Analgesia Nociception Index-Guided Remifentanil versus Standard Care during Propofol Anesthesia: A Randomized Controlled Trial

The clinical benefits to be expected from intraoperative nociception monitors are currently under investigation. Among these devices, the Analgesia Nociception-Index (ANI) has shown promising results under sevoflurane anesthesia. Our study investigated ANI-guided remifentanil administration under propofol anesthesia. We hypothesized that ANI guidance would result in reduced remifentanil consumption compared with standard management. This prospective, randomized, controlled, single-blinded, bi-centric study included women undergoing elective gynecologic surgery under target-controlled infusion of propofol and remifentanil. Patients were randomly assigned to an ANI or Standard group. In the ANI group, remifentanil target concentration was adjusted by 0.5 ng mL−1 steps every 5 min according to the ANI value. In the Standard group, remifentanil was managed according to standard practice. Our primary objective was to compare remifentanil consumption between the groups. Our secondary objectives were to compare the quality of anesthesia, postoperative analgesia and the incidence of chronic pain. Eighty patients were included. Remifentanil consumption was lower in the ANI group: 4.4 (3.3; 5.7) vs. 5.8 (4.9; 7.1) µg kg−1 h−1 (difference = −1.4 (95% CI, −2.6 to −0.2), p = 0.0026). Propofol consumption was not different between the groups. Postoperative pain scores were low in both groups. There was no difference in morphine consumption 24 h after surgery. The proportion of patients reporting pain 3 months after surgery was 18.8% in the ANI group and 30.8% in the Standard group (difference = −12.0 (95% CI, −32.2 to 9.2)). ANI guidance resulted in lower remifentanil consumption compared with standard practice under propofol anesthesia. There was no difference in short- or long-term postoperative analgesia.

Ectopic Eye Tooth Management: Photobiomodulation / low-level Laser Emission Role in Root Resorption After Fixed Orthodontic Treatment

The orthodontic treatment brings numerous benefits and, in most cases, the benefits outweigh the possible disadvantages. Root resorption (RR) is a common adverse phenomenon associated with orthodontic treatment. This study evaluates the role of low-level laser emission / Photobiomodu-lation (LE/P) in quantitative measurements of root resorption (QRR). The application of LE/P was done after each orthodontic activation with 4 types of treatment intervention (TI) on the RR after fixed orthodontic treatment (FOT) of the upper arch with ectopic eye tooth/teeth [EET]. 32 Orthodontic patients scheduled for FOT were selected and assigned to the 4 groups. These were LE/P+Self ligating bracket (SLB), LE/P+Conventional bracket (CB), Non-Photobiomodulation (non-LE/P)+SLB, and non-LE/P+CB. Standard management stages of FOT were followed in the maxilla. Each patient received a single application of LE/P labially/buccally and palatally, a total of 5 different points during each activation or appointment. The main outcome measure was QRR in maxillary anteriors before and after FOT assessed via cone-beam computed tomography (CBCT) using 3D OnDemand software. Insignificant QRR was found between before and after FOT in SLB, CLB, and LE/P, non-LE/P groups (p > 0.05). QRR in the SLB vs CB and LE/P vs non-LE/P group was significantly different in 11, 13, and 23 (p < 0.05). QRR in the LE/P+SLB group (p < 0.05) was significantly different in 11, 13, and 23 than that in the other groups. The most severe QRR was found on the 13 (0.88 ± 0.28mm and 0.87±0.27mm) and 23 (1.19 ± 0.14 mm and 1.16±0.13mm) in the CB and non-LE/P group (p < 0.001). LE/P+SLB showed highly significant superior outcome (p < 0.001) in relation to non-LE/P+CB, the QRR of 23 were 0.813± 0.114mm and 1.156± 0.166mm respectively. Significantly higher amount of QRR found in EET patients after FOT treated with the CB, non-LE/P, and non-LE/P+CB system and warrants further investigation to explore potential specific causes.

Development and Application of Nursing Risk Management Evaluation System

Objective: to construct an integrated nursing risk management assessment system, standardize nursing risk assessment and management process, and improve the implementation rate of nursing risk assessment and nursing safety quality. Methods: a special team was set up to construct an integrated nursing risk management and assessment system, including management personnel, clinical nurses and information engineers, to analyze the problems existing in the old nursing risk assessment and design an integrated nursing risk management and assessment system. Results: the integrated nursing risk management assessment system was applied in all wards of the hospital from July 2019 to September 2019, and 25,778 cases were evaluated. It has the advantages of intelligence, integration, convenient operation, historical score query, guiding standard management of high-risk patients. Conclusion: the intelligence, integration and standardization of the integrated nursing risk management assessment system can improve nursing efficiency, standardize nursing risk management, improve nursing staff satisfaction, and reduce the incidence of nursing adverse events in high-risk patients.

Schwannoma of the Appendix Orifice

Schwannomas are rare mesenchymal tumors. They are usually diagnosed incidentally during endoscopic or diagnostic imaging for another reason. Malignant transformation is rare. In this case report, we present an incidental schwannoma protruding through the appendiceal orifice diagnosed during endoscopy. A healthy 56-year-old female underwent a surveillance colonoscopy for family history of colorectal cancer. A prominent and edematous appendiceal orifice was noted, and the area was aggressively biopsied. Histopathological assessment revealed a benign schwannoma. Computerized topography was unremarkable. Subsequently, the patient underwent a right hemicolectomy. Patient is scheduled to undergo routine surveillance in three years. Grossly, schwannomas are white, encapsulated, and well-circumscribed lesions that stain strongly positive for S100, GFAP, and CD57. Histologically, schwannomas demonstrate spindle cell proliferation. Several imaging modalities have been utilized in the diagnosis and management of mesenchymal neoplasms. Despite the benign nature of the diagnosis, complete surgical resection with clear margins remains the gold standard management strategy. Our case highlights the presence of a relatively uncommon tumor in an unusual anatomical location.

Cerebellar Infarct Accompanied by Acute Hydrocephalus: A Case Report of 1-Year Follow-up in Rural Neurosurgical Practice

Cerebellar infarctions account for about 2-3% of all ischemic strokes, and acute hydrocephalus due to brainstem compression or compression of the cerebrospinal fluid (CSF) flows is a rare manifestation from a stroke of the posterior circulation. The condition is considered one of the most life-threatening complications in cerebellar infarct due to the possibility of transforaminal and upward transtentorial herniation. The management of patients with cerebellar infarct is challenging, because the patient usually presents with non-specific signs and symptoms until the patient loses consciousness. Standard management should be provided by a stroke unit team or neuro-intensive care unit. The precision timing of treatment and evaluation with close observation is crucial, even when there is no life-threatening condition at initial presentation, but sometimes it is difficult to fulfill in rural areas due to the substandard facilities and lack of resources. Here we report a case of cerebellar infarct with massive edema in association with acute hydrocephalus with the progressive deterioration that happened in a rural area. A 59-year-old male patient complained about an episode of sudden headache which was followed by dizziness, vomiting, and loss of balance. A head non-contrast CT scan in the emergency room (ER) is performed 4 hours after ictus, showed a slightly hypodense lesion in the left cerebellum, without accompanying edema and hydrocephalus. The patient was then managed conservatively in the ward. In the next 36 hours, his consciousness level was reduced and a head CT scan evaluation showed the development of massive edema of cerebellar infarct with acute hydrocephalus. The patient underwent an emergency surgical procedure with suboccipital decompressive craniectomy (SDC) with strokectomy, expanded duraplasty, and ventricular drainage (ventriculoperitoneal shunt). Satisfactory results with rapid resolution of GCS was seen at daily follow-up after surgery. A 1-year follow-up also showed remarkable outcomes.

Management of Pulmonary Thromboembolism

Pulmonary thrombo-embolism (PTE) is a major cause of cardiovascular morbidity and mortality. Incidence of PTE and its associated mortality is affected by the Prescence of associated risk factors, comorbid conditions and advancement in the treatment options. Clinical probability, D-Dimer, echocardiography and CT pulmonary angiography are used in the diagnosis. Management starts with stratification, with high-risk category being benefited from the thrombolytic therapy. Catheter directed therapy may be used in ineligible or failed cases with surgical embolectomy being used as final salvage therapy. Patients with persistent hemodynamic stability can be started on anticoagulation alone. Supportive therapy with fluid expansion and inhalational Nitric oxide may provide benefit in few. Patients with PTE should receive secondary preventive anticoagulation to prevent recurrences. High risk patients with sub-segmental PTE may benefit from anticoagulation. For early detection of long-term complications of PTE a patient cantered follow-up is needed. Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a dreaded complication with pulmonary end-arterectomy being a gold standard management option in eligible patients with non-surgical therapy (balloon pulmonary angioplasty and pulmonary vasodilators) also being used in many cases.

Non-Standard Management of Target Vessels With the Inner Branch Arch Endograft: A Single-Center Retrospective Study

Purpose: The purpose of this study was to evaluate early and mid-term results of non-standard management of the supraaortic target vessels with the use of the inner branch arch endograft in a single high-volume center. Material and methods: A single-center retrospective study including all patients undergoing implantation of an inner branch arch endograft from December 2012 to March 2021, who presented a non-standard management of the supraaortic target vessels (any bypass other than a left carotid-subclavian or landing in a dissected target vessel). Technical success, mortality, reinterventions, endoleak (EL), and aortic remodeling at follow-up were analyzed. Results: Twenty-four patients were included. In 17 (71%) cases, the non-standard management was related to innominate artery (IA) compromise (12 with IA dissection, 2 with short IA, 2 with short proximal aortic landing zone that required occlusion of IA, 1 with occluded IA after open arch repair). Two (8%) cases were related to an aberrant right subclavian artery (RSA), 1 patient (4%) due to the concomitant presence of a left vertebral artery (LVA) arising from the arch and an occluded left subclavian artery (LSA), and another patient presented with an occluded LSA distal to a dominant vertebral artery. Three (13%) cases were exclusively related to management in patients with genetic aortic syndromes. Twenty (83%) patients had a previous type A aortic dissection. Ten (42%) patients presented a thoracic or thoracoabdominal aortic aneurysm and 8 (33%) patients an arch aneurysm, 6 of them associated to false lumen (FL) perfusion. There were 2 (8%) perioperative minor strokes, and 1 patient with perioperative mortality. Seven patients presented an early type I endoleak, all resolved at follow-up. Seven patients required reinterventions during follow-up (7 reinterventions related to continuous false lumen perfusion, 3 related to Type Ia endoleak, 2 related to surgical bypass). All patients who presented with FL perfusion had complete FL thrombosis at follow-up. No patient presented aneurysm growth at follow-up. Conclusions: The use of the inner branch arch endograft with a non-standard management of the supraaortic target vessels is a possible option. Despite a high reintervention rate, regression or stability of the aneurysmal diameter was achieved in all the patients with follow-up.

Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema

Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5–7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.