Risk Factors for Readmission in Excisional Hemorrhoidectomy at a Tertiary Teaching Center.

INTRODUCTION: Unplanned readmission is often seen after excisional hemorrhoidectomy. This study aims to explore associations between patient and operative factors, and readmission rates in excisional hemorrhoidectomy. METHODS: We performed a retrospective analysis of all excisional hemorrhoidectomies performed in Capital and Coast District Health Board for an 8-year period from January 1, 2012, to December 31, 2020. The primary outcome measure was 30-day readmissions post hemorrhoidectomy. Univariate and multivariable logistic regression analyses were performed to identify risk factors to readmisson. A decision tree model was designed to further look at the interactions between risk factors. RESULTS: There were a total 370 patients undergoing 389 excisional hemorrhoidectomies over the study period. There were 47 (12.1%) readmissions. The commonest reasons for readmission were pain (48.9%) and bleeding (38%). 17% of readmitted patients required operative intervention. Readmission was associated with the use of advanced energy devices (OR 2.21; P = 0.027). Trainees were more likely to use advance energy devices than consultants (51% versus 38%, P = 0.010). Consultants were involved in more procedures requiring a removal of 3 pedicles or more than trainees (43% versus 30%, P = 0.010). A decision tree model predicts readmission based on primary operator experience, age, advanced energy device use, and patient ethnicity. CONCLUSIONS: Two risk models are presented showing the complex relationship between the factors associated with readmission after hemorrhoidectomy. Advanced energy device use was associated with an increased risk of readmission after hemorrhoidectomy in our population. Future work could involve targeted interventions to patients at increased risk of readmission such as preprocedural and postprocedural information, early interval follow-up and targeted analgesia regimes.

Idiopathic sudden sensorineural hearing loss: A critique on corticosteroid therapy.

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a condition affecting 5-30 per 100,000 individuals with the potential to significantly reduce one's quality of life. The true incidence of this condition is not known because it often goes undiagnosed and/or recovers within a few days. ISSNHL is defined as a ≥30 dB loss of hearing over 3 consecutive audiometric octaves within 3 days with no known cause. The disorder is typically unilateral and most of the cases spontaneously recover to functional hearing within 30 days. High frequency losses, ageing, and vertigo are associated with a poorer prognosis. Multiple causes of ISSNHL have been postulated and the most common are vascular obstruction, viral infection, or labyrinthine membrane breaks. Corticosteroids are the standard treatment option but this practice is not without opposition. Post mortem analyses of temporal bones of ISSNHL cases have been inconclusive. This report analyzed ISSNHL studies administering corticosteroids that met strict inclusion criteria and identified a number of methodologic shortcomings that compromise the interpretation of results. We discuss the issues and conclude that the data do not support present treatment practices. The current status on ISSNHL calls for a multi-institutional, randomized, double-blind trial with validated outcome measures to provide science-based treatment guidance.

COVID-19 response by New Zealand general surgical departments in tertiary metropolitan hospitals.

BACKGROUND: Worldwide, coronavirus disease 2019 (COVID-19) has significantly challenged the delivery of healthcare. New Zealand (NZ) faced similar potential challenges despite being geographically isolated. Given the rapid change in the COVID-19 pandemic, hospitals in NZ were tasked with formulating their own COVID-19 responses based on the Ministry of Health's (MoH) recommendations. METHODS: This paper evaluates how six metropolitan general surgical departments in NZ had responded to COVID-19 in terms of changes made to rosters, theatres, clinics, acute admissions as well as additional measures taken to reduce the risk of staff exposure. It also explores how NZ fared in comparison with international guidelines and recommendations. Data from each centre were provided by an appointed clinician. RESULTS: All centres had adapted new rosters and a restructuring of teams. Handovers, multidisciplinary team meetings and educational sessions were held virtually. Different strategies were implemented to ration hospital resources and reduce the risk of staff exposure. Non-urgent operations, endoscopies and clinics were deferred with allocation of dedicated COVID-19 operating theatres. Potential COVID-19 suspects were screened prior to admission and treated separately. Various admission and imaging pathways were utilised to increase efficiency. CONCLUSION: General surgical departments in NZ had implemented a comprehensive COVID-19 response but there is room to work towards a more unified national response. Our analysis shows that these centres across NZ had taken a similar approach which was aligned with international practices.

The all-inside all-suture technique demonstrated better biomechanical behaviors in meniscus radial tear repair.

PURPOSE: The purpose of this study was to evaluate the effectiveness of three constructs and techniques for repair of radial tears of the meniscus. METHODS: Thirty fresh frozen porcine menisci were divided equally into three groups consisting of (1) inside-out repair group, (2) a commonly used all-inside suture with anchor hybrid repair construct (AISAH) (Meniscal Cinch™), and (3) an all-inside all-suture repair construct (AIAS) (Knee Scorpion™). Radial tears were created and repaired and then the menisci were secured to the materials testing machine. Both cyclic loading and load-to-failure testing were performed. The displacement, stiffness, response to cyclic loading, and mode of failure were recorded and analyzed statistically. RESULTS: The displacement after cyclic loading (DACL) of the Cinch repair construct group was significantly higher than that of the inside-out repair construct group (p = 0.000) and AIAS repair construct (p = 0.000). There was not a statistical difference of DACL between inside-out and AIAS groups (n.s.). The inside-out construct failed at a significantly higher load than the AISAH repair construct (p = 0.000) and AIAS construct (p = 0.006). The AIAS construct failed at a significantly higher load than the AISAH repair construct (p = 0.009). The AIAS had a higher stiffness than AISAH (p = 0.047). The AIAS had a higher load at 3 mm protrusion than AISAH (p = 0.034). CONCLUSION: The AIAS repair construct had better biomechanical behaviors than AISAH construct and inside-out repair technique. Inside-out sutures and AIAS repair construct had similar biomechanical responses to cyclic loading. The AIAS can be used for meniscus tear surgical repair with less damage to peri-meniscus tissues.

Electric scooter injuries at Auckland City Hospital.

AIM: Since the introduction of shared electric scooters to Auckland in October 2018, there have been multiple reports of injuries. We aim to examine the pattern of injuries sustained while riding electric scooters in patients presenting to hospital. METHODS: We conducted a retrospective analysis of patients who presented to Auckland City Hospital Emergency Department (ED) between 15 October 2018 and 22 February 2019. Patients were firstly identified by ED staff and noted in a logbook, and secondly by searching the Trauma Registry database. Outcomes of interest were injuries, imaging, alcohol and helmet use, length of stay and interventions. RESULTS: There were 180 patients identified. The median length of stay was 4.0 hours, interquartile range (IQR) 18.4 hours. One-third of patients were admitted or transferred. Common injuries were contusions, abrasions and lacerations (65.6%), fractures (41.7%) and head injuries (17.2%). One in five patients (22.2%) required an operation. Only three patients wore a helmet. Of all patients, 23.3% had consumed alcohol, and of those with head injuries; 41.9% had consumed alcohol. CONCLUSION: This study highlights the significant number of electric scooter-related injuries, including severe head injuries. While the majority of presentations are categorised as minor trauma, these cases have placed additional demand on health system resources. This mode of transport would benefit from greater regulation, including a zero blood alcohol limit, night-time curfews, reduced speed limits and consideration of mandatory helmet use.

Management of acute sigmoid volvulus in a provincial centre-a 20-year experience.

AIM: At our institution there has been a long-standing early operative approach to large bowel volvulus as well as initial decompression with rigid sigmoidoscopy. The primary aim of this study was to investigate the safety and efficacy of this approach on reducing readmissions and complications. Secondary aims were to investigate the safety and efficacy of bedside rigid sigmoidoscopy in decompression of sigmoid volvulus and investigate the sensitivity of abdominal x-ray in the diagnosis of acute large bowel volvulus. METHOD: A retrospective study was conducted on all patients presenting with acute obstruction due to large bowel volvulus between 1 January 1998-1 January 2018. RESULTS: Thirty-four patients with acute sigmoid volvulus were identified that met the inclusion criteria with a median age of 81 years. The majority of patients 27/34 (79%) were booked for surgery on the first admission. Readmissions were reduced in the index operative group 1/20 (5%) vs the non-operative decompression group 3/4 (75%) RR 0.07 (CI 0.01-0.49 P=0.01). CONCLUSION: Early sigmoid colectomy was associated with low morbidity and found to be safe in the elderly, and the results suggest that early surgery is associated with reduced readmissions and a low complication rate, with index surgery preferable to urgent elective surgery. Rigid sigmoidoscopy is a safe method of decompression as a bridge to index surgery and was not associated with any complications in this series.

Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials.

OBJECTIVE: The aim of the study was to establish whether an inguinal neurectomy at the time of hernia repair would reduce the risk of postoperative pain for open tension-free sutured mesh repair. BACKGROUND: Inguinal hernia repair is a common operative procedure. The development of postoperative pain is uncommon, but at times debilitating. The role of inguinal neurectomy is currently unknown, with no single large study available, and previous reviews included only a few heterogeneous studies. METHODS: Relevant randomized trials were identified from searches of MEDLINE, EMBASE, and EBM Review databases until October 2014. Meta-analysis was performed based on Cochrane Methods using RevMan v5.3 software. Pain, pain scores, sensory changes, and complications over short (half to <3 months), mid (3 to <12 mo), and long term (≥12 mo) were recorded. RESULTS: All included studies performed Lichtenstein hernia repair. Eleven studies on 1031 patients showed significant reduction in pain with neurectomy for short (RR = 0.61, 0.40-0.93) and midterm (RR = 0.30, 0.20-0.46), but not for long term (RR = 0.50, 0.25-1.01). Three studies (270 patients) showed significantly reduced short-term pain (RR = 0.69, 0.52-0.90). No studies included genitofemoral neurectomy. Rates of hematoma, infection, urinary retention, and recurrence were not different between groups. CONCLUSIONS: Routine ilioinguinal neurectomy during Lichtenstein-type herniorrhaphy seems to be a safe and effective method to reduce pain in the short and midterm, but may have little long-term impact. Iliohypogastric neurectomy seems to reduce pain in at least the short term.

Quality of Life in Vestibular Schwannoma Patients Managed by Surgical or Conservative Approaches.

OBJECTIVE: The aim of our study was to assess quality of life (QOL) among patients who underwent microsurgical excision of vestibular schwannoma (VS) compared with those managed conservatively. STUDY DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: There was a total sample population of 376 patients diagnosed with a unilateral VS. INTERVENTION: A total of 223 patients with unilateral VS returned the mailed questionnaires. These were then divided into two groups-78 that had undergone microsurgical excision and 145 that were managed conservatively. Subgroups within these primary groups were created for analysis. MAIN OUTCOME MEASURE: The primary outcome measure was the Medical Outcomes Study 36 Items Short Form (SF-36). The Dizziness Handicap Inventory test, Hearing Handicap Inventory test, and Tinnitus Handicap Inventory were also used. RESULTS: The surgically managed group had a worse QOL when compared with the conservatively managed group using SF-36, significantly so in the domains of physical role limitation and social functioning. Trends were seen toward a better QOL in some domains in the subgroups of male patients and patients younger than 65 years. Worse QOL scores in the Tinnitus Handicap Inventory were seen in the subgroups with larger tumor size. Finally, on correlation analysis between all handicap inventories and SF-36, handicap due to disequilibrium had the strongest correlation with worsening of QOL. In SF-36, the vitality domain showed the greatest correlation with otologic handicap overall, whereas the role emotional domain showed the least. CONCLUSION: This study found that worse QOL scores for surgically managed versus conservatively managed VS patients are most significant in the areas of physical role limitation and social functioning. In some areas, patients who are male and younger report better QOL. Handicap due to disequilibrium seems to have the greatest negative impact on QOL. These factors should be considered when counseling patients regarding approach to VS, in the context of an experienced management program.

Cochlear implants to treat deafness caused by vestibular schwannomas.

OBJECTIVE: Rehabilitation of hearing is complicated in patients with profound bilateral hearing loss in the presence of sporadic vestibular schwannoma (VS) or neurofibromatosis 2 (NF2), especially if the tumor does not need to be removed. We present the outcome of patients who have had a cochlear implant in the tumor affected ear without removal of the primary tumor. DESIGN: This is a retrospective multicentre study investigating outcomes of cochlear implantation in profoundly deaf patients with vestibular schwannoma in the implanted ear. MATERIALS AND METHODS: Out of 11 implanted patients, 5 required no treatment for their tumor, whereas 6 had previously undergone radiotherapy. Nine patients experienced NF2, and 2 had unilateral VS in the only hearing ear. Postoperative hearing was assessed with open and closed set speech discrimination, including City University of New York (CUNY) in noise and Bamford, Kowal and Bench (BKB) sentence scores. RESULTS: Patients with untreated lesions experienced marked improvement in their BKB and CUNY scores in the implanted ear and were daily cochlear implant users. The improvement was less consistent in the patients who had radiotherapy where only 1 patient attained open set speech discrimination. CONCLUSION: Patients with unilateral VS (sporadic or those affected with NF2) whose tumor status was stable, benefited from cochlear implantation in their tumor-affected ear. Patients who had radiotherapy also benefited from CI, but their outcomes were variable.

Subscapularis repair with the suture shuttle loop technique.

Successful techniques for arthroscopic repair of subscapularis tendon tears have been previously described in the literature. Recommendations regarding portal placement, tissue mobilization, and suture passage have been published. We present a novel technique that uses a shuttle suture passed with the Viper suture passer (Arthrex, Naples, FL) through a standard anterior arthroscopy portal. The described technique easily passes a suture through the subscapularis tendon while the surgeon visualizes suture placement from the posterior portal.

Quantum interference of large organic molecules.

The wave nature of matter is a key ingredient of quantum physics and yet it defies our classical intuition. First proposed by Louis de Broglie a century ago, it has since been confirmed with a variety of particles from electrons up to molecules. Here we demonstrate new high-contrast quantum experiments with large and massive tailor-made organic molecules in a near-field interferometer. Our experiments prove the quantum wave nature and delocalization of compounds composed of up to 430 atoms, with a maximal size of up to 60 Å, masses up to m=6,910 AMU and de Broglie wavelengths down to λ(dB)=h/mv≃1 pm. We show that even complex systems, with more than 1,000 internal degrees of freedom, can be prepared in quantum states that are sufficiently well isolated from their environment to avoid decoherence and to show almost perfect coherence.

Synthesis of ruthenium carbonyl complexes with phosphine or substituted Cp ligands, and their activity in the catalytic deoxygenation of 1,2-propanediol.

A ruthenium hydride with a bulky tetra-substituted Cp ligand, (Cp(i)(Pr(4)))Ru(CO)(2)H (Cp(i)(Pr(4)) = C(5)(i-C(3)H(7))(4)H) was prepared from the reaction of Ru(3)(CO)(12) with 1,2,3,4-tetraisopropylcyclopentadiene. The molecular structure of (Cp(i)(Pr(4)))Ru(CO)(2)H was determined by X-ray crystallography. The ruthenium hydride complex (C(5)Bz(5))Ru(CO)(2)H (Bz = CH(2)Ph) was similarly prepared. The Ru-Ru bonded dimer, [(1,2,3-trimethylindenyl)Ru(CO)(2)](2), was produced from the reaction of 1,2,3-trimethylindene with Ru(3)(CO)(12), and protonation of this dimer with HOTf gives {[(1,2,3-trimethylindenyl)Ru(CO)(2)](2)-(mu-H)}(+)OTf (-). A series of ruthenium hydride complexes CpRu(CO)(L)H [L = P(OPh)(3), PCy(3), PMe(3), P(p-C(6)H(4)F)(3)] were prepared by reaction of Cp(CO)(2)RuH with added L. Protonation of (Cp(i)(Pr(4)))Ru(CO)(2)H, Cp*Ru(CO)(2)H, or CpRu(CO)[P-(OPh)(3)]H by HOTf at -80 degrees C led to equilibria with the cationic dihydrogen complexes, but H(2) was released at higher temperatures. Protonation of CpRu[P(OPh)(3)](2)H with HOTf gave an observable dihydrogen complex, {CpRu[P-(OPh)(3)](2)(eta(2)-H(2))}(+)OTf (-) that was converted at -20 degrees C to the dihydride complex {CpRu[P(OPh)(3)](2)(H)(2)}(+)OTf (-). These Ru complexes serve as catalyst precursors for the catalytic deoxygenation of 1,2-propanediol to give n-propanol. The catalytic reactions were carried out in sulfolane solvent with added HOTf under H(2) (750 psi) at 110 degrees C.

Axonal numbers in the greater auricular nerve: is there enough to go round?

HYPOTHESIS: Does the greater auricular nerve (GAN) have an appropriate number of myelinated axons for use as an interposition graft for the facial nerve? BACKGROUND: Previous studies have suggested that the GAN has a suitable cross-sectional and fascicular area for use as an interposition graft for the facial nerve. In this study, counts of myelinated axons in the GAN have been undertaken to assess, at a microscopic level, its suitability as such a graft. METHODS: Six GANs were examined, and the total myelinated axonal counts and axonal density per square millimeter of fascicular area were calculated. These counts were compared with previous studies on the facial nerve. RESULTS: Axonal density per square millimeter was comparable between greater auricular and facial nerves. However, there were significantly lower numbers of myelinated axons in the GAN compared with the published facial nerve data. CONCLUSION: The findings support the concept of "doubling over" the GAN to act as an appropriate interpositional facial nerve graft when there is a size mismatch between the two.

Estimation of atmospheric lifetimes of hydrofluorocarbons, hydrofluoroethers, and olefins by chlorine photolysis using gas-phase NMR spectroscopy.

An empirical correlation has been derived between accepted atmospheric lifetimes of a set of hydrofluorocarbons and hydrofluoroethers and relative rates of reaction with photolyzed chlorine in excess at ambient temperature. These kinetic systems were studied by nuclear magnetic resonance (NMR) spectroscopy in the gas phase, marking the first application of NMR spectroscopy to this field. The square of the Pearson coefficient R for the linear correlation between observed reaction rates and accepted atmospheric lifetimes was 0.87 for compounds of lifetime less than 20 years. The method was extended to the study of ethene and propene; the rate of reaction of propene was found to be 1.25 times that of ethene at 23 degrees C. The chief advantage of this method is its simplicity and reliance only on common tools and techniques of an industrial chemical laboratory.