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The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME). This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up. There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality. SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.

The new da Vinci Single-Port (SP) robot is a single-arm four-channel robotic system well suited for endoluminal surgery. We report our initial experience performing SP robotic transanal minimally invasive surgery (SP rTAMIS) for rectal neoplasms. Under Institutional Review Board approval, two patients with rectal neoplasms were prospectively enrolled for elective SP rTAMIS. The primary endpoint was to report the safety and feasibility of successful procedure completion with the SP robot. Secondary endpoints included patient characteristics and perioperative metrics. Both patients underwent successful SP rTAMIS resection of rectal neoplasms without intraoperative complications or conversions. The lesions were 4.0 cm and 3.0 cm in size, located 6 cm and 7 cm cephalad to the anorectal ring. Excisions were full thickness with no piecemeal extractions or specimen fragmentation. Estimated blood loss was 0 mL and 30 mL. The mean excised area was 13.4 cm2 (22.7 cm2 and 9.0 cm2). The mean docking time was 5.25 min (range 2–8 min) and mean console time was 122.5 min (98 min and 147 min). Patients tolerated a liquid diet on postoperative day (POD) 0 and were discharged on POD 1 after tolerating a low residue diet and having bowel function. Pathology showed two adenomas with negative margins. There was no immediate or delayed morbidity or mortality. Our initial experience indicates that SP rTAMIS is a safe and feasible approach for local excision of rectal lesions. While SP rTAMIS is very promising, more experience with this approach is necessary to determine its widespread applicability.

Aims and Objective: To study the clinical profile and electrocardiographic changes in children with myocarditis and their prognostic significance. Methods: 223 children presented with signs and symptoms of myocarditis from June 2016 to May 2017. Amongst them, 21 children with congenital heart disease or rheumatic heart disease and 166 children with negative cardiac markers were excluded. The remaining 36 patients with myocarditis and elevated levels of both SGOT and CKMB were studied. The patient outcome was recorded as expired or discharged. Data were analyzed using the chi-square test. Results: Majority (13; 36%) were infants. Post infancy, there was a uniform age distribution of cases. Myocarditis was commonly seen in association with culture-negative (probably viral) pneumonia, and diphtheria. Bradycardia and A-V block, although seen less frequently, were having a significant association with mortality. Congestive cardiac failure (28.6%) and cardiomegaly (25.0%) were not significantly associated with mortality. ECG changes like Sinus tachycardia and T wave inversion (most common) and ST elevation, Q waves and low amplitude (less common) were insignificantly associated with mortality. Conclusion: In children, myocarditis should be suspected especially in infants with unexplained breathlessness or fatigue, arrhythmia, or signs of acute cardiac decompensation. It was seen more with bacterial-culture-negative (viral) pneumonia and diphtheria. Continuous ECG monitoring and chest X-ray should be done. Congestive cardiac failure and cardiomegaly, though observed in a quarter of patients were not significantly associated with mortality. Bradycardia and A-V block have a poor prognosis and cardiac pacing should be considered. Echocardiography should be available in-house.

The da Vinci Single-Port (SP) robot is a novel platform designed to facilitate single-incision robotic surgery (rSILS). The objective of this study was to describe our initial experience using this platform for SP robotic (SPr) right colectomy. Under a Food and Drug Administration-regulated feasibility study and Institutional Review Board approval, a patient with cecal adenocarcinoma underwent an SPr right colectomy. The primary endpoint was the safety and feasibility of the first SPr right colectomy performed in the USA. Secondary endpoints included perioperative metrics, morbidity and mortality. An SPr Standard right colectomy was performed through a 4-cm single incision without the need for conversion or additional port placement. Estimated blood loss was 100 mL and there were no intraoperative complications. The robot was docked once with a docking time of 19 min. Total console time was 116 min and operative time was 219 min. The patient tolerated clear liquids on postoperative day (POD) 0 and a low-residue diet on POD 1. The patient had flatus and a bowel movement on POD 1. She was discharged home on POD 3. Final pathology showed pT3N0 cecal adenocarcinoma with negative margins and 0/24 lymph nodes positive for disease. Our initial experience demonstrates that an SPr right colectomy is feasible and can be safely completed. We completed an oncologic resection of a cecal adenocarcinoma without complications. The SP robot facilitates the utilization of robotic technology in a single-incision platform to perform colorectal procedures and offers promising benefits in the advancement of robotic surgery.

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.

The objective of this study was to identify patient and hospitalization characteristics associated with in-hospital mortality in infants with hypoplastic left heart syndrome (HLHS). We conducted a retrospective analysis of a large administrative database, the National Inpatient Sample dataset of the Healthcare Cost and Utilization Project for the years 2002–2016. Neonates with HLHS were identified by ICD-9 and ICD-10 codes. Hospital and patient factors associated with inpatient mortality were analyzed. Overall, 18,867 neonates met the criteria of inclusion; a total of 3813 patients died during the hospitalization (20.2%). In-hospital mortality decreased over the years of the study (27.0% in 2002 vs. 18.3% in 2016). Extracorporeal membrane oxygenation utilization was 8.1%. Univariate and multivariate logistic regression analyses were used to identify risk factors for in-hospital mortality in infants with hypoplastic left heart syndrome. Independent non-modifiable risk factors for mortality were birth weight

Background The study aims to understand the effect of COVID lockdown on MCH for slum dwellers and coping mechanisms adopted in Indore and Agra, India. Slum women's perspectives on seeking, delaying, avoiding healthcare in COVID-19, barriers and facilitators were explored. Methods In-person qualitative interviews were conducted in slums in Sept-Oct 2020 with mothers who had deliveries; pregnant women needing ante-natal care; mothers with children Results Govt. and most private hospitals refused non-COVID services during lockdown.; Police restricted movement on roads. Being on COVID duty, frontline health functionaries were not doing outreach health sessions. Women missed ante-natal check-up, Iron Folate, Tetanus toxoid; Demand side challenges included fear of COVID infection, lack of money due to livelihood loss; Home deliveries by self, neighbors were resorted to; Maternal, neonatal deaths ensued; Children missed immunization e.g., Measles, DPT. Few peri-urban slum families visited nearby rural health facility for delivery. Some families borrowed money from community saving's groups for delivery in private hospitals. Few families visited low-cost private doctor/nurse for immunization of pregnant mother, children. Conclusions Demand and supply side factors led to pregnant women and children not receiving care during lockdown. Peri-urban slum families should be encouraged to link with nearby rural health facility for MCH services during COVID-19 or similar situations. Govt. partnering with private providers near slums will help access during challenging times. Promoting community savings groups as mandated under National Urban Health Mission can enable slum families borrow with ease when in need. Key messages Government health system should set up emergency (e.g., mobile clinic) MCH services for future epidemic, disaster, should partner with private doctors/nurses near slums. Rural health infrastructure serving nearby peri-urban slums formally recognized by Govt. despite separate jurisdictions is an approach adaptable in LMIC cities.

BACKGROUND: The vein of Galen aneurysm (VGAM) is the most common type of arteriovenous malformation in the neonate. These neonates commonly present with high output cardiac failure that may be associated with pulmonary hypertension. The medical management and stabilization of these neonates can be challenging before staged transarterial embolization of the aneurysm is undertaken. CASE: A 2.34 kilogram neonate, antenatally diagnosed to have VGAM, was born at 36 weeks of gestation for fetal distress. The neonate failed to respond to medical management including inotropes, high frequency mechanical ventilation and inhaled nitric oxide. The patient’s high-output heart failure and persistent pulmonary hypertension were stabilized with veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) using central cannulation. Further transarterial staged embolization of the VGAM was undertaken on VA-ECMO support. CONCLUSION: There may be a role of VA-ECMO using central cannulation to optimize management of high output cardiac failure and persistent pulmonary hypertension in neonatal VGAM patients who fail medical management to facilitate staged transarterial embolization of the VGAM.

Aim To evaluate the outcome of distal femoral replacements versus internal fixation for elderly patients with distal femoral periprosthetic fracture in a single institution. Method A five-year retrospective observational study was conducted of a consecutive series of patients with distal femoral periprosthetic fracture who underwent either distal femoral replacement (DFR) or internal fixation (IF) in a tertiary referral centre. Clinical information analysed included patient demographics, co-morbidities, interval between primary total knee arthroplasty (TKA) to distal femoral periprosthetic fracture, type of fracture, operative technique, preoperative ASA grade, post-operative complications, intensive therapy unit (ITU) stay, length of hospital stay (LOS), re-fixation and mortality. Results Study included 27 patients of which fourteen patients underwent a DFR while 13 underwent an IF. 89% of the patients were females. Mean age of the patients at the time of fracture was 85 versus 80 (DFR vs IF). The mean interval from the primary TKA to the fracture were 80 months (range 0-181). There were no intraoperative complications in either group. Three patients required ITU stay from the DFR group while one patient from the IF group required re-fixation. Median LOS was 56 days (range 9-144) after DFR and 55 days (range 4-83) after IF. There was one 30-day mortality in the DFR group. One-year mortality for the DFR group was 7% vs 15% for the IF group. Conclusions In our study, DFR and IF were observed to have similar LOS with a higher mortality in the IF group at one year. There was one re-fixation in the IF group.

Two paediatric congenital heart disease patients presented with a brief history of low-grade fever without any focal symptoms. Their clinical features and laboratory tests were unremarkable; however, their blood cultures were positive that prompted further work-up. Infective endocarditis should be considered in any paediatric congenital heart disease patient who presents with fever without any other associated clinical features.

With a higher proportion of young individuals undergoing uncemented hip arthroplasty, a close match in the dimension of the proximal femur and the implanted prosthesis is paramount. This is a study to gain insight into geographical variation in proximal femur morphology to determine the reference values to design uncemented femoral stems for a south Indian population, and also the effect of ageing and gender on the proximal femur morphology. Materials and Methods: The study comprised of two groups. For the first group, 50 unpaired dry femur bones were obtained from adult human cadavers; and the second group was a clinical group of 50 adult patients. Standardised radiographic techniques were used to measure the extracortical and intra-cortical morphometric parameters. Based on these, dimensionless ratios were calculated to express the shape of the proximal femur. The data were expressed in terms of mean and standard deviation and a comparison made with other studies. Results: A significant difference was noted across various population subsets within the Indian subcontinent and also in comparison to the Western population, suggestive of regional variation. The measurements made in cadaveric bone differed significantly from those in live patients, especially the femoral head diameter and extra-cortical and intracortical width. Femoral offset, head height and diameter were significantly less in females. Conclusion: The south Indian population needs customised implants with an increase in neck shaft angle and a decrease in intra-cortical and extra-cortical width for press fit in hip arthroplasty. The variation between the two sexes must also be accounted for during prosthesis design.

Background Fresh frozen plasma (FFP) is the accepted standard treatment for clotting factor replacement in bleeding patients during or immediately after cardiac surgery. In the United Kingdom prothrombin complex concentrate (PCC) is not licensed in this setting, although it is being used in Europe because it has a higher concentration of clotting factor levels, and it can be administered rapidly and in small volume, resulting in less volume overload during cardiac surgery. Methods PROPHESY is a pragmatic, single-centre, open-label, randomised, controlled pilot trial that will assess whether it is feasible to perform a large trial in the future that will compare PCC versus FFP in patients who are bleeding (not on warfarin) and who require blood transfusion. Over a 15-month period, 50 patients will be randomised to PCC versus FFP if they develop active bleeding within 24 h of cardiac surgery and for whom the clinician has decided to administer FFP for treatment of bleeding. Standard laboratory and point-of-care assessments will be performed as per routine practice, and additional research blood samples will be taken at three time points to assess haemostasis. Subjects will be assessed daily up to hospital discharge or 30 days or death (whichever occurs first) and will be seen in follow-up for 90 days after surgery to assess for thromboembolic complications and hospital re-admission since discharge. Quality-of-life assessment will be performed pre-surgery and at 90 days post-surgery. We will also perform qualitative research with clinical experts and patients to explore the understanding of and experience with the interventions, as well as adherence to study procedures and protocol. Discussion There have been no randomised controlled trials that have compared the safety and efficacy of FFP versus PCC in cardiac surgery patients who are bleeding. This pilot study will assess if individual components of a large trial are deliverable to assess the safety and efficacy of the two blood products in the future. Trial registration EudraCT, 2018-003041-41; ClinicalTrials.gov, NCT03715348. Registered on 29 July 2018.

Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro-oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05-0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01-0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.

Handigodu Disease (HD) is a disorder of the osteoarticular system which is highly prevalent in several villages of two districts viz, Shimoga and Chikmaglur of the state of Karnataka, southern India. It is a rare and painful osteoarthritic disorder. The disease is known scientifically as Spondylo-epi-(meta)physeal Dysplasia, Autosomal Dominant variety, Handigodu syndrome. The International Classification of Skeletal Dysplasias has the same classification. In HD, there was no calcium homeostasis study. After an overnight fast, serum calcium, phosphorus, parathyroid hormone, and calcitonin levels were measured, as well as calcium and phosphorus urinary excretion for 24 hours. In HD, there was a decrease in calcitonin levels, which was associated with a decrease in serum total calcium and urinary calcium. The levels of parathyroid hormone, serum phosphorus, and urinary phosphorus in HD patients remain unchanged. Vitamin D3 levels were also found to be unchanged in HD patients. Because calcitonin has an antiresorption effect on bone, the observed low calcitonin in HD may indicate resorption of bone, which causes deformity and hypocalcaemia and hypocalciuria. The hypocalcitonemia without change in iPTH associated with hypocalcaemia could be due to a mutation in the Vit D receptor (VDR) or it could be an epiphenomenon.

This pre-specified analysis of DAPA-CKD assessed the impact of sodium-glucose cotransporter 2 inhibition on abrupt declines in kidney function in high-risk patients based on having chronic kidney disease (CKD) and substantial albuminuria. DAPA-CKD was a randomized, double-blind, placebo-controlled trial that had a median follow-up of 2.4 years. Adults with CKD (urinary albumin-to-creatinine ratio 200-5000 mg/g and estimated glomerular filtration rate 25-75 mL/min/1.73m2) were randomized to dapagliflozin 10 mg/day matched to placebo (2152 individuals each). An abrupt decline in kidney function was defined as a pre-specified endpoint of doubling of serum creatinine between two subsequent study visits. We also assessed a post-hoc analysis of investigator-reported acute kidney injury-related serious adverse events. Doubling of serum creatinine between two subsequent visits (median time-interval 100 days) occurred in 63 (2.9%) and 91 (4.2%) participants in the dapagliflozin and placebo groups, respectively (hazard ratio 0.68 [95% confidence interval 0.49, 0.94]). Accounting for the competing risk of mortality did not alter our findings. There was no heterogeneity in the effect of dapagliflozin on abrupt declines in kidney function based on baseline subgroups. Acute kidney injury-related serious adverse events were not significantly different and occurred in 52 (2.5%) and 69 (3.2%) participants in the dapagliflozin and placebo groups, respectively (0.77 [0.54, 1.10]). Thus, in patients with CKD and substantial albuminuria, dapagliflozin reduced the risk of abrupt declines in kidney function. HJLH and DC are co-primary authors. The DAPA-CKD Trial Committees and Investigators are listed in the Appendix.

Upper airway involvement in systemic lupus erythematosus (SLE) disease process is uncommon. A 15-year-old girl, a known patient with class IVA lupus nephritis, presented in acute renal failure due to flare-up of SLE. She underwent an uneventful elective intubation procedure for placement of a hemodialysis catheter. After 36 hours of extubation, she developed biphasic stridor and severe shortness of breath that was unresponsive to multiple medications. Prompt airway evaluation by laryngoscopy and confirmation of acute tracheal necrosis by histopathology along with reintubation and high-dose steroid therapy resulted in good outcome and recovery.

Background Cognitive impairment is common in older patients with heart failure (HF), leading to higher 30-day readmission rates than those without cognitive impairment. Objectives The aim of this study was to determine whether increased readmissions in older adults with cognitive impairment are related to HF severity and whether readmissions can be modified by caregiver inclusion in nursing discharge education. Methods This study used prospective quality improvement program of cognitive testing and inclusion of caregivers in discharge education with chart review. Two hundred thirty-two patients older than 70 years admitted with HF were screened for cognitive impairment using the Mini-Cog; if score was less than 4, nurses were asked to include caregivers in education on 2 cardiovascular units with an enhanced discharge program. Individuals with ventricular assist device, transplant, or hospice were excluded. Measurements include Mini-Cog score, 30-day readmissions, readmission risk score, ejection fraction, brain natriuretic peptide, and medical comorbidities. Results Readmission Risk Scores for HF did not correlate with Mini-Cog scores, but admission brain natriuretic peptide levels were less abnormal in those with better Mini-Cog scores. Only for patients with cognitive impairment, involving caregivers in discharge teaching given by registered and advanced practice nurses was associated with decreased 30-day readmissions from 35% to 16% (P = .01). Readmission rates without/with cognitive impairment were 14.1% and 23.8%, respectively (P = .09). Abnormal Mini-Cog screen was associated with a significantly increased risk of 30-day readmission (odds ratio, 2.23; 95% confidence interval, 1.06-4.68; P = .03), whereas nurse documentation of education with family was associated with a significantly decreased risk of 30-day readmission (odds ratio, 0.46; 95% confidence interval, 0.24-0.90; P = .02). Conclusions Involving caregivers in discharge education significantly reduced 30-day readmission rates for patients with HF and cognitive impairment. The Readmission Risk Score was similar between patients older than 70 years with and without cognitive impairment. We have hypothesis-generating evidence that identification of cognitive impairment and targeted caregiver engagement by nurses may be critical in the reduction of readmission rates for older patients with HF.

Chemotherapy-induced nausea and vomiting (CINV) is one of the most common and feared side effects in cancer patients undergoing chemotherapy. Scientific evidence proves its detrimental impact on a patient's quality of life (QoL), treatment compliance, and overall healthcare cost. Despite the CINV-management landscape witnessing a radical shift with the introduction of novel, receptor-targeting antiemetic agents, this side effect remains a chink in the armor of a treating oncologist. Though global guidelines acknowledge patient-specific risk factors and chemotherapeutic agent emetogenic potential in CINV control, a "one-fit-for-all" approach cannot be followed across all geographies. Hence, in a pioneering attempt, India-based oncologists conveyed easily implementable, region-specific, consensus-based statements on CINV prevention and management. These statements resulted from integrating the analysis of scientific evidence and guidelines on CINV by the experts, with their clinical experience. The statements will strengthen decision-making abilities of Indian oncologists/clinicians and help in achieving consistency in CINV prevention and management in the country. Furthermore, this document shall lay the foundation for developing robust Indian guidelines for CINV prevention and control.

In the era of combined antiretroviral therapy (cART), lung diseases such as chronic bronchitis (CB) and chronic obstructive pulmonary disease (COPD) are common among persons living with HIV (PLWH), particularly smokers. Although smoking is highly prevalent among PLWH, HIV may be an independent risk factor for lung diseases; however, the role of HIV and cigarette smoke (CS) and their potential interaction in the development of chronic lung diseases among PLWH has not been delineated. To investigate this interaction, cynomolgus macaques were exposed to CS and/or simian-adapted human immunodeficiency virus (SHIV) and treated with cART. The development of CB and the lung functions were evaluated following CS±SHIV treatment. The results showed that in the lung, SHIV was a strong independent risk factor for goblet cell metaplasia/hyperplasia and mucus formation, MUC5AC synthesis, loss of tight junction proteins, and increased expression of Th2 cytokines/transcription factors. In addition, SHIV and CS synergistically reduced lung function and increased extrathoracic tracheal ring thickness. Interestingly, SHIV infection generated significant numbers of HIV-gp120(+) epithelial cells (HGECs) in small airways and alveoli, and their numbers doubled in CS+SHIV-infected lungs. We conclude that even with cART, SHIV independently induces CB and pro-COPD changes in the lung, and the effects are exacerbated by CS.

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Purpose Lately there is an increasing tendency of using Patient Reported Outcome Measures (PROMs) as a final indicator of the outcome of many surgical treatments in orthopaedics and in other medical specialties. Currently there are many outcome scores in orthopaedics and most of them are site specific. In the contrary there is a lack of trauma specific outcome scores. Methods We have designed a new PROM especially for orthopaedic trauma patients, in order to measure in what extent the patients manage to return to their pre-injury state. This score uses as baseline the pre-injury status of the patient and has the aim to determine the percentage of rehabilitation after treatment for any injury. Results A total of 60 Chertsey Outcome Score for Trauma (COST) questionnaires were gathered in our outpatients department. The participants were 57% male (aged 46.81 years ± 18.5 years) and the questionnaires collected at mean 10 months post-injury. A Cronbach's Alpha value of 0.89 was identified for the whole construct. The three dimensions of the scale had good internal consistency as well (Cronbach's Alpha test values 0.74, 0.84 and 0.81 for symptoms, function and mental status respectively). Strong/moderate correlation (Spearman's Rho test 0.43–0.65) was observed between the respective physical/mental dimensions of the COST and SF-12v2 questionnaires. Conclusion There is a need among the orthopaedic trauma society for a specific PROM of trauma. COST is a useful and easy to use tool for every trauma surgeon.

We report our institution&rsquo, s treatment techniques, disease outcomes, and complication rates after radiotherapy for the management of anal canal carcinoma with intensity-modulated radiotherapy (imrt) and concurrent chemotherapy relative to prior cases managed with 3-dimensional conformal radiotherapy (3D-crt). In a retrospective review of the medical records of 21 patients diagnosed with biopsy-proven stage i (23%), stage ii (27%), or stage iii (50%) squamous-cell carcinoma of the anal canal treated with curative chemotherapy and imrt between July 2009 and December 2014, patient outcomes were determined. Results for patients treated with 3D-crt by the same group were previously reported. The median initial radiation dose to the pelvic and inguinal nodes at risk was 45 Gy (range: 36&ndash, 50.4 Gy), and the median total dose, including local anal canal primary tumour boost, was 59.4 Gy (range: 41.4&ndash, 61.2 Gy). Patients received those doses over a median of 32 fractions (range: 23&ndash, 34 fractions). Chemotherapy consisted of 2 cycles of concurrent fluorouracil&ndash, cisplatin (45%) or fluorouracil&ndash, mitomycin C (55%). Median follow-up was 3.1 years (range: 0.38&ndash, 6.4 years). The mean includes a patient who died of septic shock at 38 days. The 3-year rates of overall survival, metastasis-free survival, locoregional control, and colostomy-free survival were 95%, 100%, 100%, and 100% respectively. No patients underwent abdominoperitoneal resection after chemoradiotherapy or required diverting colostomy during or after treatment. Those outcomes compare favourably with the previously published series that used 3D-crt with or without brachytherapy in treating anal canal cancers. Of the 21 patients in the present series, 10 (48%) experienced acute grade 3, 4, or 5 toxicities related to treatment. The recommended use of imrt with concurrent chemotherapy as an improvement over 3D-crt for management of anal canal carcinoma achieves a high probability of local control and colostomy-free survival without excessive risk for acute or late treatment-related toxicities.

Background Preoperative anaemia affects one third of patients undergoing cardiac surgery and is associated with increased mortality and morbidity. Although it is recommended that perioperative teams should identify and treat patients with preoperative anaemia before surgery, introducing new treatment protocols can be challenging in surgical pathways. The aim of this study was to assess the feasibility and effectiveness of introducing a preoperative intravenous iron service as a national initiative in cardiac surgery. Methods We performed a multicentre, stepped, observational study using the UK Association of Cardiothoracic Anaesthesia and Critical Care Research Network. The primary feasibility outcome was the ability to set up an anaemia and intravenous iron clinic at each site. The primary efficacy outcome was change in haemoglobin (Hb) concentration between intervention and operation. Secondary outcomes included blood transfusion and hospital stay. Patients with anaemia were compared with non-anaemic patients and with those who received intravenous iron as part of their routine treatment protocol. Results Seven out of 11 NHS hospitals successfully set up iron clinics over 2 yr, and 228 patients were recruited into this study. Patients with anaemia who received intravenous iron were at higher surgical risk, were more likely to have a known previous history of iron deficiency or anaemia, had a higher rate of chronic kidney disease, and were slightly more anaemic than the non-treated group. Intravenous iron was administered a median (inter-quartile range, IQR [range]) of 33 (15–53 [4–303]) days before surgery. Preoperative intravenous iron increased [Hb] from baseline to pre-surgery; mean (95% confidence interval) change was +8.4 (5.0–11.8) g L−1 (P Conclusion The development of an intravenous iron pathway is feasible but appears limited to selected high-risk cardiac patients in routine NHS practise. Although intravenous iron increased [Hb], there is a need for an appropriately powered clinical trial to assess the clinical effect of intravenous iron on patient-centred outcomes.

Psammomatoid Juvenile ossifying fibroma (PsJOF) is a rare benign fibro-osseous lesion characterised to grow to unusually large size very rapidly. Its usual presentation is in younger age group mostly children and predominately involving the Sino-Naso-Orbital region. Its aggressive nature gimmicks a malignant lesion but it is rather a benign lesion with a higher recurrence rate than the conventional ossifying fibroma but lacking metastatic potential. The high recurrence rate makes it essential that the lesion is not reconstructed immediately and thorough monitoring in the follow-up period. Lesion of such clinical importance needs to be diagnosed preoperatively to provide a better and radical surgical treatment option, but the variability in its presentation as seen in this case makes it even harder to diagnose. We aim to draw attention to the rare phenomena that PsJOF presents to help readers broaden their purview in diagnosis and thereby manage them accordingly.

Bleeding in cardiac surgery is known to cause increased morbidity and mortality. The rise in the use of anti-platelet medication has led to an increase in the number of patients presenting for cardiac surgery with platelet dysfunction, who are at a heightened risk of bleeding. However, the extent of platelet inhibition is well known to differ among individuals. In the past few years, a number of point-of-care platelet function testing devices, which may be able to assess platelet reactivity, have entered the market. This review will examine the devices most commonly studied and the evidence surrounding their use in cardiac surgery and their effect on blood loss.

Tumour heterogeneity is emerging as a key driver of drug response. Understanding the heterogeneity is therefore a critical milestone towards the prediction of clinical outcome of anti-cancer drugs. There is a need for technology that can predict treatment outcome with high fidelity by contextually integrating tumor heterogeneity and phenocopying the tumor microenvironment. Tumor grade-matched matrix support, activated immune compartments and autologous ligands from individual patients were used to engineer a novel personalized ex vivo platform named CANScript. We evaluated functional outcomes as a measure of response to a panel of anticancer drugs in this CANScript platform. Histopathological and molecular characterization of the tumor explants cultured in CANScript revealed a close approximation to the parental tumor at baseline as confirmed by tumor cell viability, proliferation, critical phosphoproteomic status, global transcriptomic profiles and balance in active components of tumor and stromal phenotypes (Majumder. B et al Nat. Commun, 2015). Using more than 100 patients clinical outcome of anticancer drugs (training set) we have further built a machine learning algorithm that takes all functional outcome data from the CANScript platform and provides outcome data in a linear scale showing clinical prediction. This algorithm when applied to the test cohort of more than 40 patients with refractory breast cancer assessed in the CANScript achieved more than 90% sensitivity while keeping specificity in a desired high range for predicting short term clinical outcome. The high specificity and sensitivity observed in predicting clinical outcomes using the CANScript support the use of this novel platform to select treatment for patients with breast cancer. Citation Format: Majumder PK, Majumder B, Mehrotra DG, Radhakrishnan P, Baraneedharan U, Agarwal S, Sengupta S, Babu G. Development and validation of personalized ex vivo platform mimicking patient heterogeneous tumor microenvironment to enable personalized treatment for breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-42.

Introduction This prospective, hospital-based, cross-sectional, case-control study reports on the effectiveness of a novel loco-regional approach to provide analgesia in cardiac surgery, the ultrasound (US)-guided pectoralis-intercostal rectus-sheath (PIRS) block(1), a modified combination of pectoralis and rectus-sheath blocks, respectively. It is intended to provide analgesia for sternotomy and surgical sites of chest drains, by effectively covering the T1-T10 dermatomes. Methods In this prospective hospital-based cross-sectional case-control study, 31 patients received interfascial US-guided PIRS with levobupivacaine 0.25% immediately after induction of general anaesthesia and, again, immediately after surgery. Patients undergoing coronary artery bypass grafting also received saphenous nerve blockade to cover the vein harvesting sites. Postoperative opioid analgesia, extubation time, length of intensive care and hospital stay were recorded. Outcomes for the PIRS group were compared with a historical control group of 30 patients matched for gender, age,risk profile and timing of surgery, who received conventional opioid analgesia. Results The extubation time was 2.5 hours in the PIRS group (1-3.5), reduced from 7.5 in the control group (6-14) (interquartile range, p-value Discussion The US-guided PIRS block could be a useful technique for the provision of effective intra-, and post-, operative analgesia at the sites of cardiac surgery.

Background Children with conversion disorder experience neurological symptoms without a definable organic cause. Clinical presentation of conversion disorders is uncommon in the emergency department (ED). Case Report An 11-year-old previously healthy girl presented to the ED for management of lobar pneumonia. She developed acute visual loss subsequent to accidental placement of an intra-arterial cannula in her arm. Clinical assessments by the emergency physician, neurology, ophthalmology, and psychiatry services, and negative neuroimaging studies established the diagnosis of functional visual loss as a manifestation of conversion disorder. Why Should an Emergency Physician Be Aware of This? Conversion disorder symptoms are often without any specific markers and do not fit standard clinical guidelines. A comprehensive and step-wise evaluation of unusual clinical presentation by multiple specialties and ancillary test results should be considered to rule out organic causes and establish the diagnosis of conversion disorder, as seen in our patient.

The clinical and laboratory features of hemophagocytic lymphohistiocytosis (HLH) are nonspecific that makes the definitive diagnosis of HLH very challenging. The disease is almost universally fatal in the absence of early recognition and appropriate therapy. Elevated serum ferritin level is one of the diagnostic markers of HLH disease. We report the value of testing serum ferritin level early in the disease process in 3 pediatric patients who presented with persistent fever and sepsis-like features. Detection of elevated serum ferritin levels facilitated further testing to confirm the diagnosis of HLH and initiate early therapy with good outcomes.

Treatment of scapholunate dissociation (SLD) depends on the degree of injury. We present our technique of extensor carpi radialis longus (ECRL) tenodesis for Geissler grade 2 SLD and our preliminary results. After arthroscopic confirmation of Geissler grade 2 SLD, we use a single incision and a polyetheretherketone (PEEK) anchor, attaching half of the ECRL tendon to the scaphoid. Preliminary results include improvements in QDASH, QDASH (work) and QDASH (sports/music), a median satisfaction level of 4/5 (satisfied), and a low complication rate. Our method is a safe, reproducible, and effective treatment of symptomatic Geissler grade 2 SLD that has failed nonoperative management, with technical advantages over alternative methods in the literature.

Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the short-term gait alternations after severe tibia plateau fractures treated with circular Ilizarov frame.Gait pattern evaluation was performed to patients who were treated with circular Ilizarov frame after severe tibia plateau fractures (Schatzker IV-VI), three to six months after the frame removal. Gait evaluation performed by using a force plate in a walking platform at self selected speeds. Data collected from two walking tasks for each limb. Demographic, clinical, radiological and quality of life questionnaire (SF-12v2) and COST data were also collected.The gait pattern of sixteen patients (aged 48.8 ± 13.3 years), following treatment with circular Ilizarov frame for severe tibia plateau fractures (Schatzker IV-VI) was analysed. The tests were performed at an average of 10.4 months after the initial treatment. SF-12v2 Mental scores have returned to normal (mean 55.8 ± 11.9) but physical scores remained impaired (mean 40.6 ± 11.3). COST scores reached average levels (mean 54.1 ± 19.8). A one-way repeated measures ANOVA was conducted to compare the GRFs and gait timing data of the affected limb with the normal one. Single limb support interval was significantly reduced to the affected limb (p 0.001) and terminal stance phase was prolonged for the normal limb (p = 0.05). The rest of the GRF and gait timing data did not reach significant differences.During the early stages of rehabilitation following severe tibia plateau fractures treated with circular Ilizarov frame, the gait pattern returns to normal curve morphology, but with reduced single limb support and terminal stance phases at the affected knee. Mental status returns to normal but symptoms and function remain impaired.