Surgery Intervention Research Articles

Undergraduate deficits in plastic surgery exposure and awareness of the specialty: a systematic review.

Plastic surgery is an important specialty that involves widespread medical knowledge, some of which is taught in undergraduate curricula. The General Medical Council provides a well-defined plastic surgery curriculum for postgraduate training. However, there is no consensus on the provision for undergraduates in this specialty, potentially giving rise to a deficit in undergraduate medical education and a suboptimal basis for plastic surgery postgraduate training. Our aim was to identify the gap in undergraduate plastic surgery teaching and to understand student perceptions of the specialty as well as any trialled interventions. A prospectively registered systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The MEDLINE®, Embase™, PubMed® and Google Scholar™ databases were searched for literature relating to undergraduate exposure to plastic surgery and relevant teaching interventions. Ten studies were included in this review, categorised into three main themes: exposure during medical school, determining factors and perceptions for pursuing a plastic surgery career, and teaching interventions. Surveys assessing medical student perceptions indicate a significant deficit in exposure to plastic surgery in the undergraduate curriculum. Medical students' interest in the specialty is affected by multiple factors, including the amount of surgical exposure in medical school. Interventions to address the deficit mostly involve one-day courses. Although the literature is currently limited, studies are needed to effectively assess the outcomes of plastic surgery teaching methods in undergraduate training. Moreover, there is a need for consensus around the provision of undergraduate teaching in plastic surgery. This should be reflected in the latest undergraduate curricula in medical education.

Chitosan and Anionic Solubility Enhancer Sulfobutylether-β-Cyclodextrin-Based Nanoparticles as Dexamethasone Ophthalmic Delivery System for Anti-Inflammatory Therapy.

Cataract surgery interventions are constantly increasing, particularly among adult and elderly patients. This type of surgery can lead to inflammatory states of the ocular anterior segment (AS), usually healed via postoperative treatment with dexamethasone (DEX)-containing eye drops. The application of eye drops is challenging due to the high number of daily administrations. In this study, mucoadhesive nanoparticles (NPs) were formulated to improve the residence time of DEX on the corneal mucosa, enhancing the drug's solubility and bioavailability. The NPs were generated using an ionotropic gelation technique, exploiting the interaction between the cationic group of chitosan (CS) and the anionic group of sulfobutylether-β-cyclodextrin (SBE-β-CD). The formation of the inclusion complex and its stoichiometry were studied through phase solubility studies, Job's plot method, and Bi-directional transport studies on MDCKII-MDR1. The obtained NPs showed good chemical and physical characteristics suitable for drug loading and subsequent testing on animal mucosa. The DEX-loaded CS/SBE-β-CD NPs exhibited a prolonged residence time on animal mucosa and demonstrated enhanced drug permeability through the corneal membrane, showing a sustained release profile. The developed NPs posed no irritation or toxicity concerns upon local administration, making them an optimal and innovative drug delivery system for inflammatory AS diseases treatment.

Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review

BackgroundDespite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why.MethodsFollowing Pawson’s realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated.ResultsFrom 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients’ needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision.ConclusionsImplementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention’s goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients.Trial registrationPROSPERO (CRD42022335282).

Management of Carotid Cavernous Fistula: a Case Report of Carotid Cavernous Fistula (CCF)

Abstract
 Introduction : Carotid-cavernous fistula (CCF) is an abnormal connection between the carotid arterial system and the sinus cavernous. Abnormal vascular shunt allowed blood to flow either direct or indirect from the carotid artery into the sinus cavernous. The indications for treatment of CCF are increased ocular pressure, double vision, bruits, severe headache, and severe proptosis resulting in keratopathy due to exposed cornea. Management of CCF include conservative management, endovascular intervention, surgery, and radiology intervention.
 Case Illustration : A 61 years old female came to the hospital complained redness on both eyes since 6 months ago, the redness in these eyes unrelieved even they had been treated. The patient have history given three types of drugs but there was not improvement. physical examination shown proptosis, injection of episcleral, cloudy lens with LOCSS NC2NO2C1P1 on both eyes, other examination also shown bruit on both eyes, Laboratory results was in normal limit. Funduscopic examination shown tigroid appearance.
 Discussion : Arterialization of the conjunctival vessels is a characteristic feature of CCF, other than physical examination, patient was planned for CT angiography examination to find external causes of injury assessing ICH and ischemia. Patient got external manual compression of the ipsilateral cervical carotid artery for about 30 to 40 seconds four times per hour several times daily for 4-6 weeks.
 Conclusion : Although CCF initially can be mistaken for conjunctivitis or episcleritis. Methods of therapy for CCF include conservative management, endovascular intervention, surgery, and interventional radiology. CCF itself is generally not life threatening but requires treatment to prevent worsening of the eye

Hip prosthesis and colon surgery, a decade of surveillance on surgical site infections in Italy, a prospective cohort study: rates, trends, and disease burden in DALYs

BackgroundSurveillance programs are a key element of interventions aiming to reduce rates of surgical site infections (SSIs). The aim of this study was to evaluate rates and trends of SSIs following hip arthroplasty and colon surgery procedures in Piedmont, a region in North-western Italy, from 2010 to 2019. Further, we aimed to assess the burden of SSIs in terms of Disability-Adjusted Life-Years (DALYs).MethodsA prospective cohort study was conducted among 42 hospitals participating in the surveillance system. Procedure-specific SSI rates were calculated and the 2010 - 2019 trend was evaluated using Spearman's Rho test. Patients were stratified according to age, sex and infection risk index according to life expectancy in order to calculate DALYs, using a modified version of the ECDC’s BCoDE toolkit: disease models for both procedure types were adapted to incorporate long-term disability associated with SSIs.ResultsOverall, 20,356 hip arthroplasty and 11,011 colon surgery procedures were monitored over 10 years and were included in our analyses. Hip arthroplasty and colon surgery cumulative SSIs rates were 1.5% and 8% respectively. Using the Spearman’s Rho test, we evaluated a significant downward trend from 2010 to 2019 for colon surgery interventions (Rs − 0.7, p < 0.05), while there was no difference for hip arthroplasty. (Rs − 0.04, p > 0.05).Regarding disease burden, a total of 955.3 (95%CI 837.7–1102.98) and 208.65 (95%CI 180.87–240.90) DALYs were calculated for SSIs following hip arthroplasty, whilst 76.58 (95%CI 67.15–90.71) and 38.62 (95% CI 33.09–45.36) DALYs for SSIs in colon surgery, in 2010 and 2019, respectively.ConclusionsThe significant decrease both in terms of incidence and DALYs found in this study for colon surgery and the stability for hip arthroplasty support the role of surveillance networks in improving quality of care. Despite the smaller SSI rate, the burden associated with SSIs following hip arthroplasty was higher, which is important to consider in light of the aging population in Italy.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)—356 patients or percutaneous coronary intervention (PCI)—679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.

Clinical Trial Racial and Ethnic Disparities in Minimally Invasive Gynecologic Surgery

Study ObjectiveTo study racial and ethnicity disparities in randomized clinical trials (RCT) in Minimally Invasive Gynecologic Surgery (MIGS). DesignCross sectional study. SettingOnline review of all published MIGS RCTs in high-impact journals from 2012 to 2023. PatientsJournals included all Q1 Obstetrics & Gynecology journals, as well as The New England Journal of Medicine, The Lancet, The British Medical Journal, and The Journal of the American Medical Association. The National Institutes of Health's PubMed and the ClinicalTrials.gov websites were queried using the following search terms from the American Board of Obstetrics and Gynecology's certifying examination bulletin 2022 to obtain relevant trials: adenomyosis, adnexal surgery, abnormal uterine bleeding, cystectomy, endometriosis, fibroids, gynecology, hysterectomy, hysteroscopy, laparoscopy, leiomyoma, minimally invasive gynecology, myomectomy, ovarian cyst, robotic surgery InterventionsThe United States (US) Census Bureau data was used to estimate the expected number of participants. We calculated the enrollment ratio (ER) of actual to expected participants for US trials with race and ethnicity data available. Measurements and Main ResultsA total of 352 RCTs were identified. Of these, race and/or ethnicity data were available in 65 studies (18.5%). We analyzed the 46 studies that originated in the US, with a total of 4,645 participants. Of these RCTs only 8 (17.4%) reported ethnicity in addition to race. When comparing published RCT data to expected proportions of participants, White participants were overrepresented [70.8% versus 59.6%, ER 1.66, 95% confidence interval (CI) 1.52-1.81], as well as Black or African American participants (15.4% versus 13.7%, ER 1.15, 95% CI 1.03-1.29). Hispanic (6.7% versus 19.0%, ER 0.31, 95% CI 0.27-0.35), Asian (1.7% versus 6.1%, ER 0.26, 95% CI 0.20-0.34), Native Hawaiian or Other Pacific Islander (0.1% versus 0.3%, ER 0.21, 95% CI 0.06-0.74), and Indian or Alaska Native participants (0.2% versus 1.3%, ER 0.16, 95% CI 0.08-0.32) were underrepresented. When comparing race/ethnicity proportions to the 20 states where the RCTs were conducted, Black or African American participants were underrepresented. ConclusionIn MIGS RCTs conducted in the US, White and Black or African American participants are overrepresented compared to other races, and ethnicity is characterized in fewer than one fifth of trials. Efforts should be made to improve racial and ethnic recruitment equity as well as reporting in future MIGS RCTs.

Insertion Multi-Parachute Suturing and Knotting (IMS-K) Technique for Aortic Surgery.

Successful surgical interventions for aortic surgery, such as hemiarch repair and total arch replacement, pivot on the foundation of optimal anastomosis. We propose an alternative approach to anastomosis. The "insertion multi-parachute suturing and knotting" (IMS-K) technique entails the deployment of two parachute sutures, which can be effectively employed for both proximal and distal anastomoses. The first suture is applied loosely to the posterior half of the anastomosis and subsequently parachuted down, tightening the suture with a nerve hook. The second suture replicates the procedure in the anterior half of the anastomosis, loosely securing it in a similar manner and tightening it with a nerve hook at the end. As a result, the artificial graft is completely inserted into the aorta with a substantial grip. This technique simplifies the aortic anastomosis by ensuring procedural simplicity while minimizing bleeding risk, thus potentially advancing surgical outcomes.

First Experience With Amulet in the United States: Early Insights From EMERGE LAA Postapproval Study.

The Food and Drug Administration approved the Amulet occluder (Abbott) after demonstrating safety and effectiveness in the Amulet IDE (AMPLATZER Amulet LAA Occluder) trial. The aim of the EMERGE Left Atrial Appendage study is to evaluate early postapproval outcomes of the Amulet occluder in the United States using data from the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry. Patients with a commercial Amulet occluder implant attempt between Food and Drug Administration approval (August 14, 2021) and December 31, 2022, were included. The safety composite endpoint included all-cause death, ischemic stroke, systemic embolism, or device/procedure-related events requiring open cardiac surgery or endovascular intervention between device implantation and 7days or hospital discharge (whichever is later). Major adverse events through 45days were also reported and stratified by operator experience (early [<10 cases], moderate [10-29 cases], and high [30+ cases]). A total of 5,499 patients underwent attempted Amulet occluder implantation. Implant success was 95.8%, and complete closure was 97.2% post-left atrial appendage occlusion and 87.1% at 45days. A safety composite endpoint event occurred in 0.76% patients. Any major adverse event occurred in 2.9% and 5.7% of patients in-hospital and through 45days, respectively, driven by major bleeding and pericardial effusion (PE) requiring intervention. PE requiring surgery or percutaneous intervention decreased significantly with increasing experience both in-hospital (early vs high operator experience 1.8% vs 1.1%; P = 0.006) and at 45days (2.3% vs 1.5%; P = 0.012). The EMERGE Left Atrial Appendage study demonstrates favorable safety and effectiveness of theAmulet occluder in the real-world setting. More experienced operators had improved implant success and fewerPEs,suggesting a learning curve effect implanting this dual occlusive mechanism device.

Efficacy of electroacupuncture on myocardial protection and postoperative rehabilitation in patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and Meta-analysis.

To evaluate the efficacy of electroacupuncture (EA) intervention on myocardial protection and postoperative rehabilitation in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Eight databases, including PubMed, Embase, the Cochrane Library, Web of Science, Chinese BioMedical Literature Database, China National Knowledge Infrastructure Database, Wanfang Data, China Science and Technology Journal Database, and two clinical trial registries, were searched. All randomized controlled trials (RCTs) related to EA intervention in cardiac surgery with CPB were collected. Based on the inclusion and exclusion criteria, two researchers independently screened articles and extracted data. After the quality evaluation, RevMan 5.3 software was used for analysis. Fourteen RCTs involving 836 patients were included. Compared with the control treatment, EA significantly increased the incidence of cardiac automatic rebeat after aortic unclamping [relative risk (RR) = 1.15, 95% confidence interval (CI) (1.01, 1.31), P < 0.05; moderate]. Twenty-four hours after aortic unclamping, EA significantly increased the superoxide dismutase [standardized mean difference (SMD) = 0.96, 95% CI(0.32, 1.61), P < 0.05; low], and interleukin (IL)-2 [SMD = 1.33, 95% CI(0.19, 2.47), P < 0.05; very low] expression levels and decreased the malondialdehyde [SMD =－1.62, 95% CI(－2.15, －1.09), P < 0.05; moderate], tumour necrosis factor-α [SMD = －1.28, 95% CI(－2.37, －0.19), P < 0.05; moderate], and cardiac troponin I [SMD = －1.09, 95% CI(－1.85, －0.32), P < 0.05; low] expression levels as well as the inotrope scores [SMD = －0.77, 95% CI(－1.22, －0.31), P < 0.05; high]. There was no difference in IL-6 and IL-10 expression levels. The amount of intraoperative sedative [SMD = -0.31, 95% CI(－0.54, －0.09), P < 0.05; moderate] and opioid analgesic [SMD = -0.96, 95% CI(－1.53, －0.38), P < 0.05; low] medication was significantly lower in the EA group than in the control group. Moreover, the postoperative tracheal intubation time [SMD = －0.92, 95% CI(－1.40, －0.45), P < 0.05; low] and intensive care unit stay [SMD = －1.71, 95% CI(－3.06, －0.36), P < 0.05; low] were significantly shorter in the EA group than in the control group. There were no differences in the time to get out of bed for the first time, total days of antibiotic use after surgery, or postoperative hospital stay. No adverse reactions related to EA were reported in any of the included studies. In cardiac surgery with CPB, EA may be a safe and effective strategy to reduce myocardial ischaemia-reperfusion injury and speed up the recovery of patients after surgery. These findings must be interpreted with caution, as most of the evidence was of low or moderate quality. More RCTs with larger sample sizes and higher quality are needed to provide more convincing evidence.

Effectiveness of ultrasound-guided rhomboid intercostal and sub-serratus block for perioperative analgesia in male patients undergoing combined power-assisted liposuction with pull-through excision of the gland for breast definition and reshaping.

The newly introduced ultrasound guided interfacial rhomboid intercostal and sub-serratus (RISS) block technique demonstrated promising efficacy in managing perioperative pain among patients undergoing abdominal and thoracic procedures. Thus, this study investigated the efficiency of bilateral ultrasound-guided RISS (US-RISS) as a perioperative pain control technique in male subjects receiving gynecomastia surgery. This prospective randomized study involved sixty patients who underwent gynecomastia surgery. Individuals were randomly divided into two groups: the RISS group (N.=30) and the control group (N.=30). After anesthesia induction, the patients received bilateral US-RISS using 40 mL of 0.25% levobupivacaine, or conventional intravenous analgesia with no intervention, respectively. The primary outcome was the overall morphine consumption in 24 hours, and the secondary endpoints involved the time elapsed till rescue analgesia was requested, the quality of recovery after 24 hours and side effects' incidence. Morphine consumption was noticeably decreased in the RISS group compared to the control group, with 14.07±4.91 mg and 35.83±1.70 mg mean values, respectively (P<0.001). Furthermore, in the RISS group, the initial rescue analgesia request occurred significantly later than in the control group, with mean values of 15.58±1.41 hours and 0.96±0.63 hours, respectively (P<0.001). Additionally, within the RISS group, there was a high quality of recovery observed, with a low incidence of opioid-related adverse events in comparison to the control group. Bilateral US-RISS block is a beneficial intervention in gynecomastia surgery for pain management and improves the quality of recovery.

Using Natural Language Processing and Patient Journey Clustering for Temporal Phenotyping of Antimicrobial Therapies for Cat Bite Abscesses

BackgroundTemporal phenotyping of patient journeys, which capture the common sequence patterns of interventions in the treatment of a specific condition, is useful to support understanding of antimicrobial usage in veterinary patients. Identifying and describing these phenotypes can inform antimicrobial stewardship programs designed to fight antimicrobial resistance, a major health crisis affecting both humans and animals, in which veterinarians have an important role to play. ObjectiveThis research proposes a framework for extracting temporal phenotypes of patient journeys from clinical practice data through the application of natural language processing (NLP) and unsupervised machine learning (ML) techniques, using cat bite abscesses as a model condition. By constructing temporal phenotypes from key events, the relationship between antimicrobial administration and surgical interventions can be described, and similar treatment patterns can be grouped together to describe outcomes associated with specific antimicrobial selection. MethodsCases identified as having a cat bite abscess as a diagnosis were extracted from VetCompass Australia, a database of veterinary clinical records. A classifier was trained and used to label the most clinically relevant event features in each record as chosen by a group of veterinarians. The labeled records were processed into coded character strings, where each letter represents a summary of specific types of treatments performed at a given visit. The sequences of letters representing the cases were clustered based on weighted Levenshtein edit distances with KMeans++ to identify the main variations of the patient treatment journeys, including the antimicrobials used and their duration of administration. ResultsA total of 13,744 records that met the selection criteria was extracted and grouped into 8,436 cases. There were 9 clinically distinct event sequence patterns (temporal phenotypes) of patient journeys identified, representing the main sequences in which surgery and antimicrobial interventions are performed. Patients receiving amoxicillin and surgery had the shortest duration of antimicrobial administration (median of 3.4 days) and patients receiving cefovecin with no surgical intervention had the longest antimicrobial treatment duration (median of 27 days). ConclusionOur study demonstrates methods to extract and provide an overview of temporal phenotypes of patient journeys, which can be applied to text-based clinical records for multiple species or clinical conditions. We demonstrate the effectiveness of this approach to derive real-world evidence of treatment impacts using cat bite abscesses as a model condition to describe patterns of antimicrobial therapy prescriptions and their outcomes.

Successful healing of aneurysmal false lumen using a second-generation drug-eluting stent in spontaneous coronary artery dissection: a case report

BackgroundAccording to 2023 ESC Guideline, conservative medical management is generally recommended for the treatment of spontaneous coronary artery dissection (SCAD) except for patients with signs of ongoing myocardial ischemia. However, in some cases, invasive treatment (coronary artery bypass graft surgery or percutaneous coronary intervention (PCI)) is performed because of the progression of aneurysm in SCAD. Although there is no established strategy for the management of coronary aneurysm in SCAD, we report a case of successful healing of aneurysmal false lumen (AFL) using a second-generation drug-eluting stent (DES) in SCAD.Case presentationA 44-year-old woman without any cardiovascular risk factors was transferred to our hospital due to inferior myocardial infarction. Coronary angiography (CAG) showed multiple SCADs in the coronary artery. We performed PCI to the distal right coronary artery (RCA) because the RCA showed severe stenosis (99%) with bradycardia. Six days after the first PCI, SCAD relapsed in the mid left anterior descending artery (LAD). Furthermore, AFL was observed by intravascular ultrasound imaging. To avoid enlargement of the AFL and progression of the dissection toward the proximal site of the LAD, we performed PCI to the mid LAD to seal the entry tear of the dissection using a second-generation DES. CAG revealed that the AFL in the mid LAD completely diminished at 1 year after PCI.ConclusionsThe implantation of a second-generation DES might be one of therapeutic options for sealing AFL in SCAD patients.

Internal iliac debranching in combination with abdominal aortic stent graft to treat bilateral common iliac aneurysms

Introduction&#x0D; Common iliac artery aneurysms are often diagnosed during routine screening for infrarenal abdominal aortic aneurysms. Preserving the internal iliac artery helps avoid colonic ischemia and buttocks claudication. Hybrid surgery combining internal iliac artery transposition and endovascular treatment is a method with good early and long-term results.&#x0D; Methods&#x0D; We report of a case of bilateral common iliac artery aneurysm treated by hybrid surgery and endovascular intervention at Dong Nai General Hospital&#x0D; Results&#x0D; A 69 year-old male, diagnosed with bilateral common iliac artery aneurysm and left internal iliac artery occlusion. Surgical transposition was performed to repimplant the right internal iliac artery into the right external iliac artery, folowed by endovascular treatment, the right branch of the graft was placed at the external iliac artery, the left branch of the graft was placed at the common iliac artery. Postoperative condition was stable, no early complications recorded&#x0D; Conclusion&#x0D; Hybrid surgery to treat iliac aortic aneurysms and common iliac artery aneurysms has quite good mid- and long-term results. The initial successful implementation of this technique at Dong Nai General Hospital contributes to team development, reduces the load on central hospitals and brings practical benefits to patients.

Association of Glutamate Infusion With Risk of Acute Kidney Injury After Coronary Artery Bypass Surgery

Acute kidney injury (AKI) after cardiac surgery is associated with increased morbidity and mortality, and measures to prevent AKI have had limited success. Glutamate has been reported to enhance natural postischemic recovery of the heart, but not among animals and humans with diabetes. To summarize pooled results from the GLUTAMICS (Glutamate for Metabolic Intervention in Coronary Surgery) trials regarding the effect of glutamate on postoperative AKI among patients without diabetes undergoing coronary artery bypass graft (CABG) surgery. Data on a total of 791 patients without diabetes from 2 prospective, randomized, double-blind multicenter trials performed at 5 cardiac surgery centers in Sweden between October 4, 2005, and November 12, 2009, and between November 15, 2015, and September 30, 2020, were pooled. Patients had acute coronary syndrome, left ventricular ejection fraction of 0.30 or less, or a European System for Cardiac Risk Evaluation II score of 3.0 or more and underwent CABG with or without additional valve procedure. Statistical analysis was performed from May to November 2023. Intravenous infusion of 0.125-M l-glutamic acid or saline at 1.65 mL/kg/h for 2 hours during reperfusion, after which the infusion rate was halved and an additional 50 mL was given. The primary end point was AKI, defined as postoperative increase of plasma creatinine of 50% or more, corresponding to the Risk stage or higher in the Risk, Injury, Failure, Loss, and End-Stage kidney disease (RIFLE) criteria. A total of 791 patients without diabetes (391 who received glutamate [mean (SD) age, 69.3 (9.1) years; 62 women (15.9%)] and 400 controls [mean (SD) age, 69.6 (9.5) years; 73 women (18.3%)]) were randomized. Baseline data did not differ between groups. Glutamate was associated with a significantly lower risk of AKI (relative risk, 0.49 [95% CI, 0.29-0.83]). Dialysis was required for 2 patients in the glutamate group and 5 patients in the control group. In multivariable analysis, glutamate remained significantly associated with a protective effect against AKI (odds ratio, 0.47 [95% CI, 0.26-0.86]). In the glutamate and control groups, the rate of postoperative mortality at 30 days or less was 0.5% (2 of 391) vs 1.0% (4 of 400), and the rate of stroke at 24 hours or less was 0.8% (3 of 391) vs 1.8% (7 of 400). In this pooled analysis of 2 randomized clinical trials, infusion of glutamate was associated with a markedly lower risk of AKI after CABG among patients without diabetes. The findings are exploratory and need to be confirmed in prospective trials. ClinicalTrials.gov Identifiers: NCT00489827 and NCT02592824.

Functional anatomy of the orbit in strabismus surgery: Connective tissues, pulleys, and the modern surgical implications of the "arc of contact" paradigm.

Oculomotricity is a multidimensional domain characterised by a delicate interplay of anatomical structures and physiological processes. This manuscript meticulously dissects the nuances of this interplay, bringing to the fore the integral role of the extraocular muscles (EOMs) and their intricate relationship with the myriad orbital connective tissues as it harmoniously orchestrates binocular movements, ensuring synchronised and fluid visual tracking. Historically, the peripheral oculomotor apparatus was conceptualised as a rudimentary system predominantly driven by neural directives. While widely accepted, this perspective offered a limited view of the complexities inherent in ocular movement mechanics. The twentieth century heralded a paradigm shift in this understanding. With advances in anatomical research and imaging techniques, a much clearer picture of the gross anatomy of the EOMs emerged. This clarity challenged traditional viewpoints, suggesting that the inherent biomechanical properties of the EOMs, coupled with their associated tissue pulleys, play a pivotal role in dictating eye movement dynamics. Central to this revised understanding is the "arc of contact" paradigm. This concept delves deep into the mechanics of eye rotation, elucidating the significance of the point of contact between the EOMs and the eyeball. The arc of contact is not just a static anatomical feature; its length and orientation play a crucial role in determining the effective torque generated by a muscle, thereby influencing the amplitude and direction of eye rotation. The dynamic nature of this arc, influenced by the position and tension of the muscle pulleys, offers a more comprehensive model for understanding ocular kinematics. Previously overlooked in traditional models, muscle pulleys have now emerged as central players in the biomechanics of eye movement. These anatomical structures, formed by dense connective tissues, guide the paths of the EOMs, ensuring that their pulling angles remain optimal across a range of gaze directions. The non-linear paths resulting from these pulleys provide a more dynamic and intricate understanding of eye movement, challenging two-dimensional, linear models of orbital anatomy. The implications of these revelations extend beyond mere theoretical knowledge. The insights garnered from this research promise transformative potential in the realm of strabismus surgery. Recognising the pivotal role of muscle pulleys and the "arc of contact" paradigm allows for more precise surgical interventions, ensuring better post-operative outcomes and minimising the risk of complications. Surgical procedures that previously relied on basic mechanical principles now stand to benefit from a more nuanced understanding of the underlying anatomical and physiological dynamics. In conclusion, this manuscript serves as a testament to the ever-evolving nature of scientific knowledge. Challenging established norms and introducing fresh perspectives pave the way for more effective and informed clinical interventions in strabismus surgery.

Complications after pylori-preserving pancreatoduodenal resection in a 14-year-old girl with a solid pseudopapillary tumor of the pancreas

Pancreatoduodenal resection (PDR) is one of the most difficult surgical interventions in abdominal surgery of childhood. We present our clinical observation of a postoperative complication in a 14-years-old girl.The girl was operated on for a solid pseudopapillary tumor of the head of the pancreas, laparoscopically assisted pylori-preserving PDR was performed, mobilization and removal of the tumor was performed, distally between the stump of the pancreas and the Roux-en-Y loop of pancreatoejunoanastomo was formed. Mechanical jaundice occurred in the late postoperative period. Percutaneous transhepatic cholangiostomy, recanalization of hepaticoejunoanastomosis with the formation of external-internal transhepatic drainage was performed. 5 courses of balloon dilation of the stricture of the biliodigestive anastomosis were performed later.We demonstrate some complications of PDR in children and show possible options for their correction.

Results of horizontal strabismus surgery in the period from 2017 to 2023 at the Clinic for Eye Diseases Tuzla

Aim: To evaluate results of surgical intervention of horizontal strabismus or to evaluate results of horizontal strabismus surgery intervention and to identify factors that influence the success of the surgery. Medical documentation of 144 patients that have done their first horizontal strabismussurgery at the Clinic for Eye Diseases in Tuzla from February 2017 until February 2023. Main measure of successful surgery was defined as an eye deviation no more than 10 prism diopters 2 years after the surgery. Results of post-operative binocular vision and vision acuity improvements were analyzed. Pre-operative deviation, diagnosis, binocular function, visual acuity and age were analyzed as factors that influence the success of the surgery.Patients and methods: Patients were divided into 2 groups, first under the age of 7 (48.6%) and above the age of 7 (51.4%). In order to assess set goals of the research, Chi square test, Wilcoxon matched-pairs signed-rank test and logistic regression analysis with forced entry were used. Average age of the respondents was 9.67±4.15 years old (med. 8, mod. 7, min. 5 and max 20), while 69 (47.9%) had esotropia and 75 (52.1%) had exotropia. Average pre-operative deviation was 6.62±42.28 PD, (median 0, modus 60 PD), while minimum and maximum deviation was in range from -60 PD to +35 PD. Average post-operative deviation was 5.46±10.06 PD.Results:Success of the surgery for esotrpia was 49.3% and for 97.3%. Before surgery, 13 (9%) had binocular vision, and after the surgery 80 (55.6%) of the respondents had the binocular vision. Success rate of the surgery was 67.1% for respondents younger than 7 and was 81.1% for the respondents older than 7.Conlusion: No statistically significant improvement for vision acuity was observed.

Impact of Comorbidities as Predictors on Hospital Length of Stay (LOS) and Mortality in Hip Fracture (HF) Patients in a Rural Community

Purpose: Studies on HF at a rural health system area are rare. The research question is “Which demographic, preoperative variables would be independent predictors of outcomes on mortality and hospital LOS?”&#x0D; Methods: The design is a community-based cross-sectional study with risk factor analyses. We ascertained HF cases from hospital trauma center registry and Epic software. We employed both descriptive and analytic approaches including multivariable regression analyses of predictors on outcomes.&#x0D; Results: Of 201 HF patients, 85.6% occurred in 65 and above years (seniors). Among seniors, females consisted of 64.0% with mean age ± SD: 83.72 ± 7.56 years; extracapsular HF, 55.2%; specified falls, 51.7%; obesity, 15.2%; complication, 3.5%; surgery interventions, 80.8%; mortality within 1, 9.3%; 3, 11.6%; 6, 15.1%; and 12 months, 22.1% after hospital admission. Holding all other variables constant, no surgical intervention increased mortality risk within 1-month (OR=28.87, 95% CI: 4.43; 188.16), 3-months (OR=33.47; 95% CI: 5.24; 213.88), 6-months (OR=21.78; 95% CI: 3.67; 129.48), and 12-months (OR=4.17; 95% CI: 1.33;13.04) compared to surgical intervention; obesity increased 1-month mortality risk (OR=6.00; 95% CI: 1.06; 34.09) compared to no obesity; and patients transferred from community hospital compared to those who were not had an increased 1-month (OR= 8.54; 95% CI: 1.25; 58.13), 3-month (OR=15.31; 95% CI: 2.21; 106.16), 6-month (OR=21.19; 95% CI: 3.34; 134.43), and 12-month (OR=5.14; 95% CI: 1.85; 14.28) mortality risk. Hospital LOS was 3.06 days higher in obese patients than non-obese patients and 2.11 days higher in surgery greater than 48 hours when compared to surgery within 48 hours, holding all other variables constant.&#x0D; Conclusions and Potential Impact: We believe that surgical intervention decreases, and obesity increases HF mortality. Obesity and delayed surgical intervention increase hospital LOS. The results of this study have the potential benefit for improving community health of rural, elderly populations in northeast Indiana.

Advancements in Laser Eye Surgery Through Sectional Study

Background: Laser in situ corneal surgery (LASIK) This technique has been considered as the most widespread and most widely performed refractive intervention in eye surgery in the world, which may show a high satisfaction index among patients after surgery. Objective: This study aimed to evaluate the results of vision quality for patients suffering from myopia and astigmatism after LASIK surgery. Patients and methods: We conducted a cross-sectional study of 74 patients ages 28-54 who suffered from myopia and astigmatism who underwent LASIK surgery. This study extended from February 16, 2022, to September 9, 2023. This study determined the importance of LASIK surgery in improving the visual function of patients in the long term in terms of satisfaction and happiness after surgery, functional improvement, and achieving the expected quality of vision. Results: Our results found that the percentage of males, which included 47 patients, was greater than that of females, which included 27 patients. The data for both surgery time were (22.46 ± 0.8) minutes, and corneal thickness was (498 ± 4.0 microns, recovery time was (3.6 ± 2.4) days. Our outcomes found that the surgery to be a good option, and it was 98%. The main goal was achieved. It was 96%. They were satisfied with the result. It was 95.40%. Happiness after LASIK was 99%. Conclusion: LASIK surgery has shown that the surgical procedure is the most healing, the quickest to perform, and the safest, which increases functional improvement and which contributes significantly.&#x0D; Great quality optical resolution. Our results confirm that there is great patient satisfaction with LASIK surgery, which is attributed to the quality of this surgery, which improves visual ability in a safer and more accurate way.