Platypnea-orthodeoxia Syndrome (POS) in Moderate COVID-19: An Uncommonly Common Bedside Sign?

Platypnoea-Orthodeoxia syndrome (POS) is the presence of postural hypoxaemia along with breathlessness in recumbent position. It is an uncommon syndrome with elusive pathophysiologic mechanisms. We observed POS in patients of moderate COVID-19 who required hospital admission to our indoor facility and oxygen supplementation when saturation was documented in sitting and supine positions for evaluation of platypnea. MATERIALS AND METHODS: We conducted an observational, cross sectional, retrospective analysis of pulse oximetry readings of patients with stage 2 COVID-19 admitted in ward during the period from 15th May 2020 to 30th May 2020. The difference in the peripheral oxygen saturation in sitting and supine positions, documented as a routine standard of care, especially in patients with platypnea, was calculated and demographic details and co-morbidities were noted from indoor record forms. RESULTS: Of the 53 patients of stage 2 COVID-19 who were included in the study, 15 (28%) had platypnoea-orthodeoxia syndrome at the time of presentation and 18(33.9%) patients with platypnoea had ≥ 3% desaturation in sitting position as compared to supine position. Rest of the 20 (37.7%) patients had neither platypnoea nor orthodeoxia. All the patients presenting with platypnoea-orthodeoxia required oxygen therapy during the course of treatment. Amongst the 33 patients who were hypoxic and required oxygen supplementation, 15 patients (45.4%) had oxygen saturation of ≥94% in the supine position at presentation. CONCLUSION: Platypnoea-orthodeoxia syndrome is common in patients with stage 2 COVID 19 infection who require oxygen therapy. POS can be easily documented by using pulse oximeter without the need of any specialised equipment. Hence, we propose that documentation of POS at the time of admission in primary health care or resource depleted settings would help in successful triage of the patients needing oxygen therapy. We also propose that oxygen saturation in sitting position be documented as far as possible. Further clinical studies are necessary to validate this observation.

Precision Medicine in Colorectal Surgery.

This article reviews advances in precision medicine for colorectal carcinoma that have influenced screening and treatment, and potentially prevention. Advances in molecular techniques have made it possible for better patient selection for therapies; therefore, mutational analysis should be performed at diagnosis to guide treatment. Future efforts should focus on validating these treatments in specific subgroups and on understanding the mechanisms of resistance to therapies to enable treatment optimization, promote efficacy, and reduce treatment costs and toxicities.

International Summit on Laparoscopic Pancreatic Resection (ISLPR) "Coimbatore Summit Statements".

The International Summit on Laparoscopic Pancreatic Resection (ISLPR) was held in Coimbatore, India, on 7th and 8th of October 2016 and thirty international experts who regularly perform laparoscopic pancreatic resections participated in ISPLR from four continents, i.e., South and North America, Europe and Asia. Prior to ISLPR, the first conversation among the experts was made online on August 26th, 2016 and the structures of ISPLR were developed. The aims of ISPLR were; i) to identify indications and optimal case selection criteria for minimally invasive pancreatic resection (MIPR) in the setting of both benign and malignant diseases; ii) standardization of techniques to increase the safety of MIPR; iii) identification of common problems faced during MIPR and developing associated management strategies; iv) development of clinical protocols to allow early identification of complications and develop the accompanying management plan to minimize morbidity and mortality. As a process for interactive discussion, the experts were requested to complete an online questionnaire consisting of 65 questions about the various technical aspects of laparoscopic pancreatic resections. Two further web-based meetings were conducted prior to ISPLR. Through further discussion during ISPLR, we have created productive statements regarding the topics of Disease, Implementation, Patients, Techniques, and Instrumentations (DIPTI) and hereby publish them as "Coimbatore Summit Statements".

The Role of Image-guided Radiotherapy in the Treatment of Anorectal Cancer Using Prone Belly-board Positioning.

AIM: To evaluate Radiation Therapy Oncology Group planning target volume margins of 7-10 mm for radiation therapy in anorectal cancer using prone belly-board positioning without image guidance. PATIENTS AND METHODS: 375 kV cone beam computed tomography image-guided radiotherapy (IGRT) images from 20 patients treated for anorectal cancer were retrospectively analyzed for setup shifts. We calculated the total translational shift for each patient and the frequency with which setup shifts exceeded 7 mm and 10 mm. RESULTS: A total of 42.7% of treatments required shifts >7 mm and 20.8% >10 mm. The mean translational shift was 7.1 mm. 70% of patients experienced shifts ≥7 mm in 20% or more of their treatments and 25% of ≥10 mm in 20% or more of their treatments; 15% experienced shifts ≥10 mm in over half of their treatments. van Herk calculations suggest margins of 12.8 mm are necessary for accuracy without IGRT. CONCLUSION: IGRT using a prone belly board and 7-10 mm margins requires daily image-guidance to prevent planning target volume misses and ensure optimal dose delivery.

How many operating rooms are needed to manage non-elective surgical cases? A Monte Carlo simulation study.

BACKGROUND: Patients often wait to have urgent or emergency surgery. The number of operating rooms (ORs) needed to minimize waiting time while optimizing resources can be determined using queuing theory and computer simulation. We developed a computer program using Monte Carlo simulation to determine the number of ORs needed to minimize patient wait times while optimizing resources. METHODS: We used patient arrival data and surgical procedure length from our institution, a tertiary-care academic medical center that serves a large diverse population. With ~4800 patients/year requiring non-elective surgery, and mean procedure length 185 min (median 150 min) we determined the number of ORs needed during the day and evening (0600-2200) and during the night (2200-0600) that resulted in acceptable wait times. RESULTS: Simulation of 4 ORs at day/evening and 3 ORs at night resulted in median wait time = 0 min (mean = 19 min) for emergency cases requiring surgery within 2 h, with wait time at the 95th percentile = 109 min. Median wait time for urgent cases needing surgery within 8-12 h was 34 min (mean = 136 min), with wait time at the 95th percentile = 474 min. The effect of changes in surgical length and volume on wait times was determined with sensitivity analysis. CONCLUSIONS: Monte Carlo simulation can guide decisions on how to balance resources for elective and non-elective surgical procedures.

Integrating Chemotherapy into the Management of Oligometastatic Colorectal Cancer: Evidence-Based Approach Using Clinical Trial Findings.

BACKGROUND: This study used case reports to review the role of systemic chemotherapy in oligometastatic colorectal cancer (CRC) and to suggest ways to integrate clinical research findings into the interdisciplinary management of this potentially curable subset of patients. METHODS: This educational review discusses the role of chemotherapy in the management of oligometastatic metastatic CRC. RESULTS: In initially resectable oligometastatic CRC, the goal of chemotherapy is to eradicate micrometastatic disease. Perioperative 5-fluorouracil and oxaliplatin together with surgical resection can result in 5-year survival rates as high as 57 %. With the development of increasingly successful chemotherapy regimens, attention is being paid to chemotherapy used to convert patients with initially unresectable metastasis to patients with a chance of surgical cure. The choice of chemotherapy regimen requires consideration of the goals for therapy and assessment of both tumor- and patient-specific factors. CONCLUSION: This report discusses the choice and timing of chemotherapy in patients with initially resectable and borderline resectable metastatic CRC. Coordinated multidisciplinary care of such patients can optimize survival outcomes and result in cure for patients with this otherwise lethal disease.

Emerging modalities in breast cancer imaging.

Breast cancer continues to be the most frequently diagnosed malignancy and the second leading cause of death caused by cancer in women in the United States. Although each of the emerging imaging techniques discussed in this article has advantages compared with standard mammography, they are not perfect, and each has inherent limitations. To date, none have been studied by large randomized clinical trials to match the proven benefits of screening mammography; namely the reduction of mortality caused by breast cancer by nearly 30%.

Diagnostic imaging of hepatic lesions in adults.

Multiphase contrast-enhanced magnetic resonance imaging (MRI) is the current modality of choice for characterization of liver masses incidentally detected on imaging. Contrast-enhanced computed tomography (CT) performed in the portal phase is the mainstay for the screening of liver metastases. Characterization of a liver mass by CT and MRI primarily relies on the dynamic contrast-enhancement characteristics of the mass in multiple phases. Noninvasive MRI and CT imaging characteristics of benign and malignant liver masses, coupled with relevant clinical information, allow reliable characterization of most liver lesions. Some cases may have nonspecific or overlapping features that may present a diagnostic dilemma.

Radiofrequency ablation and breast cancer: a review.

BACKGROUND: Radiofrequency ablation (RFA) use in breast cancer is a developing area of research. There have been a number of published studies over the last decade, which explores the feasibility of minimally invasive techniques in breast cancer treatment. In this review, we will discuss the most recent data on radiofrequency ablation and examine the current methods, outcomes, complications, and limitations of RFA in breast cancer therapy. METHODS: Pub Med search for English Language articles on RFA in breast cancer. RESULTS: More than 25 studies were reviewed and we searched for number of tumors, average size, electrode used, if they successfully ablated the tumor, when the tumor was then resected and if the patients experienced any complication from the ablation. CONCLUSIONS: Radiofrequency ablation is an emerging minimally invasive therapy in small, localized breast cancer. Currently, no clinical trials have been published to directly compare RFA to the current standard of surgical resection. Ultimately, RFA will need clinical trials to evaluate oncologic outcomes involving long interval follow-up to determine survival, local control and disease progression before it becomes a reasonable alternative to surgical resection.

Relative value units poorly correlate with measures of surgical effort and complexity.

BACKGROUND: The relationship between procedural relative value units (RVUs) for surgical procedures and other measures of surgeon effort are poorly characterized. We hypothesized that RVUs would poorly correlate with quantifiable metrics of surgeon effort. METHODS: Using the 2010 American College of Surgeons - National Surgical Quality Improvement Program (NSQIP) database, we selected 11 primary current procedural terminology codes associated with high volume surgical procedures. We then identified all patients with a single reported procedural RVU who underwent nonemergent, inpatient general surgical operations. We used linear regression to correlate length of stay (LOS), operative time, overall morbidity, frequency of serious adverse events (SAEs), and mortality with RVUs. We used multivariable logistic regression using all preoperative NSQIP variables to determine other significant predictors of our outcome measures. RESULTS: Among 14,481 patients, RVUs poorly correlated with individual LOS (R(2) = 0.05), operative time (R(2) = 0.10), and mortality (R(2) = 0.35). There was a moderate correlation between RVUs and SAEs (R(2) = 0.79) and RVUs and overall morbidity (R(2) = 0.75). However, among low- to mid-level RVU procedures (11-35) there was a poor correlation between SAEs (R(2) = 0.15), overall morbidity (R(2) = 0.05), and RVUs. On multivariable analysis, RVUs were significant predictors of operative time, LOS, and SAEs (odds ratio 1.06, 95% confidence interval: 1.05-1.07), but RVUs were not a significant predictor of mortality (odds ratio 1.02, 95% confidence interval: 0.99-1.05). CONCLUSIONS: For common, index general surgery procedures, the current RVU assignments poorly correlate with certain metrics of surgeon work, while moderately correlating with others. Given the increasing emphasis on measuring and tracking surgeon productivity, more objective measures of surgeon work and productivity should be developed.