Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients: A mini review for clinicians.

Among critically ill patients, severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality. Yet, it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease. In addition, management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions. To help clinicians acquire an up-to-date approach to severe tuberculosis, this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.

A TRIZ-driven conceptualisation of finger grip enhancer designs for the elderly.

Background: Elderly people with severe finger weakness may need assistive health technology interventions. Finger weakness impedes the elderly in executing activities of daily living such as unbuttoning shirts and opening clothes pegs. While studies have related finger weakness with ageing effects, there appears to be no research that uses an algorithmic problem-solving approach such as the theory of inventive problem-solving (TRIZ) to recommend finger grip assistive technologies that resolve the issue of finger weakness among the elderly. Using TRIZ, this study aims to conceptualise finger grip enhancer designs for elderly people. Methods: Several TRIZ tools such as the cause-and-effect chain (CEC) analysis, engineering contradiction, physical contradiction, and substance-field analysis are used to conceptualise solutions that assist elderly people in their day-to-day pinching activities. Results: Based on the segmentation principle, a finger assistant concept powered by a miniature linear actuator is recommended. Specific product development processes are used to further conceptualise the actuation system. The study concluded that the chosen concept should use a DC motor to actuate fingers through tendon cables triggered by a push start button. Conclusions: Finger pinch degradation worsens the quality of life of the elderly. A finger grip enhancer that assists in day-to-day activities may be an effective option for elderly people, not only for their physical but also their mental well-being in society.

The Emerging Role of Robotics in Pelvic Exenteration Surgery for Locally Advanced Rectal Cancer: A Narrative Review.

Pelvic exenteration surgery for locally advanced rectal cancers is a complex and extensive multivisceral operation, which is associated with high perioperative morbidity and mortality rates. Significant technical challenges may arise due to inadequate access, visualisation, and characterisation of tissue planes and critical structures in the spatially constrained pelvis. Over the last two decades, robotic-assisted technologies have facilitated substantial advancements in the minimally invasive approach to total mesorectal excision (TME) for rectal cancers. Here, we review the emerging experience and evidence of robotic assistance in beyond TME multivisceral pelvic exenteration for locally advanced rectal cancers where heightened operative challenges and cumbersome ergonomics are likely to be encountered.

Tumor necrosis is significantly associated with reduced recurrence-free survival after curative resection of gastrointestinal stromal tumors.

BACKGROUND OBJECTIVES: The impact of tumor necrosis as a prognostic factor in gastrointestinal stromal tumor (GISTs) is still debated. The objective was to determine whether tumor necrosis is an independent risk factor for survival in patients with GISTs. METHODS: Patients undergoing surgery for primary GIST from March 2003 to October 2018 at two sarcoma referral centers were retrospectively identified. Patients who received neoadjuvant imatinib were excluded. Multivariable Cox regression models were produced, to assess whether tumor necrosis was an independent predictor of either overall or recurrence-free survival. RESULTS: Forty-one out of 195 (21.0%) patients had tumor necrosis. Tumor necrosis was associated with a significantly higher modified National Institute of Health risk score, with 29 out of 41 (70.7%) patients with necrosis classified as high risk, compared to 52 out of 153 (34.0%) without (p < .001). Tumor necrosis was found to be independently predictive of recurrence-free survival (hazard ratio: 5.26, 95% CI: 2.62-10.56, p < .001) on multivariable analysis. At 5 years, 44.3% of patients with necrosis had either died or developed recurrence, compared to 9.9% of those without. CONCLUSION: Tumor necrosis is an independent predictor of recurrence-free survival in patients with operable GISTs. It should be routinely reported by pathologists, and used by clinicians when counseling patients and deciding on adjuvant therapy.

Risk factors to differentiate between benign proximal biliary strictures and perihilar cholangiocarcinoma.

BACKGROUND: The aim of this study was to evaluate potential risk factors associated with benign lesions and perihilar cholangiocarcinoma (PHC) in patients presenting with proximal biliary strictures (PBS). METHODS: Patients with PBS who were referred to a specialist HPB centre between 2008 and 2016 were identified. Patients with primary sclerosing cholangitis, metastatic PHC or hilar obstruction by a peripheral tumour were excluded. The final diagnosis was determined either by (1) resection histology or (2) combination of biopsy and clinical course. Multivariable analysis of clinical, laboratory and radiological data was undertaken to identify independent predictors of benign and malignant lesions. RESULTS: 155 consecutive patients were identified, including 25 patients (16%) with benign PBS. Abdominal pain (odds ratio [OR] 3.36; p = 0.027), serum CA19.9 < 100 U/ml (OR 10.35; p = 0.001), and absence of mass on imaging (OR 4.66; p = 0.004) were all associated with the presence of benign lesions on multivariable analysis. CONCLUSIONS: This study has identified several independent variables that may differentiate between benign and malignant proximal biliary strictures. A larger multi-institutional study would be warranted to validate these findings, and to develop a risk score to stratify patients with suspected PHC.

Spontaneous partial regression of a microcystic jejunal mesenteric lymphangioma and a proposed management algorithm.

Mesenteric lymphangiomas are relatively rare, with clinical symptoms ranging from an asymptomatic presentation to an acute abdomen. The natural history and biological behaviour of this entity can range from slow indolent lesions to aggressive tumours with a risk of malignant transformation. Spontaneous regression of a mesenteric lymphangioma is rare. We herein report a case of a jejunal mesenteric lymphangioma that was initially detected incidentally in an asymptomatic patient with a subsequent sudden increase in size with resulting surrounding mass effect after 9 months and a spontaneous partial regression at surgical resection. Our case is the first reported case which outlines a period in the natural history and evolution of microcystic mesenteric lymphangioma, illustrating the sudden enlargement likely attributable to spontaneous and self-limiting haemorrhage and subsequent partial regression at surgical resection. We thenceforth propose a possible management algorithm for adult patients with mesenteric lymphangiomas.

Buried coin in the gastric mucosa.

A 29-year-old man presented to the Accident and Emergency department with abdominal cramping following ingestion of a 50 p coin 2½ weeks prior to presentation. He had not observed it pass in his stools. An abdominal radiograph confirmed the presence of the 50 p coin in his stomach. Subsequently, he had an oesophagogastroduodenoscopy (OGD) performed with a failure to visualise the coin. 1½ weeks later, he returned to the department as he was still unable to observe its passing in his stools. A repeated abdominal radiograph and a CT of the abdomen and pelvis revealed that the coin was still in his stomach. A second OGD was performed once again with a failure to visualise the coin. It appeared that the coin had migrated into his gastric mucosa.

Returning Aircrew with Chronic Hepatitis B Back to Flying While on Nucleos(t)ide Analogues.

BACKGROUND: Chronic Hepatitis B (CHB) remains a major cause of morbidity in several parts of the world. Aircrew with immune-active hepatitis are unfit for flying duties due to the risk of acute hepatic decompensation; those who have begun on treatment are generally also disqualified from flying duties due to the potential side effects of antiviral treatment. As treatment endpoints for nucleos(t)ide analogues (NUC) are typically achieved after prolonged therapy, aircrew treated for CHB may be subjected to an extended period of flying restriction.METHODS: We present a retrospective case series of seven aircrew who were returned to flying duties while on varying combinations of NUC for the treatment of CHB. All seven aircrew were comanaged by the flight surgeon and hepatologist, reviewed by a panel of flight surgeons, and had achieved normalized liver function tests prior to resumption of flying duties; two out of the seven aircrew had detectable serum Hepatitis B virus (HBV) DNA when reinstated back to flying duties. Only one aircrew member experienced side effects from the NUC treatment. This was promptly evaluated and managed prior to resumption of flying duties to ensure flight safety.DISCUSSION: Aircrew with CHB infection can be safely allowed back to flying duties, especially when their conditions have been well controlled via treatment with any of the NUC regimes. While there are limited studies evaluating the use of NUC in aircrew performing flight duties, our study has shown that NUC are generally well tolerated and have a good safety profile which is compatible with flying duties.Tan D, Kwan C, Tan BBC, Gan WH. Returning aircrew with chronic Hepatitis B back to flying while on nucleos(t)ide analogues. Aerosp Med Hum Perform. 2019; 90(1):37-42.

Report of a Novel Case of Anaplastic Olfactory Groove Meningioma and Its Methylation Subtype.

We report a novel case of a World Health Organization grade 3 anaplastic meningioma arising from the olfactory groove in an 83-year-old woman. Molecular and methylation profiling confirm this lesion to be an NF2 subtype, methylation class intermediate type B meningioma. As most meningiomas in this location are indolent SMO subtype lesions, our report suggests that even though rare, aggressive NF2 subtype meningiomas can also occur along the midline anterior skull base.