Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages.

BACKGROUND: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Contribution to the biostratigraphy of the Middle-Upper Eocene rock units at North Eastern Desert; an integrated micropaleontological approach.

Foraminifera and calcareous nannofossils have been integrated to improve the biostratigraphy of the Middle-Upper Eocene rocks at North Eastern Desert. Biostratigraphic analysis has enabled the identification of three planktic biozones, Globigerinatheka kugleri/Morozovella aragonensis (E9), Morozovelloides crassatus (E13) and Turorotalia cerroazulensis pomeroli/T. cerr. cerroazulensis. Meanwhile, the occurrence of calcareous nannofossils Reticulofenestra dictyoda, Pontosphaera multipora and Reticulofenestra umbilica within Morozovelloides crassatus Zone (E13) were attributed to Discoaster saipanensis Zone (NP17). Furthermore the quantitative analysis of small benthic foraminifera suggests four benthic assemblages (abundance zones) which correlated with their equivalents in the study area and neighboring areas. Therefore, a Middle Lutetian age (∼45.8 Ma) is proposed for Observatory Formation which dated back to the Bartonian. While, the Qurn Formation is assigned to late Bartonian-early Priabonian age with paraconformity (∼3.6 Ma) between the Observatory and Qurn formations as the result of tectonic instability at the late of Lutetian age. All of the recorded planktic species discontinue at the upper Eocene Maadi Formation of Priabonian age where the environment turned more shallowing inconsistent with planktic habitat. The Lutetian/Bartonian and Bartonian/Priabonian stage bounderies have been also discussed.

Does radiography still have a significant diagnostic role in evaluation of acute traumatic wrist injuries? A prospective comparative study.

AIM: The aim of this study was to evaluate and compare the diagnostic role of radiography and multi-detector computed tomography (MDCT) in acute traumatic wrist injuries. PATIENTS AND METHODS: One hundred sixty-eight patients with acute wrist trauma were enrolled in our study. All patients had submitted to radiography and MDCT within 24 h after wrist trauma. The diagnostic role of radiography and MDCT was evaluated and compared. The effective radiation dose of the two techniques was calculated. RESULTS: One hundred four (61.9%) and 84 (50%) out of 168 patients had acute wrist injuries on MDCT and radiographic examinations, respectively. Using MDCT results as a reference standard, the sensitivity, specificity, and accuracy of radiography in the diagnosis of distal radius fracture were 85.7, 96, and 92.3%, respectively, and in the diagnosis of scaphoid fracture were 62.5, 97.3, and 88.5%, respectively. As regards detection of acute traumatic wrist injuries, we observed no significant difference between the two modalities (P = 0.1347); in addition, both modalities had high consistency (κ = 0.8359). The mean effective radiation dose of radiography was 0.01 mSv and of MDCT was 0.1 mSv. CONCLUSION: Radiography still remains as the first screening tool in acute traumatic wrist injuries and MDCT is complementary to it and used as a problem-solving tool or for preoperative planning.

Level I lymph node involvement in patients with N1b papillary thyroid carcinoma: a prospective study.

Most of the studies on the incidence, pattern, and predictive factors of lymph node (LN) metastasis with papillary thyroid carcinoma (PTC) have been performed retrospectively and no common consensus has been reached regarding the predictors for the involvement of level I LNs. This study was conducted prospectively to determine the incidence and the possible predictors of level I involvement in N1b PTC patients. The study included 30 consecutive patients with N1b stage of PTC. All the patients underwent neck dissection (ND) including level I. The relation between involvement of level I LNs and various clinicopathological variables was studied. Unilateral neck dissection was performed in 24 patients and bilateral neck dissection in six patients leading to 36 NDs. Level I was excised in all patients, with five specimens (14%) positive for metastasis. Levels II, III, IV, V, VI, and VII were positive in 52.8, 58.3, 58.3, 33.3, 63, and 22.2%, respectively. Level I involvement was significantly related to the number of lymph node levels affected (p = 0.003) and macroscopic extranodal invasion (p = 0.04). It was not related to the involvement of other individual levels, gender, age, size of the largest thyroid nodule, size of the largest LN involved, or histo-pathological variant of the tumor. This study suggests that including level I in therapeutic neck dissection for N1b PTC patients might be recommended in selected cases of multiple level involvement and macroscopic extranodal invasion requiring sacrifice of internal jugular vein, spinal accessory nerve, or sternomastoid muscle.

Predictors of developing significant mitral regurgitation following percutaneous mitral commissurotomy with inoue balloon technique.

Background. Despite the high technical expertise in percutaneous mitral commissurotomy (PMC), mitral regurgitation (MR) remains a major procedure-related complication. The aim of this work is to find out the most sensitive and applicable predictors of development of significant mitral regurgitation (SMR) following percutaneous mitral commissurotomy using Inoue balloon technique. Methods. We studied prospectively the preprocedural (clinical, echocardiography, and hemodynamic) and procedural predictors of significant mitral regurgitation (identified as increase of ≥2/4 grades of pre-PMC MR by color Doppler flow mapping) following valvuloplasty using Inoue balloon in 108 consecutive patients with severe mitral stenosis. Multiple stepwise logistic regression analysis was performed for variables found positive on univariate analysis to determine the most important predictor(s) of developing SMR. Results. The incidence of SMR following PMC using Inoue technique was 18.5% (10 patients). MV scoring systems were the only variables that showed significant differences between both groups (Group A without SMR and Group B with SMR). However, no clinical, other echocardiographic measurements, hemodynamic or procedural variables could predict the development of SMR. Using multiple regression analysis, the best predictive factor for the risk of SMR after Inoue BMV was the total MR-echo score with a cutoff point of 7 and a predictive percentage of 97.7%. Conclusions. The total MR-echo score is the only independent predictor of SMR following PMC using Inoue technique with a cutoff point of 7.

Dyspnea, pulmonary function and exercise capacity in adult Saudi patients with sickle cell disease.

OBJECTIVE: To examine pulmonary function, dyspnea and exercise capacity in adult Saudi sickle cell disease (SCD) patients. METHODS: The patients were recruited from the hematology clinic at King Khalid University Hospital in Riyadh from January to December 2005. The study involved 39 patients with stable SCD (20 women and 19 men), with a mean age of 22.7+/-7.1 years, hemoglobin level of 95.5+/-14.6 g/L and hemoglobin F level of 13.7+/-8.6%. Patients underwent pulmonary function tests (PFT) (forced expiratory volume in first second [FEV1], forced vital capacity [FVC], and diffusion capacity of carbon monoxide [DLco] data are presented as a percentage of the normal prediction), a 6-minute walk test (6MWT) and echocardiography. Dyspnea was assessed using the Borg score. The 6MWT data were compared to body mass index-matched healthy controls. RESULTS: Forty-one percent of SCD patients had mild dyspnea at rest, and this increased to 61% at the end of the 6MWT. Pulmonary function tests were abnormal in 51% (36% of patients had a restrictive pattern, 10% had isolated decrease in DLco, and 5% had a mixed restrictive-obstructive pattern). The 6MWD was shorter in SCD patients compared to the controls (368+/-67 versus 407+/-47m, p=0.005). No hematological variables correlated with outcome variables. CONCLUSION: Chronic pulmonary complications in adult Saudi SCD patients are relatively mild but common. Pulmonary function in these patients differs from that published for African-origin SCD patients. This difference may reflect a different natural history of SCD in the 2 populations.

Is serum alanine transaminase level a reliable marker of histological disease in chronic hepatitis C infection?

BACKGROUND: Approximately 20-30% of patients chronically infected with hepatitis C virus (HCV) have persistently normal alanine transaminase (PNALT) levels. These patients are described to have a mild degree of histological liver damage. We aimed to assess the histological liver changes in HCV patients with PNALT. PATIENTS AND METHODS: Sixty-five patients with HCV and PNALT (group A) underwent a liver biopsy. PNALT was defined as three or more determinations identified to be within the normal range over 6 months or longer. The demographical features and histological changes were compared with 66 consecutive patients with chronic HCV infection and elevated ALT (group B). All patients had a detectable HCV RNA. Histological disease was scored according to the METAVIR system. RESULTS: Females were more likely to have normal ALT levels (65%). The mean ALT level in Group A and B was 30 and 105 IU/L respectively. No patient in either group had normal histology. The mean necro-inflammatory scores in groups A and B (2.0+/-0.68 vs 2.09+/-0.67) and the mean fibrosis scores (2.11+/-0.87 vs 2.24+/-1.04) were not significantly different. Bridging fibrosis in groups A and B was seen in 24.6 and 37.9% patients, respectively, while cirrhosis was seen in 6.2 and 7.6% patients respectively. Hepatic steatosis in groups A and B (0.94+/-0.86 vs 1.0+/-1.02 respectively) was also not significantly different and did not show any association with the fibrosis scores across the two groups. In group A, the necro-inflammatory and fibrosis scores of patients with and without steatosis were not statistically significant. Age was the only predictor of normal ALT levels. However, increasing age did not show a significant increase in histological activity in either group beyond a certain age. CONCLUSION: This study demonstrates that ALT is a poor surrogate marker for inflammation and fibrosis in HCV patients. Given the presence of significant necro-inflammation in PNALT patients, the risk/benefit ratio justifies treatment without the need for a liver biopsy.

Six Minute Walk Test to assess functional capacity in chronic liver disease patients.

AIM: To examine the utility of Six Minute Walk Test (6MWT) in patients with chronic liver disease (CLD). METHODS: Two hundred and fifty subjects between the ages of 18 and 80 (mean 47) years performed 6MWT and the Six Minute Walk Distance (6MWD) was measured. RESULTS: The subjects were categorized into four groups. Group A (n = 45) healthy subjects (control); group B (n = 49) chronic hepatitis B patients; group C (n = 54) chronic hepatitis C patients; group D (n = 98) liver cirrhosis patients. The four groups differed in terms of 6MWDs (P < 0.001). The longest distance walked was 421 +/- 47 m by group A, then group B (390 +/- 53 m), group C (357 +/- 72 m) and group D (306 +/- 111 m). The 6MWD correlated with age (r = -0.482, P < 0.01), hemoglobin (r = 0.373, P < 0.001) and albumin (r = 0.311, P < 0.001) levels. The Child-Pugh classification was negatively correlated with the 6MWD in cirrhosis (group D) patients (r = -0.328, P < 0.01). At the end of a 12 mo follow-up period, 15 of the 98 cirrhosis patients had died from disease complications. The 6MWD for the surviving cirrhotic patients was longer than for non-survivors (317 +/- 101 vs 245 +/- 145 m, P = 0.021; 95% CI 11-132). The 6MWD was found to be an independent predictor of survival (P = 0.024). CONCLUSION: 6MWT is a useful tool for assessing physical function in CLD patients. We suggest that 6MWD may serve as a prognostic indicator in patients with liver cirrhosis.

Tracheobronchomegaly-Mounier-Kuhn syndrome.

Tracheobronchomegaly is a rare disorder of uncertain etiology, characterized by marked dilatation of the trachea and major bronchi, associated with tracheal diverticulosis, bronchiectasis and recurrent respiratory tract infection. We are reporting a 60-year-old man from the Kingdom of Saudi Arabia with this condition and review the literature for such a rare entity.

High grade squamous cervical lesions following negative Papanicolaou smears: false-negative cervical cytology or rapid progression.

The cervical cytologic finding of a high grade squamous intraepithelial lesion (HGSIL) or carcinoma shortly following a negative smear is unusual. To determine if such cases are due to screening errors, inadequate sampling, or rapidly progressive lesions, a review of negative smears (immediately preceding a diagnosis of HGSIL or carcinoma by at most 2 yr) was performed on 17 patients (all such patients in our 1990-92 files, representing 6% (17/290) of such diagnoses). The time between negative smear and positive result averaged 9.3 mo. Eighty-eight percent of these patients had prior histories of a cytologic abnormality. Upon review, 16 of 17 "negative" smears contained a cytologic abnormality. Atypical immature squamous metaplastic type cells (AISMTs) were found in 11 of 16 cases, atypical squamous cells or slight dysplasia were found in 5 of 16, HGSIL was found in 5 of 16, and atypical cells of undetermined type and origin were noted in 1 of 16. Combinations of the above diagnoses were present in 6 of 16 cases. The number of abnormal cells per slide was estimated, with < 10 cells in 1 case, < 50 in 4 cases, 50-100 in 7 cases, 100-200 in 3 cases, and > 200 in 1 case. In this study, screening and/or evaluation errors were the dominant cause of false-negative cytologic diagnoses, with AISMTs accounting for the most commonly missed or misinterpreted cells. These cells are small and have hyperchromatic nuclei with elevated nucleus to cytoplasmic ratio and nuclear irregularities.

Accumulation of interferon gamma-producing TH1 helper T cells in nasal polyps.

We investigated the mechanisms involved in the formation of nasal polyps by examining T-cell clones and their production of soluble mediators in nasal polyps. Recently, the allergic origin of nasal polyps has been challenged. To study this question we characterized T cells from polyp tissue of allergic individuals in terms of their cytokine pattern. Nasal polyp T cells were cloned from allergic individuals undergoing polypectomy. Polyp tissue was dispersed enzymatically, and T cells were stimulated with mitogen and interleukin-2. Control T cells were obtained from peripheral blood of nonallergic donors. Cytokine production of interleukin-4 and interferon was then determined by indirect enzyme-linked immunosorbent assay tests. Polyp T-cell clones were found to produce high interferon but low interleukin-4 levels that were not significantly different from control peripheral blood T-cell clones. In addition, immunoglobulin production by dispersed polyp tissue was investigated. Immunoglobulin levels were higher in polyp tissues than in serum with immunoglobulin A predominating. These results suggest that the inflammatory reaction in nasal polyps is different than that seen in a typical type I hypersensitivity response.