From Illness to Resilience: Mediating Factors of Quality of Life in Patients with Congenital Heart Disease.

Background: Congenital heart disease (CHD) is a leading cause of childhood morbidity, with an estimated prevalence of 0.8-1%. However, advances in diagnosis and treatment now allow 90% of childhood CHD patients to survive to adulthood, leading to increased interest in their quality of life (QoL). In this study, we examine the impact of clinical and psychosocial variables, including the number of surgical interventions (NSI), age at surgery, school achievement, and social support, as mediating factors of QoL in CHD patients. Methods: The study included 233 CHD patients (132 males) with an average age of 15.2 ± 2.07 years, including 80 with cyanotic CHD and 153 with acyanotic CHD. The severity of illness ranged from mild to severe, with 30 patients having a severe illness, 119 having a moderate illness, and 84 having a mild illness. One-hundred-sixty-three patients underwent surgery. Clinical data on diagnosis, the severity of CHD, the type of CHD, and surgical interventions were collected from patient records, and a semi-structured interview was conducted to explore the relationship between CHD diagnosis and various aspects of life. QoL was assessed using the Abbreviated World Health Organization Quality of Life questionnaire (WHOQOL-Bref) questionnaire. Results: Ten mediation models were analyzed, each with three hypotheses (paths). In all models the first hypothesis was supported. Analyses of the second and third hypotheses revealed three feasible models of mediation through the effect of NSI on QoL in CHD patients. Conclusions: Our findings indicate that patients with more severe and cyanotic CHD generally require more surgical interventions, which may increase the risk of negative outcomes and affect patients' perception of QoL. These results have important implications for healthcare providers and psychologists who work with childhood CHD patients.

Nationwide Analysis of Penetrating Thoracic Aortic Injury: Injury Patterns, Management, and Outcomes.

INTRODUCTION: Penetrating thoracic aortic injuries (PTAI) represent a rare form of thoracic trauma. Unlike blunt thoracic aortic injuries (BTAI), only scarce data, included in small case series, are currently available for PTAI. The purpose of this study was to describe injury patterns, surgical management, and outcomes of patients with PTAI and compare to those with BTAI. MATERIALS AND METHODS: A 9-y retrospective cohort study (2007-2015) was conducted using the National Trauma Data Bank. Patient demographics, injury profile, procedures performed, and patient outcomes were compared between the PTAI and BTAI group. RESULTS: A total of 2714 patients with PTAI and 14,037 patients with BTAI were identified. Compared to BTAI, PTAI patients were younger (28 versus 42 y, P < 0.001), more often male (89.1% versus 71.7%, P < 0.001), and more likely to arrive without signs of life (27.6% versus 7.5%, P < 0.001). PTAI patients had less associated injuries, overall, compared to those with BTAI; however, were more likely to have injuries to the esophagus, diaphragm, and heart. Patients with PTAI were less likely to undergo endovascular (5.8% versus 30.5%, P < 0.001) or open surgical repair (3.0% versus 4.2%, P < 0.001) compared to BTAI. While the large majority of PTAI patients expired before their hospital arrival or in the emergency department, the in-hospital mortality rate among those who survivedemergency department stay was 43.1%. CONCLUSIONS: Most patients with PTAI present to the hospital without any signs of life, and their overall mortality rate is extremely high. Only a small portion of PTAI patients who survived the initial resuscitation period underwent surgical interventions for thoracic aortic injuries. Further studies are still warranted to clarify the indications and types of surgical interventions for PTAI.

Surgical interventions for implant placement in the anterior maxilla: A systematic scoping review with evidence mapping.

OBJECTIVES: Simplification and standardization of interventions are critical challenges to improving performance in implant dentistry. This study aimed to systematically identify and schematically present the evidence base of the implant dentistry surgical interventions for the anterior maxilla as a basis for further development and standardization. METHODS: Electronic searches were conducted in PubMed, Embase and Cochrane CENTRAL. Primary clinical studies reporting surgical interventions in the anterior maxilla, with a sample size of at least ten patients, were included. Bibliometric information and study details were extracted. Descriptive analysis and a mind map approach were used to describe the documentation of different surgical interventions. RESULTS: Two hundred and seventy-two studies reporting on 9001 patients were included. Within the past two decades, the number of literatures on implant placement in the anterior maxilla has increased dramatically (7 studies before 2005, 151 studies after 2016). Overall, the evidence map identified six primary operations and 33 variations. For hopeless tooth extraction, immediate implant placement was the most frequently reported (141 studies, 4670 patients); flapless implant placement with hard tissue augmentation and immediate provisionalization was the most commonly reported variation (33 studies, 987 patients). Type 3/4 implant placement (62 studies, 1902 patients) and implant site augmentation (33 studies, 788 patients) were frequently reported for missing teeth. Geographical differences were observed, with type 2 placement studies almost exclusively from Europe. CONCLUSIONS: Research on immediate implant placement was the most reported surgical intervention in the anterior maxilla. Hard tissue augmentation was frequently reported simultaneously with or before implant placement. Immediate provisionalization was mainly used for type 1 implant placement. The finding that six primary operations with 33 variations have been reported indicates the need for additional research to simplify and consolidate the surgical approach.

Reconstruction, oversewing, or taking the anastomosis down - which surgical intervention is most potent in the treatment of anastomotic leaks following colorectal resections?

PURPOSE: Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL. METHODS: All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient's outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma). RESULTS: A total of 2,724 colorectal resections were documented. Grade C AL occurred in 92 (4.4% AL occurrence-rate) and 31 (7.2% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions). CONCLUSION: In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.

European Academy of Neurology/Movement Disorder Society-European Section Guideline on the Treatment of Parkinson's Disease: I. Invasive Therapies.

BACKGROUND AND PURPOSE: This update of the treatment guidelines was commissioned by the European Academy of Neurology and the European section of the Movement Disorder Society. Although these treatments are initiated usually in specialized centers, the general neurologist should know the therapies and their place in the treatment pathway. METHODS: Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the spectrum of approved interventions including deep brain stimulation (DBS) or brain lesioning with different techniques (radiofrequency thermocoagulation, radiosurgery, magnetic resonance imaging-guided focused ultrasound surgery [MRgFUS] of the following targets: subthalamic nucleus [STN], ventrolateral thalamus, and pallidum internum [GPi]). Continuous delivery of medication subcutaneously (apomorphine pump) or through percutaneous ileostomy (intrajejunal levodopa/carbidopa pump [LCIG]) was also included. Changes in motor features, health-related quality of life (QoL), adverse effects, and further outcome parameters were evaluated. Recommendations were based on high-class evidence and graded in three gradations. If only lower class evidence was available but the topic was felt to be of high importance, clinical consensus of the guideline task force was gathered. RESULTS: Two research questions have been answered with eight recommendations and five clinical consensus statements. Invasive therapies are reserved for specific patient groups and clinical situations mostly in the advanced stage of Parkinson's disease (PD). Interventions may be considered only for special patient profiles, which are mentioned in the text. Therapy effects are reported as change compared with current medical treatment. STN-DBS is the best-studied intervention for advanced PD with fluctuations not satisfactorily controlled with oral medications; it improves motor symptoms and QoL, and treatment should be offered to eligible patients. GPi-DBS can also be offered. For early PD with early fluctuations, STN-DBS is likely to improve motor symptoms, and QoL and can be offered. DBS should not be offered to people with early PD without fluctuations. LCIG and an apomorphine pump can be considered for advanced PD with fluctuations not sufficiently managed with oral treatments. Unilateral MRgFUS of the STN can be considered for distinctly unilateral PD within registries. Clinical consensus was reached for the following statements: Radiosurgery with gamma radiation cannot be recommended, unilateral radiofrequency thermocoagulation of the pallidum for advanced PD with treatment-resistant fluctuations and unilateral radiofrequency thermocoagulation of the thalamus for resistant tremor can be recommended if other options are not available, unilateral MRgFUS of the thalamus for medication-resistant tremor of PD can be considered only within registries, and unilateral MRgFUS of the pallidum is not recommended. CONCLUSIONS: Evidence for invasive therapies in PD is heterogeneous. Only some of these therapies have a strong scientific basis. They differ in their profile of effects and have been tested only for specific patient groups. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

European Academy of Neurology/Movement Disorder Society - European Section guideline on the treatment of Parkinson's disease: I. Invasive therapies.

BACKGROUND AND PURPOSE: This update of the treatment guidelines was commissioned by the European Academy of Neurology and the European section of the Movement Disorder Society. Although these treatments are initiated usually in specialized centers, the general neurologist and general practitioners taking care of PD patients should know the therapies and their place in the treatment pathway. METHODS: Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the spectrum of approved interventions including deep brain stimulation (DBS) or brain lesioning with different techniques (radiofrequency thermocoagulation, radiosurgery, magnetic resonance imaging-guided focused ultrasound surgery [MRgFUS] of the following targets: subthalamic nucleus [STN], ventrolateral thalamus, and pallidum internum [GPi]). Continuous delivery of medication subcutaneously (apomorphine pump) or through percutaneous ileostomy (intrajejunal levodopa/carbidopa pump [LCIG]) was also included. Changes in motor features, health-related quality of life (QoL), adverse effects, and further outcome parameters were evaluated. Recommendations were based on high-class evidence and graded in three gradations. If only lower class evidence was available but the topic was felt to be of high importance, clinical consensus of the guideline task force was gathered. RESULTS: Two research questions have been answered with eight recommendations and five clinical consensus statements. Invasive therapies are reserved for specific patient groups and clinical situations mostly in the advanced stage of Parkinson's disease (PD). Interventions may be considered only for special patient profiles, which are mentioned in the text. Therapy effects are reported as change compared with current medical treatment. STN-DBS is the best-studied intervention for advanced PD with fluctuations not satisfactorily controlled with oral medications; it improves motor symptoms and QoL, and treatment should be offered to eligible patients. GPi-DBS can also be offered. For early PD with early fluctuations, STN-DBS is likely to improve motor symptoms, and QoL and can be offered. DBS should not be offered to people with early PD without fluctuations. LCIG and an apomorphine pump can be considered for advanced PD with fluctuations not sufficiently managed with oral treatments. Unilateral MRgFUS of the STN can be considered for distinctly unilateral PD within registries. Clinical consensus was reached for the following statements: Radiosurgery with gamma radiation cannot be recommended, unilateral radiofrequency thermocoagulation of the pallidum for advanced PD with treatment-resistant fluctuations and unilateral radiofrequency thermocoagulation of the thalamus for resistant tremor can be recommended if other options are not available, unilateral MRgFUS of the thalamus for medication-resistant tremor of PD can be considered only within registries, and unilateral MRgFUS of the pallidum is not recommended. CONCLUSIONS: Evidence for invasive therapies in PD is heterogeneous. Only some of these therapies have a strong scientific basis. They differ in their profile of effects and have been tested only for specific patient groups.

Lessons from a 30 year follow-up of monozygotic twins with discordant phenotype due to a ring 13 chromosomal mosaicism in one of them.

At the 43rd annual meeting of the ASHG in 1993, the senior author reported monozygotic twins with discordant phenotype due to a ring 13 chromosomal mosaic syndrome in one of them. Her major manifestations included: intrauterine growth restriction (IUGR), failure to thrive (FTT), delayed developmental milestones/intellectual disability (DDM/ID), left hemihypoplasia of her body with leg length discrepancy, left profound deafness due to inner ear malformation, telecanthus, dental anomalies mainly on the left side, congenital torticollis due to Klippel-Feil anomaly, 13 ribs, scoliosis, dislocation of the left hip, and distinctive left hand and feet. A blood karyotype at age 31/2 was normal. Silver-Russell syndrome was initially suspected; however, at age 4, a karyotype on skin fibroblasts showed a ring 13 chromosomal mosaicism, 46,XX,15s+/46,XX,-13,+r(13),15s+, with a higher frequency on the left side of the body. Since then, we have been involved in the management of this patient for 30 years. This has ultimately allowed us to compare her achievements with her normal monozygotic twin. In this long term follow-up, we want to emphasize the importance of: (a) early recognition of genetic syndromes, especially of mosaicisms, and of early intervention programs, (b) the involvement of different specialists in the management of patients with MCA, and (c) mentioning how familial and socioeconomic issues may limit or enhance the full potential of patients with some genetic disorders.

Urinary tuberculosis: still a challenge.

BACKGROUND: Urinary tuberculosis (TB) is a challenging disease to cope with, as there has been no noticeable difference in basic diagnostic and therapeutic options in clinical practice over time. PURPOSE: The aim of the current review was the critical assessment and evaluation of TB, which remains a major global health problem. METHODS: The available literature regarding TB in the PubMed database was extensively searched. RESULTS: New interdisciplinary team approaches such as next-generation sequencing are promising for the diagnosis and treatment of the disease. The epidemiology of the disease is changing with globalization and increasing migration events; however, the knowledge here is limited. Despite ongoing destruction, kidney functions need to be preserved as much as possible, and relatively rapid development of minimally invasive techniques relieved the surgeons in this regard. Experience is increasing in minimally invasive techniques that provide better comfort for patients compared to extensive radical surgeries. CONCLUSIONS: Knowing the pathogenesis of urinary TB is essential for understanding the range of clinical manifestations. The onset of the disease is usually insidious. Despite modern TB drugs, reconstructive surgery, and minimally invasive procedures, progression cannot be prevented in some patients, and patient selection is essential, but we still do not have sufficient information and objective parameters to predict progression.

Identifying competing interest disclosures in systematic reviews of surgical interventions and devices: a cross-sectional survey.

BACKGROUND: A competing interest is an important source of bias in research and disclosure is frequently employed as a strategy to manage it. Considering the importance of systematic reviews (SRs) and the varying prevalence of competing interests in different research fields, we conducted a survey to identify the range of competing interests in SRs assessing surgical interventions or devices and explored the association between the competing interest disclosures and authors' conclusions. METHODS: We retrieved SRs of surgical interventions and devices published in 2017 via PubMed. Information regarding general characteristics, funding sources, and competing interest disclosures were extracted. We conducted a descriptive analysis of the studies' characteristics and compared them between Cochrane SRs (CSRs) and non-Cochrane SRs using the Chi-square test. Results were expressed as odds ratio and their 95% confidence interval. RESULTS: One hundred fifty-five SRs published in 2017 were included in the study. More than half of the SRs (58.7%) reported their funding sources and 94.2% reported authors' competing interest disclosures. Among 146 SRs that stated competing interest disclosures, only 35 (22.6%) SRs declared at least one author had a competing interest. More than 40 terms were used to describe competing interests. Cochrane SRs (CSRs) were more likely to provide a detailed description of competing interests compared to those in non-CSRs (48.0% versus 25.4%, P = 0.023). No association between positive conclusions and competing interest disclosures was found (P = 0.484, OR = 0.43, 95%CI: 0.08, 2.16). In the subgroup analyses, SRs stating no competing interest disclosure were more likely to report positive conclusions than those stating at least one type of competing interest, but the difference is not significantly different (P = 0.406, OR = 1.38, 95%CI: 0.64, 2.98). CONCLUSION: In surgical SRs, there is a high percentage of competing interest disclosures but without detailed information. The identification and statement of competing interests with a detailed description, particularly the non-financial ones, needs improvement. Some efficient and effective methods/tools for identifying, quantifying, and minimizing potential competing interests in systematic reviews remains valuable.

Exploring mechanisms of action in clinical trials of complex surgical interventions using mediation analysis.

BACKGROUND: Surgical interventions allow for tailoring of treatment to individual patients and implementation may vary with surgeon and healthcare provider. In addition, in clinical trials assessing two competing surgical interventions, the treatments may be accompanied by co-interventions. AIMS: This study explores the use of causal mediation analysis to (1) delineate the treatment effect that results directly from the surgical intervention under study and the indirect effect acting through a co-intervention and (2) to evaluate the benefit of the surgical intervention if either everybody in the trial population received the co-intervention or nobody received it. METHODS: Within a counterfactual framework, relevant direct and indirect effects of a surgical intervention are estimated and adjusted for confounding via parametric regression models, for the situation where both mediator and outcome are binary, with baseline stratification factors included as fixed effects and surgeons as random intercepts. The causal difference in probability of a successful outcome (estimand of interest) is calculated using Monte Carlo simulation with bootstrapping for confidence intervals. Packages for estimation within standard statistical software are reviewed briefly. A step by step application of methods is illustrated using the Amaze randomised trial of ablation as an adjunct to cardiac surgery in patients with irregular heart rhythm, with a co-intervention (removal of the left atrial appendage) administered to a subset of participants at the surgeon's discretion. The primary outcome was return to normal heart rhythm at one year post surgery. RESULTS: In Amaze, 17% (95% confidence interval: 6%, 28%) more patients in the active arm had a successful outcome, but there was a large difference between active and control arms in the proportion of patients who received the co-intervention (55% and 30%, respectively). Causal mediation analysis suggested that around 1% of the treatment effect was attributable to the co-intervention (16% natural direct effect). The controlled direct effect ranged from 18% (6%, 30%) if the co-intervention were mandated, to 14% (2%, 25%) if it were prohibited. Including age as a moderator of the mediation effects showed that the natural direct effect of ablation appeared to decrease with age. CONCLUSIONS: Causal mediation analysis is a useful quantitative tool to explore mediating effects of co-interventions in surgical trials. In Amaze, investigators could be reassured that the effect of the active treatment, not explainable by differential use of the co-intervention, was significant across analyses.

[Preoperative cardiovascular risk evaluation before elective noncardiac surgical interventions]. / Präoperative kardiovaskuläre Risikoevaluation vor elektiven, allgemeinchirurgischen Eingriffen.

A careful and standardized but nevertheless individually adapted and targeted medical history and physical examination are essential components of a preoperative evaluation. The individual cardiovascular risk profile characterized by noninvasive diagnostics requires a targeted further assessment with noninvasive and invasive diagnostic investigations, which should be targeted to the medical needs of the individual patient. The aim is to assess the individual risk of undesired major adverse cardiac events (MACE). The preoperative examination procedures should be limited to the medically necessary needs in order to be able to optimally utilize the material and personnel resources. This review article presents a practical guide for preoperative cardiovascular risk evaluation in patients scheduled for elective, noncardiac surgery.

Effectiveness and safety of surgical interventions for treating adolescent idiopathic scoliosis: a Bayesian meta-analysis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is the most common form of spinal deformity in children and adolescents which presents as complex three-dimensional (3D) deformity of the spine and rib cage. This study aimed to estimate the effectiveness and safety of surgical interventions for AIS using Bayesian meta-analysis. METHODS: The PubMed, EMBASE, and Cochrane Controlled Register of Trials were searched through Oct 1, 2019, without language restrictions. Relevant studies evaluating combined effectiveness and safety of surgical interventions for AIS were included according to eligibility criteria. The primary outcome measures included pulmonary function (change of absolute forced vital capacity and forced expiratory volume in 1 second from pre-operation to post-operation) and incidence of complications. The secondary outcome measure was change of Cobb angle from pre-operation to post-operation. Data was pooled using a random effects model in pairwise meta-analysis. Bayesian meta-analysis combined direct and indirect evidence using a Bayesian framework. RESULTS: Twenty-eight case-controlled studies with totally 1970 participants were included. This Bayesian meta-analysis combining direct and indirect evidences indicated that posterior fusion with instrumentation without thoracoplasty (PSF) had the highest probability to achieve better pulmonary function and lower complication rate; video assisted anterior fusion with instrumentation without thoracoplasty (VAT) had the highest probability to obtain better Cobb angle correction based on analysis of rank probability. CONCLUSION: This Bayesian meta-analysis demonstrated that PSF had the highest probability to achieve better post-surgical pulmonary function and lower complication rate, which gives a practical recommendation of PSF as a primary surgical treatment for AIS. The results also support statistics that current surgeries adopted more PSF but less open anterior approach surgery and thoracoplasty. More research work is required to address the effectiveness and safety of VAT for treating AIS more convincingly.

[Treatment of Takayasu arteritis]. / Therapie der Takayasu-Arteriitis.

Despite advances in the diagnosis and treatment, the mortality rate of Takayasu arteritis (TAK) is still elevated even today. The diagnosis is often made after a long time delay and the course of the disease is characterized by progressive structural vascular lesions. Recently, new recommendations for the management of large vessel vasculitis were published by the European League Against Rheumatism (EULAR). For induction of remission oral glucocorticoids (GC) are administered in an initial daily dose of 40-60 mg. As experience has shown that the cumulative GC demand in TAK is high, GC-sparing treatment with moderately potent immunosuppressants, such as methotrexate, azathioprine and mycophenolate mofetil is recommended from the time of initial diagnosis. In cases of a relapsing course, tocilizumab or tumor necrosis factor (TNF)-alpha inhibitors can be used as an additive off-label treatment. If vascular stenoses persist despite supposedly sufficient inflammation control and if these stenoses are symptomatic, vascular surgery or interventional treatment procedures can be indicated. Such revascularization or even surgical procedures for the treatment of aneurysms should be performed during phases of sufficient drug control of the vasculitis. In quite a few patients progressive vascular lesions continue to develop despite clinical and laboratory analytical remission. Due to the poor correlation of clinical symptoms and acute phase markers with the progression of vascular lesions, the distinction between active and inactive diseases is often a challenge in the clinical practice. Imaging studies can then support therapeutic decisions but are not yet formally and comprehensively validated in the long-term course of TAK.

[Multilevel arterialization of the venous bed in treatment of critical lower limb ischaemia]. / Étazhnaia arterializatsiia venoznogo rusla v lechenii kriticheskoi ishemii nizhnikh konechnostei.

Presented herein is original experience in using a technique of arterialization in patients with critical lower limb ischaemia on the background of diffuse multilevel occlusive lesions of femoral, crural arteries and arteries of the foot in 214 patients. We used a new method of treatment by means of oxygenation of the sural group of muscles and the foot through the small saphenous vein and indirect communicating veins. This method does not require destruction of the valvular apparatus of the communicants themselves, promoting opening of previously not functioning ones, as well as appears to be a powerful stimulus for the development of collateral circulation of the extremity. Alterations introduced into the design characteristics of a valvulotome make it possible to avoid lateral injury of the venous wall in the area of confluence of tributaries, preventing incomplete resection of the valve. The method expands the boundaries of operability of patients with the absence of the receiving arterial bed of the calf and foot. It may be combined with arterial primary and repeat reconstructions in patients with depleted receiving channel of the calf as an effective additional path of outflow. It also makes it possible to lower the level of amputation in the developed necrosis of the distal part of the foot. Based on clinical laboratory and instrumental findings, the patients were diagnosed by the aetiological factor of the occlusive process and its extension, substantiating the indications for operative treatment with the use of one or another venous basin. Comparative assessment of reversion of arterial blood flow through the great saphenous vein, small saphenous vein, and posterior tibial vein, according to the findings of bioelectromagnetic diagnosis of reactivity of tissues demonstrated that the most effective method was that of arterialization thought the small saphenous vein. With the help of the questionnaire of quality of life in patients with performed arterialization of the calf and foot through the small saphenous vein for critical lower limb ischaemia we obtained 5-year remote results. Upon completion of this period, 87.3% of the limbs were saved and composite measures of the patients' quality of life proved to be high, ranging from 53 to 69 points.

Rotational Thromboelastometry Helps to Reduce Blood Product Consumption in Critically Ill Patients during Small Surgical Procedures at the Intensive Care Unit - a Retrospective Clinical Analysis and Literature Search.

BACKGROUND: Patients at intensive care units (ICUs) are often transfused to correct increased coagulation parameters (prothrombin time and activated partial thromboplastine time) and/or low platelet count. Thromboelastometry using whole blood is considered to be superior to these tests. In clinical praxis, prolonged standard tests are seen but thromboelastometry values are normal. The objective was to compare the blood product consumptions before and after the introduction of thromboelastometry assays into the treatment protocol during small surgical procedures at our mixed ICU. METHODS: We analyzed 1,879 patients treated at our ICU who underwent small interventions. We compared the fresh frozen plasma and platelet consumption before and after the introduction of rotational thromboelastometry into the routine use. The obtained data were compared to relevant research results from the PubMed database, the MeSH index in the Medline database, and Google Scholar using key words 'tromboelastometry', 'fresh frozen plasma' and 'platelets'. RESULTS: Annual fresh frozen plasma and platelet consumptions were significantly decreased following thromboelastometry introduction. The number of patients and procedures did not differ significantly during the periods analyzed. CONCLUSION: Routine thromboelastometry assays can enable significant reduction of blood product consumption in critically ill patients undergoing small surgery without any bleeding complications.

Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature.

BACKGROUND: To define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life. METHODS: A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews. RESULTS: Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost. CONCLUSIONS: No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.

An analysis of cardiac defects and surgical interventions in 84 cases with full trisomy 18.

Trisomy 18 (Edwards syndrome) is the second most common autosomal trisomy after trisomy 21. Medical issues commonly include cardiac defects, such as ventricular septal defect (VSD) and atrial septal defect (ASD). If untreated, these conditions can contribute to the associated infant mortality. The objective of the study was review parent-reported information on 84 cases with full trisomy 18 focusing on prenatal and postnatal assessment and confirmation of cardiac defects and on subsequent treatment with cardiac surgery and post-surgery outcomes. At birth, 65 parent responses indicated the presence of VSD (77.4%), 38 ASD (45.2%), and 50 patent ductus arteriosus (PDA) (59.5%). The presence of multiple cardiac defects was also analyzed including 25 cases with VSD, ASD, and PDA at birth. The total reduced to 18 at survey completion. Twenty-four cases had one or more cardiac defects repaired for a total of 34 corrective surgeries. Age at surgery varied from 2 weeks to 41 months of age with most performed under 1 year of age. Twenty-one cases were still living at the time of survey completion (87.5%). From these date we provide recommendations and implications.

Case Series of Surgical Treatment in Pediatric Thyroid Carcinoma in a Single Institution.

Introduction: The prevalence of thyroid carcinoma (TC) among pediatric and adolescent populations is infrequent, yet its global occurrence is escalating. Insufficient information pertaining to TC in the pediatric populace of Indonesia presents issues in the identification and management of patients with this condition. The objective of this study is to provide a detailed account of a collection of pediatric TC cases that were recorded at a tertiary care center throughout an extended interval of eight years. Presentation of Cases: The present study conducted a retrospective data analysis of ten patients who received a diagnosis of TC during the period spanning from 2014 to 2022. The present study focused on analyzing the clinical manifestation, diagnostic measures, treatment modalities, and immediate postoperative consequences of TC. All patients diagnosed with thyroid cancer exhibited the presence of neck lump. Nine patients underwent total thyroidectomy, while one patient underwent isthmolobectomy. The histopathologic evaluation confirmed the diagnosis of thyroid cancer in every individual. There were a significant number of patients, up to 50%, who encountered complications after undergoing surgery. Two patients reported the hoarseness of voice, whereas two other patients experienced the signs of hypocalcemia. Only one patient exhibited both these symptoms simultaneously. Discussion: The implementation of total thyroidectomy as a surgical intervention in pediatric patients poses a notable challenge. Postoperative monitoring for potential complications following surgery for total thyroidectomy is imperative. Conclusions: The current study provides evidence that the utilization of total thyroidectomy in combination with lymph node dissection as indicated in patients with lymph node metastases in pediatric patients with thyroid carcinoma leads to a significant reduction in the probability of recurrence of lymph node enlargement. During the performance of surgical procedures, meticulous observation plays a key role in mitigating the risk of postoperative complications, such as hypoparathyroidism, hypocalcemia, and injury to the recurrent laryngeal nerve. Thus, it is imperative to conduct follow-up procedures for post-surgical interventions among pediatric patients diagnosed with TC.

Acute Development of Traumatic Intracranial Aneurysms After Civilian Gunshot Wounds to the Head.

In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (cGSWH) was ∼3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission computed tomographic angiography (aCTA) in cGSWH. Over the period from 2017 to 2022, 341 patients were admitted to R. Adams Cowley Shock Trauma Center with cGSWH; 136 subjects had aCTA ∼3 (standard deviation [SD] 3.5) h post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, and outcomes were analyzed. Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission Glasgow Coma Scale (GCS) score was 6 (SD 3.9). Entry site was frontal in 41, temporal in 55, parietal in 18, occipital in 6, suboccipital in 9, temporo-parietal in 1, and frontobasal-temporal in 6. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subject: 24 were located along the middle cerebral artery (MCA), 6 in the anterior cerebral artery (ACA), 3 in the internal carotid artery (ICA), 1 in the posterior cerebral artery (PCA), and 1 in the middle meningeal artery (MMA). Eleven TICAs resolved spontaneously in nine patients. Eight aneurysms were treated by endovascular means, two via combined endovascular/open approaches. Forty-nine patients died, 10 of whom had 15 TICAs. Eighty patients developed intracerebral hematoma s (ICHs). Regression models showed that the presence of an ICH was the main predictor of TICA in cGSWH. Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with cGSWH suggest hidden TICAs. Nearly 30% of patients had spontaneous resolution within 1 week. When CTA was performed acutely, TICAs were 10 times more frequent in cGSWH than in previous literature, and those patients were more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of cGSWH.

How to Use the New European Academy of Neurology/Movement Disorder Society European Section Guideline for Invasive Therapies in Parkinson's Disease.

BACKGROUND: The decision to choose invasive treatments for Parkinson's disease (PD) is complex and needs careful consideration. OBJECTIVES: Although the recommendations of the European Academy of Neurology/Movement Disorder Society European Section guideline for invasive therapies of PD are useful, the different clinical profiles of people with PD who seek advice for possible invasive therapy need further attention. METHODS AND RESULTS: Here we describe 8 clinical standard situations of people with PD unsatisfied with their current oral treatment where invasive therapies may be considered. These are PD patients presenting with the following symptoms: (1) severe motor fluctuations, (2) beginning of levodopa-responsive fluctuations, severe tremor at (3) young or (4) advanced age, (5) impulse control disorders and related behavioral disorders, (6) hallucinations and psychosis, (7) minimal cognitive impairment or mild dementia, and (8) patients in need of palliative care. For some of these conditions, evidence at lower level or simple clinical considerations exist. CONCLUSIONS: There are no one-fits-all answers, but physician and patient should discuss each option carefully considering symptom profile, psychosocial context, availability of therapy alternatives, and many other factors. The current paper outlines our proposed approach to these circumstances.