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International Journal of Surgery Case... Mar 2024Perioperative anesthetic management in cases of severe airway obstruction with positional symptoms can be associated with difficulties in ventilation or intubation, with...
INTRODUCTION AND IMPORTANCE
Perioperative anesthetic management in cases of severe airway obstruction with positional symptoms can be associated with difficulties in ventilation or intubation, with a risk of acute respiratory decompensation at every stage of anesthesia.
CASE PRESENTATION
Here we describe the anesthetic management of an 18-year-old woman with a mature teratoma who presented with progressive exertional dyspnea that was aggravated in the supine position in the operating room. After tracheal intubation, the tidal volume decreased, airway pressure increased, and pet CO2 grew beyond 105 mmHg without oxygen desaturation, prompting a femoro-femoral cardio-pulmonary bypass.
CLINICAL DISCUSSION
Cardio-pulmonary bypass (CPB) can facilitate tumor dissection by safely deflating the lungs and retracting the heart, enhancing exposure and reducing risks of hemodynamic or respiratory complications. However, systemic heparinization may increase complications, necessitating a preoperative risk assessment.
CONCLUSION
Preoperative management of large mediastinal masses requires careful attention to tumor anatomical details and relationships with surrounding structures. Preoperative preparation includes multimodality imaging and multidisciplinary team discussions to assess MMS risk, requiring specialized center management.
PubMed: 38759398
DOI: 10.1016/j.ijscr.2024.109575 -
Frontiers in Neurology 2024As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition,...
As health systems organize to deliver the highest quality stroke care to their patients, there is increasing emphasis being placed on prehospital stroke recognition, accurate diagnosis, and efficient triage to improve outcomes after stroke. Emergency medical services (EMS) personnel currently rely heavily on dispatch accuracy, stroke screening tools, bypass protocols and prehospital notification to care for patients with suspected stroke, but novel tools including mobile stroke units and telemedicine-enabled ambulances are already changing the landscape of prehospital stroke care. Herein, the authors provide our perspective on the current state of prehospital stroke diagnosis and triage including several of these emerging trends. Then, we provide commentary to highlight potential artificial intelligence (AI) applications to improve stroke detection, improve accurate and timely dispatch, enhance EMS training and performance, and develop novel stroke diagnostic tools for prehospital use.
PubMed: 38756217
DOI: 10.3389/fneur.2024.1389056 -
BMC Surgery May 2024Hypoalbuminemia and anemia are commonly observed indications for one anastomosis gastric bypass (OAGB) reversal and remain significant concerns following the procedure....
PURPOSE
Hypoalbuminemia and anemia are commonly observed indications for one anastomosis gastric bypass (OAGB) reversal and remain significant concerns following the procedure. Sufficient common channel limb length (CCLL) is crucial to minimize nutritional complications. However, limited literature exists regarding the impact of CCLL on OAGB outcomes. This study aimed to assess the effect of CCLL on weight loss and nutritional status in patients who underwent OAGB.
METHODS
A prospective cohort study was conducted from August 2021 to July 2022, involving 64 patients with a body mass index of 40-50 kg/m. The standardized length of the biliopancreatic limb (BPLL) for all patients in this study was set at 175 cm. Additionally, the measurement of the common channel limb length (CCLL) was performed consistently by the same surgeon for all included patients.
RESULTS
The mean age and BMI of the patients were 39.91 ± 10.03 years and 43.13 ± 2.43 kg/m, respectively, at the time of surgery. There was a statistically significant negative correlation between CCLL and percent total weight loss (%TWL) at the 12-month mark after OAGB (P = 0.02). Hypoalbuminemia was observed in one patient (1.6%), while anemia was present in 17 patients (26.6%) at the one-year follow-up. Statistical analysis revealed no significant difference in the incidence of anemia and hypoalbuminemia between patients with CCLL < 4 m and those with CCLL ≥ 4 m.
CONCLUSION
A CCLL of 4 m does not appear to completely prevent nutritional complications following OAGB. However, maintaining a CCLL of at least 4 m may be associated with a reduced risk of postoperative nutritional deficiencies.
Topics: Humans; Gastric Bypass; Female; Male; Malnutrition; Prospective Studies; Adult; Postoperative Complications; Middle Aged; Weight Loss; Obesity, Morbid; Hypoalbuminemia; Anemia; Nutritional Status; Body Mass Index; Anastomosis, Surgical
PubMed: 38755612
DOI: 10.1186/s12893-024-02438-8 -
Heart (British Cardiac Society) May 2024The practical application of 'virtual' (computed) fractional flow reserve (vFFR) based on invasive coronary angiogram (ICA) images is unknown. The objective of this...
BACKGROUND
The practical application of 'virtual' (computed) fractional flow reserve (vFFR) based on invasive coronary angiogram (ICA) images is unknown. The objective of this cohort study was to investigate the potential of vFFR to guide the management of unselected patients undergoing ICA. The hypothesis was that it changes management in >10% of cases.
METHODS
vFFR was computed using the Sheffield VIRTUheart system, at five hospitals in the North of England, on 'all-comers' undergoing ICA for non-ST-elevation myocardial infarction acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). The cardiologists' management plan (optimal medical therapy, percutaneous coronary intervention (PCI), coronary artery bypass surgery or 'more information required') and confidence level were recorded after ICA, and again after vFFR disclosure.
RESULTS
517 patients were screened; 320 were recruited: 208 with ACS and 112 with CCS. The median vFFR was 0.82 (0.70-0.91). vFFR disclosure did not change the mean number of significantly stenosed vessels per patient (1.16 (±0.96) visually and 1.18 (±0.92) with vFFR (p=0.79)). A change in intended management following vFFR disclosure occurred in 22% of all patients; in the ACS cohort, there was a 62% increase in the number planned for medical management, and in the CCS cohort, there was a 31% increase in the number planned for PCI. In all patients, vFFR disclosure increased physician confidence from 8 of 10 (7.33-9) to 9 of 10 (8-10) (p<0.001).
CONCLUSION
The addition of vFFR to ICA changed intended management strategy in 22% of patients, provided a detailed and specific 'all-in-one' anatomical and physiological assessment of coronary artery disease, and was accompanied by augmentation of the operator's confidence in the treatment strategy.
PubMed: 38754969
DOI: 10.1136/heartjnl-2024-324039 -
Cell Reports May 2024The advent of PARP inhibitors (PARPis) has profoundly changed the treatment landscape of BRCA1/BRCA2-mutated cancers. Despite this, the development of resistance to...
The advent of PARP inhibitors (PARPis) has profoundly changed the treatment landscape of BRCA1/BRCA2-mutated cancers. Despite this, the development of resistance to these compounds has become a major challenge. Hence, a detailed understanding of the mechanisms underlying PARPi sensitivity is crucially needed. Here, we show that loss of the POLE3-POLE4 subunits of DNA polymerase epsilon (Polε) strongly sensitizes cancer cells to PARPis in a Polε level-independent manner. Loss of POLE3-POLE4 is not associated with defective RAD51 foci formation, excluding a major defect in homologous recombination. On the contrary, treatment with PARPis triggers replicative gap accumulation in POLE3-POLE4 knockout (KO) cells in a PRIMPOL-dependent manner. In addition to this, the loss of POLE3-POLE4 further sensitizes BRCA1-silenced cells to PARPis. Importantly, the knockdown of 53BP1 does not rescue PARPi sensitivity in POLE3-POLE4 KO cells, bypassing a common PARPi resistance mechanism and outlining a potential strategy to sensitize cancer cells to PARPis.
PubMed: 38753485
DOI: 10.1016/j.celrep.2024.114205 -
Clinical Case Reports May 2024Afferent loop syndrome is a rare post-operative complication following upper gastrointestinal bypass surgeries, usually occurring within the first two weeks...
Afferent loop syndrome is a rare post-operative complication following upper gastrointestinal bypass surgeries, usually occurring within the first two weeks post-operation. This case report, however, outlines afferent loop syndrome almost a decade post-surgery, which was managed conservatively. A 54-year-old woman presented with a few days' history of epigastric pain, vomiting, and constipation. She had undergone a sleeve gastrectomy and was converted to a Roux-en-Y gastrojejunostomy for weight loss 9 and 7 years ago, respectively. Serum lipase was elevated at 1410 IU/L. Computed tomography showed high-grade proximal small bowel obstruction, involving the efferent and afferent loops of the Roux-en-Y gastric bypass. The patient was given intravenous rehydration, electrolyte replacement and had a nasogastric tube inserted. She was discharged on day 5 of admission without significant sequelae. Afferent limb syndrome should be considered in patients with altered upper gastrointestinal anatomy who present with pancreatitis, regardless of the time period post-operatively. Future guidelines should further more outline the factors indicated for surgical versus conservative management.
PubMed: 38751958
DOI: 10.1002/ccr3.8627 -
Frontiers in Radiology 2024Aortofemoral bypass surgery is a common procedure for treating aortoiliac occlusive disease, also known as Leriche syndrome, which can cause lower extremity ischemic...
Aortofemoral bypass surgery is a common procedure for treating aortoiliac occlusive disease, also known as Leriche syndrome, which can cause lower extremity ischemic symptoms. Diagnostic imaging techniques play a crucial role in managing pseudoaneurysms (PSAs), with Duplex ultrasound and Computed Tomography-angiography (CTA) being effective tools for early diagnosis. Pseudoaneurysms (PSAs) present as pulsating masses with various symptoms, and prompt intervention is essential to avoid complications. A case report is presented involving an 82-year-old male who underwent aorto-bifemoral bypass surgery and later developed a pseudoaneurysm (PSA) of the left branch. Surgical treatment involved the removal of the pseudoaneurysm (PSA) and graft replacement. Other cases from the literature are also described, emphasizing the rarity and potential severity of non-anastomotic pseudoaneurysms (PSAs) in reconstructive vascular surgery. Periodic screening of patients who undergo reconstructive vascular surgery is crucial to detect pseudoaneurysms (PSAs) early and prevent complications. Asymptomatic pseudoaneurysms (PSAs) can grow significantly and become life-threatening if not identified in a timely manner. Regular post-operative imaging, such as annual Computed Tomography-angiography (CTA) and/or Duplex ultrasound, is recommended to ensure early diagnosis and appropriate management of complications.
PubMed: 38751596
DOI: 10.3389/fradi.2024.1327050 -
Annals of Thoracic and Cardiovascular... 2024Achieving a secure anastomosis and complete hemostasis is essential for surgically treating type A acute aortic dissection (TAAAD). This study assessed the clinical...
PURPOSE
Achieving a secure anastomosis and complete hemostasis is essential for surgically treating type A acute aortic dissection (TAAAD). This study assessed the clinical feasibility of "tailored stand-up collar (TSC)" technique for constructing the distal stump.
METHODS
We enrolled 68 patients who underwent ascending aortic repair for TAAAD. Patients were categorized according to the technique for distal stump construction: conventional (C) group using only a felt strip (32 cases); post-aortotomy (P) group, with a Hydrofit-felt strip attached after aortotomy (18 cases), and TSC group, where a Hydrofit-felt strip attached during cooling (18 cases). Pre-operative characteristics, procedural profiles, and post-operative outcomes were evaluated.
RESULTS
The pre-operative characteristics were identical among the groups. The durations of cardiopulmonary bypass, hemostasis, and surgery were significantly shorter in the P and TSC groups. The duration of open distal in the TSC group (21 min) was significantly shorter than the other two groups. Post-operative additional procedures were not required for the TSC group and their post-operative hospital stay was significantly shorter (47.1% of patients were discharged within 2 weeks).
CONCLUSION
The TSC technique would be practical because of its high reproducibility in terms of ease of use, shorter anastomotic time, and secure hemostasis.
Topics: Humans; Aortic Dissection; Female; Male; Treatment Outcome; Middle Aged; Aged; Blood Vessel Prosthesis Implantation; Time Factors; Feasibility Studies; Acute Disease; Length of Stay; Retrospective Studies; Operative Time; Aortic Aneurysm; Aortic Aneurysm, Thoracic; Adult; Postoperative Complications
PubMed: 38749718
DOI: 10.5761/atcs.oa.23-00214 -
PLoS Computational Biology May 2024Computational cognitive models have been used extensively to formalize cognitive processes. Model parameters offer a simple way to quantify individual differences in how...
Computational cognitive models have been used extensively to formalize cognitive processes. Model parameters offer a simple way to quantify individual differences in how humans process information. Similarly, model comparison allows researchers to identify which theories, embedded in different models, provide the best accounts of the data. Cognitive modeling uses statistical tools to quantitatively relate models to data that often rely on computing/estimating the likelihood of the data under the model. However, this likelihood is computationally intractable for a substantial number of models. These relevant models may embody reasonable theories of cognition, but are often under-explored due to the limited range of tools available to relate them to data. We contribute to filling this gap in a simple way using artificial neural networks (ANNs) to map data directly onto model identity and parameters, bypassing the likelihood estimation. We test our instantiation of an ANN as a cognitive model fitting tool on classes of cognitive models with strong inter-trial dependencies (such as reinforcement learning models), which offer unique challenges to most methods. We show that we can adequately perform both parameter estimation and model identification using our ANN approach, including for models that cannot be fit using traditional likelihood-based methods. We further discuss our work in the context of the ongoing research leveraging simulation-based approaches to parameter estimation and model identification, and how these approaches broaden the class of cognitive models researchers can quantitatively investigate.
PubMed: 38748770
DOI: 10.1371/journal.pcbi.1012119 -
Sao Paulo Medical Journal = Revista... 2024Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as prophylaxis has demonstrated promising results.
OBJECTIVES
We aimed to compare the bleeding endpoints between PwHAi on BPA and those on emicizumab prophylaxis.
DESIGN AND SETTING
Systematic review of interventions and meta-analysis conducted at the Universidade Federal de Goiás, Goiânia, Goiás, Brazil.
METHODS
The CENTRAL, MEDLINE, Scopus, and LILACS databases were searched on February 21, 2023. Two authors conducted the literature search, publication selection, and data extraction. The selected publications evaluated the bleeding endpoints between PwHAi on emicizumab prophylaxis and those on BPA prophylaxis. The risk of bias was evaluated according to the Joanna Briggs Institute criteria. A meta-analysis was performed to determine the annualized bleeding rate (ABR) for treated bleeds.
RESULTS
Five publications (56 PwHAi) were selected from the 543 retrieved records. Overall, bleeding endpoints were lower during emicizumab prophylaxis than during BPA prophylaxis. All the publications had at least one risk of bias. The only common parameter for the meta-analysis was the ABR for treated bleeds. During emicizumab prophylaxis, the ABR for treated bleeds was lower than during BPA prophylaxis (standard mean difference: -1.58; 95% confidence interval -2.50, -0.66, P = 0.0008; I2 = 68.4%, P = 0.0031).
CONCLUSION
Emicizumab was superior to BPA in bleeding prophylaxis in PwHAi. However, both the small population size and potential risk of bias should be considered when evaluating these results.
SYSTEMATIC REVIEW REGISTRATION
CRD42021278726, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278726.
Topics: Humans; Hemophilia A; Antibodies, Bispecific; Antibodies, Monoclonal, Humanized; Hemorrhage
PubMed: 38747872
DOI: 10.1590/1516-3180.2023.0102.R1.20022024