Optimal Timing Of Surgery Research Articles

A prototype for on-site generation of chlorinated disinfectant for use in rural aqueducts

Sodium hypochlorite has significant potential as a sanitation solution in hard-to-reach areas. Few studies have investigated the optimal electrolysis parameters for its production with volumes greater than 10 L. This study evaluated sodium hypochlorite production through electrolysis in a 22-L prototype and identified the optimal operating parameters. Tests were performed using graphite electrodes with areas of 68.4 cm2 at the laboratory scale and 1 865.0 cm2 at the prototype scale. A design for experiments with different operating times, chloride concentrations, and electric current intensities was developed. The optimal operating time, sodium chloride concentration, and current intensity at the laboratory scale were 120 min, 150 g of chloride per liter, and 3 A, respectively, leading to the production of 5.02 g/L of the disinfectant with an energy efficiency of 12.21 mg of Cl2 per kilojoule. At the prototype scale, the maximum sodium hypochlorite concentration of 3.99 g of chloride per liter was achieved with an operating time of 120 min, a sodium chloride concentration of 100 g of chloride per liter, and a current intensity of 70 A, reaching an energy efficiency of 42.56 mg of Cl2 per kilojoule. In addition, this study evaluated the influences of the chloride concentration, current intensity, and operating time on the production of sodium hypochlorite at the two scales, and formulated the equations showing the trends of sodium hypochlorite production and energy efficiency in the electrochemical systems. The 22-L prototype model for production of this oxidizing substance is promising for disinfection of large volumes of water in areas that are difficult to access.

Optimal coordination of directional overcurrent relays and distance relays using different optimization algorithms

The focus of this study is on solving the coordination problem between distance relays (DISRs) and directional overcurrent relays (DOCRs), which is a complex nonlinear problem with various constraints. Ensuring proper coordination between DOCRs and distance relays is critical for maintaining the security of electrical networks. The primary objective of employing optimization algorithms is to determine the optimal operating time for zone-2 of distance relays, as well as the DOCRs setting, time dial setting (TDS), and pickup current (Ipickup). The optimization techniques must also guarantee that the primary and backup relays operate in sequence without any violation. To this end, both recent and well-established optimization algorithms are evaluated using an 8-bus network, with the aim of determining the DOCRs setting and the optimal operating time for zone-2 of distance relays. Furthermore, a comparative analysis of different optimization algorithms, including both traditional and recent techniques, is conducted.

What Factors Identified in Initial Osteoarthritis Management Are Associated With Poor Patient-reported Outcomes After THA? A Register-based Study.

Some patients report long-term pain or no improvement in health-related quality of life (HRQoL) or are dissatisfied after THA. However, factors associated with these poorer patient-reported outcomes after surgery are inconsistent and have typically been studied in the late phase of hip osteoarthritis (OA) among patients already eligible for surgery. Earlier identification of risk factors would provide time to address modifiable factors, helping to improve patients' pain, HRQoL, and satisfaction after surgery and reduce the burden on orthopaedic clinics by referring patients who are better prepared for surgery. We analyzed data from patients with hip OA referred to a first-line OA intervention program in primary healthcare at a stage when they had not been referred for THA, and asked: (1) What percentage of patients who proceed to THA report lack of improvement in pain, lack of improvement in HRQoL as measured by the EQ-5D, or are not satisfied with surgery 1 year after THA? (2) What associations exist between baseline factors at referral to this first-line OA intervention program and these poorer patient-reported outcomes 1 year after THA? We included 3411 patients with hip OA (mean age 67 ± 9 years, 63% [2160 of 3411] women) who had been referred for first-line OA interventions between 2008 and 2015 and subsequently underwent THA for OA. All patients were initially identified through the Swedish Osteoarthritis Register, which follows and evaluates patients in a standardized national first-line OA intervention program. Then, we identified those who were also registered in the Swedish Arthroplasty Register with a THA during the study period. We included only those with complete patient-reported outcome measures for pain, HRQoL, and satisfaction preoperatively and 1-year postoperatively, representing 78% (3411 of 4368) of patients, who had the same baseline characteristics as nonrespondents. Multiple logistic regression was used to assess the associations between 14 baseline factors and the aforementioned patient-reported outcomes of pain, HRQoL, and satisfaction 1 year after THA, adjusted for all included factors. Five percent (156 of 3411) of the study population lacked improvement in pain, 11% (385 of 3411) reported no improvement in HRQoL, and 10% (339 of 3411) reported they were not satisfied with surgery 1 year after THA. Charnley Class C (multiple-joint OA or another condition that affects the ability to walk) was associated with all outcomes: lack of improvement in pain (OR 1.84 [95% CI 1.24 to 2.71]; p = 0.002), lack of improvement in HRQoL (OR 1.83 [95% CI 1.42 to 2.36]; p < 0.001), and not being satisfied (OR 1.40 [95% CI 1.07 to 1.82]; p = 0.01). Older age was associated with a lack of improvement in pain (OR per year 1.03 [95% CI 1.01 to 1.05]; p = 0.02), lack of improvement in HRQoL (OR per year 1.04 [95% CI 1.03 to 1.06]; p < 0.001), and not being satisfied (OR per year 1.03 [95% CI 1.01 to 1.05]; p < 0.001). Depression was associated with a lack of improvement in pain (OR 1.54 [95% CI 1.00 to 2.35]; p = 0.050) and with not being satisfied (OR 1.50 [95% CI 1.11 to 2.04]; p = 0.01) but not with a lack of improvement in HRQoL (OR 1.04 [95% CI 0.76 to 1.43]; p = 0.79). Having four or more comorbidities was associated with a lack of improvement in HRQoL (OR 2.08 [95% CI 1.39 to 3.10]; p < 0.001) but not with a lack of improvement in pain and not being satisfied. The results of this study showed that older age, Charley Class C, and depression in patients with first-line OA interventions were risk factors associated with poorer outcomes regarding pain, HRQoL, and satisfaction after THA. Screening patients with hip OA for depression early in the disease course would provide increased time to optimize treatments and may contribute to better patient-reported pain, HRQoL, and satisfaction after future THA. Further research should focus on identifying the optimal time for surgery in patients with depression, as well as what targeted interventions for depression can improve outcome of surgery in these patients. Level III, therapeutic study.

Optimal timing of surgery for patients with infective endocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) is a disease associated with high risk of morbidity and mortality. Recent literature suggests that surgery during index hospitalization may be performed safely without increased risk of adverse clinical outcomes. However, risk associated with specific surgical timing during index hospitalization remains unclear. Purpose The purpose of this meta-analysis is to assess the association of early surgery with mortality in patients with IE. Methods We performed a literature search for studies reporting an association between early surgery and study endpoints. The primary endpoint was in-hospital mortality. The secondary endpoint was long-term mortality. Early surgery was defined as surgery within 14 days of admission. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results A total of 15 studies with 2491 participants (900 with early surgery vs 1591 with delayed surgery) were included. The mean duration of follow-up was 33 months (ranging between 6 to 66 months). Early surgery was not associated with increased risk of in-hospital or long-term mortality compared to delayed surgery (OR 1.08, 95% CI 0.80, 1.46; P=0.63; OR 1.12, 95% CI 0.68, 1.86; P=0.65). Heterogeneity was low: Chi2 = 7.85, I2 = 0%. Subgroup analysis by time to surgery demonstrated that early surgery was not associated with increased risk of in-hospital mortality for surgeries performed within 2 days, 7 days, or 14 days of hospitalization (OR 0.87, 95% CI 0.58, 1.32; P=0.51; OR 1.06, 95% CI 0.78, 1.43; P=0.72; OR 0.51, 95% CI 0.21, 1.23; P=0.13). Heterogeneity was low: Chi2 = 4.84, I2 = 0%. Conclusions Early surgery performed within 14 days of initial hospitalization is not associated with increased risk of in-hospital mortality or long-term mortality compared to delayed surgery.

Removal of Fe Impurity Ions from a Spent Vanadium Electrolyte Using Capacitive Deionization Based on Resin/Activated Carbon Composite Electrodes

Capacitive deionization (CDI) based on LSC-957 resin/carbon composite electrodes was used to remove Fe impurity ions from a spent vanadium electrolyte, which enabled simple and efficient regeneration of the electrolyte. The experiments conducted in this study demonstrated that 3:1 was the optimal mass ratio of LSC-957 resin to activated carbon for the preparation of the composite electrodes, and the optimal operating voltage and operating time were 0.9 V and 6 h, respectively. After five stages of CDI tandem treatment, the adsorption rate of Fe impurity ions was 86.84% and the loss rate of V was only 3.8%. The energy efficiency of the regenerated electrolyte was 84.49%, and its performance was significantly improved compared to the spent vanadium electrolyte. The adsorption process of composite electrodes was analyzed by kinetic and isothermal models’ fit, SEM-EDS, and FTIR. This work has provided an effective and novel method for removing impurity ions from a spent electrolyte.

Adding Fuel to the Fire: Infective Endocarditis and the Challenge of Cerebrovascular Complications

Infective endocarditis is a deadly disease and made more deadly by neurologic complications. We review the cerebrovascular complications of infective endocarditis and focus our discussion on medical and surgical management. While management of stroke in the setting of infective endocarditis differs from standard stroke treatment, mechanical thrombectomy has proven safe and successful. Optimal timing of cardiac surgery in the setting of stroke remains an area of debate, but additional observational studies continue to add more detail to the discussion. Cerebrovascular complications in the setting of infective endocarditis remain a high stakes clinical challenge. Timing of cardiac surgery in IE complicated by stroke exemplifies these dilemmas. While more studies have suggested that earlier cardiac surgery is likely safe for those with small ischemic infarcts, there remains a need for more data defining optimal timing of surgery in all forms of cerebrovascular involvement.

Early versus delayed surgery following neoadjuvant chemoradiation for esophageal cancer: a systematic review and meta-analysis.

Neoadjuvant chemoradiotherapy (nCRT) followed by surgery, is the mainstay of managing locally advanced esophageal cancer. However, the optimal timing of surgery after neoadjuvant therapy is not defined clearly. A systematic search of PubMed, Embase and Cochrane databases was conducted. 6-8weeks were used as a cut-off to define early and delayed surgery groups. Overall Survival (OS) was the primary outcome, whereas pathological complete resolution (pCR), R0 resection, anastomotic leak, perioperative mortality, pulmonary complications, and major complication (> Clavien-Dindo grade 2) rates were secondary outcomes. Cohort studies and national registry bases studies were analysed separately. Survival data were pooled as Hazard Ratio (HR) and the rest as Odds Ratio (OR). According to heterogeneity, fixed-effect or random-effect models were used. Twelve retrospective studies, one RCT, and six registry-based studies (13,600 participants) were included. Pooled analysis of cohort studies showed no difference in OS (HR 1.03, CI 0.91-1.16), pCR (OR 0.98, CI 0.80-1.20), R0 resection (OR 0.90, CI 0.55-I.45), mortality (OR 1.03, CI 0.59-1.77), pulmonary complications (OR 1.26, CI 0.97-1.64) or major complication rates (OR 1.29, CI 0.96-1.73). Delayed surgery led to increased leak (OR 1.48, CI 1.11-1.97). Analysis of registry studies showed that the delayed group had a better pCR rate (OR 1.12, CI 1.01-1.24), with no improvement in survival (HR 1.01, CI 0.92-1.10). Delayed surgery was associated with increased mortality (OR 1.35, CI 1.07-1.69) and major complication rate (OR 1.55, CI 1.20-2.01). Available RCT reported surgical outcomes only. National registry-based studies' analysis shows that delay in surgery is riskier and leads to higher mortality and major complication rates. Further, well-designed RCTs are required.

Updates to improve oncological results in rectal cancer

Background: Preoperative radiotherapy (RT) or chemoradiotherapy (CRT) followed by a total mesorectal excision (TME) has become the standard of care for locally advanced rectal cancer (LARC). The optimal timing of surgery after neoadjuvant CRT in LARC is still controversial. Aim of this study was to evaluate the effect of increasing time interval between the end of CRT and surgery on pathological outcomes.

Anatomy, Biomechanics and Treatment of Tibiofibular Syndesmosis Injuries

Syndesmosis injuries are quite common globally. Often occurs due to the rotation of the foot or excessive movement in either upward or downward directions at the ankle. These may lead to several injuries, leading to pain, swelling, instability, and a decrease in ankle function. Diagnosing syndesmosis injuries can be challenging since they might not be easily identified through X-rays or clinical examinations. Some other diagnostic approaches, including computed tomography scans or magnetic resonance techniques which can provide information regarding the severity of such injuries. The main treatment approach for syndesmosis injuries depends on how unstable or displaced the joints. Non-surgical treatment options involving immobilization and restrictions on weight-bearing activities can effectively manage minimally displaced injuries. However, surgical intervention with fixation through screws, suture buttons, or other devices is recommended for significantly displaced injuries. The optimal timing for surgery, preferred technique for fixation, and appropriate duration of fixation are still topics of debate requiring research. Generally speaking, though, most patients with syndesmosis injuries tend to have outcomes; however, there is a possibility that some patients may experience pain and stiffness in their ankle joint movements over time while others may develop arthritis or mal-union conditions.

Academic performance in children with pectus excavatum: a real-world research with propensity score matching.

The optimal timing of surgery for pectus excavatum (PE) is controversial. A large proportion of children will not undergo surgery before puberty. However, untimely surgery may lead to a decline in the children's social adaptation and competitiveness because the children have already developed psychological and physiological impairments due to PE at an early age. The study retrospectively compared the academic performance in PE children undergoing the Nuss procedure versus nonsurgical observation. This retrospective real-world research study included 480 PE patients with definite surgical indications, in whom it was first recommended that they undergo surgery between the ages of 6 and 12 years old. Academic performance was collected at baseline and 6 years later. A generalized linear regression was calculated to screen the factors affecting the performance. A propensity score matching (PSM) analysis was conducted to reduce the potential for confounding factors between surgical and nonsurgical PE patients. Haller index (HI) and pulmonary function were recognized as factors affecting baseline performance according to the generalized linear regression. For PE children with surgical indications, their academic performance significantly declined after 6 years of nonsurgical observation (52.1% ± 17.1% versus 58.3% ± 16.7%, p = 0.042). The academic performance in the surgery group was better than that in the nonsurgery group 6 years after PSM (60.7% ± 17.7% versus 52.1% ± 17.1%, p = 0.008). The severity of PE will affect the academic performance of children.For PE children with definite surgical indications between the ages of 6 and 12 years old, surgical intervention rather than nonsurgical observation is more conducive to the development of children's academic performance.

Modeling the process of biological deferrization of underground waters in contact loading of bioreactor

The conducted analysis of modern biotechnologies in the field of groundwater treatment showed that one of the development trends is the direction of biological iron removal, which has not only a long history and fundamentality of research into the physiology, ultrastructure and life mechanisms of ferrobacteria, but also a wide implementation of the method at water treatment plants in Europе, Australia, Canada, USA, Japan. The introduction of modern technological equipment at such stations calls for the need to forecast their work using methods of mathematical modeling of processes with their subsequent computer implementation. The work provides a brief analysis of existing mathematical models, most of which are based on the kinetics of enzymatic reactions and are presented as modifications of the Michaelis-Menten and Monod equations.&#x0D; Despite the large number of studies on this topic, until now there is no comprehensive model that would take into account all the processes that take place in the contact loading of bioreactors, in contrast to the physicochemical mechanisms in the filtering process, for which modern multicomponent mathematical models have been developed.&#x0D; The aim of the work is to development of a mathematical model of the kinetics of the process of biological iron removal groundwater in bioreactors and verification of its computer implementation with the data of experimental studies. The mathematical model is represented by the Cauchy problem for a nonlinear system of differential equations in partial derivatives of the first order. The system of the Cauchy problem consists of five equations with five unknown functions, which describe the distribution the concentration of ferrum cations, bacteria and the matrix structures in two phases (movable and immobilized) both in space and time The inverse influence of the characteristics of the process, in particular, the concentration of matrix structures in the inter-pore space, as well as characteristics of the medium with the help of coefficients of mass exchange and porosity, were taken into account. The model makes it possible to predict changes in cleaning efficiency depending on the duration of the filter cycle, filtration speed, Fe2+ concentration, the content of iron bacteria and their matrix structures in the interpore space, and to determine the optimal time of operation of the bioreactor between washings&#x0D;

Early cholecystectomy following percutaneous transhepatic gallbladder drainage is effective for moderate to severe acute cholecystitis in the octogenarians

BackgroundAcute cholecystitis (AC) is a life-threatening infectious/inflammatory disease in older patients. This study aimed to investigate the safety and optimal timing of surgery in patients aged ≥ 80 years with moderate to severe AC who received percutaneous transhepatic gallbladder drainage (PTGBD). MethodsFrom January 2008 to February 2021, 152 patients were retrospectively enrolled. Clinical outcomes were compared among patients who received laparoscopic cholecystectomy (LC), open cholecystectomy (OC), and conversion surgery, and between those who received early (< 6 weeks after PTGBD) and delayed cholecystectomy (≥ 6 weeks after PTGBD). Logistic regression analysis was used to identify risk factors for recurrent AC, further biliary events, conversion, and perioperative complications. ResultsSixty-seven patients underwent LC, 62 underwent OC, and 23 underwent conversion surgery. Operation-related complications and mortality rates did not differ among the types of surgery; however, LC group had shorter operative time than the other groups. Eighty-two patients underwent early cholecystectomy, while 70 underwent delayed cholecystectomy. There were no differences in operative time, operation-related complications, and mortality rates between the groups. However, higher rates of recurrent AC and biliary events were observed in the delayed cholecystectomy group (52.9% vs. 4.9% and 57.1% vs. 8.5%, p < 0.001). On multivariate analysis, delayed cholecystectomy was a significant risk factor for recurrent AC (odds ratio [OR] = 19.42, p < 0.001) and further biliary events (OR = 15.95, p < 0.001). ConclusionsEarly cholecystectomy is recommended for patients aged ≥ 80 years with moderate to severe AC following PTGBD.

Application of comprehensive score of risk factors to determine the best time for surgical intervention in neonatal necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is a severe digestive systemic disease. Surgery is critical treatment for NEC patients. However, it is still hard to predict the optimal timing of surgery. Our study aimed to explore the indicative effect of comprehensive risk factors method in surgical intervention in NEC patients. Retrospective analysis was made on newborns with NEC, who were divided into group I (patients with NEC conservative therapeutic approach or no necrosis or perforation found in NEC operation) and group II (patients with necrosis or perforation found in NEC operation or failure of NEC conservative approach). Clinical manifestations and complications were recorded and the risk factors scores were calculated. The receiver operating characteristic curve and Youden index were calculated. One hundred and six NEC patients in Huizhou Central People's hospital were analysed. Significant difference was observed in the comprehensive scores of the two groups to judge the indications of NEC surgery. Among the risk factors of NEC surgery, the incidence specificity of abdominal induration, abdominal tenderness, hypotension and pneumoperitoneum was 100% in group II. The area under the curve of the comprehensive score of risk factors was 0.981 (95% confidence interval 0.958-1.000). The best cutoff value obtained by the maximum Youden index is 3.5 (sensitivity 97.2%; specificity 52.8%). When the specificity is 100%, the best interception value is 7.5 (sensitivity 91.4%; specificity 100%). Complications such as surgical intervention, mortality, stenosis after conservative treatment, perforation or necrosis during surgery were significantly different in different comprehensive scores. Abdominal induration, abdominal tenderness, hypotension and pneumoperitoneum are independent predictors of NEC surgery. Comprehensive risk factors score may be a potentially useful clinical decision-making tool for NEC surgery.

Robust electron spin qubit control in a nanowire double quantum dot

Robust and efficient manipulation of electron spin qubits in quantum dots is of great significance for the reliable realization of quantum computers and execution of quantum algorithms. In this paper, we study the robust control on a singlet-triplet qubit based on inverse engineering, one technique of shortcuts to adiabaticity (STA), in a nanowire double quantum dot in the presence of magnetic field and strong spin-orbit coupling. The optimization of STA with respect to the systematic errors, contributed from the control field and the perturbative interaction, is explored. Moreover, we also apply optimal control techniques combining with STA, referred to as robust inverse optimization, to design optimal control fields and optimal operation time. This article is part of the theme issue 'Shortcuts to adiabaticity: theoretical, experimental and interdisciplinary perspectives'.

Postanesthesia complications in pediatric patients with previous SARS-CoV-2 infection: A cohort study.

Children with SARS-CoV-2 infection are at increased risk for postanesthesia complications. There is minimal data regarding how long that elevated complication risk persists beyond initial SARS-CoV-2 diagnosis. We investigated postanesthesia complications in children with SARS-CoV-2 infection within 90 days of diagnosis. We completed a single-center, retrospective, case-control study of pediatric patients with confirmed SARS-CoV-2 infection within 90 days undergoing anesthesia between January 3-October 7, 2020. Each SARS-CoV-2 positive patient was matched 1:2 by age and type of procedure with a non-SARS-CoV-2 cohort. The primary outcome was the rate of all postanesthesia complications within 30 days of the procedure, defined as unplanned escalations of care within 48 h, cardiac, respiratory, thrombotic, and hemorrhagic events within 30 days. Secondary outcomes were 30-day mortality and hospital length of stay. Of the 341 patients included, 114 patients were SARS-CoV-2 positive and 227 were SARS-CoV-2 negative. Patients with a positive test 0-7 days prior to anesthesia had an increased risk difference in all postanesthesia complications within 30 days (19.9, 95% CI [4.7, 35.1], p= .001) and increased risk difference in length of hospital stay (7.8, 95% CI [1.2, 14.4], p< .001). Patients who underwent anesthesia greater than 42 days from SARS-CoV-2 diagnosis had an increased risk difference in cardiac complications within 30 days (4.3, 95% CI [0.9, 10.0], p= .029). There was no increased hospital length of stay among SARS-CoV-2 positive patients diagnosed greater than 8 days before anesthetic. There were no deaths within 30 days of anesthetic. Postanesthesia complications are higher in children who undergo anesthesia within 7 days of SARS-CoV-2 diagnosis. Additional cardiac risk may persist beyond the immediate period of initial diagnosis. Larger samples are needed to further evaluate the risk of delayed postanesthesia complications and guide optimal timing of surgery.

Optimal timing for surgery in infective endocarditis

Optimal timing for surgery in infective endocarditis

The Optimal Timing of Surgery Following Stereotactic Body Radiation Therapy for Borderline Resectable or Locally Advanced Pancreatic Cancer

<h3>Purpose/Objective(s)</h3> In patients undergoing pre-operative stereotactic body radiotherapy (SBRT) for borderline resectable or locally advanced pancreatic adenocarcinoma (BRPC/LAPC), the optimal timing of surgery following SBRT is unknown. We aimed to assess the impact of time from SBRT to surgery on outcomes in this setting. <h3>Materials/Methods</h3> Patients treated at a single institution with BRPC/LAPC, who underwent neoadjuvant multi-agent chemotherapy followed by SBRT, and then surgical resection, were included in this analysis. Covariates were stratified by time from SBRT to surgery. Pearson's Chi-squared test was used to compare cohorts by time from SBRT to surgery with respect to baseline and treatment characteristics. A Cox regression model was used to identify variables associated with survival outcomes, with statistically significant covariates in univariable analysis included in multivariable modeling. <h3>Results</h3> One hundred seventy-one patients were ultimately included for analysis. The median time from SBRT to surgery was 6.4 weeks (range: 2.7 – 25.3, IQR 2.7 weeks). There was no statistically significant difference in age, sex, tumor location, neoadjuvant chemotherapy type (FOLFIRINOX vs gemcitabine/nab-paclitaxel) or chemotherapy duration >4 months, pathologic complete response (pCR) rates, or R0 resection rates by time from SBRT to surgery, using a 6-week cutoff. Local progression-free survival (LPFS) was higher in patients for whom time from SBRT to surgery was >6 weeks (1-yr LPFS 81.5% vs 70.2%, median LPFS 12.1 vs 10.8 months, log-rank P=.039). No difference in distant metastases-free survival or overall survival was detected. In univariable Cox regression, age, SBRT dose, neoadjuvant chemotherapy duration/type, tumor location, presence of pCR, and surgical margin status were not associated with LPFS, but time from SBRT to surgery less than 6 weeks (P=.042; HR 1.84 95% CI 1.02 – 3.30) and baseline elevated CA19-9 >200 U/mL (P=.018; HR 2.09, 95%CI 1.14 – 3.84) were significantly associated with reduced LPFS. In multivariable analysis, time from SBRT to surgery < 6 weeks (P=.011; HR 2.18, 95% CI 1.19 – 3.97) and baseline elevated CA19-9 (P=.006; HR 2.38, 95% CI 1.28 – 4.42) remained independently associated with reduced LPFS. Sensitivity analysis was performed excluding patients who had surgical resection >15 weeks after completion of SBRT (n=4). Time from SBRT to surgery <6 weeks and elevated baseline CA19-9 remained independently associated with reduced LPFS. <h3>Conclusion</h3> Prolongation of time from SBRT to surgery may be associated with improved local progression free survival. Further study is warranted to understand the factors that may contribute to differential local control rates based on time from SBRT to surgery.

Giant left atrium and Giant Eustachian valve in a patient with stenosis of mitral valve prosthesis

Giant left atrium (LA) is a extremely rare condition due to decline in rheumatic heart disease incidence. Giant Eustachian valve (EV) is an exceptionally rare finding, visualized on echocardiography in only 0.20% in adults. Typically is functionless in adults. We report a giant LA due to prosthetic mitral valve (MV) stenosis, seen on echocardiography, with late stage presentation in a 73-year-old woman. She had a history of MV replacement due to rheumatic MV disease 20-years ago. Echocardiography was suggestive for severe stenosis of MV prosthesis and giant LA with a size of 12.6x13.1cm, while computed tomography scan revealed a LA size of 17 × 11 cm. Giant EV was accidental finding on echocardiogram, that extended from the orifice of the inferior vena cava to the interatrial septum, without clinical significance. The patient was offered to undergo cardiac surgery on many occasions, but she kept refusing surgery. At last she accepted,unfortunately she died before proceeding to surgical intervention. A rheumatic giant LA due to stenosis of MV prosthesis is rarely reported entity in the literature and may be associated with significant morbidity and mortality. Optimal timing for surgery is crucial. Giant EV is rare accidental finding on echocardiography. Pre-operative identification of this structure is important, as it could be mistaken for pathology, ending with unnecessary treatment. This is a first echocardiographic report of coexistence of giant LA and giant EV.

Timing of Surgery and Treatment Options for Congenital Ptosis in Children: A Narrative Review of the Literature.

Congenital ptosis has varying degrees of impact on the visual development or psychological health of a child depending on its severity. Some controversies and misconceptions remain regarding the management of congenital ptosis in children. Particularly, the accurate diagnosis of the severity of congenital ptosis in younger children, assessment of the visual developmental status of the child, optimal timing of surgery, and treatment choice are still issues in clinical practice that need to be explored. This report presents a comprehensive review of these aspects of the correction of congenital ptosis to provide a valuable reference for clinical practice. Our review shows that currently used surgical procedures for ptosis may result in over- or under-correction to varying degrees. The differences may be due to the physical condition and age of the child and the degree of cooperation during preoperative examination and assessment, resulting in inaccurate results. Alternatively, intraoperative swelling and bleeding may lead to errors in the values recorded by the surgeon. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Three perspectives: the approach to neoadjuvant treatment of rectal cancer according to medical oncologists, radiation oncologists, and surgeons

Background: Two treatment options considered for radiotherapy are short-course radiotherapy and immediate surgery, or chemoradiation with 5-Fluorouracil based chemotherapy and delayed surgery. Aim of the study: Evaluate the real-life treatment approaches of medical, radiation, and surgical oncologists, to neoadjuvant treatment of rectal cancers. Material and methods: An online survey was established via Google Forms. The survey was taken voluntarily by medical oncologists, radiation oncologists, surgical oncologists, and general surgeons. Results: Of those who participated, 183 were medical oncologists, 36 were radiotherapists, and 36 were surgeons. Most of the study population preferred long-course radiation therapy and chemotherapy (85%). Meanwhile, two-thirds of the participants preferred chemotherapy prior to operating. The most frequent chemotherapy cycles for the pre-operative setting were ‘three’ and ‘four-or-more’ (27.8% and 25.1%, respectively). Medical oncologists had a significantly higher tendency to offer chemotherapy between radiation therapy and surgery compared to the other groups. Optimal time of surgery was different between groups, but there was no difference among groups between surgery and the ‘watch &amp; wait’ strategy. Neoadjuvant chemotherapy regimens were significantly different between groups. Conclusions: We found that the new pre-operative chemotherapy regimen with short-course radiotherapy was slowly adopted into current practice. Also, medical oncologists tended to prefer pre-operative chemotherapy in comparison to the other groups.