O Internato de Formação Especializada em Neurocirurgia: Qual o Atual Panorama Nacional?

Introduction: In Portugal, the number of neurosurgery residents has been rising steadily. However, there are no robust studies assessing the level of satisfaction and quality of the current training programs. The aim of this study was to describe and quantify the level of satisfaction about Neurosurgery residency in 2019, in Portugal.Material and Methods: Quantitative observational cross-sectional study based on an original questionnaire about the level of satisfaction of neurosurgical training in Portugal in 2019, sent electronically to residents and young consultants between October and December 2019.Results: A total of 37 responses were obtained from physicians aged around 29.0 (± 4.0) years old, of which 78.4% were men and 54.1% from centers in the center/south of the country/islands. Overall, 51.4% of the answers came from first three years’ residents. As for the theoretical training, there was dissatisfaction with the morbidity and mortality meetings (59.5%), existence of sessions/anatomical lab (89.2%), participation in medical education (64.9%) and in research (64.9%). As for practical training, there was dissatisfaction only towards outpatient clinics (56.8%). There is a tendency for the first surgery to occur in the first month of residency and, in ascending order, firstly a cranial trauma surgery (5.09 ± 4.59 months), then for cerebrospinal fluid diseases (5.95 ± 4.3 months), peripheral nerves (6.0 ± 7.0 months), craniotomy (6.59 ± 3.88 months) and lumbar spine diseases (11.41 ± 1.5 months). Pediatric surgery was the last type of surgery to begin (19.36 ± 20.0 months). There seems to be a generalized satisfaction with the annual (59.5%) but not with thefinal examination (37.8%).Conclusion: This study has succeed at being a better description of the Portuguese neurosurgical centers and of the level of satisfaction about neurosurgical training in Portugal.

Evaluation of Inpatient Surgical Wards' Performance at the Hospitals Affiliated with Tehran University of Medical Sciences in 2018

Background: Surgery wards account for a significant portion of hospital costs, followed by patient costs. Improving surgery wards' performance plays a major role in enhancing the accountability and efficiency of the hospital. This study aimed to evaluate the performance of inpatient surgical wards at the hospitals affiliated with Tehran University of Medical Sciences(TUMS). Methods: A descriptive, cross-sectional, retrospective study was performed at all hospitals affiliated with TUMS in 2018. To measure the efficiency of these wards, three indicators have been considered; bed occupancy rate, the average length of stay, and bed turnover. Data have been analyzed using Excel software based on the Pabon Lasso model . Results: Among the 15 active surgical departments, 5 (33.31 %) were categorized in quadrant three, including ophthalmology, obstetrics and gynecology, vascular and trauma surgery, plastic surgery, and infertility department. The oral and maxillofacial surgery and general surgery departments were the poorest in their performance and located in quadrant one. Ten surgical wards out of 38 (26.33 %) have reported a satisfactory performance. Conclusion: Understanding and comparing the performance of clinical departments is also useful in making decisions for standardizing the patterns of health services delivery, evidence-based management in health care centers, and enhancing accountability in the health system. It is suggested that managers revise the departments in the inefficient area to reduce the number of inefficient departments or attract more patients by marketing, diversifying services, and increasing the quality of services.

Enhanced recovery after surgery protocol versus conventional care in emergency abdominal trauma surgery: a prospective, randomised, controlled study

Background: Since 1990s there has been a defined role of ERAS in elective surgeries, to optimize the peri-operative care, reducing post-operative complications and length of stay and hence, the overall costs. However, there is paucity of literature in its effectiveness in emergency trauma surgeries. The aim of the study was to investigate the feasibility and outcomes of ERAS protocol in emergency abdominal surgery in the setting of trauma.Methods: Institutional IEC approved study. A prospective randomized of 52 patients with abdominal trauma undergoing emergency laprotomy were included in the study and divided into two groups: ERP and conventional group. The ERP included early feeding, early urinary catheter removal, early mobilization/physiotherapy, early intravenous line removal and early optimal oral analgesia. The primary end-points were the length of hospital stay and secondary end-points included complication rate and re-admission rate.Results: The two groups were comparable with regards to age, gender, mechanism of injury and ISS score. Hospital stay was significantly shorter in the ERAS group: 4.67 days verses 13.36 days (p<0.001). There were 15 and 11 complications in the control and study group respectively. When graded as per the Clavien-Dindo classification there was no significant difference in the 2 groups (p=0.306).Conclusions: This study shows that early recovery programs can be successfully implemented with significant shorter hospital stays without any increase in postoperative complications in trauma patients undergoing emergency laparotomy for abdominal trauma.

Evaluation of the COVID-19 Infection Rate in the Perioperative Period of Elective Surgeries of the Hand and Microsurgery

Background: After the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic (coronavirus disease 2019 [COVID-19]), the world started reducing the number of elective surgeries to reduce the transmission of the coronavirus. Some priority elective surgeries were performed, and there was no increase in contagion rates due to safety protocols and protection measures. The study aims to present the coronavirus infection rate of elective hand surgeries and microsurgery performed during pandemics. Methods: A retrospective study evaluating 188 patients submitted to elective surgical procedures. The exclusion criteria were patients infected by COVID-19 before the surgery and patients who submitted to trauma surgery. Only 108 patients were eligible for this study. The mean age was 47.8 years (range: 15 days-81 years). There were 63 females and 45 males. They were divided into 2 groups: outpatient (n = 49) and inpatient (n = 59) procedures. Results: The overall COVID infection rate was 6.48%. The outpatient infection rate was 2.08%, whereas the inpatient infection rate was 10.17% (Student t test: P = .089). The main factor correlated with infection in the postoperative period was the number of postoperative outpatient visits (Student t test: P = .089). No statistical differences were observed between the variables studied, but there was a tendency for patients who submitted to inpatient surgery to get infected by COVID-19 ( P = .089). The statistical power was 0.8 (Cohen’s d test), showing that large samples are needed to analyze the correlation better. Conclusion: We concluded that the safety of performing elective hand surgery during the pandemic remains unclear, and more studies with larger samples are needed.

Fournier Gangrene: Case Report & Litarature Review

Introduction: Necrotizing fasciitis of the perineal and vaginal region is a symptom of Fournier's gangrene, which is caused by a synergistic polymicrobic infection. The clinical presentation varies depending on the original aetiology, ranging from anorectal or vaginal pain with limited evidence of cutaneous necrosis to a rapidly spreading necrosis of the skin and soft tissue, to systemic sepsis without any obvious signs or symptoms. Case history: A 65-year-old male who was admitted in hospital with the chief complaint of Scrotal enlargement, discomfort, hyperemia, pruritus, crepitus, and fever. There may also be a foul-smelling discharge. Symptoms usually appear during a two- to seven-day period. Soft-tissue gas may be present before clinical crepitus is detected. The patient with Fournier gangrene frequently seems poorly on physical examination, with prodromal signs of fever and lethargy lasting 2-7 days. Edema of the overlaying skin is usually present, as is acute pain and tenderness in the genitalia; pruritus may also be present.Skin may show evidence of trauma, surgery, insect or human bites or injection sites, In Respiratory system, B/L Air entry present. In cardiovascular system, S1 and S2 sound heard and Patient get conscious and well oriented to time, place, and person. Then, as quickly as possible, treatment was began; he did not improve after treatment, and treatment would continue till the conclusion of my care. Conclusion: We focus on professional management and superior nursing care in this study so that we may provide the complete treatment that Fournier Gangrene requires while also effectively managing the complex case. After a full recovery, the patient's comprehensive health care team collaborates to help the patient regain his or her previous level of independence and happiness.

An Ode to Gillies and Millard: “The Ten Commandments Applied to Self-Inflicted Head and Neck Gunshot Wounds”

Within the field of craniofacial trauma surgery, reconstruction following high-energy ballistic injuries to the face remains a daunting task requiring a multidisciplinary approach for best outcomes. These injuries are complex with large defects requiring reconstruction of different lamellae and skeletal buttresses of the face and no 2 are exactly alike. The reconstruction efforts are multidimensional and focus on restoring facial height, width, projection, jaw occlusion, and function. We present a challenging course of a 56 year old patient with a self- inflicted gunshot wound to the face that resulted in devastating injuries to the mandible and midface. We describe our multistage and multiple technique surgical approach that spanned nearly 2 years and 11 operations that included open reduction, internal fixation of extensive facial fractures, primary bone grafting, free fibula for maxillary reconstruction and palatal fistula obliteration, pre-expanded paramedian forehead flap, and mandibular distraction. In reviewing the patient’s course, his complications, and wins, we were inspired by the fundamentals principles of head and neck reconstruction as we interpreted from the famous “Ten Commandments of Drs. Gillies and Millard.” We discuss these Commandments with the reader in our reflection of this challenging reconstruction and hope others, particularly, those in training are encouraged to find application of the “Ten Commandments” we review as they develop their own surgical practices and styles.

Bronchoscopy Decreases Ventilator-Associated Pneumonia in Trauma Patients

Health care-associated pneumonias (HAPs) are a significant comorbidity seen in hospitalized patients. Traumatic injury is a known independent risk factor for the development of HAP. Trauma-related injuries also contribute to an increase in the rate of pneumonia in mechanically ventilated patients requiring intensive care unit (ICU) treatment. In 2011, the ventilator-associated pneumonia (VAP) rate among ICU patients at our institution (CMMC) increased dramatically. As a result, our infection control specialists performed a focused review of these patients and found a likely association between these infections and patients requiring pre-hospital intubation. Their determination prompted a July 2012 revision of the CMMC Trauma/Surgery Admission ICU protocol for ventilated patients to include bronchoscopy for all patients who have been intubated pre-hospital providing no contraindications were present. Our aim was to ascertain any influence of the protocol change on the rate of VAP. We conducted a retrospective medical record review of trauma patients who were intubated in the field or ED and seen at our institution (an accredited Level 1 trauma center) from 2012 to 2018. Applying the current definition of VAP from the Centers for Disease Control and Prevention (CDC) to data collected from the CMMC trauma registry, we observed a 13% lower VAP rate in the bronchoscopy group ( YB) as compared to the group that did not receive bronchoscopy (NB) ( P < .025). Based on our results, we determined that bronchoscopy performed in this setting does support a statistically significant decrease in the rate of ventilator-associated pneumonia.