Clinical efficacy and long-term immunogenicity of an early triple dose regimen of SARS-CoV-2 mRNA vaccination in cancer patients.

INTRODUCTION: Three doses of SARS-CoV-2 mRNA vaccines have been recommended for cancer patients to reduce the risk of severe disease. Anti-neoplastic treatment, such as chemotherapy, may affect long-term vaccine immunogenicity. METHOD: Patients with solid or haematological cancer were recruited from 2 hospitals between July 2021 and March 2022. Humoral response was evaluated using GenScript cPASS surrogate virus neutralisation assays. Clinical outcomes were obtained from medical records and national mandatory-reporting databases. RESULTS: A total of 273 patients were recruited, with 40 having haematological malignancies and the rest solid tumours. Among the participants, 204 (74.7%) were receiving active cancer therapy, including 98 (35.9%) undergoing systemic chemotherapy and the rest targeted therapy or immunotherapy. All patients were seronegative at baseline. Seroconversion rates after receiving 1, 2 and 3 doses of SARS-CoV-2 mRNA vaccination were 35.2%, 79.4% and 92.4%, respectively. After 3 doses, patients on active treatment for haematological malignancies had lower antibodies (57.3%±46.2) when compared to patients on immunotherapy (94.1%±9.56, P<0.05) and chemotherapy (92.8%±18.1, P<0.05). SARS-CoV-2 infection was reported in 77 (28.2%) patients, of which 18 were severe. No patient receiving a third dose within 90 days of the second dose experienced severe infection. CONCLUSION: This study demonstrates the benefit of early administration of the third dose among cancer patients.

Acute Ischemic Stroke During the Convalescent Phase of Asymptomatic COVID-2019 Infection in Men.

Importance: Acute ischemic stroke (AIS) is a known neurological complication in patients with respiratory symptoms of COVID-19 infection. However, AIS has not been described as a late sequelae in patients without respiratory symptoms of COVID-19. Objective: To assess AIS experienced by adults 50 years or younger in the convalescent phase of asymptomatic COVID-19 infection. Design, Setting, and Participants: This case series prospectively identified consecutive male patients who received care for AIS from public health hospitals in Singapore between May 21, 2020, and October 14, 2020. All of these patients had laboratory-confirmed asymptomatic COVID-19 infection based on a positive SARS-CoV-2 serological (antibodies) test result. These patients were individuals from South Asian countries (India and Bangladesh) who were working in Singapore and living in dormitories. The total number of COVID-19 cases (54 485) in the worker dormitory population was the population at risk. Patients with ongoing respiratory symptoms or positive SARS-CoV-2 serological test results confirmed through reverse transcriptase-polymerase chain reaction nasopharyngeal swabs were excluded. Main Outcomes and Measures: Clinical course, imaging, and laboratory findings were retrieved from the electronic medical records of each participating hospital. The incidence rate of AIS in the case series was compared with that of a historical age-, sex-, and ethnicity-matched national cohort. Results: A total of 18 male patients, with a median (range) age of 41 (35-50) years and South Asian ethnicity, were included. The median (range) time from a positive serological test result to AIS was 54.5 (0-130) days. The median (range) National Institutes of Health Stroke Scale score was 5 (1-25). Ten patients (56%) presented with a large vessel occlusion, of whom 6 patients underwent intravenous thrombolysis and/or endovascular therapy. Only 3 patients (17%) had a possible cardiac source of embolus. The estimated annual incidence rate of AIS was 82.6 cases per 100 000 people in this study compared with 38.2 cases per 100 000 people in the historical age-, sex-, and ethnicity-matched cohort (rate ratio, 2.16; 95% CI, 1.36-3.48; P < .001). Conclusions and Relevance: This case series suggests that the risk for AIS is higher in adults 50 years or younger during the convalescent period of a COVID-19 infection without respiratory symptoms. Acute ischemic stroke could be part of the next wave of complications of COVID-19, and stroke units should be on alert and use serological testing, especially in younger patients or in the absence of traditional risk factors.

Soft Tissue Reconstruction of Complete Circumferential Defects of the Upper Extremity.

BACKGROUND: Upper extremity soft tissue defects with complete circumferential involvement are not common. Coupled with the unique anatomy of the upper extremity, the underlying etiology of such circumferential soft tissue defects represent additional reconstructive challenges that require treatment to be tailored to both the patient and the wound. The aim of this study is to review the various options for soft tissue reconstruction of complete circumferential defects in the upper extremity. METHODS: A literature review of PubMed and MEDLINE up to December 2016 was performed. The current study focuses on forearm and arm defects from the level at or proximal to the wrist and were assessed based on Tajima's classification (J Trauma 1974). Data reviewed for analysis included patient demographics, causality, defect size, reconstructive technique(s) employed, and postoperative follow-up and functional outcomes (when available). RESULTS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 14 unique articles were identified for a total of 50 patients (mean=28.1 years). Underlying etiologies varied from extensive thermal or electrical burns to high impact trauma leading to degloving or avulsion, crush injuries, or even occur iatrogenically after tumor extirpation or extensive debridement. Treatment options ranged from the application of negative pressure wound dressings to the opposite end of the spectrum in hand transplantation. CONCLUSIONS: With the evolution of reconstructive techniques over time, the extent of functional and aesthetic rehabilitation of these complex upper extremity injuries has also improved. The proposed management algorithm comprehensively addresses the inherent challenges associated with these complex cases.

Early experience in single-site laparoscopic cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy is currently the gold standard for removal of symptomatic gallbladders. The push in recent years toward reducing the number of ports required to perform this surgery has led to the development of single-incision laparoscopic cholecystectomy (SILC). We report our early experience with SILC and assess its feasibility and safety. METHODS: A prospective study was conducted of the first 100 patients who presented with complaints of biliary colic and underwent laparoscopic cholecystectomy via the single-port technique at our institution. SILC was performed via a single-port device such as a flexible umbilical port that could accommodate up to three surgical instruments. The port was inserted into a transumbilical incision around 15-20 mm long. Data on operative details and postoperative outcomes were collected and evaluated. RESULTS: The mean operation time was 67.8 minutes. Six patients needed conversion, requiring extra 5-mm ports to complete the surgery. No serious intraoperative complications, such as bile duct injury or bile leakage, were encountered. Cosmesis from the scar hidden within the umbilical fold was excellent. CONCLUSION: Our initial results of single-port laparoscopic cholecystectomy are promising, with no complications being seen in this early series. However, the drawbacks include the higher cost of equipment and a steeper learning curve. Further evaluation is required to assess the risks and benefits of this approach when compared with conventional laparoscopic cholecystectomy.

Type 1 Bland Sutton colonic atresia complicated by fetalis hydrops in a premature neonate.

Colonic atresia (CA) is an unusual cause of neonatal intestinal obstruction where a section of the colon has failed to form, leading to blockage or absence. A premature baby was delivered at 32 weeks of gestation via caesarian section following fetal distress. She was grossly oedematous and diagnosed with severe fetalis hydrops secondary to anaemia. She was resuscitated and stabilized. On the sixth day of life, the neonate's abdomen became severely distended with billous vomiting and failure to pass meconium. We suspected intestinal obstruction and performed an omnipaque enema which revealed dilated small bowel loops and a bowel atresia. Exploratory laparotomy confirmed a Type 1 Bland Sutton CA with mucosal web. An end colostomy was successfully performed and uneventful. In our case report, we describe a rare occurrence of postnatally diagnosed CA, complicated by fetalis hydrops and anaemia.

Simulation in surgery: a review.

The ability to acquire surgical skills requires consistent practice, and evidence suggests that many of these technical skills can be learnt away from the operating theatre. The aim of this review article is to discuss the importance of surgical simulation today and its various types, exploring the effectiveness of simulation in the clinical setting and its challenges for the future. Surgical simulation offers the opportunity for trainees to practise their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance. This enables better patient safety and standards of care. Surgical simulators can be divided into organic or inorganic simulators. Organic simulators, consisting of live animal and fresh human cadaver models, are considered to be of high-fidelity. Inorganic simulators comprise virtual reality simulators and synthetic bench models. Current evidence suggests that skills acquired through training with simulators, positively transfers to the clinical setting and improves operative outcome. The major challenge for the future revolves around understanding the value of this new technology and developing an educational curriculum that can incorporate surgical simulators.