Effects of ventilatory bundles on patient outcomes among ICU patients: A systematic review and meta-analysis.

BACKGROUND: Ventilator bundles are suggested to prevent ventilator-associated pneumonia (VAP), but significant variations in the effects of the bundle on patient outcomes have been reported. OBJECTIVES: To synthesize the evidence and evaluate the effects of the ventilator bundle on patient outcomes among critically ill adult patients. METHODS: A broad search was performed in seven databases for relevant articles published from January 2002 to November 2022. Randomized controlled trials and quasi-experimental studies investigating the effects of implementing ventilator bundles in adult intensive care units (ICUs) were included. Two independent reviewers performed the study selection, data extraction, and risk of bias assessment. All data for meta-analysis were pooled using the random-effects model. RESULTS: After screening, 19 studies were included in the meta-analysis. Evidence of low-to-moderate certainty showed that the ventilator bundle reduced the rate of VAP (risk ratio [RR] = 0.64; P = 0.003), length of ICU stay (mean difference [MD] = -2.57; P = 0.03), mechanical ventilation days (MD = -3.38; P < 0.001), and ICU mortality (RR = 0.76; P = 0.02). Ventilator bundle was associated with improved outcomes, except mortality. CONCLUSIONS: The ventilator bundle, especially the IHI ventilator bundle, was effective in decreasing the incidence of VAP and improving most of the VAP-related outcomes. However, given the low-to-moderate certainty of evidence and high heterogeneity, these results should be interpreted with caution. A future study that adopts hybrid implementation trials with high methodological quality is needed to confirm the effects of the ventilator bundle on patient outcomes.

Salvaging the Unsalvageable Giant Cell Tumors of Bone: The 'Longitudinal Sandwich Technique'.

Management of Campanacci Grade III Giant Cell Tumors of bone (GCT) is challenging. Although selected cases of Grade III GCTs can still be managed with intralesional extended curettage, wide excision of the lesion is usually recommended when there is extensive cortical destruction. This study describes the outcome of 'longitudinal sandwich technique' for extended curettage of Grade III GCTs with more than 50% cortical destruction. Here, the deficiency of cortex was made up for by using bone graft/graft substitute, used alongside cement placed in a longitudinal fashion. Twelve patients operated with this technique between Jan 2012 and Jan 2018 were reviewed. Majority of the lesions involved the lower limbs. Bone graft was used in eight whereas commercial bone graft substitute was used in the remaining four, along with bone cement in all. On follow-up ranging from 38 to 84 months (median follow-up 59 months), there were 4 local recurrences (33.33%). All recurrences were managed successfully with repeat surgery without the need for bony resection. Mean MSTS score during the last follow-up was 25.08 ± 2.31 and all patients were disease-free during the last follow-up. 'Longitudinal sandwich technique' helps to expand the indications of extended curettage even for aggressive Grade III GCTs, with satisfactory outcomes.

Orthopedic Sub-specialization: Need or Hype? Opinion from Nepalese Orthopedic Surgeons.

BACKGROUND: In Nepal, the trend of rushing to orthopedic subspecialty fellowship is rising up. It's debatable whether this pattern of practice is advancing orthopaedic care. There are issues with cost of subspecialty training and work satisfaction after it. Thus, this study aims to analyze orthopaedic surgeon's prospect regarding subspecialty training in Nepal. METHODS: This is a cross sectional observational study designed to take opinion of orthopaedic surgeons of Nepal regarding subspecialty practice in orthopedics. Structured closed ended questionnaire was designed in form of "Survey app" and was disseminated to maximum possible via electronic media. RESULTS: Out of total 93 respondents (mean age 37.07 years), 45.7% had a subspecialty training. Among fellowship completed surgeons (42), mean duration of fellowship was 6.92 months, India was the commonest destination (53.49%), and Arthroscopy was highest followed by Spine and Arthroplasty. Among them who haven't done fellowship (51), 100% mentioned to have interest in doing one. Maximum respondents recommended paid/sponsored fellowships (94.62%) and of 12 months' duration (44.1%). Total of 97.85% agreed that fellowship training in orthopedics has really become important. Only 4.3% agreed that fellowship is an unnecessary burden/hype. Only 16.1% agreed that surgeons get detached from mainstream orthopedics after fellowship and also only 11.9% agreed that there retains any threat to mother orthopedics in future. CONCLUSIONS: With emerging practice of subspecialty in Orthopedics in Nepal, a six months' duration fellowship and paid fellowship program is the major choice. Thus, the fraternity should work on to promote subspecialty practice and trainings.

Relationship between height and osteosarcoma at the time of diagnosis in the Indian population: A retrospective study.

BACKGROUND: It has been indicated in several instances that tall stature is also an important risk factor in the development of osteosarcoma. This relationship between height and osteosarcoma is substantiated even more by the increasing evidences being put forth in the recent literature on dependence of certain tumors on the growth factors and their receptors, acting through autocrine or paracrine mechanisms. There has been no study on the Indian population that attempts to define such a relationship. PURPOSE: The primary objective of this study was to define relationship between height of patients and osteosarcoma at the time of diagnosis in the Indian population. MATERIALS/METHODS: Retrospective data was collected from the old hospital records. Height of patients at the time of diagnosis was compared with expected height of patients of the same age with reference to the standardized growth charts provided by the Indian Academy of Paediatrics. RESULTS: Out of 98 patients, there were 65 male and 33 female patients with M: F ratio being 1.97:1. The mean age at diagnosis was 17 (SD = 8) years with range of 5-55 years (median = 17 years). Height of the patients at the time of diagnosis was 155.18 (SD = 15.47) cm with range of 115 cm-184 cm (median = 159 cm). Overall, patients with Osteosarcoma were found to be shorter than the expected height deduced from the national growth charts. When patients were divided into two groups of those who were of growing age and those who had completed growth, results were similar. CONCLUSION: The observation that majority of patients with osteosarcoma in our study were stunted, is an important finding. It could be deduced from this observation that these patients are unable to mount the usual biological response to the overstimulated growth as part of tumorigenesis in osteosarcoma. This could point to a different scenario in the Indian population and more studies need to be carried out with larger number of patients to further elaborate on this observation.

The Effect of Intra-operative Text Messages in Reducing Anxiety Levels Among Family Members of Patients Undergoing Major Musculoskeletal Tumour Surgery.

BACKGROUND: The family of patients undergo profound anxiety when their family member is undergoing major oncological surgery. In this study, we evaluated the effectiveness of periodic intraoperative text messages regarding the status of ongoing surgery in reducing anxiety levels among the patients' family members. MATERIALS AND METHODS: Family members of 60 patients (one for each patient) who were undergoing major oncological surgery lasting more than 1 h were recruited and randomized into two groups (30 patients each). Group 1 (no SMS group) did not receive any text message while Group 2 (SMS group) received periodic intraoperative text messages. Respondents aged less than 16 years, those with associated psychiatric illnesses, and those who did not consent to the study were excluded. Anxiety among family members was assessed using the Visual Analogue Scale for Anxiety (VAS-A) and Anxiety component of Hospital Anxiety and Depression Scale (HADS-A) at five different periods; (P1) 1 day prior to surgery (P2) at separation from family at the operation theatre (P3) 1 h after commencement of surgery (P4) immediately after completion of surgery, and (P5) 1 day after surgery. RESULTS: The mean VAS-A and HADS-S scores between both the groups did not show a statistically significant difference for P1, P2 and P5 assessment periods (preoperative period, separation in operation theatre, post-operative period). However, mean VAS-A and HADS-A scores were significantly higher for Group 1 compared to Group 2 during P3 and P4 periods, 1 h after commencement of surgery and completion of surgery, respectively. CONCLUSION: Periodic text messages updating the status of ongoing surgery helps to reduce anxiety for family members of patients undergoing oncological surgery during the intraoperative period.

Effectiveness of extra-corporeal shock wave therapy (ESWT) vs methylprednisolone injections in plantar fasciitis.

INTRODUCTION: In Plantar Fasciitis, the main concern of the patients is the pain that disturbs their day to day activities. Different modalities of treatments are being used for its pain management. This study seeks to investigate and compare decrease in level of pain following treatment with Methylprednisolone injections (DMP) Vs Extra-Corporeal Shock Wave Therapy (ESWT) in plantar fasciitis. METHODS: This prospective comparative non randomized study was conducted in 60 patients of any age presenting with Plantar Fasciitis at B&B Hospital, Kathmandu. Patients were divided into 2 groups (30 each) based on patients preference. Methylprednisolone injection was given to one group and another group received ESWT. Follow up of both groups were carried out at 6 weeks, 3 months and 6 months and the outcome was measured with Visual Analogue Pain Scale (VAS). Statistical analysis wasdone using SPSS software, version 13. Chi-square and Independent t-test were applied to look for significant variations in outcome. RESULTS: Follow-up at 6 weeks revealed 26 (86.7%) patients attaining VAS < 5 in ESWT group in comparison to 16 (53.3%) patients of DMP group (p = 0.005). At the end of 6 months, 5 patients in DPM group still had significant pain (VAS ≥ 5) compared to 2 patients in ESWT group (p = 0.02). However 11 patients of DMP group and 23 of ESWT group received single episode of treatment only and had persistent symptomatic pain relief (VAS < 5) during all follow ups at 6 weeks, 3 months and 6 months (p = 0.004). CONCLUSIONS: Plantar fasciitis was more prevalent in overweight population and females. Significant improvement in pain was observed with both ESWT and DMP Injections. However, ESWT was found to be more effective than DMP Injections for treatment of Plantar Fasciitis.

Rheumatoid subacromial-subdeltoid bursitis with rice bodies: A case report.

Subacromial-subdeltoid bursitis of a shoulder with rice bodies is relatively uncommon. The understanding of the pathogenesis of rice body formation is yet approximate only but some clinical conditions like rheumatoid arthritis, tuberculous arthritis, seronegative inflammatory arthritis, juvenile rheumatoid arthritis and osteoarthritis are related to it. We describe a case of a 44 years old female with subacromial-subdeltoid bursitis of her right shoulder with numerous rice bodies' formation as a presenting feature of rheumatoid arthritis. She underwent subacromial and subdeltoid bursectomy with the removal of rice bodies and had immediate improvement of symptoms.

Isolated spontaneous primary tubercular erector spinae abscess: a case report and review of literature.

Isolated spontaneous primary tubercular erector spinae abscess in an immunocompetent patient is very rare. Here, we report such a case of 21-year-old female, which was successfully managed with timely diagnosis and intervention. Isolated primary tubercular abscess of erector spinae is a rare differential diagnosis of low back pain; however, it must be suspected in an endemic region for tuberculosis, especially when raised erythrocytic sedimentation rate and C-reactive protein are present. Excision along with anti tubercular therapy proved to be a successful strategy in our patient.

High tumor volume and local recurrence following surgery in osteosarcoma: A retrospective study.

BACKGROUND: Osteosarcoma is a high grade malignant, osteoid forming, primary bone tumor affecting the metaphysis of long bones. Local recurrence (LR) in osteosarcomas is a sinister. Theoretically, a high tumor volume at the time of presentation will limit surgical margins, involve vital neurovascular bundles and show poor response to chemotherapy thereby causing high rates of amputations (as against limb salvage surgery) and should be associated with poor survival rates. This study evaluated objectively if high tumor volume is a significant predictor of local recurrence (LR) in operated cases of osteosarcomas. MATERIALS AND METHODS: Operated cases of osteosarcoma (presenting to the Orthopedic outpatient or the Medical Oncology outpatient between January 1, 2004 and January 1, 2011 were included in the study. Their preoperative clinical data and investigations along with the operative notes were traced from the medical/departmental records. Details of chemotherapy received in the neo-adjuvant and postoperative periods were noted. Besides, all demographic data were also noted. Tumor volume was calculated using the available magnetic resonance images using the formula: ([π/6] × length × width × depth). Post data extraction, patients were divided in two groups, Groups I (without LR) and Group II (with LR). RESULTS: A total of 95 cases of biopsy proven osteosarcomas were identified. Of which 64 were male and 31 females. There were 15 (15.8%) local recurrences. 71% (57/80) patients without LR fell in the age group of 10-20 years, while 66% (10/15) patients with LR were in the age group of 10-20 years. Limb salvage surgery was done in 81.05% (77/95) patients while a total of 18 patients underwent amputation. Of the 80 cases in Group I (without LR), 40 (50%) patients had tumor volume >200 c.c., 30 patients (37.5%) had tumor volume between 50 and 200 c.c. while only 10 patients had tumor volumes <50 c.c. This was in contrast to the tumor volume noted in Group II (with LR) of 15 patients where 8 patients had a tumor volume between 50 and 200 c.c., five had bigger tumor volumes of >200 c.c. and only two patients were smaller in size, with a tumor volume <50 c.c. The mean tumor volume in the group without LR was 406.74 ± 771.67 c.c. as compared with 195.77 ± 226.8 c.c. in the group with local recurrence. Using Mann-Whitney test, the difference between the two groups was found to be statistically insignificant (P = 1.403). CONCLUSIONS: We conclude that high tumor volume is not a significant predictor of LR in osteosarcomas thus patients with high tumor masses should not be denied limb salvage. However, we recommend that the decision on attempting limb salvage should not only be based on the tumor volume alone.