Cognitive Ability as a Non-modifiable Risk Factor for Post-prostatectomy Urinary Incontinence: A Double-Blinded, Prospective, Single-Center Trial

Introduction: Urinary incontinence (UI) is a wide-spread and feared side-effect of conventional or even robot-assisted laparoscopic prostatectomy (RALP) due to its high impact on patients' quality of life (QoL). Non-modifiable risk factors for UI have already been identified – on surgical and patient side. Yet, to our knowledge, focus thus far has not been placed on functional aspects regarding general cognitive ability.Materials and Methods: This is an observational single-center, prospective, double-blinded evaluation of 109 RALPs performed between 07/2020 and 03/2021. All patients underwent a Mini Mental State Examination (MMSE) prior to surgery to evaluate their cognitive ability. Early post-prostatectomy incontinence (PPI) was evaluated using a standardized 1 h pad test performed 24 h after removal of the urinary catheter. The association between MMSE results and PPI were evaluated using univariate and multivariate logistic regression models.Results: Multivariate logistic regression analyses identified MMSE results and nerve sparing (NS) as independent predictors for PPI in patients with an intermediate MMSE result (25–27 points) having a 3.17 times higher risk of PPI when compared to patients with a good MMSE result (≥28) (95% Confidence Interval (CI): 1.22–9.06, p = 0.023), while patients without NS had a 3.53 times higher risk of PPI when compared to patients with NS (95% CI: 1.54–11.09, p = 0.006).Conclusion: A lower cognitive ability should be treated as a non-modifiable risk-factor for early PPI. In the future it could find its place as a clinical screening tool to identify patients who require more attention especially in the pre-, but also in the postoperative phase.

Functional outcome in operated patients of multilevel lumbar canal stenosis and use of HRQoL role in depicting the anxiety and its correlation with the pain

Background Lumbar canal stenosis (LCS) is a degenerative spinal disease of elderly people, and it not only impairs the mechanical activity but also alters the economic and mental status of the patients indirectly. This is single-center observational prospective study conducted for 2 years and included 30 consecutive operated patients of multilevel LCS patients and excluded the patients with single-level LCS, with primary LCS or with grade II subluxation. We analyzed the various measurement indices used for the surgical outcome assessment as ED-5D 5L and OLBPDI (Oswestry low back pain disability index). Statistical analysis was done using SPSS (Statistical Package for Social Sciences) Version 21.0 statistical Analysis Software. The independent t test, post hoc analysis, Wilcoxon signed rank statistic test and RM-ANOVA test were also applied. Result Most patients have improvement in pain and all the components of HRQoL (health-related quality of life) after surgery, which was further improved in mean follow-up of 1 year. Our study also suggested that the patients with higher anxiety/depression have higher pain intensity and low HRQoL, which was persistent in postoperative period (p < .001). Conclusion ED-5D 5L and OLBPD are good indices to assess all the components of quality of life and give valuable information overall. Anxiety has shown important correlation with the pain component in both preoperative and postoperative phase.

The Most Significant Surgical Risk Factors of Giant Intracranial Meningiomas: Localization Matters Much More than Grading and Volume of Peritumoral Brain Edema. A Retrospective Clinical Neuroradiological and Immunohistochemical Study

Background: Giant intracranial meningiomas (GIMs) are extremely rare and are usually considered arduous to resect totally with poorer prognosis. The real mechanisms by which a meningioma can grow to be defined as "giant" are unknown, as well as the real biological , radiological profile and the different outcomes.Methods: We performed a retrospective review of a consecutive series of surgically-treated patients suffering from intracranial Meningioma. All the patients were assigned on the ground of the preoperative imaging to the Giant and Medium/Large Meningiomas. We investigated whether the presence large diameter on radiological diagnosis is indicative for different mortality rate, grading, characteristic and clinical/neurological outcome.Results: The study shows that surgically treated giant meningiomas have a higher risk of developing complications in the postoperative phase (Chi square= 11.121, dF=1, p=0.001). The direct proportional relationship between peritumoral brain edema (PBE) volume and tumor volume was present only in the medium/large group and was not present in the giant meningioma group. When comparing the degree of performance there is a statistically significant difference between localization and KPS immediately postoperatively (p=0.04) particularly for sphenopetroclival meningiomas (p=0.071), and partially with GIM of the olfactory groove with arterial encasement. The most frequently encountered complications include the occurrence of ischemia (p=0.049), infection (p=0.03), and the occurrence of postoperative seizures.Conclusions: We identified that the major surgical risk factor for GIMs is location, where the petro-clival region and, to a lesser extent the anterior basicranium offer a greater risk of neurovascular involvement and arterial encasement. On other hand, the risk correlated with PBE is poorer in GIM although there is a well-noted correlation between the Edema volume and outcome in meningiomas.

Effects of early home-based strength and sensory-motor training after total hip arthroplasty: study protocol for a randomized controlled trial

BackgroundTotal hip arthroplasty (THA) is very effective in alleviating pain, but functional deficits persist up to a year following surgery. Regardless of standard physiotherapy programs, significant additional muscular atrophy and weakness occurs. Deficits in strength have serious adverse consequences for these patients with respect to physical function, the maintenance of independence and the requirement for revision surgery. Progressive resistance training in rehabilitation following THA has been shown to significantly enhance muscle strength and function. The fundamental principle is to progressively overload the exercised muscle as it becomes stronger. Different strength training protocols have been used at different times in the postoperative phase, in group or individual practices, with major differences being in center-based and home-based programs with or without supervision. The primary objectives of our study are to evaluate whether an early postoperative home-based strength training protocol is feasible for all elective THA patients, does not cause major adverse effects and can improve patient functional outcomes at 3 months and 1 year following surgery.Methods/DesignThis study is a prospective multicenter randomized clinical trial to be conducted in the orthopedic departments of two Slovenian hospitals. In each hospital, 124 patients aged 60 or older with unilateral osteoarthritis, an ASA score between 1 and 3, signed informed consent form, and no terminal illness disabling rehabilitation participation will be randomly assigned to the intervention or control group. THA with an anterior approach will be performed. All patients will receive current standard physiotherapy during hospitalization. Patients in the intervention group will also learn strength and sensory-motor training exercises. Upon discharge all will receive USB drives with exercise videos, written exercise instructions and a training diary. Physiotherapists will perform the assessments (physical tests and the maximal voluntary isometric contraction assessment), and patients will fill out outcome assessment questionnaires (the Harris Hip Score and 36-Item Short Form Health Survey) at baseline and 1, 3 and 12 months after surgery.DiscussionThe main purpose of our study is to design a new standardized rehabilitation protocol with videos that will be effective, safe and accessible to all Slovenian THA patients.Trial registrationClinicalTrials.gov ID: NCT04061993. Protocol ID: PRT_PhD. Record Verification April 2021. https://clinicaltrials.gov/ct2/show/NCT04061993

Perioperative Management of Subdural Hemorrhage (SDH) Trepanation Decompression with Hemophilia A

<p>Hemophilia is a serious inherited blood disease, transmitted by women, that affects mainly men and lasts for a lifetime. Hemophilia A is the most common form. If any of the factors necessary for blood clotting are absent or insufficient, the clotting mechanism is disturbed, causing insatiable bleeding. The most common cause of death in hemophilia patients is cerebral hemorrhage due to head trauma. In cases of intracranial hemorrhage, surgery should be performed immediately to obtain a better prognosis. A 17-year-old man diagnosed with a 2x4 loss of consciousness due to intracranial subdural hemorrhage (SDH) in the left frontotemporoparietal region and cerebral edema on day 4 accompanied by subfalcine herniation to the right with hemophilia A, planned trepanation decompression for SDH evacuation. The patient received 4000 units of factor VIII injection before surgery. Bleeding during surgery was 1100cc and he received a transfusion of 1940cc blood products until hemodynamically stable. In the postoperative phase, he was admitted to the ICU for 8 days, extubation was performed after the condition improved. In patient with hemophilia, evacuation of bleeding should be performed immediately, but there is a high risk of rebleeding. A recombinant factor VIII substitute should be administered immediately for the treatment of acute bleeding in patients with severe haemophilia A. Anesthetic maintenance should include reducing the risk of hypertension and tachycardia to minimize bleeding.</p>

Myasthenia gravis after glioblastoma resection: paraneoplastic syndrome or coincidence? A unique case report and review of the literature

Paraneoplastic neurological syndromes (PNS) can manifest with every type of malignancy. A well-known syndrome is myasthenia gravis (MG) in combination with thymomas. No association between primary brain tumors and neuromuscular disorders has been described. Here, we present a case of a 65-year-old patient who developed MG, following an uncomplicated, gross-total resection of a glioblastoma. To our knowledge, this is the first case describing the onset of MG during the early postoperative phase after glioblastoma resection. Current criteria of PNS are insufficient when the neurological syndrome is diagnosed at the time of a malignancy or shortly thereafter and should be revisited.

Results of the observational prospective RealFLOT study

Background Perioperative FLOT (5-fluorouracil, oxaliplatin and docetaxel) has recently become the gold standard treatment for fit patients with operable gastric (GC) or gastroesophageal (GEJ) adenocarcinoma, getting a 5-year overall survival (OS) of 45%, over 23% with surgery alone. Methods RealFLOT is an Italian, multicentric, observational trial, collecting data from patients with resectable GC or GEJ adenocarcinoma treated with perioperative FLOT. Aim of the study was to describe feasibility and safety of FLOT, pathological complete response rate (pCR), surgical outcomes and overall response rate (ORR) in an unselected real-world population. Additional analyses evaluated the correlation between pCR and survival and the prognostic role of microsatellite instability (MSI) status. Results Of 206 patients enrolled that received perioperative FLOT at 15 Italian centers, 124 (60.2%) received at least 4 full-dose cycles, 190 (92.2%) underwent surgery, and 142 (68.9%) started the postoperative phase. Among patients who started the postoperative phase, 105 (51.0%) received FLOT, while 37 (18%) received de-intensified regimens, depending on clinical condition or previous toxicities. pCR was achieved in 7.3% of cases. Safety profile was consistent with literature. Neutropenia was the most common G 3–4 adverse event (AE): 19.9% in the preoperative phase and 16.9% in the postoperative phase. No toxic death was observed and 30-day postoperative mortality rate was 1.0%. ORR was 45.6% and disease control rate (DCR) was 94.2%. Disease-free survival (DFS) and OS were significantly longer in case of pCR (p = 0.009 and p = 0.023, respectively). A trend towards better DFS was observed among MSI-H patients. Conclusions These real-world data confirm the feasibility of FLOT in an unselected population, representative of the clinical practice. pCR rate was lower than expected, nevertheless we confirm pCR as a predictive parameter of survival. In addition, MSI-H status seems to be a positive prognostic marker also in patients treated with taxane-containing triplets.

Progressive Rehabilitation of a Professional Soccer Player After an Anterior Cruciate Ligament Reconstruction in Phase 1: Clinical Perspective with Video Demonstration

We outline a case of success in the rehabilitation of a Romanian first-division soccer player who sustained an anterior cruciate ligament (ACL) rupture with a meniscal tear during competition in the 2012–2013 season. The ligament was reconstructed with an autologous hamstrings graft and partial meniscectomy was performed. The player returned to same-level competition in 7 months and has remained at that level, free of knee injury, to the present (6 years later). Based on postoperative phase 1 as proposed by the Royal Dutch Society for Physical Therapy, we proposed a clinical progression of exercises with video demonstrations to address body functions and structures and the level of activities and participation. All phase 1 objectives were achieved, and all criteria needed to advance to phase 2 of the ACL rehabilitation process were attained.

Selective HIF stabilization alleviates hepatocellular steatosis and ballooning in a rodent model of 70% liver resection

Background: Small-for-size syndrome looms over patients needing liver resection or living-donor transplantation. Hypoxia has been shown to be crucial for the successful outcome of liver resection in the very early postoperative phase. While poorly acceptable as such in real-world clinical practice, hypoxia responses can still be simulated by pharmacologically raising levels of its transducers, the hypoxia-inducible factors (HIF). We aimed to assess the potential role of a selective inhibitor of HIF degradation in 70% hepatectomy (70%Hx). Methods: In a pilot study, we tested the required dose of roxadustat to stabilize liver HIF1α. We then performed 70%Hx in 8-week-old male Lewis rats and administered 25 mg/kg of roxadustat (RXD25) at the end of the procedure. Regeneration was assessed: ki67 and EdU immunofluorescent labeling, and histological parameters. We also assessed liver function via a blood panel and functional gadoxetate-enhanced magnetic resonance imaging, up to 47 hours after the procedure. Metabolic results were analyzed by means of RNA sequencing. Results: Roxadustat effectively increased early HIF1α transactivity. Liver function did not appear to be improved nor liver regeneration to be accelerated by the experimental compound. However, treated livers showed a mitigation in hepatocellular steatosis and ballooning, known markers of cellular stress after liver resection. RNA sequencing confirmed that roxadustat unexpectedly increases lipid breakdown and cellular respiration. Conclusions: Selective HIF stabilization did not result in an enhanced liver function after standard liver resection, but it induced interesting metabolic changes that are worth studying for their possible role in extended liver resections and fatty liver diseases.

The ClearSight system for postoperative arterial blood pressure monitoring after carotid endarterectomy: a validation study

Background The majority of postoperative events in patients undergoing carotid endarterectomy(CEA) are of hemodynamic origin, requiring preventive strict postoperative arterial blood pressure(BP) control. This study aimed to assess whether BP monitoring with non-invasive beat-to-beat ClearSight finger BP(BPCS) can replace invasive beat-to-beat radial artery BP(BPRAD) in the postoperative phase. Methods Single-centre clinical validation study using a pre-specified study protocol. In 48 patients with symptomatic carotid artery stenosis, BPCS and BPRAD were monitored ipsilateral in a simultaneous manner during a 6-hour period on the recovery unit following CEA. Primary endpoints were accuracy and precision of BP derived by ClearSight(Edward Lifesciences,Irvine,CA,USA) versus the reference standard(Arbocath 20 G,Hospira,Lake Forest,IL,USA) to investigate if BPCS is a reliable non-invasive alternative for BP-monitoring postoperatively in CEA-patients. Validation was guided by the standard set by the Association for Advancement of Medical Instrumentation(AAMI), considering a BP-monitor adequate when bias(precision) is &lt;5(8)mmHg. Secondary endpoint was percentage under- and overtreatment, defined as exceedance of individual postoperative systolic BP-threshold by BPRAD or BPCS in contrast to BPCS or BPRAD, respectively. Results The bias(precision) of BPCS compared to BPRAD was -10(13.6), 8(7.2) and 4(7.8) mmHg for systolic, diastolic and mean arterial pressure(MAP), respectively. Based on BPCS, undertreatment was 5.6% and overtreatment was 2.4%, however percentages of undertreatment quadrupled for lower systolic BP-thresholds. Conclusions Non-invasive MAP, but not systolic and diastolic BP, was similar to invasive BPRADduring postoperative observation following CEA, based on AAMI-criteria. However, as systolic BP is currently leading in postoperative monitoring to adjust BP-therapy on, BPcs is not a reliable alternative for BPRAD.