Bone Infarct Associated Osteosarcoma: Epidemiologic and Survival Trends

Background Bone tumors are not a frequent occurrence and bone-infarct-associated sarcomas are even rarer. The prognosis of this disease is poor and its treatment remains a challenge. Nevertheless, hardly any analyses in literature report on secondary osteosarcoma (SO) on bone infarct and most of the data available do not provide sufficient details. We evaluated whether this condition could be further characterized and if prognosis could be influenced by the chemotherapy treatment. In particular, we sought to determine (1) the main features of this rare disease; (2) the overall survival (OS) rate; (3) the OS rate associated to chemotherapy treatment; (4) the correspondence between our results and published data in terms of survival. Methods We retrospectively reviewed patients admitted at Rizzoli Orthopedic Institute of Bologna between 1992 and 2018 (1465 total cases of osteosarcoma). We identified a list of 11 cases of SO on bone infarct (cohort 1). We conferred about the epidemiology, surgical and chemotherapy (ChT) treatment and surveillance of infarct-associated osteosarcoma showing the correlation to data present in literature, corresponding to 15 case reports published within 1962-2018 (cohort 2). Results (1) cohort 1 was made of 11 patients: six females and five males, median age was 55 years. Nine (81%) were grade 4, two (19%) grade 3. Tumor predominantly arise on distal femur (64%). Most of patients had localized osteosarcoma at the diagnosis (81%); resection surgery was the elective treatment (73%) followed by amputation (18%). Of 11 patients, seven received also ChT (64%). (2) Five-years OS was 62% (95% CI: 28-84). Median OS was 74 months (95% CI: 12-not reached). The cumulative incidence of cancer-related deaths (CICRD) was 37.7% (95% CI: 11.4-64.5) at 120 months. (3) In the group treated with only surgery OS was 50% at 5 years. For patients treated with any form of ChT, OS was 71% at 5 years (p=0.4773) and hazard ratio (HR) 0.56. The CICRD was 29% (at 2 years of follow-up. Instead, it was of 50% for patients treated only with surgery. (4) Median survival was 74 months and 19 months for cohort 1 and cohort 2 respectively (p=0.09). Data analysis showed a decreased HR for cohort 1 compared to cohort 2 (HR 0.378). Results confirmed also stratifying for age and ChT administration (HR 0.355). Conclusions Based on this work, our opinion is that the choice to undergo the patients to ChT combined to surgery could improve their prognosis.

Endobronchial hamartoma in a young COVID-19 symptomatic woman. Radical endoscopic treatment with a disposable bronchoscope. Case Report

Pulmonary hamartomas represent the most frequent family of benign lung tumors that typically involve the lung parenchyma and only rarely grow as endobronchial tumors. The elective treatment of endobronchial hamartoma is the bronchoscopic resection, and in those cases in which tumor extension and localization makes it not possible, surgical treatment must be evaluated. Patients with symptomatic COVID-19, hospitalized, frequently undergo a chest CT scan and in some cases, occasional findings may emerge, requiring diagnostic investigations such as bronchoscopy and interventional pulmonology procedures. Therefore, in such a delicate pathological condition, such as COVID-19, the need to perform bronchoscopy and interventional pulmonology procedures, minimizing the risk of viral transmission and ensuring necessary assistance, represents a great challenge for pulmonologists. In this article authors describe, for the first time in literature, a rare case of endobronchial hamartoma, radically resected using a single use bronchoscope, in a young female patient hospitalized for symptomatic COVID-19.

A Review Article on Role of Jaloukavacharan (Blood Letting) in Oshtha Roga (Diseases of Lip)

Raktmokshana is one of the parasurgical, detoxification strategies for Panchakarma. It is the course of disposal of vitiated Dosha that collect in the body. Jaloukavacharan is sort of Raktmokshana which is drilled internationally in India since antiquated occasions to treat Oshthrogas, in which vitiated Kapha, Pitta and Rakta Doshas get let from the body. Jaloukavacharan is a powerful blood filtration treatment which has property to die down the aggravation, enlarging, redness and consuming sensation promptly and in which little amount of blood eliminated to kill collected vitiated Pitta,Kapha and Rakta dosha of many blood borne sicknesses. Accordingly sicknesses brought about by Pitta, Kapha and Rakta Dosha are remembered. Likewise it is a lot more secure and less confounded Normal interaction. Jalaukavcharana is exceptionally powerful old strategy for Panchakarma ignored by Physicians. There are many results of present day medication. So it is the need to spread mindfulness about Jalaukavcharana and its adequacy. In this manner Jalaukavcharana is the elective treatment promising more powerful and more secure results for the general public. Keywords: Raktamokshana, Jaloukavacharan, Pitta-Kapha Dosha, Rakta Dosha, Hirudin, Oshtha Roga .

Equilibrium in Competitive Insurance Markets with Medical Tourism

In recent years, the rising healthcare costs in the United States have led many citizens to travel outside the country for medical care. Although such practice, commonly known as ‘medical tourism’, has become more and more popular, many insurance companies hesitate to incorporate a medical tourism option into insurance contracts. In this article, we wish to understand the theoretical rationale of that by designing an insurance contract in an environment where medical tourism is available. One crucial characteristic that influences consumers’ decision on whether to choose medical tourism is their tolerance levels associated with unexpected costs when travelling abroad for healthcare. In this article, we wish to investigate how the individuals with preference heterogeneity would self-select between the options of domestic treatment and treatment abroad offered in the contract. The results suggest that when the healthcare costs from both the treatment abroad and the domestic treatment are high and/or there is a higher chance of needing an elective treatment for the individual, insurance companies will more likely incorporate medical tourism in the contract. JEL Classification: C73, I13, D82, D86

Visceral pseudoaneurysms and the role of endovascular treatment – a case report

Introduction: Visceral pseudoaneurysms are pathological dilations of the visceral arteries and/or their branches. They are a rare entity but with devastating consequences given their high potential for rupture and hemorrhage. The evolution of endovascular techniques has changed the paradigm in the treatment of this entity, making it the preferred option for the elective treatment of visceral pseudoaneurysms. Clinical case: The authors described the case of a pancreatic pseudoaneurysm in a young male patient, with past medical history of chronic pancreatitis and pancreatic pseudocyst, marked smoking and alcoholic habits, which presented with an abdominal pain and a drop in hemoglobin. After discussing the case with the Vascular Surgery department, it was decided towards an endovascular treatment given the patient's clinical stability and appropriate anatomical location for the proposed intervention. Coil embolization via humeral artery was performed with immediate angiographic success, and clinical, analytical and imaging improvement in the postoperative period. Conclusion: In addition to open surgical repair and laparoscopic surgery, there are also endovascular procedures for the treatment of visceral pseudoaneurysms, so the vascular surgeon must be aware with the available strategies, taking into account the patient, the characteristics and location of the visceral pseudoaneurysm.

Ketogenic diet as elective treatment in patients with drug-unresponsive hyperinsulinemic hypoglycemia caused by glucokinase mutations

Background Hyperinsulinemic hypoglycemia (HI) is the most frequent cause of recurrent hypoglycemia in children. Despite diagnostic and therapeutic advances, it remains an important cause of morbidity, leading to neurological complications, such as psychomotor retardation and epilepsy. Patients with diffuse drug-unresponsive HI manifest neurological impairment and neurobehavioral problems, even though surgically treated with a near-total pancreatectomy. Based on the analogies between HI and GLUT1 deficiency, both presenting with neuroglycopenia and lack of alternative cerebral energy sources, we administered a ketogenic diet (KD) in three drug-unresponsive GCK-HI patients with the aim of preserving neurodevelopment and avoiding the need of a near-total pancreatectomy. They presented recurrent symptomatic hypoglycemia, intellectual disability and refractory epilepsy. Patients were treated with classical KD for 79, 27 and 18 months, respectively. Results All patients became asymptomatic in a few days and showed an important improvement of the alert state. Epilepsy disappeared and no appearance of novel hypoglycemic lesions was detected with a brain MRI. Cognitive and adaptive abilities rapidly improved and normalized. IQ rose significantly from 81 to 111 (p = 0.04) in patient 1, from 82 vs 95 (p = 0.04) in patient 2, from 60 to 90 (p = 0.04) in patient 3. Conclusions We demonstrated the safety and efficacy of KD in the treatment of drug-unresponsive GCK-HI at a short and long-term. The neuroprotective effects of KD determined the recovery from epilepsy and intellectual disabilities and averted the need of a near-total pancreatectomy. All patients and their families reported an improvement of physical and psychosocial well-being, with a substantial improvement of their quality of life. These results might change the course and the quality of life of these patients and their families, having a relevant impact on human lives. Therefore, KD might be considered the elective treatment in unresponsive forms of GCK-HI.

Multicenter Mid-Term Outcomes of the Chimney Technique in the Elective Treatment of Degenerative Pararenal Aortic Aneurysms

Purpose Chimney endovascular abdominal aortic aneurysm repair (CHEVAR) has predominantly been described as an alternative technique for the management of urgent presentations of degenerative pararenal aortic aneurysms (dPAAs). However, the role of CHEVAR in the treatment of asymptomatic patients remains unknown. The aim of current multinational study was to evaluate the outcomes of elective CHEVAR of dPAAs. Material and Methods Retrospective analysis of 267 consecutive dPAA patients treated with elective CHEVAR at 13 European and US centers from 2008 to 2014. Primary endpoints were 30 days and out of hospital CHEVAR-related mortality. Secondary endpoints included persistent type Ia endoleak or endotension, angiographically confirmed occlusion and/or high-grade chimney graft (CG) or involved splanchnic vessel stenosis identified at index procedure and/or during follow-up, as well as CHEVAR-related re-intervention. Results Mean follow-up time was 25.5±13.3 months. The 442 visceral vessels were involved and mean number of CGs per patient was 1.63±0.7. 436 targeted vessels were successfully cannulated. The aortic graft intentionally covered 6 renal arteries and immediate technical success was 98.6%. The 30 days mortality was 1.9% (n=5), while the in-hospital complication rate was 10.1% (n=27) including 3 strokes, 1 permanent dialysis, and 1 intestinal ischemia. No 30 day type Ia endoleaks were detected and 3.2% of CGs (n=14, including the intentionally covered) had evidence of occlusion and/or stenosis. The overall CHEVAR-related mortality was 2.2% (n=6). Freedom from primary and secondary type Ia endoleak/endotension rates at 3 years was 93.0% and 98.0%, respectively. Primary and secondary CG patency was 87.0% and 89.0%. Primary and secondary endovascular freedom from any endpoint at 3 years was 81.0% and 94.0% respectively. Conclusion Elective use of CHEVAR in the management of dPAAs seems to be durable. These results are comparable to published outcomes with other total endovascular strategies, which justifies an expanded role for CHEVAR in the treatment of asymptomatic patients presenting with dPAAs.

423 Patient Perspective on the Use of the Independent Sector to Maintain Elective NHS Services During the COVID-19 Pandemic

Introduction COVID-19 resulted in the suspension of planned treatments for patients worldwide leaving millions suffering the physical and mental effects of delay. Reports indicate that when services have been re-established, patients have been afraid to take up appointments. Hospitals put processes in place to counter this, notably separating emergency and elective patient cohorts. Most notably seen by the co-operation between the NHS and independent private healthcare providers in March 2020 at the height of the pandemic. We undertook a study to ascertain the perceptions of NHS patients who underwent elective treatment at independent ‘cold’ sites during the COVID-19 pandemic. Method A cross-sectional study with structured telephone interviews of patients who had planned elective treatments at ‘cold’ independent hospitals between March and September 2020. 1150 patients were identified, and a 20% sample formed a 230 patient study group, with 158 (70%) agreeing to participate. Results 30% of patients delayed their treatment due to COVID related concerns, with 76% of these only accepting treatment because this was at a ‘cold’ site. 46% of patients perceived treatment at a ‘cold’ site as the most important factor contributing to their safety. 153 patients (97%) supported the paid arrangement between the NHS and the independent sector to provide separate ‘cold’ sites for elective treatments. Discussion Safely restarting elective services to allow important planned treatments to take place, as was the pandemic continues, is a priority. Our study indicates that physical separation of patient pathways impacted most on patient confidence, and that the use of ‘cold’ sites is a viable option.

Maintenance of Elective Patient Care at Berlin University Children's Hospital During the COVID-19 Pandemic

Background: In Germany, so far the COVID-19 pandemic evolved in two distinct waves, the first beginning in February and the second in July, 2020. The Berlin University Children's Hospital at Charité (BCH) had to ensure treatment for children not infected and infected with SARS-CoV-2. Prevention of nosocomial SARS-CoV-2 infection of patients and staff was a paramount goal. Pediatric hospitals worldwide discontinued elective treatments and established a centralized admission process.Methods: The response of BCH to the pandemic adapted to emerging evidence. This resulted in centralized admission via one ward exclusively dedicated to children with unclear SARS-CoV-2 status and discontinuation of elective treatment during the first wave, but maintenance of elective care and decentralized admissions during the second wave. We report numbers of patients treated and of nosocomial SARS-CoV-2 infections during the two waves of the pandemic.Results: During the first wave, weekly numbers of inpatient and outpatient cases declined by 37% (p < 0.001) and 29% (p = 0.003), respectively. During the second wave, however, inpatient case numbers were 7% higher (p = 0.06) and outpatient case numbers only 6% lower (p = 0.25), compared to the previous year. Only a minority of inpatients were tested positive for SARS-CoV-2 by RT-PCR (0.47% during the first, 0.63% during the second wave). No nosocomial infection of pediatric patients by SARS-CoV-2 occurred.Conclusion: In contrast to centralized admission via a ward exclusively dedicated to children with unclear SARS-CoV-2 status and discontinuation of elective treatments, maintenance of elective care and decentralized admission allowed the almost normal use of hospital resources, yet without increased risk of nosocomial infections with SARS-CoV-2. By this approach unwanted sequelae of withheld specialized pediatric non-emergency treatment to child and adolescent health may be avoided.

‘I feel that injustice is being done to me’: a qualitative study of women’s viewpoints on the (lack of) reimbursement for social egg freezing

Background During the last decade, the possibility for women to cryopreserve oocytes in anticipation of age-related fertility loss, also referred to as social egg freezing, has become an established practice at fertility clinics around the globe. In Europe, there is extensive variation in the costs for this procedure, with the common denominator that there are almost no funding arrangements or reimbursement policies. This is the first qualitative study that specifically explores viewpoints on the (lack of) reimbursement for women who had considered to uptake at least one social egg freezing cycle in Belgium. Methods To understand the moral considerations of these women, drawing from twenty-one interviews, this paper integrates elements of a symbiotic empirical ethics approach and thematic analysis. Results We identify three themes: (1) From ongoing concern to non-issue; (2) Negotiating the reimbursement for social egg freezing; (3) From fully out-of-pocket to (partial) free good. In the first theme, we found that some women were concerned about the cost of social egg freezing and the lack of clear information about it. Furthermore, they reported moral sentiments of injustice which they attributed to their lack of acknowledgement for their struggles and needs. Other women perceived the reimbursement controversy of social egg freezing as something far removed from their lived experience. The second theme illustrates diverse views on reimbursement, ranging from viewing social egg freezing as an elective treatment unbefitting reimbursement to preferences for greater public responsibility and wider access. Finally, we describe the participants’ varying proposals for partial reimbursement and the idea that it should not be made available for free. Conclusions This research adds important empirical insights to the bioethics debate on social egg freezing, in particular by presenting (potential) users’ views on the lack of reimbursement. Based on our results, it seems an oversimplification to portray social egg freezers as merely affluent women who are not concerned about the coverage of egg freezing costs. While there is much more to say about the ethical and political complexities of the reimbursement of this procedure, our study highlighted the voices of (potential) users and showed that at least some of them express a preference or a need for reimbursement.