Showing papers by "Bethesda Hospital published in 2020"

Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study.

Abstract: Background The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide However, little is known about the causes of death and the virus's pathologic features Objective To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests Design Prospective cohort study Setting Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19 Patients The first 12 consecutive COVID-19-positive deaths Measurements Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed Clinical data and medical course were evaluated Results Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2) Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively) Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart Limitation Limited sample size Conclusion The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it Primary funding source University Medical Center Hamburg-Eppendorf

Neurologic characteristics in coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

Abstract: Importance: Coronavirus disease 2019 (COVID-19) is a newly emerging infectious disease that has caused a global pandemic. The presenting symptoms are mainly respiratory symptom, yet studies have reported nervous system involvement in the disease. A systematic review and meta-analysis of these studies are required to understanding the neurologic characteristic of the disease and help physicians with early diagnosis and management. Objective: To conduct a systematic review and meta-analysis on the neurologic characteristics in patients with COVID-19. Evidence Review: Authors conducted a literature search through PubMed from January 1st, 2020 to April 8th, 2020. Furthermore, the authors added additional sources by reviewing related references. Studies presenting the neurologic features of COVID-19 patients in their data were included. Case reports and case series were also included in this review. The quality of the studies was assessed based on the Oxford Center for Evidence-Based Medicine guidelines. Selected studies were included in the meta-analysis of proportion and the heterogeneity test. Finding: From 280 identified studies, 33 were eligible, with 7,559 participants included. Most of the included studies were from China (29 [88%]). Muscle injury or myalgia was the most common (19.2%, 95%CI 15.4-23.2%) neurologic symptom of COVID-19, followed by headache (10.9%, 95%CI 8.62-13.51%); dizziness (8.7%, 95%CI 5.02-13.43%); nausea with or without vomiting (4.6%, 95%CI 3.17-6.27%); concurrent cerebrovascular disease (4.4%, 95%CI 1.92-7.91%); and impaired consciousness (3.8%, 95%CI 0.16-12.04%). Underlying cerebrovascular disease was found in 8.5% (95%CI 4.5-13.5%) of the studies. Conclusion: Neurologic findings vary from non-specific to specific symptoms in COVID-19 patients. Some severe symptoms or diseases can present in the later stage of the disease. Physicians should be aware of the presence of neurologic signs and symptoms as a chief complaint of COVID-19, in order to improve management and prevent a worsening outcome of the patients.

Evidence-based guidelines for managing patients with primary ER+ HER2− breast cancer deferred from surgery due to the COVID-19 pandemic

Abstract: Many patients with ER+ HER2− primary breast cancer are being deferred from surgery to neoadjuvant endocrine therapy (NeoET) during the COVID-19 pandemic. We have collated data from multiple international trials of presurgical endocrine therapy in order to provide guidance on the identification of patients who may have insufficiently endocrine-sensitive tumors and should be prioritised for early surgery or neoadjuvant chemotherapy rather than NeoET during or in the aftermath of the COVID-19 pandemic for safety or when surgical activity needs to be prioritized. For postmenopausal patients, our data provide strong support for the use of ER and PgR status at diagnosis for triaging of patients into three groups in which (taking into account clinical factors): (i) NeoET is likely to be inappropriate (Allred ER 10%) indicates a higher priority for early surgery. Too few data were available for premenopausal patients to provide a similar treatment algorithm. These guidelines should be helpful for managing patients with early ER+ HER2− breast cancer during and in the aftermath of the COVID-19 crisis.

Vitamin D deficiency among patients with COVID-19: case series and recent literature review

Abstract: The world is now challenging the pandemic of COVID-19 infection. This is the third and most extensive pandemic. Previous studies showed the plausibility of vitamin D prophylaxis and therapy for COVID-19, particularly in settings where hypovitaminosis D is frequent. Recent study from Indonesian showed that the prevalence of vitamin D deficiency was 23.0%. The examination of vitamin D status is not a routine in the Indonesian clinical setting. This study is a case series from confirmed cases of COVID-19 in Bethesda Hospital Yogyakarta Indonesia. The data of clinical symptoms, signs and laboratory examinations were obtained from the electronic medical records. The vitamin D status was measured by Enzyme-Linked Fluorescent Assay (ELFA) method. We searched PubMed and Google Scholar for studies that included terms for Vitamin D and COVID-19. The data were obtained from 10 participants consisting of 50% male and 50% female. The mean age was 49.6 years. The prevalence of vitamin D deficiency in this study was 90% (vitamin D levels < 20 ng/mL) and 10% of insufficiency (vitamin D levels < 30 ng/mL). Patients in this study had various symptoms such as fatigue (60%), fever (50%), dry cough (40%), non-specific headache (10%), and diarrhea (10%); have no symptoms (20%); and also had the various chronic diseases as comorbidity such as hypertension (40%), diabetes (10%), COPD (10%), and post stroke (10%). All of the COVID-19 patients in this study had hypovitaminosis D. The prevalence of vitamin D deficiency in this case series is 90% and only 1 patient (10%) had vitamin D insufficiency. There are many health benefits of vitamin D and very few adverse effects. Randomized controlled trials need to determine and evaluate this recommendation in preventing or treating COVID-19. Clinicians should continue to treat people with vitamin D deficiency especially in managing COVID-19 patients.

Teaching Heuristics and Mnemonics to Improve Generation of Differential Diagnoses

Abstract: Background: Differential diagnosis (DDx) is one of the key cognitive skills that medical learners must develop. However, little is known regarding the best methods for teaching DDx skills. As metac...

Practice Advisory on the Appropriate Use of NSAIDs in Primary Care

Abstract: Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.

Longitudinal study on nerve ultrasound and corneal confocal microscopy in NF155 paranodopathy.

Abstract: We report the case of a 27-year-old patient with subacute anti-neurofascin-155 neuropathy with bifacial palsy, who showed excellent response to rituximab. We provide longitudinal data of established clinical scores, nerve conduction studies, antibody titers, and novel imaging methods (nerve ultrasonography and corneal confocal microscopy). Clinical and electrophysiological improvement followed the reduction of serum antibody titer and correlated with a reduction of corneal inflammatory cellular infiltrates whereas the increase in the cross-sectional area of the peripheral nerves remained 12 months after first manifestation. Our findings suggest that novel techniques provide useful follow-up parameters in paranodopathies.

Characteristics of metastatic brachial plexopathy in patients with breast cancer.

Abstract: Brachial plexopathy in cancer patients is a rare but significant complication that causes pain and disability of the upper extremities. Clinical features of breast cancer patients with metastatic brachial plexopathy (MBP) have not been studied. We aimed to investigate the characteristics of MBP in breast cancer patients. We retrospectively reviewed medical records of patients with breast cancer with MBP who visited Asan Medical Center from 2000 to 2016; we enrolled 44 patients. We comprehensively reviewed the characteristics, range of metastatic lymph nodes, initial symptoms, location, and severity of brachial plexus injury by electrodiagnostic study, radiologic findings, and associated complications. The mean age of patients with MBP was 51.9 ± 9.3 years; 25% were diagnosed with stage IV breast cancer at initial diagnosis. Weakness was the most common initial symptom of MBP (52.3%). Most patients showed limitation of shoulder range of motion and pain; 66% of patients exhibited malignant lymphedema. Forty-one patients were evaluated by electromyography; upper nerve trunk involvement (22.0%) was more frequent than lower nerve trunk involvement (9.8%). Nineteen patients underwent brachial plexus MRI, and supraclavicular area (SCA) metastasis was most frequent (57.9%). Sixteen patients were examined by both brachial plexus MRI and electromyography; patients with SCA metastasis exhibited significantly more frequent malignant lymphedema (p = 0.019) and upper nerve trunk involvement (p = 0.035), compared with patients with non-SCA metastasis. Our study revealed clinical features of MBP in breast cancer patients. Additional diagnostic evaluation focused on metastasis or aggravated metastatic tumor is needed when breast cancer patients are diagnosed with brachial plexopathy.

Demographic and procedural characteristics in the RECording COurses of vasculaR Diseases (RECCORD) registry - the first 1000 patients.

Abstract: Summary: Background: The RECcording COurses of vasculaR Diseases (RECCORD) registry established by the German Society of Angiology – Society for Vascular Medicine aimed to address the lack in conte...

Intrapartum non-invasive electrophysiological monitoring: A prospective observational study.

Abstract: Introduction Doppler ultrasound cardiotocography is a non-invasive alternative that, despite its poor specificity, is often first choice for intrapartum monitoring. Doppler ultrasound suffers from signal loss due to fetal movements and is negatively correlated with maternal body mass index (BMI). Reported accuracy of fetal heart rate monitoring by Doppler ultrasound varies between 10.6 and 14.3 bpm and reliability between 62.4% and 73%. The fetal scalp electrode (FSE) is considered the reference standard for fetal monitoring but can only be applied after membranes have ruptured with sufficient cervical dilatation and is sometimes contra-indicated. A non-invasive alternative that overcomes the shortcomings of Doppler ultrasound, providing reliable information on fetal heart rate, could be the answer. Non-invasive fetal electrocardiography (NI-fECG) uses a wireless electrode patch on the maternal abdomen to obtain both fetal and maternal heart rate signals as well as an electrohysterogram. We aimed to validate a wireless NI-fECG device for intrapartum monitoring in term singleton pregnancies, by comparison with the FSE. Material and methods We performed a multicenter cross-sectional observational study at labor wards of 6 hospitals located in the Netherlands, Belgium, and Spain. Laboring women with a healthy singleton fetus in cephalic presentation and gestational age between 36 and 42 weeks were included. Participants received an abdominal electrode patch and FSE after written informed consent. Accuracy, reliability, and success rate of fetal heart rate readings were determined, using FSE as reference standard. Analysis was performed for the total population and measurement period as well as separated by labor stage and BMI class (≤30 and >30 kg/m2 ). Results We included a total of 125 women. Simultaneous registrations with NI-fECG and FSE were available in 103 women. Overall accuracy is -1.46 bpm and overall reliability 86.84%. Overall success rate of the NI-fECG is around 90% for the total population as well as for both BMI subgroups. Success rate dropped to 63% during second stage of labor, similar results are found when looking at the separate BMI groups. Conclusions Performance measures of the NI-fECG device are good in the overall group and the separate BMI groups. Compared with Doppler ultrasound performance measures from the literature, NI-fECG is a more accurate alternative. Especially, when women have a higher BMI, NI-fECG performs well, resembling FSE performance measures.

Effectiveness and safety of insulin glargine 300 U/mL in insulin‐naïve patients with type 2 diabetes after failure of oral therapy in a real‐world setting

Abstract: Aim To evaluate the effectiveness and safety of initiating basal insulin-supported oral therapy (BOT) with insulin glargine 300 U/mL (Gla-300) in patients with type 2 diabetes inadequately controlled on oral antidiabetic drugs (OADs). Materials and methods This non-interventional, multi-centre, prospective 52-week study, conducted in Germany and Switzerland, documented patients with type 2 diabetes with an HbA1c of between 7.5% and 10.0%, currently treated with OADs, after the physician had decided to start a BOT regimen with Gla-300. The primary endpoint was the rate of achievement of the individualized predefined HbA1c target. Results Of 1748 patients included, 1153 comprised the full analysis set, of whom 721 completed documentation of 12 months of Gla-300 treatment. Twelve months after starting Gla-300, 49.9% achieved their individualized HbA1c target, and 61.1% achieved either their HbA1c target or a fasting plasma glucose (FPG) of ≤110 mg/dL. Mean HbA1c decreased by -1.22% ± 1.05% to 7.28% ± 0.92% and mean FPG by -51.5 (±48.63) mg/dl to 132.9 ± 33.0 mg/dL. Median duration of HbA1c target achievement was 341 days and probability to remain on target after 6 months was 81%. Hypoglycaemia incidence and rates remained low after 12 months of Gla-300 treatment; no severe or severe nocturnal hypoglycaemia was observed. Body weight remained unchanged. Conclusions Starting a BOT regimen with Gla-300 allowed about 60% of 721 German and Swiss patients with inadequately controlled type 2 diabetes to achieve glycaemic control within 12 months in daily clinical practice. Glycaemic control was achieved without weight gain or increased risk of nocturnal or severe hypoglycaemia.

HIV treatment outcomes among people with initiation CD4 counts >500 cells/µL after implementation of Treat All in South African public clinics: a retrospective cohort study.

Abstract: Introduction The World Health Organisation recommends to Treat All people with HIV, irrespective of CD4 count. However, people with CD4 counts >500 cells/µL may be asymptomatic and therefore less motivated to adhere to antiretroviral therapy (ART). We aimed to assess whether people initiated with CD4 counts >500 cells/µL had worse treatment outcomes compared to those initiated at lower CD4 counts. Methods We performed a retrospective cohort study among non-pregnant adults initiating ART at eight public clinics in South Africa between September 2016, when Treat All was implemented, and August 2017. We assessed whether initiation CD4 count >500 cells/µL was associated with the outcomes of attrition (death, lost to follow-up or treatment interruption >180 days), and viraemia >1000 copies/mL, by twelve months using Cox proportional hazards and Poisson regression models. Results and discussion Among 4952 patients initiating ART, the median age was 32.4 years (interquartile range (IQR) 27.2 to 39.7), 58.9% were women and 30.3% had an initiation CD4 count >500 cells/µL. After twelve months, 3382 (68.3%) were retained in care, 303 (6.1%) had transferred to another clinic, 1010 (20.4%) were lost to follow-up, 232 (4.7%) had a treatment interruption >180 days and 25 (0.5%) were known to have died. Overall, 1267 experienced attrition at a median time of 91 days (IQR 23 to 213), with 302 of these (23.8%) experiencing attrition immediately after their ART initiation visit. Among those in care at twelve months with viral load results, 4.6% had viraemia. In multivariable analysis, the hazard of attrition was similar between patients newly eligible for ART with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted hazard ratio 1.03, 95% confidence interval (CI) 0.90 to 1.17). The risk of viraemia was lower among patients with CD4 counts >500 cells/µL compared to those with CD4 ≤500 cells/µL (adjusted risk ratio 0.58, 95% CI 0.37 to 0.92). Conclusions After implementation of Treat All in South African public clinics, we found that patients newly eligible for ART with initiation CD4 counts >500 cells/µL had comparable or better outcomes compared to those with lower CD4 counts. These finding support ongoing implementation of Treat All in our setting.

Incarcerated Spigelian Hernias: A Rare Cause of a High-grade Small Bowel Obstruction.

Abstract: A Spigelian hernia is a very rare hernia, making up approximately 0.1% of all abdominal wall hernias. This hernia goes through a defect in the Spigelian fascia which is the part of the transversus abdominis aponeurosis lateral to the rectus muscle, often at the level of the arcuate line, where the fascia is widest and weakest. We present the case of a 77-year-old female with no past surgical history who presented to our teaching hospital with high-grade small bowel obstruction secondary to an incarcerated Spigelian hernia. She was taken to the operating room for a laparotomy and a portion of the small bowel mesentery was found to be strangulated. The hernia was reduced, and the defect was repaired primarily. The diagnosis of a Spigelian hernia can often be difficult to diagnose on history and physical examination alone, but computed tomography (CT) imaging can be a valuable adjunct in diagnosis. Prompt surgical treatment should ensue when the diagnosis of high-grade bowel obstruction is made in a patient with imaging findings consistent with a Spigelian hernia.

Guidance and Standards for Breast Cancer Care in Europe.

Abstract: The increasing incidence and mortality rates of breast cancer have led to the necessity of initiating and developing clinical practice guidelines in order to optimize cancer control and provide patients with the best care. These guidelines are either national or issued by reputed relevant European societies-like European Society for Medical Oncology. Many of the recommendations are concordant in-between the guidelines. However, there are still considerable discrepancies to be noted between guidelines from different European countries, which could hinder physicians from implementing their recommendations. The present paper summarizes and compares the recommendations included in the various European guidelines.

Current Perspectives of the Australian Knee Society on Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction.

Abstract: CONTEXT The importance of rehabilitation and evaluation prior to return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction has been reported. OBJECTIVE This study sought to investigate current perspectives of Australian orthopedic surgeons on rehabilitation and RTS evaluation. DESIGN Survey. PARTICIPANTS Members of the Australian Knee Society. MAIN OUTCOME MEASURES A 14-question survey was disseminated to Australian Knee Society members (orthopedic surgeons) to investigate (1) preferred graft choice, (2) estimated retear rate, (3) importance of preoperative and postoperative rehabilitation, and (4) preferred timing of RTS and evaluation prior to RTS discharge. RESULTS Of all 85 Australian Knee Society members contacted, 86% (n = 73) responded. Overall, 66 respondents (90.4%) preferentially used hamstring tendon autografts. All surgeons estimated their retear rate to be ≤15%, with 31 (42.5%) <5%. Twenty-eight surgeons (38.4%) reported no benefit in preoperative rehabilitation. The majority of surgeons (82.2%-94.5%) reported that postoperative rehabilitation was important within various periods throughout the postoperative timeline. Most surgeons did not permit RTS until ≥9 months (n = 56, 76.7%), with 17 (23.3%) allowing RTS between 6 and 9 months. The most highly reported considerations for RTS clearance were time (90.4%), functional capacity (90.4%), and strength (78.1%). Most commonly, knee strength and/or function was assessed via referral to a preferred rehabilitation specialist (50.7%) or with the surgeon at their practice (11.0%). CONCLUSIONS This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS evaluation. This is despite the current evidence demonstrating the benefit of preoperative and postoperative rehabilitation, as well as the emerging potential of RTS assessments consisting of strength and functional measures to reduce reinjury rates.

Effects of Bag Mask Ventilation and Advanced Airway Management on Adherence to Ventilation Recommendations and Chest Compression Fraction: A Prospective Randomized Simulator-Based Trial.

Abstract: The role of advanced airway management (AAM) in cardiopulmonary resuscitation (CPR) is currently debated as observational studies reported better outcomes after bag-mask ventilation (BMV), and the only prospective randomized trial was inconclusive. Adherence to CPR guidelines ventilation recommendations is unknown and difficult to assess in clinical trials. This study compared AAM and BMV with regard to adherence to ventilation recommendations and chest compression fractions in simulated cardiac arrests. A total of 154 teams of 3-4 physicians were randomized to perform CPR with resuscitation equipment restricting airway management to BMV only or equipment allowing for all forms of AAM. BMV teams ventilated 6 ± 6/min and AAM teams 19 ± 8/min (range 3-42/min; p < 0.0001 vs. BMV). 68/78 BMV teams and 23/71 AAM teams adhered to the ventilation recommendations (p < 0.0001). BMV teams had lower compression fractions than AAM teams (78 ± 7% vs. 86 ± 6%, p < 0.0001) resulting entirely from higher no-flow times for ventilation (9 ± 4% vs. 3 ± 3 %; p < 0.0001). Compared to BMV, AAM leads to significant hyperventilation and lower adherence to ventilation recommendations but favourable compression fractions. The cumulative effect of deviations from ventilation recommendations has the potential to blur findings in clinical trials.

Effect of the Dutch Hip Fracture Audit implementation on mortality, length of hospital stay and time until surgery in elderly hip fracture patients; a multi-center cohort study.

Abstract: Background In 2040 the estimated number of people with a hip fracture in the Netherlands will be about 24,000. The medical care for this group of patients is complicated and challenging. Multidisciplinary approaches aim to improve clinical outcome. Quality indicators that gain insight in the treatment and outcome of hip fracture patients may help to optimize and monitor the standard of medical care. The Dutch Hip Fracture Audit (DHFA) is a new multidisciplinary quality indicator that is implemented in the Dutch hospitals in 2017. Aim The aim of this study was to determine the effect of the implementation of the DHFA on 30-day mortality, length of hospital stay and time until surgery in elderly with a hip fracture in the Netherlands. Methods A multicenter retrospective comparative cohort study was conducted and data were extracted from the Dutch Nationwide Trauma Registration (LTR). Included were patients aged 60 years and older with a hip fracture (femoral neck and trochanteric) and admitted in one of the ten participating hospitals registered in 2015 and 2017. Data from 2015, before implementation of DHFA, were compared with data from 2017, when the DHFA was implemented. The primary outcome was 30-day mortality; secondary outcomes were length of hospital stay and time until surgery. Multivariable regression models were used to compare outcomes between groups. Results 3808 patients were included, 1839 in the 2015 cohort and 1969 in the 2017 cohort. 29% was male; mean age 82 years. The multilevel analysis showed a positive non-significant difference between groups on the primary outcome30-day mortality (OR adjusted 1.23, 95%CI 0.93 - 1.63). The secondary outcomes length of hospital stay (adjusted effect estimates -0.002, 95%CI -0.03 - 0.03) and time until surgery (adjusted effect estimates 0.292, 95%CI -2.68 - 3.26) showed no differences between groups. Conclusions Implementation of the DHFA quality indicator does have a positive non-significant trend on 30-day mortality, but showed no impact on length of hospital stay and time until surgery. More research on relevant quality indicators seems therefore mandatory.

Adenomyosis: diagnostics and treatment

Abstract: Adenomyosis is a frequent additional condition in patients with endometriosis and should be included in diagnostic and treatment concepts. Description of diagnostic and therapeutic approaches in patients with adenomyosis in relation to patient age, family planning status, peritoneal and/or deep endometriosis and symptoms. The current literature on adenomyosis including case reports was analyzed. Due to the lack of evidenced-based approaches the most probable trends in diagnostics and treatment are discussed. Adenomyosis plays an important role in fertile patients with dysmenorrhea, dyspareunia and pelvic pain, with or without additional peritoneal or deep endometriosis. It has a negative impact on fertility and can cause a variety of symptoms. The disease can be diagnosed by a skilled examiner and treatment concepts exist. Adenomyosis can be diagnosed by a combination of clinical history, gynecological examination, transvaginal ultrasound and magnetic resonance imaging. Various medical and surgical treatment approaches are available to reduce symptoms and to increase fertility. The course of action depends on the family planning status of the patient.

Study of onchocerciasis-related visual impairment in North Kivu province of the Democratic Republic of Congo in Africa

Abstract: Purpose: The Objective of this study is to determine baseline data regarding onchocercal eye lesions and associated visual loss in the Nord Kivu province, an onchocerciasis hyperendemic tropical rain forest area in the Democratic Republic of Congo (DRC). Methods: A cross-sectional study was conducted in the Nord Kivu province of the DRC during which 2150 subjects were examined ophthalmologically. The eye examination included visual acuity (VA), slit-lamp examination, ophthalmoscopy, intraocular pressure, and visual field assessment by the confrontation test. Patients with suspicion of glaucoma were further evaluated by Humphreys automated perimeter. Results: 39 (1.81%) out of 2150 subjects had onchocerciasis-related eye lesions and 4 (0.19%) were blind (VA

High-output chyloperitoneum following laparoscopic Nissen fundoplication treated with retrograde transvenous thoracic duct embolization

Abstract: Iatrogenic injury of the thoracic duct with clinical significant chyloperitoneum is a rare complication of abdominal surgery. Chyloperitoneum following laparoscopic Nissen fundoplication has been described in a few cases only. Most interventionists use the antegrade transperitoneal approach for thoracic duct embolization. A 61-year-old woman had been operated with laparoscopic Nissen fundoplication and hiatoplasty. A few weeks later she presented with high-output chyloperitoneum due to large leakage of the proximal thoracic duct. Conservative treatment and conventional transnodal lymphangiography did not result in a significant improvement. Thoracic duct embolization via retrograde transvenous access was challenging but both technically and clinically successful. To the best of our knowledge, this is the first case-report about thoracic duct embolization with retrograde transvenous access in the rare situation of chylous ascites following laparoscopic fundoplication. Thoracic duct embolization with the seldom used retrograde transvenous access may be the more physiologic and safer route in doing this and might be used as treatment of first choice.

Effects of Eperisone Hydrochloride and Non-Steroid Anti-Inflammatory Drugs (NSAIDs) for Acute Non-Specific Back Pain with Muscle Spasm: A Prospective, Open-Label Study

Abstract: Background Low back pain (LBP) occurs as a common condition and may harm the patient's quality-of-life. Non-steroid anti-inflammatory drugs (NSAIDs) and eperisone form a drug regiment that has been reported as effective in improving low back pain, yet the evidence for its efficacy and safety is lacking. Objective The aim of this study was to evaluate the effect of eperisone hydrochloride and ibuprofen compared with ibuprofen alone in reducing symptoms of patients with acute non-specific back pain with a muscle spasm. Methods This was an open-label, prospective study involving 100 subjects with symptoms of back pain and muscle spasm. Eligible participants were randomly allocated to an experimental group (54 patients) and a control group (46 patients). The experimental group received eperisone 50 mg three times daily + ibuprofen 400 mg twice daily, and the control group received ibuprofen 400 mg twice daily over a 4-week duration. The primary outcomes were measured with the visual analog scale (VAS), and finger-to-floor (FTF) distance at baseline, week 2, and week 4. Results After 4 weeks of follow-up, results from 59 subjects were collected. In both groups, VAS and FTF were decreased compared to baseline. Clinically significant pain reduction (>50% than baseline) was observed to be higher in the experimental group compared with the control group in the fourth week (72.4% vs 46.7%, P 0.05). Conclusion The combination of eperisone hydrochloride and ibuprofen effectively reduces pain and improves functional outcomes over ibuprofen alone with a similar safety profile in these patients with acute non-specific back pain with muscle spasm.

Major Bleed Post Minimally Invasive Surgical Repair of Inguinal Hernia

Abstract: At our center, over 200 patients undergo minimally invasive repairs of inguinal hernias every year using a laparoscope and a robotic-assisted technique. In three patients who underwent a minimally invasive procedure for uncomplicated indirect inguinal hernia, the postoperative course was complicated with bleeding and required an exploratory laparotomy. Post-procedure, the patients developed tachycardia and hypotension with a drop in hemoglobin, for which the patients required surgical re-exploration in an emergent fashion. The factors leading to bleeding were analyzed and are reported herein to increase awareness and prevent the occurrence of these complications during inguinal hernia surgery.

Idiopathic Pneumatosis of Small Bowel and Bladder.

Abstract: An 81-year-old woman presented with multiple episodes of loose bowel movements. CT scan of the abdomen and pelvis revealed pneumatosis cystoides intestinalis and asymptomatic emphysematous cystitis. The patient had an extensive workup with no obvious identified pathology to explain diffuse pneumatosis of the small bowel and bladder. Her symptoms improved with symptomatic management, empirical antibiotics, and no surgical intervention.

Flexor Pollicis Longus Rupture in a Scaphoid Nonunion: A Case Report.

Abstract: Background Flexor pollicis longus (FPL) tendon rupture is a rare complication of scaphoid nonunion. Case Description A fit active 70-year-old woman ruptured her FPL when it abraded on a painless 50-year-old scaphoid nonunion. She had asymptomatic scaphoid nonunion advanced collapse (SNAC) arthritis. At surgery, the sharp mobile volar scaphoid osteophytes were excised and the volar wrist capsule was repaired. A vascularized fat flap based on a perforator of the radial artery was used to augment the volar wrist capsule repair and to create a smooth gliding surface for the FPL. The ruptured FPL tendon was reconstructed with a palmaris longus graft. Literature Review Complete rupture of the FPL tendon secondary to scaphoid nonunion is a rare complication. It can be easily misdiagnosed because the original injury may be unrecognized or forgotten. A consensus regarding the optimal surgical management has not been reached. Clinical Relevance The objective of surgery in this case was to restore FPL function and prevent a recurrent rupture. The asymptomatic SNAC arthritis was not treated. No further wrist surgery was required. The patient was asymptomatic with a functioning FPL tendon 4 years after surgery.

A European survey on treatment of hydrosalpinges in infertile women on behalf of the European Society for Gynaecological Endoscopy (ESGE) Special Interest Group (SIG) on Reproductive Surgery.

Abstract: A questionnaire-based survey was conducted among members of the European Society for Gynaecological Endoscopy (ESGE), with the aim of increasing awareness of the diagnosis and surgical treatment of tubal disease as an alternative to in-vitro fertiliszation (IVF). Seventeen participants (34%) occasionally used a test for prediction of the ovarian reserve before surgery, and the most commonly used test was anti-mullerian hormone assay (39/50; (80%). Laparoscopy was the preferred method for staging tubal disease (43/50; 86%).Thirty-seven (76%) participants always performed salpingectomy or tubal occlusion before the first IVF attempt. Thirty (60%) of the gynaecological surgeons considered the outcome with tubal surgery and IVF to be similar in mild tubal disease, whereas for severe disease, 31/50 (62%) felt that surgery had worse outcome. Among other factors to be considered in choosing a strategy for treating infertility, 20/50 (40%) of respondents listed the stage of disease. The findings of this survey suggest that first-line treatment for women younger than 35 years old with minor tubal pathology, is tubal surgery. IVF appears to be offered if there are other infertility factors, if the patient is >38 years old and if moderate to severe tubal disease is present.

Uterine Sandwich Method: A Case of Posterior Placenta Previa in an In Vitro Fertilization Pregnancy Complicated by Velamentous Cord Insertion.

Abstract: The risk of postpartum hemorrhage (PPH) and placental adhesion anomalies, including placenta previa, may be increased in pregnancies conceived by in vitro fertilization (IVF) and other forms of assisted reproduction technologies. The uterine compression suture, known as the "uterine sandwich method," may be useful in pregnancies complicated by placenta previa. We report an unusual case of placenta previa complicated by velamentous cord insertion, which was treated by a B-Lynch suture, a Bakri balloon tamponade, and vaginal packing.

Hands-On Times, Adherence to Recommendations and Variance in Execution among Three Different CPR Algorithms: A Prospective Randomized Single-Blind Simulator-Based Trial.

Abstract: Background: Alternative cardiopulmonary resuscitation (CPR) algorithms, introduced to improve outcomes after cardiac arrest, have so far not been compared in randomized trials with established CPR guidelines. Methods: 286 physician teams were confronted with simulated cardiac arrests and randomly allocated to one of three versions of a CPR algorithm: (1) current International Liaison Committee on Resuscitation (ILCOR) guidelines (“ILCOR”), (2) the cardiocerebral resuscitation (“CCR”) protocol (3 cycles of 200 uninterrupted chest compressions with no ventilation), or (3) a local interpretation of the current guidelines (“Arnsberg“, immediate insertion of a supraglottic airway and cycles of 200 uninterrupted chest compressions). The primary endpoint was percentage of hands-on time. Results: Median percentage of hands-on time was 88 (interquartile range (IQR) 6) in “ILCOR” teams, 90 (IQR 5) in “CCR” teams (p = 0.001 vs. “ILCOR”), and 89 (IQR 4) in “Arnsberg” teams (p = 0.032 vs. “ILCOR”; p = 0.10 vs. “CCR”). “ILCOR” teams delivered fewer chest compressions and deviated more from allocated targets than “CCR” and “Arnsberg” teams. “CCR” teams demonstrated the least within-team and between-team variance. Conclusions: Compared to current ILCOR guidelines, two alternative CPR algorithms advocating cycles of uninterrupted chest compressions resulted in very similar hands-on times, fewer deviations from targets, and less within-team and between-team variance in execution.

Syncope: A Very Atypical Presentation of COVID-19

Abstract: Possible COVID-19 patients have presented commonly to United States Emergency Departments. Patients presenting with cough, fever and shortness of breath are easy to identify as suspected cases. Unfortunately, not all COVID-19 patients present this way. Atypical presentations are a risk factor for healthcare worker (HCW) transmission of this disease. In this case report we describe the unusual case of COVID-19 presenting as syncope without any other risk factors. HCWs need to be aware of atypical COVID-19 presentations and to maintain proper use of personal protective equipment.

Prevalence of metabolic disorders in obese triple negative breast cancer patients

Abstract: Introduction Obesity is a risk factor for hormone receptor positive breast cancer in postmenopausal women. However, the association between triple negative breast cancer risk and metabolic abnormalities is not yet clear. Moreover, little is known regarding the prevalence of these abnormalities in this group of women. Here we present the prevalence of metabolic abnormalities in a single cohort of obese postmenopausal triple negative breast cancer patients. Methods Monocentric, retrospective, single cohort analysis of triple negative breast cancer patients treated between January 2008 and December 2017 at Pius Hospital Oldenburg. For quantitative or numerical variables, central tendency and dispersion measures were used. Values are presented as mean number of patients or percentage. Results Among 2745 breast cancer cases, 43 obese postmenopausal patients with a mean age of 64 years (range 51 to 90) had triple negative breast cancer. Most were diagnosed with invasive ductal (n = 39; 90.7 %), high-grade carcinoma (n = 35; 81.4 %), with a tumor size between 2 and 5 cm (n = 19; 44.2 %). Half the cohort lacked lymph node involvement; 5 patients showed distant metastasis (11.6 %). The majority had no family history of breast cancer (n = 32; 74.4 %), were non-smokers (n = 37; 86 %), and had a history of pregnancy (n = 35; 81.4 %). Frequent metabolic abnormalities included hypertension (n = 31; 72.1 %) and dyslipidemia (n = 36; 83.7 %) whereas type 2 diabetes or glucose intolerance were less prevalent (n = 13; 30.2 %). Conclusion Hypertension and dyslipidemia were more prevalent in the study cohort than type 2 diabetes. Moderately obese patients were most frequently affected. These findings partially align with international studies which observed an association between triple negative breast cancer and elevated levels of blood glucose and triglycerides, but not between tumor disease and hypertension.