Thoracic outlet syndrome: single-center experience on the transaxillary approach with the aid of the TRIMANO Arthrex arm.

Thoracic outlet syndrome (TOS) is a pathology caused by compression on the neurovascular bundle by the first rib. The treatment of TOS is conservative management by analgesia and physiotherapy; however, if there is no response to conservative treatment, surgery is indicated through thoracic outlet decompression by first rib resection. Several surgical techniques are available, including supraclavicular, transaxillary, and transthoracic first rib resection approaches. The transaxillary approach provides better visualization on the neurovascular bundle and, thus, is sometimes the preferred method of treatment. The transaxillary approach has been criticized due to safety concerns regarding the neural bundle during surgical exposure. During surgery, hyperabduction of the arm is obtained by a surgical assistant, and the quality of exposure can decrease with time, or an iatrogenic injury to the neural bundle (brachial plexus) can occur from the hyperabduction. The use of the TRIMANO Arthrex arm can help in the exposure, instead of a surgical aide, because it provides stable exposure and visualization for the operating surgeon. We performed a retrospective review of patients undergoing transaxillary first rib resection using the TRIMANO Arthrex arm between June 2021 and December 2022. During installation, the patient is placed in the lateral decubitus position and the TRIMANO Arthrex arm is fixed at the operating table at the height of the patient's shoulder. Thus, the surgical aide can help the surgeon during the surgery, rather than placing the arm into and out of hyperabduction. The use of hyperabduction is limited to 15 minutes, followed by 5 minutes of rest, to decrease the tension on the neurovascular bundle. The surgeon then performs the transaxillary approach and systematically resects the first rib, scalene muscles, and subclavian muscles. By this approach, the inferior brachial plexus is also lysed. In our review, we found a total of 15 procedures of first rib resection for the treatment of TOS with the aid of the TRIMANO Arthrex arm that met our inclusion criteria. All procedures were performed by the same surgeon. None of the patients sustained an injury to the neurovascular bundle. All the patients had an uneventful hospital stay postoperatively, and none presented with a hematoma. The drain placed during surgery was removed on postoperative day 2. All patients had at least one radiograph taken during their hospitalization, with no pleural effusion or pneumothorax found. The use of the TRIMANO Arthrex arm is safe and can help in the positioning and installation of the patients undergoing transaxillary first rib resection. It decreases the number of surgical assistants and offers great comfort for the surgeon because it provides stable exposure for the operating surgeon.

The Effect of the COVID-19 Crisis on Vascular Surgery Training in France.

In France, since March 2020, the healthcare system has experienced a significant decrease or even suspension of surgical activity and admissions due to the coronavirus disease 2019 (COVID-19). This activity is essential to the acquisition of technical skills for all trainees enrolled in the Vascular and Endovascular Surgery Training Program either as residents or fellows. The crisis may have affected the training of vascular surgery trainees. We describe the consequences and effects of the COVID-19 crisis on the training of vascular surgery trainees. A cross-sectional study using an anonymous survey of 12 items was sent to all surgeons in training, registered at the French College of Vascular and Endovascular Surgery (CFCVE). Responses were collected between July and November 2021. Fifty-two responses were collected from trainees (residents=48%; fellows=52%), seven of who contracted COVID-19 disease. The crisis affected their scheduled and emergency surgical activities, in 96% and 77%, respectively. Thirty-one percent of responders stopped all activity, for an average of 1.5 months. Eighteen percent of responders were reassigned to other services (emergency department, ICU, vascular access unit, etc...) for an average duration of two months. Sixty-seven percent of responders believe that their level of surgical training was affected due to the crisis. Fifty-six percent of responders do not think they have achieved their training objectives (55% for fellows, 65% for senior vascular surgery residents (4th, 5th, and 6th year), and 92% for junior vascular surgery residents (year 1, 2, and 3), contributing that to the COVID-19 crisis and its effect on the flow of patients during the crisis. Additional training time (> 3 months) and the utilization of simulation training to reduce the gap produced by the COVID-19 crisis were favored in 60% and 73% of cases respectively. The COVID-19 health crisis has affected the training of surgical trainees in vascular and endovascular surgery in France. Endovascular and vascular surgical French students in training are waiting now, for additional educational proposals, allowing them to make up for their lack of practice.

Direct Acting Oral Anticoagulants Following Gastrointestinal Tract Surgery.

ABSTRACT: Direct-acting oral anticoagulants (DOACs) vary in bioavailability and sites of absorption in the gastrointestinal tract (GIT). Data on DOAC use after major GIT surgery are limited. The aim of this case series was to report the impact of surgical resection or bypass of the GIT on rivaroxaban and apixaban peak plasma concentrations. This was a case series of patients who received rivaroxaban or apixaban after GIT surgery, during the period of July 1, 2019, to December 31, 2020. Peak plasma concentrations of rivaroxaban and apixaban were assessed for the expected concentrations. Of the 27 assessed patients, 18 (66.7%) received rivaroxaban, and 9 (33.3%) received apixaban. After rivaroxaban therapy, 4 of 5 patients (80%) who underwent gastrectomy, and 3 of 3 patients (100%) who underwent duodenum and proximal jejunum exclusion had peak plasma concentrations of rivaroxaban lower than the effective range, whereas 11 of 11 patients (100%) who underwent distal bowel or ileostomy had peak rivaroxaban plasma within the effective range. After apixaban therapy, 5 of 6 patients (83.3%) who underwent total or partial gastrectomy achieved effective peak concentrations. All the patients who underwent proximal and distal bowel resection or bypass had peak concentrations of apixaban within the effective range. In conclusion, surgical resection or bypass of the upper GIT could affect DOAC absorption and subsequently peak plasma concentrations. This effect was more observed among rivaroxaban recipients. An injectable anticoagulant or vitamin K antagonist may be preferred if DOAC concentrations cannot be measured after GIT surgery.

A Hospital-based Study of the Prevalence and Usage of Complementary and Alternative Medicine Among Saudi Psychiatric Patients.

Introduction Complementary and alternative medicine (CAM) therapies, used singularly or in combination with more conventional therapies, are routinely used by citizens of the Kingdom of Saudi Arabia (KSA) for medical care or seeking wellness. However, the prevalence of CAM therapies among Saudi psychiatric patients is not yet documented. To better understand the importance of CAM in today's medical field, particularly within the KSA and for psychiatric patients, this descriptive study aims to characterize the use of CAM therapies by a sample of psychiatric patients in the KSA. Methods This cross-sectional hospital-based study describes the use of CAM therapies by Saudi psychiatric patients being treated at one of the largest government hospitals in the KSA. Using a pretested questionnaire, adult psychiatric patients waiting for their appointment or during their stay at a government hospital in Riyadh were interviewed regarding the use of CAM therapies after agreeing to participate. Results Forty-five adult psychiatric patients agreed to participate in this study. The average age of the participants in the study was 35. Of the participants, 62% were females, 91.1% were outpatients, and 44.4% were diagnosed with depression. Moreover, 82.2% of the participants reported using one or more types of CAM therapies within the past year to address mental illness. Of those who used CAM therapies, 62.2% did so to improve their quality of life; 59.5% did so for treatment, supportive treatment, or both, and 54.1% used CAM therapies to help control symptoms. The most frequent CAM therapies used by psychiatric patients were spiritual therapies such as Quran recitation; body therapies, mainly exercise; and mind therapies, mainly relaxation techniques. These CAM therapies were used mainly as treatments or supportive treatments for depression. Most of the participants who used CAM therapies were satisfied with the use of these therapies (75.7%). Finally, 45.9% of the participants had not discussed the use of CAM therapies with their doctors, primarily because of their reluctance to share private information, especially spiritual matters, with the treating physicians. Conclusions The study results suggest a high prevalence of CAM therapy use among Saudi adult psychiatric patients, as well as a high level of satisfaction with such therapies. However, since about half of the patients had not discussed the use of CAM therapies with their physicians, and since some of the CAM therapies may cause unfavorable interactions when used alongside certain medications or medical interventions, healthcare providers should be diligent about inquiring of their psychiatric patients any use of CAM therapies, not only during the initial visit but also during the follow-up visits as well.

The interplay between academic performance and quality of life among preclinical students.

BACKGROUND: The high academic performance of medical students greatly influences their professional competence in long term career. Meanwhile, medical students greatly demand procuring a good quality of life that can help them sustain their medical career. This study examines validity and reliability of the tool among preclinical students and testifies the influence of their scholastic performance along with gender and academic year on their quality of life. METHODS: A cross sectional study was conducted by distributing World Health Organization Quality of Life, WHOQOL-BREF, survey among medical students of year one to three at Alfaisal University. For validity, item discriminate validity(IDV) and confirmatory factor analysis were measured and for reliability, Cronbach's α test and internal item consistency(IIC) were examined. The association of GPA, gender and academic year with all major domains was drawn using Pearson's correlation, independent samples t-test and one-way ANOVA, respectively. RESULTS: A total of 335 preclinical students have responded to this questionnaire. The construct has demonstrated an adequate validity and good reliability. The high academic performance of students positively correlated with physical (r = 0.23, p < 0.001), psychological health (r = 0.29, p < 0.001), social relations (r = 0.11, p = 0.03) and environment (r = 0.23, p < 0.001). Male student scored higher than female peers in physical and psychological health. DISCUSSION: This study has identified a direct relationship between the academic performance of preclinical students and their quality of life. CONCLUSION: The WHOQOL-BREF is a valid and reliable tool among preclinical students and the positive direction of high academic performance with greater QOL suggests that academic achievers procure higher satisfaction and poor achievers need a special attention for the improvement of their quality of life.