reported that they routinely review women who have had OASIs. However, 56.4% were unaware if their obstetrics department followed a standard protocol for OASIs. Surgeons practising in metropolitan centres reported higher rates of their obstetrics department following a protocol (P = 0.013), and greater access to investigative tools (P < 0.001), when compared to rural-based surgeons. CONCLUSIONS: Most ANZ colorectal surgeons have had minimal training in OASI management. Colorectal surgeons are more commonly involved with OASI patients in the non-acute setting. Management protocols involving a multidisciplinary team of both colorectal surgeons and obstetricians should be clearly defined, and the gap between metropolitan and rural centres needs to be reviewed.

7.
Am J Primatol ; 82(12): e23204, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33043502

RESUMO

Understanding the physiological processes that underpin primate performance is key if we are to assess how a primate might respond when navigating new and changing environments. Given the connection between a mammal's ability to thermoregulate and the changing demands of its thermal environment, increasing attention is being devoted to the study of thermoregulatory processes as a means to assess primate performance. Infrared thermography can be used to record the body surface temperatures of free-ranging animals. However, some uncertainty remains as to how these measurements can be used to approximate core body temperature. Here, we use data collected from wild vervet monkeys (Chlorocebus pygerythrus) to examine the relationship between infrared body surface temperature, core body (intra-abdominal) temperature, and local climate, to determine to what extent surface temperatures reflect core body temperature. While we report a positive association between surface and core body temperature-a finding that has previously been used to justify the use of surface temperature measurements as a proxy for core temperature regulation-when we controlled for the effect of the local climate in our analyses, this relationship was no longer observed. That is, body surface temperatures were solely predicted by local climate, and not core body temperatures, suggesting that surface temperatures tell us more about the environment a primate is in, and less about the thermal status of its body core in that environment. Despite the advantages of a noninvasive means to detect and record animal temperatures, infrared thermography alone cannot be used to approximate core body temperature in wild primates.

8.
Clin Neurol Neurosurg ; 197: 106199, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32916397

RESUMO

The prediction of outcome after mechanical thrombectomy (MT) of basilar artery occlusion (BAO) remains an area of investigation. The objective of this study was to evaluate the prognostic role of presenting National Institute Health of Stroke Scale (NIHSS) scores in predicting favorable 90-day functional outcome. A survey of 7 electronic databases from inception to May 2020 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate odds ratios (ORs) for favorable 90-day function outcome (modified Rankin Score 0-2) were extracted and pooled by meta-analysis of proportions with random effects modeling. A total of 10 individual studies satisfied criteria for selection and described a total of 941 BAO patients managed by MT. Analysis revealed 590 (63%) males with a mean age of 66.6 years. The median presenting NIHSS was 19, and 316 (34%) patients were reported to have a favorable functional status 90-days after treatment. Lower presenting NIHSS scores independently and significantly predicted favorable 90-day functional outcome in BAO patients with a pooled OR of 0.89 (95% CI, 0.87-0.92; I2 = 18%; P-heterogeneity = 0.28). Meta-regression did not detect any clinical parameter that influenced this trend direction or its significance, and bias assessments were unremarkable. We confirm in this study via a consensus within the literature that the presenting NIHSS score predicts 90-day functional outcome in BAO patients treated by MT. Further, its standardized use allows more meaningful comparisons between interventions and anatomical locations.

9.
Colorectal Dis ; 2020 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-32978813

RESUMO

AIM: The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced or recurrent colorectal cancer with colorectal peritoneal metastases at a single centre. The literature contains limited data on the safety and oncological outcomes of patients who undergo this combined procedure. METHODS: Six patients who underwent combined PE, CRS and HIPEC at Royal Prince Alfred Hospital, Sydney, between January 2017 and February 2020 were identified and included. Data were extracted from prospectively maintained databases. RESULTS: Three patients underwent surgery for advanced primary rectal cancer, while two patients had recurrent sigmoid cancer and one had recurrent rectal cancer. All patients had synchronous peritoneal metastases. Two patients required total PE and two patients had a central (bladder-sparing) PE. The median peritoneal carcinomatosis index was 6 (range 3-12) and all patients underwent a complete cytoreduction. The median operating time was 702 min (range 485-900) and the median blood loss was 1650 ml (range 700-12,000). The median length of intensive care unit and hospital stay was 4.5 and 25 days, respectively. There was no inpatient, 30-day or 90-day mortality. Three patients (50%) experienced a major (Clavien-Dindo III/IV) complication. At a median follow-up of 11.5 months (range 2-18 months), two patients died with recurrent disease, one patient was alive with recurrence, while three patients remain alive and disease-free. Of the three patients who developed recurrent disease, one had isolated pelvic recurrence, one had pelvic and peritoneal recurrences and one had bone metastases. CONCLUSION: Early results from this initial experience with simultaneous PE, CRS and HIPEC suggest that this combined procedure is safe and feasible; however, the long-term oncological and quality of life outcomes require further investigation.

10.
Eur J Surg Oncol ; 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-32972815

RESUMO

BACKGROUND: Cost-effective cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for treatment of patients with peritoneal malignancy remains an ongoing financial challenge for healthcare systems, hospitals and patients. This study aims to describe the detailed in-hospital costs of CRS and HIPEC compared with an Australian Activity Based Funding (ABF) system, and to evaluate how the learning curve, disease entities and surgical outcomes influence in-hospital costs. METHODS: A retrospective descriptive costing review of all CRS and HIPEC cases undertaken at a large public tertiary referral hospital in Sydney, Australia from April 2017 to June 2019. In-hospital cost variables included staff, critical care, diagnosis, operating theatre, and other costs. Univariate and multivariate analyses were conducted to investigate the differences between actual cost and the provision of funding, and potential factors associated with these costs. RESULTS: Of the 118 CRS and HIPEC procedures included in the analyses, the median total cost was AU$130,804 (IQR: 105,744 to 153,972). Provision of funding via the ABF system was approximately one-third of the total CRS and HIPEC costs (p < 0.001). Surgical staff proficiency seems to reduce the total CRS and HIPEC costs. Surgical time, length of intensive care unit and hospital stay are the main predictors of total CRS and HIPEC costs. CONCLUSION: Delivery of CRS and HIPEC is expensive with high variability. A standard ABF system grossly underestimates the specific CRS and HIPEC funding required with supplementation essential to sustaining this complex highly specialised service.

11.
ANZ J Surg ; 90(11): 2242-2247, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32734711

RESUMO

BACKGROUND: An inguinal hernia is one of the most common surgical pathologies, and therefore the repair of an inguinal hernia is one of the most common general surgical procedures. The aim of this study was to assess the trend in inguinal hernia repair (IHR) rates in Australia between 2000/2001 and 2014/2015 using population data from public and private hospitals. METHODS: ICD-10 data cubes from the Australian Institute of Health and Welfare were analysed to determine the number of inguinal hernia repairs performed, open or laparoscopically, between 2000/2001 and 2014/2015 financial years. These data were combined with the Australian Bureau of Statistics population data estimates for the corresponding years, to give a procedure per 100 000 estimates. RESULTS: Incidence of IHRs within Australia decreased from 217 to 194 per 100 000 population over the 15-year study period. There was a clear shift towards increased uptake of laparoscopic surgery with a subsequent fall in rates of open IHRs. Males accounted for the majority of IHR procedures. Unilateral repair was more common; however, the incidence of unilateral repair rates decreased while bilateral IHR rates increased over the study period. CONCLUSION: Laparoscopic techniques are increasingly being used within public and private institutions across the country for inguinal hernia repair. There has also been a decrease in the incidence of IHR procedures performed per year over the 15-year period studied, consistent with published literature from Europe and the USA.

12.
ANZ J Surg ; 2020 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-32755032

RESUMO

BACKGROUND: C-reactive protein (CRP) is a useful marker for monitoring response to treatment in sepsis. The aim of this study was to examine the use of CRP trajectory in predicting the need for intervention in conservatively managed patients with acute diverticulitis (AD). METHODS: A retrospective review of patients with AD who were managed conservatively was performed. They were divided into four groups based on CRP relative to the median at day 0 and 2: 'Low rise' (levels below median at day 0 and 2), 'High rise' (levels above median at day 0 and 2), 'Rapid rise' (levels below median at day 0 but above median at day 2) and 'Decline' (levels above median at day 0 but below median at day 2). RESULTS: Intervention was required in 64 of 456 (14%) with 30 (48%) of these performed after day 2 of admission. There were 150 patients (54%) in the 'Low rise', 76 (27%) in the 'Decline', 26 patients (9%) in the 'Rapid rise' and 25 patients (9%) in the 'High rise' groups. Within these groups 5%, 8%, 19% and 32% of patients required intervention (P = 0.001). On multivariate analysis, patients with a pelvic abscess were more likely to need intervention (odds ratio 19.1 (confidence interval 6.2-59.4), P < 0.0001). CONCLUSION: The CRP trajectory during the initial 48 h of admission can predict the need for intervention in AD patients being managed conservatively. Patients with a 'Rapid rise' or 'High rise' in CRP from day 0 to 2 are more likely to need intervention.

13.
J Card Surg ; 35(7): 1570-1582, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32652784

RESUMO

BACKGROUND: While minimally invasive techniques for aortic valve replacement (AVR) have been shown to be safe, limited data exist comparing the varying approaches. This study aimed to compare the outcomes between two minimally invasive approaches for AVR: mini-sternotomy (MS) and right anterior thoracotomy (RAT). MATERIALS AND METHODS: A systematic search of MEDLINE, EMBASE, and OVID was conducted for the period 1990-2019. Nine observational studies (n = 2926 patients) met the inclusion criteria. RESULTS: There was no difference in operative mortality between MS and RAT (odds ratio [OR]: 0.87, 95% confidence interval [CI]: 0.41-1.85; P = .709). Meta-analyses favored MS over RAT in reoperation for bleeding (OR: 0.42, 95% CI: 0.28-0.63; P < .001), aortic cross-clamp time (standardized mean difference [SMD]: -0.12, 95% CI: -0.20 to 0.029; P = .009), and the rate of conversion to sternotomy (OR: 0.32, 95% CI: 0.11-0.93; P = .036). The rate of permanent pacemaker insertion approached borderline significance in favor of MS (OR: 0.54, 95% CI: 0.26-1.12; P = .097). In-hospital outcomes of stroke, atrial fibrillation, and surgical site infection were similar between the two groups. The length of hospital stay was shorter for RAT (SMD: 0.12, 95% CI: 0.027-0.22; P = .012) and the length of postoperative ventilation was borderline significant in favor of RAT (SMD: 0.16, 95% CI: -0.027 to 0.34; P = .095). CONCLUSIONS: This study highlights important differences in short-term outcomes between MS and RAT as approaches for AVR. This has important implications for patient selection, especially in the elderly, where such approaches are becoming more common-place.


Assuntos
Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Esternotomia/métodos , Toracotomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Resultado do Tratamento
14.
J Neurointerv Surg ; 2020 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-32606102

RESUMO

BACKGROUND: The management of unruptured intracranial aneurysms (UIAs) has evolved significantly over the last few decades. Our objective was to evaluate the 100 most cited UIA articles by bibliometric analysis to identify nature, content and shifts over time. METHODS: Elsevier's Scopus database was interrogated for the 100 most cited articles that focused on UIA. Older versus newer articles were compared, with categorical data analyzed using Pearson's Chi-square, and continuous data analyzed using Wilcoxon's rank-sum test. RESULTS: The 100 most cited articles were published between 1975 and 2015, with the majority of these reporting patient clinical outcomes (n=69). There were 47/69 (68%) articles that described surgical intervention, with 38/47 (81%) and 18/47 (38%) including endovascular and open approaches, respectively . Publications peaked in 2004 (n=8), and the most common country of correspondence was the United States (n=59). Compared to older articles, newer articles had statistically higher citation rates (P<0.01), higher number of authors (P<0.01) with more multiple institution collaborations (P=0.01), greater disclosures of funding (P<0.01), more focus on endovascular treatments (P=0.04), in more journals with a clinical, non-surgical focus (P<0.01) published under open access policies (P<0.01). CONCLUSIONS: In the 100 most cited articles about UIAs to date, there is a distinct shift towards more co-authored efforts utilizing multi-institutional efforts focused on endovascular approaches supported by funding. The emergence of endovascular techniques has refreshed the need for more contemporary rupture risk prediction models and natural history data to validate current attitudes towards clinical management after these minimally invasive procedures for UIAs.

15.
J Pediatr Urol ; 16(4): 461.e1-461.e9, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32698984

RESUMO

BACKGROUND: Surgical correction of undescended testes is a common surgical procedure which can be performed via a two-incision technique or a single high scrotal incision (Bianchi technique). The Bianchi technique requires less surgical time and may be associated with less pain in the initial postoperative period, however it has been adopted slowly due to a lack of familiarity and perceived technical challenges of the technique. Traditionally postoperative orchiopexy pain is managed with a caudal or ilioinguinal/iliohypogastric nerve block. As urologists at our site adopted the Bianchi technique, the anesthesiologists stopped performing caudals or ilioinguinal/iliohypogastric nerve blocks as local infiltration appeared sufficient. Therefore, this quality improvement (QI) project endeavoured to assess Alberta Children's Hospital's care pathway in its effectiveness to control pain in the first 24 h following pediatric orchiopexy using the Bianchi technique. METHODS: We completed a prospective QI project examining a care pathway for patients undergoing orchiopexy using the Bianchi technique. Eligible patients were healthy and aged 6 months to 12 years. A multimodal analgesic approach including local anesthetic surgical infiltration was used. Pain scores (FLACC) were recorded for up to 2 h postoperatively and a PPPM was completed at 24 h postoperatively. RESULTS: Sixty-four patients were included in the final analysis. The median discharge FLACC score was 0 (range 0-2) (Table 2). Median intraoperative morphine administered was 0.09 mg/kg with no significant correlations between the amount of morphine administered and postoperative pain measures. Median PPPM scores were 4 and 3.5 for unilateral and bilateral procedures, respectively. CONCLUSIONS: We have demonstrated that orchiopexies repaired using the Bianchi technique following the care pathway established at Alberta Children's Hospital are associated with minimal pain scores. Our QI project suggests that combining a Bianchi technique with a simple multimodal analgesic approach including local infiltration, negates the need for regional anesthesia techniques, yet still provides adequate analgesia.

16.
Ann Coloproctol ; 36(3): 133-147, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32674545

RESUMO

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR "Hemorrhoid"[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel "walk-in-walk-out" techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

17.
World Neurosurg ; 142: 368-370, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32683009

RESUMO

We present a remarkable image of a woman, 24 weeks pregnant, who sustained polytrauma after a high-speed motor vehicle collision. Evaluation revealed traumatic bilateral subdural hematoma in the fetus and an unstable T12-L1 fracture in the patient. The standard of care for her unstable fracture was surgical fixation; however, this was hampered by the desire to continue the pregnancy in the interest of the premature fetus. This case presented a unique additional consideration in the management of the polytrauma neurosurgery patient and underscores the importance of coordinated team work and patient counseling to achieve the optimal patient outcome.

18.
J Neurointerv Surg ; 2020 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-32487766

RESUMO

BACKGROUND: Currently, there are no large-scale studies in the neurointerventional literature comparing safety between transradial (TRA) and transfemoral (TFA) approaches for flow diversion procedures. This study aims to assess complication rates in a large multicenter registry for TRA versus TFA flow diversion. METHODS: We retrospectively analyzed flow diversion cases for cerebral aneurysms from 14 institutions from 2010 to 2019. Pooled analysis of proportions was calculated using weighted analysis with 95% CI to account for results from multiple centers. Access site complication rate and overall complication rate were compared between the two approaches. RESULTS: A total of 2,285 patients who underwent flow diversion were analyzed, with 134 (5.86%) treated with TRA and 2151 (94.14%) via TFA. The two groups shared similar patient and aneurysm characteristics. Crossover from TRA to TFA was documented in 12 (8.63%) patients. There were no access site complications in the TRA group. There was a significantly higher access site complication rate in the TFA cohort as compared with TRA (2.48%, 95% CI 2.40% to 2.57%, vs 0%; p=0.039). One death resulted from a femoral access site complication. The overall complications rate was also higher in the TFA group (9.02%, 95% CI 8.15% to 9.89%) compared with the TRA group (3.73%, 95% CI 3.13% to 4.28%; p=0.035). CONCLUSION: TRA may be a safer approach for flow diversion to treat cerebral aneurysms at a wide range of locations. Both access site complication rate and overall complication rate were lower for TRA flow diversion compared with TFA in this large series.

19.
Oncotarget ; 11(22): 2074-2082, 2020 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-32547705

RESUMO

Epidermal Growth Factor Receptor variant III (EGFRvIII) is an active mutant form of EGFR that drives tumor growth in a subset of glioblastoma (GBM). It occurs in over 20% of GBMs, making it a promising receptor for small molecule targeted therapy. We hypothesize that poor penetration of the blood-brain barrier by previously tested EGFR-tyrosine kinase inhibitors (EGFR-TKIs) such as afateninb, erlotinib, gefitinib, and lapatinib played a role in their limited efficacy. The present study examined the effects of osimertinib (previously known as AZD9291) on EGFRvIII+ GBM models, both in vitro and in vivo. Therefore, a panel of six GBM stem cells (GSCs) expressing EGFRvIII+ was evaluated. The EGFRvIII+ GSC differed in the expression of EGFRvIII and other key genes. The GSC line D317, which expresses high levels of EGFRvIII and has robust tyrosine kinase activity, was selected for assessing osimertinib's efficacy. Herein, we report that osimertinib inhibits the constitutive activity of EGFRvIII tyrosine kinase with high potency (<100 nM) while also inhibiting its downstream signaling. Further, osimertinib inhibited D317's growth in vitro and in both heterotopic and orthotopic xenograft models. Additional preclinical studies are warranted to identify EGFRvIII+ GBM's molecular signature most responsive to osimertinib.

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