Summary
Deep neuromuscular block aims to improve operative conditions during laparoscopic surgery with a lower intra‐abdominal pressure. Studies are conflicting on whether meaningful improvements in ...quality of recovery occur beyond emergence, and whether lower intra‐abdominal pressure is achieved. In this pragmatic randomised trial with 1:1 allocation, adults undergoing elective laparoscopic surgery were allocated to moderate neuromuscular block reversed with neostigmine, or deep neuromuscular block reversed with sugammadex. Allocation was revealed to the anaesthetist only. Primary outcome was cognitive recovery of the Postoperative Quality of Recovery Scale, 7 days after surgery. Secondary outcomes included recovery in other domains of the Postoperative Quality of Recovery Scale at 15 min and 40 min; days 1, 3, 7, 14; and 1 and 3 months after surgery. Chi‐square test was used for the primary outcome, and generalised linear mixed model for recovery over time between groups. Of 350 participants randomised, 140 (deep) and 144 (moderate) were analysed for the primary outcome. There was no difference in the Postoperative Quality of Recovery Scale cognitive domain at day 7 (deep 92.9% vs. moderate 91.8%, OR 1.164; 95%CI 0.486–2.788, p = 0.826), or at any other time‐point. No significant difference was observed for physiological, emotive, activities of daily living, nociception, or overall recovery. Length of stay in the recovery area (mean (SD) deep 108 (58) vs. moderate 109 (57) min, p = 0.78) and hospital (1.8 (1.9) vs. 2.6 (3.5) days, p = 0.019) was not different. Intra‐abdominal pressure and surgical operating conditions were not different between groups. Deep neuromuscular block did not improve quality of recovery compared with moderate neuromuscular block in operative laparoscopic surgery over a 1‐h duration.
The aim of the present work is to analyse the influences of inelastic surface excitations of collision partners, transfer channels and entrance channel mass asymmetry in the formation of
110
Sn via ...different fusion paths. For aforesaid purpose, fusion dynamics of
40
Ca +
70
Zn,
46
Ti +
64
Ni and
50
Ti +
60
Ni reactions have been examined theoretically by using symmetric–asymmetric Gaussian barrier distribution (SAGBD) model and coupled channel model. Within SAGBD model, calculations based on Winther and Aky
u
¨
z-Winther parametrization of diffuseness of Woods–Saxon potential predict larger fusion cross sections relative to one-dimensional calculations. In order to retrieve fusion data, the diffuseness parameter of Woods–Saxon potential has been optimized with respect to Winther and Aky
u
¨
z-Winther diffuseness, and using such optimum value of diffuseness parameter, the SAGBD calculations adequately described fusion dynamics of
40
Ca +
70
Zn,
46
Ti +
64
Ni and
50
Ti +
60
Ni reactions. Within coupled channel model, calculations performed by incorporating
2
+
and
3
-
vibrational states of participants appropriately reproduce fusion data at near and above barrier energies for studied reactions. However, low-energy data points of
40
Ca +
70
Zn and
46
Ti +
64
Ni reactions are not recovered by above calculations. This discrepancy between data and coupled channel calculations can be ascribed to the presence of neutron transfer channel with positive
Q
-value for
40
Ca +
70
Zn and
46
Ti +
64
Ni reactions. Furthermore, larger mass asymmetric systems in entrance channel have been found to show more sub-barrier fusion enhancement, thereby pointing towards that larger entrance channel mass asymmetry favours the fusion process.
Summary
Efforts to reduce postoperative venous thromboembolism are challenging due to heterogeneity in thromboprophylaxis practice. As a result, a ‘one‐size‐fits‐all’ approach that accounts for ...surgery‐specific risk, but fails to account for patient‐level variation, is often adopted by healthcare networks. Updated clinical practice guidelines have advocated an individualised risk‐stratified approach that balances the risk:benefit ratio associated with thromboprophylaxis; however, there are limited data confirming effectiveness of these recommendations on the incidence of postoperative venous thromboembolism and bleeding. We developed the surgical‐thrombo‐embolism‐prevention protocol, a novel risk‐stratified algorithm that classified patients into low‐, intermediate‐, and high‐risk profiles according to surgical procedure and patient baseline medical risk. Expert‐endorsed risk‐specific thromboprophylaxis strategies were then applied. A staged quality improvement program was developed to implement the protocol. We postulated that compliance with the protocol would reduce postoperative venous thromboembolism rates without increasing the incidence of postoperative bleeding. Between June 2013 and March 2018, we evaluated the efficacy, safety and sustainability of this risk‐stratified approach in 24,953 surgical admissions at a dedicated cancer centre. By final implementation, program compliance was 91%. Postoperative venous thromboembolism rates reduced from 3.1 per 1000 surgical admissions to 0.6 per 1000 surgical admissions (relative risk reduction 79%; p < 0.005). Postoperative bleeding rates also declined from 10.0 per 1000 surgical admissions to 6.3 per 1000 surgical admissions (relative risk reduction 37%; p = 0.02). Sustained improvement was evident more than 3 years after implementation. Implementation of the surgical‐thrombo‐embolism‐prevention protocol significantly reduced the incidence of postoperative venous thromboembolism supporting its validation at other institutions.
Background:
Among some of the known complications, breakage of epidural catheter, though is extremely rare, is a well-established entity. Visualization of retained catheter is difficult even with ...current radiological imaging techniques, and active surgical intervention might be necessary for removal of catheter fragment. We report such a case of breakage of an epidural catheter during its insertion which led to surgical intervention.
Case Description:
A 52-year-old, an 18G radiopaque epidural catheter was inserted through an 18G Tuohy needle into the epidural space at T8-T9 interspace in left lateral position. Resistance was encountered. While the catheter was being removed with gentle traction along with Tuohy needle, it sheared off at 12 cm mark. After informing the operating surgeon and the patient, immediately an magnetic resonance imaging and computed tomography (CT) scan were done. CT scan with sagittal and coronal reconstruction was done. Epidural catheter was visualized at D9 lamina-spinous process junction who was removed by surgical intervention.
Conclusion:
Leaving of epidural catheter puts the anesthetist in a dilemma. To evade such an event, it is important to stick to the traditional guiding principle for epidural insertion and removal. In spite of safety measures, if event occurs, the patient should be informed about it. Surgery is reserved for symptomatic patients or asymptomatic patients to avoid future complications.
We report for the first time the conversion of incoherent infrared light around 4.4µm into a near-infrared signal at 810nm in erbium-doped GaGeSbS fibers and bulk glass samples. This energy ...conversion is made possible by pumping erbium doped chalcogenide samples at 982 nm and simultaneously exciting them with a 4.4µm infrared signal. This result paves the way for the development of an "all-optical" gas sensor able to detect various gas traces using a remote detection based on commercial silica fibers.
Background:
Sacrococcygeal joint dislocation is very rare. There are seven cases of sacrococcygeal joint dislocation found in the literature; most are anterior, and only one prior case of posterior ...dislocation was reported involving the mid-coccygeal joint. Here, we report another case of posterior dislocation of the sacrococcygeal joint.
Case Description:
A 19 year-old female developed acute low-back and groin pain following a fall from the first floor. She was diagnosed with an unstable pelvic fracture along with posterior dislocation of the sacrococcygeal joint. The next day, after being hemodynamically stabilized, she underwent percutaneous fixation of the sacral fracture, while the sacrococcygeal joint dislocation was managed conservatively. Her pain decreased, and she was discharged on the third postoperative day and followed up to 6 weeks.
Conclusion:
Most sacrococcygeal joint dislocations can be managed conservatively.
Background:
Vertebral osteomyelitis caused by
Stenotrophomonas maltophilia
is very rare. There are only two cases reported in literature. Here, we present a 48-year-old immunocompetent male who, ...following a lumbar microdiscectomy, developed postoperative spondylodiscitis due to
S. maltophilia
that mimicked a cotton granuloma.
Case Report:
Two months ago, a 48-year-old male underwent a lumbar L4-L5 microdiscectomy, he newly presented with the left thigh and leg pain of 4 weeks duration. Laboratory studies revealed a CRP of 26 mg/l, an ESR of 6 mm (1
st
h), and total leukocyte count of 7.85 thousand/ul. The MRI T2 images showed a focal hyperintense lesion in the left lateral recesses at the L4-L5 level; the accompanying hypointense-smooth margin resembled a cotton granuloma. At surgery, we found a localized epidural collection of pus;
S. maltophilia
was isolated from the culture. His symptoms gradually improved, and symptoms fully resolved with 3 months of subsequent antibiotic therapy.
Conclusion:
S. maltophilia
causing vertebral osteomyelitis is extremely rare and can sometimes mimic a cotton granuloma. MR diagnosis, surgical decompression, and obtaining cultures are requisite to direct appropriate antibiotic therapy.
Background:
Congenital absence of the lumbosacral facet joint is extremely rare, with only 26 cases reported in the literature. Here, we present a patient with the unilateral absence of the left ...fifth lumbar inferior articular process and reviewed the relevant literature.
Case Description:
A 32-year-old gentleman, who had undergone right L4-5 lumbar microdiscectomy 3 months ago now presented with acute low back and left leg pain following a fall. He is now presented with acute low back and left leg pain following a fall. Plain radiographs of the L-S spine revealed an absent left L5–S1 zygapophyseal joint. The magnetic resonance imaging and computed tomography studies additionally confirmed an absent unilateral left L5 lumbar inferior articular process.
Conclusion:
Patients presenting for lumbar surgery may have unilaterally absent lumbosacral zygapophyseal joints, which may impact the outcome of surgical treatment.
Background:
Following decompressive cervical surgery for significant spinal cord compression/myelopathy, patients may rarely develop the “White Cord Syndrome (WCS).” This acute postoperative ...reperfusion injury is characterized on T2W MRI images by an increased intramedullary cord signal. However, it is a diagnosis of exclusion, and WCS can only be invoked once all other etiologies for cord injury have been ruled out.
Case Description:
A 49-year-old male, 3 days following a C3-C7 cervical laminectomy and C2-T1 fusion for extensive cord compression due to ossification of the posterior longitudinal ligament (OPLL), developed acute quadriparesis. This new deficit should have been attributed to an intraoperative iatrogenic cord injury, not the WCS.
Conclusion:
Very rarely patients sustain postoperative significant/severe new neurological deficits attributable to the WCS. Notably, the WCS is a diagnosis of exclusion, and all other etiologies (i.e. intraoperative iatrogenic surgeon-based mechanical cord injury, graft/instrumentation extrusion, failure to adequately remove/resect OPLL thus stretching cord over residual disease, other reasons for continued cord compression, including the need for secondary surgery, etc.) of cord injury must first be ruled out.
Background:
Gout is a common metabolic disorder of purine metabolism, causing arthritis in the distal joints of the appendicular skeleton. Spine involvement is rare, and very few cases of spinal gout ...have been reported. The authors present a rare case of axial gout with tophaceous deposits in the thoracic spinal canal resulting in cord compression and mimicking a meningioma.
Case Description:
A 33-year-old male presented with chronic mid back pain and a progressive paraparesis. The presumed diagnosis was meningioma based on MR imaging with/without contrast that showed a posterolateral, right-sided, and T10-T11 intradural extramedullary lesion. Notable, was hyperuricemia found on hematological studies. The patient underwent a decompressive laminectomy (T9-T11) for excision of the lesion, intraoperatively, an intraspinal, chalky, white mass firmly adherent to and compressing the dural sac was removed. The histopathology confirmed the diagnosis of a gouty tophus. Postoperatively, the patient’s pain resolved, and he regained the ability to walk.
Conclusion:
A gouty tophus should be included among the differential diagnostic considerations when patients with known hyperuricemia present with back pain, and paraparesis attributed to an MR documented compressive spinal lesion.
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