Ambulatory Endoscopic Thyroidectomy via a Chest-Breast Approach Has an Acceptable Safety Profile for Thyroid Nodule.

Introduction: With the growing esthetic requirements, endoscopic thyroidectomy develops rapidly and is widely accepted by practitioners and patients to avoid the neck scar caused by open thyroidectomy. Although ambulatory open thyroidectomy is adopted by multiple medical centers, the safety and potential of ambulatory endoscopic thyroidectomy via a chest-breast approach (ETCBA) is poorly investigated. Material and Methods: Patients with thyroid nodules who received conventional or ambulatory ETCBA at Xiangya hospital, Central South University from January 2017 to June 2020 were retrospectively included. The incidence of postoperative complications, 30-days readmission rate, financial cost, duration of hospitalization, mental health were mainly investigated. Results: A total of 260 patients were included with 206 (79.2%) suffering from thyroid carcinoma, while 159 of 260 received ambulatory ETCBA. There was no statistically significant difference in the incidence of postoperative complications (P=0.249) or 30-days readmission rate (P=1.000). In addition, The mean economic cost of the ambulatory group had a 29.5% reduction compared with the conventional group (P<0.001). Meanwhile, the duration of hospitalization of the ambulatory group was also significantly shorter than the conventional group (P<0.001). Patients received ambulatory ETCBA showed a higher level of anxiety (P=0.041) and stress (P=0.016). Subgroup analyses showed consistent results among patients with thyroid cancer with a 12.9% higher complication incidence than the conventional ETCBA (P=0.068). Conclusion: Ambulatory ETCBA is as safe as conventional ETCBA for selective patients with thyroid nodules or thyroid cancer, however with significant economic benefits and shorter duration of hospitalization. Extra attention should be paid to manage the anxiety and stress of patients who received ambulatory ETCBA.

Vestibular Schwannoma Surgery: Outcome and Complications in Lateral Decubitus Position versus Semi-sitting Position-A Personal Learning Curve in a Series of 544 Cases over 3 Decades.

OBJECTIVE: To retrospectively evaluate influence of intraoperative positioning (semisitting vs. lateral decubitus) and surgeon's learning curve with regard to functional outcome of patients with vestibular schwannoma. METHODS: This study included 544 patients (median age 57 years) and spanned 3 decades: 1991-1999 (n = 103), 2000-2009 (n = 210), and 2010-2019 (n = 231). Surgery was performed in the lateral decubitus position in 318 patients and the semisitting position in 163 patients. Large T3 and T4 tumors were present in 77% of patients. RESULTS: Complete tumor removal was achieved in 94.3% of patients. A significant reduction in surgery duration and blood loss was observed over 3 decades for T3 (from 325 to 261 minutes, P < 0.001) and T4 (from 440 to 330 minutes, P < 0.001), but not for T1 and T2, tumors. The semisitting position diminished surgical time in T3 and T4 tumors by 1 more hour (P < 0.001). Over 3 decades, facial nerve outcome improved significantly from 59.8% House-Brackmann grade 1-2 in the first decade to 81.7% in the last decade (P < 0.001). Furthermore, hearing was preserved in 45.3%: 23.3% of patients in the first decade and 50.5% in the last decade (P = 0.03). However, neither facial nerve outcome nor hearing preservation significantly differed in patients operated on in the lateral decubitus versus the semisitting position. The most common complication was cerebrospinal fluid leak (6.1%) followed by hemorrhage (3.5%) and pulmonary embolism (2.2%). CONCLUSIONS: Follow-up over 3 decades illustrates a learning curve with significantly improved results. While the semisitting position accelerates the procedure and is associated with reduced blood loss, it does not significantly influence functional outcome.

Clinical and structural outcomes after arthroscopic rotator cuff repair: a comparison between suture bridge techniques with or without medial knot tying.

PURPOSE: To compare arthroscopic suture bridge (SB) techniques with medial tying to those without tying, considering clinical and structural outcomes. METHODS: We included 124 patients with rotator cuff tears after arthroscopic rotator cuff repair (ARCR). Fifty-three patients with clinical and structural evaluations 3, 12, and 24 months postoperatively were included and divided into 29 patients with medial tying (WMT group) and 24 without tying (WOMT group). Clinical outcomes comprised the University of California Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcomes were evaluated with magnetic resonance images (MRI) using Sugaya classifications. RESULTS: JOA and UCLA scores in the WMT and WOMT groups improved significantly from before surgery to 24 months after surgery (P < 0.01, respectively). No significant difference was noted between groups. No significant postoperative retears (Sugaya types 4 and 5) between WMT and WOMT groups were noted at 3 months (5 vs 3 cases), 12 months (6 vs 5 cases), and 24 months (7 vs 6 cases) postoperatively. Complete healing (Sugaya type 1) was noted at 3 months (8 vs 11 cases), 12 months (10 vs 10 cases), and 24 months (8 vs 13 cases, P = 0.024) postoperatively. Incomplete healing (Sugaya types 2 and 3) were noted at 3 months (16 vs 10 cases), 12 months (13 vs 9 cases), and 24 months (14 vs 5 cases, P = 0.024) postoperatively. CONCLUSION: Clinical outcomes for both techniques were comparable, but the number of incompletely healed tendons in SB with medial tying was significantly larger at 24 months after surgery. LEVEL OF EVIDENCE: This study is a level III, case-control study. CLINICAL RELEVANCE: This study revealed the influence of medial tying in rotator cuff repair.

Position of draining venous cannula in extracorporeal membrane oxygenation for respiratory and respiratory/circulatory support in adult patients.

Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with severe pulmonary and/or cardiac failure. Blood is drained from the venous system and pumped through a membrane oxygenator where it is oxygenated. For pulmonary support, the blood is returned to the patient via a vein (veno-venous ECMO) and for pulmonary/circulatory support it is returned via an artery (veno-arterial ECMO).Veno-venous ECMO can be performed either with a single dual-lumen cannula or with two separate single-lumen cannulas. If the latter is chosen, flow direction can either be from the inferior caval vein (IVC) to the right atrium or the opposite. Earlier research has shown that drainage from the IVC yields less recirculation and therefore the IVC to right atrium route has become the standard in most centers for veno-venous ECMO with two cannulas. However, recent research has shown that recirculation can be minimized using a multistage draining cannula in the optimal position inserted via the right internal jugular vein and with blood return to the femoral vein. The clinical results with this route are excellent.In veno-arterial ECMO the most common site for blood infusion is the femoral artery. If venous blood is drained from the IVC, the patient is at risk of developing a dual circulation (Harlequin syndrome, North-South syndrome, differential oxygenation) meaning a poor oxygenation of the upper part of the body, while the lower part has excellent oxygenation. By instead draining from the superior caval vein (SVC) via a multistage cannula inserted in the right internal jugular vein this risk is neutralized.In conclusion, the authors argue that draining blood from the SVC and right atrium via a multistage cannula inserted in the right internal jugular vein is equal or better than IVC drainage both in veno-venous two cannula ECMO and in veno-arterial ECMO with blood return to the femoral artery.

Positioning Patients Undergoing Orthopedic Procedures.

Positioning patients for orthopedic procedures can be a daunting experience for nurses because of the wide variety of orthopedic procedures and available positioners. Understanding what to use for a particular procedure can help perioperative nurses feel more confident and allow them to provide the safest patient care possible. This knowledge also helps avoid workflow delays because of missing or incorrect equipment. Educators or senior staff nurses can provide access to information and education that will help ensure that nurses provide efficient, safe care for patients undergoing orthopedic procedures. Training should begin in the employee orientation phase and be provided when new additions or modifications to positioning policies occur. The educator should validate staff member competency on a regular basis to help ensure the correct equipment is used and to disseminate knowledge regarding any changes or upgrades to positioners.

Úlceras por presión: cómo prevenirlas / Pressure ulcers: how to prevent them

Las úlceras por presión han constituido un problema para la salud en general a través del tiempo. La realidad es que son una preocupación para el cuidado de la salud y todos los profesionales son responsables de su prevención y tratamiento. Se requieren múltiples estrategias de intervención para evitar el daño de la piel; una de ellas, el manejo de las cargas sobre los tejidos blandos. La correcta elección de las superficies de apoyo, la adecuada redistribución de la presión especialmente en las prominencias óseas y un progresivo programa de movilización constituyen las bases para evitar la producción de las úlceras por presión. (AU)

Pressure ulcers (PU) have been as a health problem throughout time. The reality is that PU are a global health care concern and all the professionals need to be responsible for the prevention and treatment of them. Multiple intervention strategies are needed to avoid the skin breakdown. Managing loads on the skin and associated soft tissue is one of these strategies. Properly chosen support surfaces, adequate periodic pressure redistribution, protection of specially vulnerable bony prominences and a progressive program of joint mobilization are the basis to avoid PU production. (AU)

The efficacy and safety of the left lateral position for endoscopic retrograde cholangiopancreatography.

BACKGROUND/AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is typically performed in prone position. In cases of difficulty in prone position, ERCP can be performed in left lateral position. We aimed to evaluate the efficacy and safety of left lateral position for ERCP compared with those of prone position. PATIENTS AND METHODS: Between August 2015 and March 2016, a total of 62 patients with native papilla who underwent ERCP were randomly assigned to undergo the procedure in left lateral position (n = 31) or prone position (n = 31). The outcomes of procedures were compared between the two groups. RESULTS: There were no significant differences between the two groups in terms of the demographic data, indications for ERCP, comorbidities, anticoagulation agents, the types and doses of sedative agents, and procedural durations. The rates of technical success and adverse events were similar (96.8 and 40%, respectively, in left lateral group and 100 and 32.3%, respectively, in prone group). The rates of unintentional pancreatic duct (PD) cannulation and the acquisition of pancreatograms in left lateral group were significantly greater than those in prone group (9/30, 30.0% vs. 3/31, 9.7%, P = 0.046; 7/30, 23.3% vs. 1/31, 3.2%, P = 0.020, respectively). However, there was no significant difference in the rate of post-ERCP pancreatitis (6/30, 20% vs. 5/31, 16.1%, P = 0.694). CONCLUSION: The left lateral position for ERCP can be as effective and safe as prone position. Due to increased rates of unintended PD cannulation and contrast injection, the initial use of left lateral position may be limited to cases that exhibit difficulty in prone position.

Examination Under Anesthesia for Posterior Wall Acetabular Fracture A Survey of the OTA Membership.

OBJECTIVES: The purpose of this survey was to learn more about the indications, criteria, and methods surgeons use for performing examination under anesthesia (EUA) for "intermediate" sized posterior wall acetabular fractures (those involving 20% to 40% of the posterior wall) and to find what criteria are used to determine hip instability. METHODS: An 18 question survey was posted on the Ortho- paedic Trauma Association's website and was used to gather anonymous data from orthopaedic surgeons regarding their approach to the intermediate sized posterior wall fracture. RESULTS: Considerable variability existed among re- sponses to many of the questions asked. Based on the an - swers given to the survey, a consensus of 75% or more of respondents was found for the following: 1. Supine position for the examination (100%); 2. "Live" fluoroscopy is used during the examination (97%); 3. The AP and obturator oblique are the x-rays most frequently used (81% and 76%, respectively); 4. The hip is placed in flexion and adduction during the exam (100% and 84%, respectively); 5. Axial load is applied during the examination (90%); Finally, 6. instabil - ity is defined as subluxation on exam by most respondents (98%), and any perceived visible subluxation is what defines instability (88%). CONCLUSION: Most surgeons agreed with the following: 1. Supine is the position of choice for the examination; 2. "Live" fluoroscopy is used during the examination; 3. The AP and obturator oblique are the x-rays most frequently used; 4. The hip is placed in flexion and adduction during the exam; 5. Axial load is applied during the examination; and 6. Instability is defined as subluxation on exam.

Head Position in the Early Phase of Acute Ischemic Stroke: An International Survey of Current Practice.

BACKGROUND: Evidence to recommend a specific head position for patients in the early phase of acute ischemic stroke (AIS) is scarce. The aim of this study was to assess current head position practice for AIS patients among physicians from hospitals in different countries. METHODS: A cross-sectional survey research design was used; physicians who are part of a stroke research network were invited to participate by e-mail. Descriptive statistics were used. RESULTS: An invitation to participate was delivered to 298 doctors from 16 countries and 42.9% completed all survey questions. Participant responses were evenly divided in sitting up and lying flat position as the most usual at their hospital: 52.8% (95% confidence interval [CI], 43.7-61.0) of respondents preferred sitting up, whereas 47.2% (95% CI, 38.2-55.5) preferred lying flat; 53.9% (95% CI, 45.3-62.5) of participants answered that no written protocol specifying the indicated head position for stroke patients was available at their hospital or department, and 71% (95% CI, 63.2-78.9) recognized being uncertain about the best position for AIS patients. CONCLUSIONS: Common practice differs between physicians, and there is a lack of consensus about the best strategy regarding head position for AIS patients in many countries. An opportunity exists for a randomized trial to resolve this uncertainty and develop evidence-based consensus protocols to improve patient management and outcomes.

Elevated serum creatine kinase after neurosurgeries in lateral position with intraoperative neurophysiological monitoring is associated with OP duration, BMI and age.

OBJECTIVES: Elevated serum levels of creatine kinase (CK) reflect skeletal muscle injury, which may lead to renal dysfunction following surgery. High CK levels are known to occur after neurosurgical interventions, especially following lateral positioning, but a consensus on possible risk factors is still lacking. Here we investigate risk factors for postoperative CK excess in a patient population at high risk (lateral position) with a special focus on the influence of intraoperative neurophysiological monitoring (IONM), particularly Motor Evoked Potentials (MEPs). METHODS: We analyzed patient charts from elective surgeries in lateral position between 2010 and 2012 and where IONM was performed and where postoperative CK-levels were available. In these patients, the anesthesia regimen excluded muscle relaxants. Patient charts were reviewed retrospectively for patient characteristics, CK levels and indicators of renal dysfunction. The MEP response intensity was measured. These patients were compared to a matched (age, BMI, surgery duration) control group of patients operated with IONM, but operated in prone or supine position. RESULTS: We included 96 patients (55 female, mean age 50years). The maximal CK level (CKmax) occurred on postoperative days 2 or 3 (mean 1763U/L). In a multivariate linear regression model, log(CKmax) correlated positively with duration of surgery (p<0.001) and BMI (p=0.007), and negatively with age (p=0.007), but not with MEP response intensity (p=0.481). We did not observe impaired renal function. CONCLUSIONS: CK excess following neurosurgical procedures in lateral position correlated positively with duration of surgery and BMI and negatively with age. MEP stimulations of the muscles at risk did not cause further CK elevation. SIGNIFICANCE: In patients undergoing long neurosurgeries without muscle relaxants, we recommend special care regarding positioning and perioperative management.

Early skin-to-skin contact, rooming-in, and breastfeeding: a comparison of the 2004 and 2011 National Surveys in Taiwan.

OBJECTIVES: We examined progress in the practice of early skin-to-skin contact and rooming-in, and their association with breastfeeding, using national samples of postpartum women in the years 2004 and 2011 in Taiwan. METHODS: This study was a secondary data analysis using 2004 and 2011 national surveys of 12,201 and 12,405 postpartum women, respectively. RESULTS: More women had early skin-to-skin contact in 2011 than in 2004 (54.9% vs 20.6%, p < 0.001). Although fewer women practiced rooming-in in 2011 than in 2004 (33.8% vs 45.8%, p < 0.001), the percentage of women rooming-in for 24 hours improved from 6.1 percent to 22.7 percent from 2004 to 2011, and for rooming-in from 12 to less than 24 hours, the percentage improved from 4.3 percent to 10.9 percent (p < 0.001). The rate of breastfeeding increased by 50 percent during hospitalization (from 57.4% to 85.6%) and by 150 percent at 6 months postpartum (from 20.1% to 50.2%). After adjustment for background characteristics, women who had early skin-to-skin contact were more than twice as likely to breastfeed their infants during hospitalization, and about 1.2 times as likely to breastfeed at 6 months postpartum. The odds ratio for breastfeeding at 6 months generally increased as the duration of rooming-in increased in 2004 (OR ranged from 1.37 to 2.47). In 2011, only rooming-in for 12 to less than 24 hours (OR = 1.31) and 24 hours (OR = 1.98) daily significantly increased the odds ratio for breastfeeding at 6 months postpartum. CONCLUSIONS: Significant improvements in early skin-to-skin contact, the duration of rooming-in, and breastfeeding were observed in Taiwan. Early skin-to-skin contact and rooming-in for more than 12 hours were associated with increased chances for exclusive breastfeeding and breastfeeding at 6 months postpartum.

Nascer no Brasil: o retrato do nascimento na voz das mulheres / Born in Brazil: the birth of the picture in women's voice

Vídeo: Nascer no Brasil - O retrato do nascimento na voz das mulheres é o tema da série em DVD Nascer no Brasil. Depoimentos emocionantes de mulheres logo após o nascimento de seus filhos dão voz aos números da pesquisa Nascer no Brasil – Inquérito Nacional sobre Parto e Nascimento, estudo inédito coordenado pela Escola Nacional de Saúde Pública Sergio Arouca (Ensp/Fiocruz), que teve como objetivo conhecer os determinantes, a magnitude e os efeitos das intervenções obstétricas no parto, incluindo as cesarianas desnecessárias, assim como a motivação das mulheres pela escolha do parto. Vídeo: Parto, da violência obstétrica às boas práticas No Brasil, a chance de dar à luz sem intervenções durante o trabalho de parto é remota. Apenas 5 por cento das mulheres tiveram essa experiência, segundo a pesquisa Nascer no Brasil, coordenada pela Fiocruz. Muitos procedimentos passaram a ser usados de forma rotineira causando mais traumas do que benefícios. O vídeo de Bia Fioretti, coproduzido pela VideoSaúde Distribuidora da Fiocruz, aborda a realidade de nascer no Brasil e para qual direção caminhamos...

[Operative neurosurgery: personal view and historical backgrounds. 6. Positioning, instruments].

Important points of positioning and instruments at the time of performing microneurosurgery according to the traditional Zuerich school style were presented based on the experience of ca. 1,000 surgeries/year for around 13.5 years. Most of the instruments and equipment had been taken over from the time of Prof. Yasargil. Positioning: Three positions, supine, knee-elbow and siting position were almost all the positions, which we have used and special mention was directed to the sitting position. Around 1/3 of our surgeries were done in the sitting position. Its indication includes lesions not only in the posterior fossa, but in the parieto-occipital region and in the cervico-thoracal region down to the Th5. Good fixation of the head with Mayfield 3-pin-fixation apparatus with the use of one pin mostly around the medial root of the mastoid process (thickness of the bone and small amount of soft tissue) is of cardinal importance and prevention of excessive flexion (with the one-finger breadth between the chin and its underlying neck), so that strangulation of the tracheal tube and the jugular venous system can be avoided and also the below mentioned jugular compression maneuver can be done effectively. Basic knowledge of prevention of air embolism was pointed out: knowledge of usual anatomical entrance sites of the air (emissary veins, diploic veins, veins entering into the venous sinuses, venous plexus around the craniocervical junction etc.), detection of the air entrance sites by jugular compression and their sealing with tissue adhesives Tissucol. Endotidal CO2 value should be above 4.0 kPk. Importance of reclination of the position in case of further falling down of the CO2 value was emphasized. Special mention was made about the patent foramen ovale as a risk of air embolism. Advantages of the sitting position in the performance of supracerebellar infratentorial/transtentorial SCIT/SCTT approach and transvertebralis dural ring approach TVDRA were emphasized and the use of linear incision was stressed at the time of performance of all these surgeries including the posterior circulation revascularization, occipital artery-posterior cerebral artery/superior cerebellar artery OA-PCA/SCA bypass and occipital artery-posterior inferior cerebellar artery OA-PICA bypass. As for the operating microscope, importance of the eyepiece-lens assembly with mouthpiece was emphasized. Appropriate selection of this system enables surgery of long duration in a comfortable and non-tiring condition in terms of the arm length of the surgeon and his immediate reaction especially at the time of intraoperative premature rupture of an aneurysm or of minute delicate focusing at the time of microvascular suturing without withdrawal of one or both hands from the operative field for handling the operating microscope. An arm rest enables secure, effective, precise and tireless performance of microsurgery in every operating position, so that the use of height an adjustable oil pressure driven arm rest was presented along with a simply height adjustable and easily movable chair. As for the bipolar coagulator pincette, the followings were discussed: more than three different lengths of byonett forceps, each of three different tip-sizes, with isolated tips, dosis and method of coagulation. Practically no need of monopolar coagulation was pointed out. Suction tube also should have different length and size according to the depth and situations. Its vacuum power should be regulated also in accordance with changing situation in every stage of surgery. The vacuum power is regulated at surgeon's request by scrub nurses or circulating nurses, so that the surgeon can concentrate only on the precise maneuver of the tip of the suction tube. For the same reason, foot pedals for the bipolar coagulator, drilling and trepanation should be stepped by other than the surgeon, so that he can concentrate on the tip the of instrument for precise maneuvering. As tissue destruction apparatus, we prefer to use CUSA to laser, as the former enables preservation of blood vessels at the time of tissue destruction and suction by appropriate power application. Besides these, the followings items were discussed: scissors (blunt tips), Lyla retractor (variously tapered tips and fixation or holding at the other peripheral end), drilling (turning direction adjustable, cutting and diamond burr) etc.