Standard Management Protocol Research Articles

Vestibular Schwannoma Resection in a Consecutive Series of 502 Cases via the Retrosigmoid Approach: Technical Aspects, Complications, and Functional Outcome

Outcome in vestibular schwannoma (VS) surgery has improved enormously over the last decades. Surgical positioning remains a matter of discussion. A standardized protocol for diagnostics and management has been applied and evaluated for complications and functional outcome. We examined 502 VS tumors in 483 patients (227 men and 256 women) between 2005 and 2016. According to our patient selection and treatment algorithm, 488 operations (97%) were performed in the semi-sitting position, and 14 (3%) were in the supine position. Auditory and facial functions were analyzed before and after surgery as were perioperative complications. There were 182 patients (36%) with small tumors (Hannover classification T1-T3A) and 320 (64%) large tumors (T3B or T4). Of the patients, 14% were neurofibromatosis type 2 cases. Complete tumor resection was achieved in 96.4%. Hearing preservation occurred in 44% of patients with small tumors and 23% of those with large tumors (Hannover classification), and correlated significantly with tumor size (P < 0.001). Facial palsy (House Brackmann grades II-VI) was present in 63 patients before and in 185 patients after surgery. Useful facial function (House Brackmann grades I-III) early after surgery was maintained in 86% of patients with small tumors and in 77% of patients with large tumors. Intraoperative complications included air embolism in 45 cases (9%), sinus injury in 3 cases, cerebrospinal fluid leakage in 46 cases (9%), and local hemorrhage in 19 cases (4%). Surgical revision was indicated in 31 cases (6%). In a standardized setting, the semi-sitting position allowed a safe approach. This setting offers the advantage of bimanual tumor nerve handling by the surgeon and an optimal visualization of important functional structures.

Integration of a standardized diabetic management protocol into an ERAS program

Objectives: To avoid hyperglycemia among laparotomy patients with diabetes (DM) on an Enhanced Recovery After Surgery (ERAS) program. Secondary objective to decrease the rate of surgical site infection (SSI) among DM laparotomy patients.

Implementation of Neonatal Neurocritical Care Program Improved Short-Term Outcomes in Neonates With Moderate-to-Severe Hypoxic Ischemic Encephalopathy

BackgroundDespite the introduction of therapeutic hypothermia, infants with moderate-to-severe hypoxic-ischemic encephalopathy remain at risk of mortality and morbidity. A dedicated service with standardized management protocols and improved communication may help improve care. We aimed to evaluate the impact of a dedicated neonatal neurocritical care service on short-term outcomes in infants with hypoxic-ischemic encephalopathy. MethodsWe performed a retrospective cohort study (July 2008 to December 2017) on term and near-term infants admitted to two tertiary neonatal intensive care units with moderate-to-severe hypoxic-ischemic encephalopathy, before and after neonatal neurocritical care service implementation. The primary outcome was brain magnetic resonance imaging findings consistent with those of hypoxic-ischemic encephalopathy. Secondary outcomes included the cooling initiation rate, hospital stay duration, antiseizure medication use, and inotrope use. Regression analysis and interrupted time series analysis were performed after adjusting for confounding factors. ResultsIn total, 216 infants with moderate-to-severe hypoxic-ischemic encephalopathy were analyzed—109 before and 107 after neonatal neurocritical care implementation. After adjusting for confounding factors, there was a significant reduction in primary outcomes (adjusted odds ratio: 0.3, confidence interval: 0.15 to 0.57, P < 0.001) after neonatal neurocritical care implementation. Average hospital stay duration reduced by 5.2 days per infant (P = 0.03), identification of eligible infants for cooling improved (P < 0.001), antiseizure medication use reduced (P = 0.001), and early inotropes use reduced (P = 0.04). ConclusionImplementation of a neonatal neurocritical care service associated with decreased brain injury shortened the hospital stay duration and improved the care of infants with moderate-to-severe hypoxic-ischemic encephalopathy.

The effect of a low carbohydrate formula on glycaemia in critically ill enterally-fed adult patients with hyperglycaemia: A blinded randomised feasibility trial

Enteral nutrition is a source of carbohydrate that may exacerbate hyperglycaemia. Its treatment, insulin, potentially exacerbates glycaemic variability. This was a prospective, parallel group, blinded, randomised feasibility trial. Patients were eligible if 18 years or over when admitted to the intensive care unit and receiving enteral nutrition (EN) exclusively with two consecutive blood glucose>10mmol/L. A standardized glucose management protocol determined administration of insulin. Key outcome measures were insulin administered and glycaemic variability (coefficient of variation) over the first 48h. 41 patients were randomized to either standard EN (14.1g/100mL carbohydrate; n=20) or intervention EN (7.4g/100mL carbohydrate; n=21). Overall 59% were male, mean (±SD) age of 62.3 years±10.4, APACHE II score of 16.5±7.8 and a median (IQR) Body Mass Index 29.0kg/m2 (25.2-35.5). Most patients (73%) were mechanically ventilated. Approximately half (51%) were identified as having diabetes prior to ICU admission. Patients in the intervention arm received less insulin over the 48h study period than those in the control group (mean insulin units over study period (95% CI) 45.0 (24.4-68.7) vs. 107 (56.1-157.9) units; p=0.02) and had lower mean glycaemic variability (12.6 vs. 15.9%, p=0.01). There was a small difference in the mean percentage of energy requirements met (intervention: 72.9 vs. control: 79.1%; p=0.4) or protein delivered (78.2 vs. 85.4%; p=0.3). A low carbohydrate formula was associated with reduced insulin use and glycaemic variability in enterally-fed critically ill patients with hyperglycaemia. Further large trials are required to determine the impact of this formula on clinical outcomes. Registered under Australian and New Zealand Clinical Trials Registry, ANZCTR number: 12614000166673.

Nonsurgical Management of Rectal Cancer.

Neoadjuvant chemoradiotherapy followed by surgical resection is the standard of care for locally advanced rectal adenocarcinoma. Up to one third of patients achieve pathologic complete response (CR) with neoadjuvant therapy. Promising disease-free and overall survival outcomes have been reported in patients who achieve clinical CR after neoadjuvant therapy without surgical resection. Furthermore, patients who have local recurrence have acceptable disease control outcomes with salvage resection. With consideration of morbidities associated with surgical resection and similar clinical outcomes, interest in nonsurgical management of low rectal cancers has emerged. Randomized clinical trials are being conducted to evaluate a nonsurgical approach in rectal cancer. Lack of consensus on the definition of clinical CR, molecular biomarkers, and standardized nonsurgical management protocols is a significant barrier for routine clinical implementation of a nonsurgical management approach. This article aims to provide a concise review of the clinical experience and practical approach to the nonsurgical management of locoregional rectal adenocarcinoma.

Management of diabetic women with threatened preterm birth: a survey of Maternal-Fetal Medicine providers

Objective: To evaluate variation in management of diabetic women with threatened preterm birth (PTB).Study design: Thirty-two-question electronic maternal-fetal medicine (MFM) provider survey advertised on the Society for MFM website, newsletter, and Facebook page with questions about antenatal steroid use in diabetic women and glycemic management strategy after steroid administration. Descriptive statistics were used to summarize respondent characteristics, practice patterns, and satisfaction with current practice. Multivariable logistic regression was performed to determine if there were any factors independently associated with provider-reported satisfaction.Result: We obtained 159 completed surveys: 69% from board-certified MFM providers and 31% from MFM fellows. Almost half (48%) of respondents reported caring for diabetic women with threatened PTB at least weekly. Overall, 74% were concerned about the risk of maternal hyperglycemia after steroids, but 86% believed the neonatal benefit outweighed maternal risk. More than half (64%) agreed or strongly agreed that steroids for diabetic pregnant women were “evidence-based,” and as such, the majority answered that they administer steroids always or most of the time, ranging from 92% for women with uncontrolled type 1 diabetes to 100% for women with diet-controlled gestational diabetes. The frequency of hospitalization and management approach to obtain glycemic control varied by diabetes type and degree of antepartum glycemic control. Two-thirds of MFM providers reported being satisfied with their current practice in caring for these women. Use of a standard protocol for glycemic management was also associated with increased odds of satisfaction (aOR 4.5, 95% CI 1.3–16.1) whereas use of a continuous insulin infusion for all women with insulin-dependent diabetes was associated with decreased odds of satisfaction (aOR 0.3, 95% CI 0.1–0.8). There was no significant association observed between number of years in practice or frequency of care for diabetic women with threatened PTB and provider satisfaction. Overall, 49% of respondents desired a protocol to guide glycemic management, and 74% believed more research is needed to optimize care of diabetic women receiving steroids for threatened PTB.Conclusion: While there are no prospective studies examining the neonatal benefit of antenatal steroids in diabetic women, MFM respondents believe steroid use in this context is evidence-based and report they are administering steroids almost universally in this population. Variation exists in the glycemic management strategy used after steroid administration. While use of a standard protocol for glycemic control was associated with practice satisfaction, routine use of a continuous insulin infusion for all women with insulin-dependent diabetes was associated with lower odds of satisfaction. More research is needed to optimize care of diabetic women receiving steroids for threatened PTB as maternal and neonatal outcomes related to these practices remain unknown.

Center variation in screening for and management of metabolic syndrome in pediatric liver transplant recipients: A survey of SPLIT centers.

PTMS-a clustering of hypertension, dyslipidemia, glucose intolerance/diabetes, and obesity-is increasingly recognized as a contributor to long-term morbidity after transplant. We sought to describe pediatric liver transplant center protocols and provider practices in screening for and managing these conditions. Cross-sectional survey of pediatric liver transplant providers from centers that participate in Studies of Liver Transplantation (SPLIT). Of 49 survey respondents from 39 centers, 64% were hepatologists or surgeons, 18% nurses/NPs/PAs, 12% coordinators, and 4% other. All providers felt that pediatric liver transplant recipients should be routinely screened for PTMS components. For each condition, at least 70% felt that the liver transplant team should be primarily responsible for routine screening. For each condition, at least 30% of providers reported that their center had no standardized protocol for screening. For diagnostic evaluation and initial management, >60% of providers reported that their center had no standardized protocol for glucose intolerance/diabetes, dyslipidemia, or obesity. Almost 40% had no standardized workup or initial management protocol for hypertension or chronic kidney disease. Of centers that did have screening or workup protocols, most were based on existing center practice, provider consensus, or informal review of published evidence. Screening tools, treatment steps, and thresholds for referral to another specialist varied widely. Transplant providers intend to screen for and initiate management of PTMS components in these children, but protocols and practices vary substantially. This highlights opportunities for multi-center collaboration on protocols or interventions to improve screening and management.

Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes?

Objective:The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients.Materials and Methods:The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed.Results:The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%.Conclusion:Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.

Diabetes management in Guinea Bissau: a situational analysis.

IntroductionThere is an increasing commitment in the African Region towards diabetes care, following acknowledgement that it is an important public health issue which needs to be addressed in order to improve population health. We conducted a situational analysis of diabetes care in Guinea Bissau in order to identify the main issues faced in the management of the disease in this country.MethodsThe study design was qualitative and data collection was done using semi directive interviews and focus groups with participants involved in primary diabetes care and management in Guinea Bissau (health care professionals, non-governmental organization staff, traditional healers) and patients. The data was analyzed using the five-phase approach of the thematic analysis framework.ResultsThe major themes identified included: the lack of specialists and properly trained healthcare personnel; no standardized care protocol for diagnosis, treatment, follow up and proper management for diabetic patients; resources poor primary health care settings; no validated epidemiological dataset on prevalence and the lack of awareness about diabetes (in general population and also in medical staff).ConclusionThis first situational analysis can serve as a baseline to develop an action plan to address the main issues identified.

Development of Software Based Vendor Independent WLAN Controller

Wireless hotspots have become popular, due to their ability to provide inexpensive and easy-to-deploy network infrastructures. Controlling and maintaining large-scale wireless infrastructures with traditional methods is complex and error-prone. Hence, it is necessary to use centralised solutions to handle configuration, monitoring and management functions in large-scale wireless hotspots. Existing solutions solve these problems within their hardware ecosystems and are constrained by vendor being depended on hardware and software restrictions. In this study, we propose and evaluate a wireless local area network (WLAN) access point (AP) controller built on top of a standard WLAN management protocol and free of any particular hardware and software restrictions. The proposed WLAN controller is a software component based on the control and provisioning of wireless access points (CAPWAPs) protocol. The proposed controller is evaluated by means of a TestBed including a variety of WiFi devices from different vendors to solve a QoS-LB problem.

Predictors in profile of referred newborns for their outcome in a tertiary newborn referral facility

Background: This study was aimed to assess newborn referral and factors contributing to outcome of referred newborns.Methods: This prospective observational study was conducted in a tertiary newborn referral facility for a period of one year. Referred newborns fulfilling inclusion criteria were enrolled in study, and assessed in terms of demographic profile, transport characteristics, physiological variables. Investigations, management of neonatal illness was done as per standard management protocols, they were followed up to their outcome.Results: Out of 2000 enrolled referred newborns, 30.10% were expired. Mean gestational age for survived newborns was 36.54±2.92 (SD) weeks, for expired newborns 35.24±3.99 (SD) weeks. Mean weight for survived newborns 2312.27 gms ±555.71 (SD), for expired newborns 1936.71 gms ±665.67 (SD). Out of total 60.05% newborns transported from periphery, had higher mortality i.e. 35% as compared to newborns transported from urban place i.e. 25%. Mean transport duration for survived newborns 61.94 minutes ±55.18 (SD), for expired newborns 89.51 minutes ±88.94 (SD). Prolonged CRT was observed in 57.45% newborns, grunting 19.70%, Cyanosis 11%, gasping 7.6%, apnea 5%, respiratory distress 39.80%, hypothermia 74.95%, and 25.50% required resuscitation on admission. Unattended delivery, self-arranged mode of transport, prolonged CRT, respiratory distress, apnea , hypothermia on admission, weight on admission(&lt;1500gms), hypoglycaemia and duration of transport more than 1 hour found statistically significant independent variables associated with mortality of referred newborns.Conclusions: A significant number of neonatal deaths can be prevented, if referral system is structured and organized. Improper referral leads to poor physiological profile of referred newborns, which leads to their poor outcome. There are many independent variables which are affecting the outcome of referred newborns. These independent variables can be taken care in holistic way once the referral system is cultured and nurtured in existing health system.

Hypertonic milk replacers increase gastrointestinal permeability in healthy dairy calves

Hypertonic milk replacers are commonly used in animal production systems and their effect on the gastrointestinal system of young animals is insufficiently studied. Total lactose inclusion or its partial replacement with dextrose increases intestinal osmotic pressure, which may compromise gastrointestinal barrier function. In this experiment, we investigated the effect of increased osmolality of calf milk replacer (CMR) on gastrointestinal permeability in 30 Holstein Friesian (n = 17) or crossbred (n = 13) bull calves. The osmolality of CMR increased as result of a gradual replacement of lactose by monosaccharides (dextrose and galactose). Calves were acquired from dairy farms that followed a standardized protocol for colostrum management, including 3 feedings of colostrum in the first 24 h. Calves were then transported to the research facility between 0 and 3 d of age, fed a milk replacer with 0% dextrose twice daily for the first 2 wk of age, and subsequently exposed to their respective treatments from 3 until 7 wk of age. Meal size was 3.2 L at 3 wk of age and increased to 3.5 L at 7 wk of age. No solids were provided throughout the study and calves had ad libitum access to water. Treatments included 4 levels of dextrose inclusion (replacing lactose): 0% (L1, n = 5), 13.3% (L2, n = 5), 26.7% (L3, n = 5), and 40% (L4, n = 5) and an additional treatment (G+D, n = 10) that included 20% galactose and 20% dextrose and matched the galactose supply of L1 and the osmolality of L4. Carbohydrates were exchanged based on hexose equivalents. Across treatments, the estimated osmolality ranged from 439 (L1) to 611 mOsm/kg (L4 and G+D). Gastrointestinal permeability was assessed by fractional urinary recovery of indigestible markers (lactulose, d-mannitol, and Cr-EDTA) delivered as a single dose at 3 and 7 wk of age. Marker recoveries were expressed as percentage of oral dose and assessed in 6-h and 24-h quantitative urinary collections. Increasing the osmolality of the CMR linearly increased urinary Cr-EDTA and lactulose recoveries at 3 and 7 wk of age. Lactulose and Cr-EDTA recoveries did not differ between G+D and L4, suggesting that the source of monosaccharide (dextrose and galactose) in CMR had no effect on gastrointestinal permeability. The observed increase in gastrointestinal permeability to large molecules (Cr-EDTA and lactulose) with increased osmolality suggests that hypertonic CMR may compromise gastrointestinal barrier function.

Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department.

Introduction:Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival.Methods:A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores.Results:Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores.Conclusions:Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.

Kimura’s Disease: Presenting as a Giant Head and Neck Mass

We report an interesting case of Kimura’s disease (KD) that presented as a giant head and neck mass. KD is a rare chronic inflammatory disorder and usually presents as small subcutaneous swellings in the head and neck region. Such a large mass of 15 × 17.5 cm as seen in our patient has previously not been reported, to the best of our knowledge. The radiological picture was that of an enlarged subcutaneous mass with heterogeneous enhancement of the salivary gland. The histological findings were helpful in identifying the lesion as KD. The combination of these two aided us in differentiating it from other lesions such as follicular lymphoma, angiolymphoid hyperplasia with eosinophilia (ALHE) and Langerhan’s histiocytosis. There is no standard protocol for management of this disease owing to its rarity. Due to the extensive and ill-defined nature of the lesion in our patient, we have started the patient on systemic high-dose corticosteroid therapy to downsize the lesion and we plan to follow up with surgical excision if needed.

Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons.

Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction. Cross sectional study, Level IV. Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport. A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9months in 67% and overall 94% from 6 to 12months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery. Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis

Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend. To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care. Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included. Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals. There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%). In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.

National survey on current management of ovarian tumors in pediatric age group

Aim of the studyTo investigate the current management of ovarian tumors in children by the Egyptian pediatric surgical association (EPSA) consultants who are dealing with approximately 80% of these cases in our country. MethodsFollowing approval of EPSA executive board, an online questionnaire was sent via e-mails on EPSA online group mail to all registered consultants. Repeated reminders were sent biweekly for 6 weeks. ResultsResponses were received from 82 consultants (response rate 82/111, 73.87%). Diagnosis74.39% of respondents indicated abdomino-pelvic mass as most common presenting symptom. Concerning imaging requested, US and CT were reported by 60.98%. AFP and HCG were requested by 84.15% as serum tumor markers. SurgeryApproximately 50% of respondents perform 1–3 cases per year. Diagnostic laparoscopy was done by 70.73%. Transverse abdominal incision was the commonest in use during surgeries (81.71%). Out of all respondents, 65.85% never encountered intraoperative complications, whereas the remaining 34.15% had different complications (mainly rupture and spillage). Minimally invasive surgery (MIS) was adopted by 53.66% in only benign looking tumors. A total of 69.51% perform ovarian sparing surgery (OSS) in benign masses whenever possible. Follow upBenign tumors were the most common type observed by 86.59% of respondents. In benign lesions, 28.05% of surgeons never ask for follow up and the remaining 71.95% follow patients with different schedules. ConclusionsThere is a paradigm shift toward MIS and OSS in the current practice of EPSA consultants. No actual standard protocol of management is present for ovarian tumors in Egypt and they still fall at the edge between many subspecialties. The results of this survey urge for establishment of uniform guidelines with international reference to be adopted in our nation, in addition to start a national prospective registration system for these tumors which is currently lacking in Egypt.

Perceptual-cognitive three-dimensional multiple-object tracking task can help the monitoring of sport-related concussion

ObjectivesWhile the rate of sport-related concussion is increasing, more effective tools are needed to help monitor the diagnosis and return to play of athletes. The three-dimensional multiple-object tracking (3D-MOT) exercise...

Paleoenvironmental Reconstructions Improve Ecosystem Services Risk Assessment: Case Studies from Two Coastal Lagoons in South America

Paleoenvironmental reconstructions are increasingly being used in conservation biology, ecosystem management, and evaluations of ecosystem services (ES), but their potential to contribute to the ES risk assessment process has not been explored. We propose that the long-term history of the ecosystem provides valuable information that augments and strengthens an ES risk assessment and that it should be considered routinely when undertaking risk assessments. We adjusted a standard ecosystem-based risk management (EBRM) protocol to include paleoenvironmental data, and tested the modified approach on two coastal lagoons in South America. Paleolimnological reconstructions in both lagoons indicate that salinity and nutrients (in Laguna de Rocha), and salinity (in Ciénaga Grande de Santa Marta), as controlled by hydrologic connectivity with the ocean and freshwater tributaries, have been the key variables behind ecosystem’s function. This understanding, applied to inform various components and steps in the EBRM protocol, suggests that the maintenance of hydrological connections should be a management priority to minimize risk to ES. This work illustrates the utility of including paleoenvironmental data in an EBRM context and highlights the need for a more holistic approach to risk management by incorporating the long-term history of ecosystem function.

A Dedicated Pediatric Spine Deformity Team Significantly Reduces Surgical Time and Cost.

As high-quality health care becomes increasingly expensive, improvement projects are focused on reducing cost and increasing value. To increase value by reducing operating room (OR) utilization, we studied the effect of a dedicated team approach for posterior spinal fusion (PSF) for scoliosis. With institutional support, an interdisciplinary, dedicated team was assembled. Members developed standardized protocols for anesthetic management and patient transport, positioning, preparation, draping, imaging, and wake-up. These protocols were initially implemented with a small interdisciplinary team, including 1 surgeon (Phase 1), and then were expanded to include a second surgeon and additional anesthesiology staff (Phase 2). We compared procedures performed with a dedicated team (the Dedicated Team cases) and procedures performed without a such a team (the Casual Team cases). Because of the heterogeneous nature of PSF for scoliosis, we developed a case categorization system: Category 1 was relatively homogeneous and indicated patients with fusion of ≤12 levels, no osteotomies, and a body mass index (BMI) of <25 kg/m, and Category 2 was more heterogeneous and indicated patients with fusion of >12 levels and/or ≥1 osteotomy and/or a BMI of ≥25 kg/m. In total, 89 Casual Team and 78 Dedicated Team cases were evaluated: 71 were in Category 1 and 96 were in Category 2. Dedicated Team cases used significantly less OR time for both Categories 1 and 2 (p < 0.001). In Category-1 cases, the average reduction was 111.4 minutes (29.7%); in Category-2 cases, it was 76.9 minutes (18.5%). The effect of the Dedicated Team was scalable: the reduction in OR time was significant in both Phase 1 and Phase 2 (p < 0.001). The Dedicated Team cases had no complications. Cost reduction averaged approximately $8,900 for Category-1 and $6,000 for Category-2 cases. By creating a dedicated team and standardizing several aspects of PSFs for scoliosis, we achieved a large reduction in OR time. This increase in team efficiency was significant, consistent, and scalable. As a result, we can routinely complete 2 Category-1 PSFs in the same OR with the same team without exceeding standard block time.