Comparison of different approaches to combined spinal epidural anesthesia (CSEA) under the guidance of ultrasound in cesarean delivery of obese patients: a randomized controlled trial

Background Combined spinal epidural anesthesia (CSEA) is commonly performed in cesarean deliveries. However, it is difficult to perform in obese parturients because of positioning challenges. The aim of this study was to compare the effect of different approaches to CSEA under the guidance of ultrasound. Methods One hundred obese patients (BMI ≥ 30 kg/m2) who underwent elective cesarean section were randomly enrolled. Patients were assigned to a median approach group and a paramedian approach group randomly. Clinical characteristics were compared between groups. First-attempt success rate, the median positioning time and total operation time, ultrasonic predicted anesthesia puncture depth, actual puncture depth, anesthesia adverse reactions, complications after anesthesia, and patients’ satisfaction with the epidural puncture were recorded. Results The first-attempt success rate was significantly different between the two groups [92% (46/50) vs. 76% (38/50), P = 0.029]. The median positioning time and total operation time in the paramedian approach group were higher than those in the median approach group (227.7 s vs. 201.6 s, P = 0.037; 251.3 s vs. 247.4 s, P = 0.145). The incidence of postanesthesia complications in the paramedian approach group was significantly lower than that in the median approach group (2% vs. 12%, P = 0.026), and patient satisfaction was higher in the paramedian approach group than in the median approach group (P = 0.032). Conclusion The ultrasound-guided paramedian approach for CSEA is time-consuming, but it can effectively improve the success rate of the first puncture, reduce the incidence of anesthesia-related adverse reactions, and improve patient satisfaction. Trial registration: This study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024722) on July 24, 2019

Anterolateral approach with two incisions versus posterior median approach in the treatment of middle- and distal-third humeral shaft fractures

Background The surgical approaches remain controversial for the treatment of middle and distal-third humeral shaft (MDTHS) fractures. This study compared clinical effects of the anterolateral approach with two incisions (AATI) and the posterior median approach (PMA) in the treatment of MDTHS fractures. Methods A retrospective analysis was carried out. One hundred sixty-six patients with MDTHS fractures were selected from January 2015 to January 2017 in Xi’an Hong Hui Hospital. According to surgical approaches, patients were divided into AATI (86 cases) and PMA group (80 cases). All patients were treated with open reduction and plate fixation. Operation indexes were compared, including incision length, operation time, and bleeding. Bryan-Morrey score was used to evaluate elbow joint function. Complication incidence was compared, such as incision infection, iatrogenic radial nerve injury, and nonunion. Results The AATI group showed smaller incision length, less bleeding, lower iatrogenic radial nerve injury rate, and better elbow function than that of PMA group (P<0.05). Conclusions The middle and distal-third humeral shaft fractures can be successfully cured by both approaches. Compared with the posterior median approach, it has better clinical effects of the anterolateral approach with two incisions, which is worthy of clinical application and promotion.

Egy ritka sérvtípus kétszeri megjelenése klinikánkon

Összefoglaló. Esetismertetések: 66 éves nő vizsgálatai irreponibilis fájdalmas inguinalis terime miatt kezdődtek. Ultrahangvizsgálat során a panaszok hátterében femoralis sérvben kizárt gangraenás appendix vermiformis igazolódott. Inguinalis metszésből appendectomiát és hernioplasticát végeztünk. Posztoperatív szövődménye nem volt, szövettana appendicitist igazolt. Pár héttel később egy 76 éves, több társbetegséggel rendelkező férfi fájdalmas, sercegő gangraenás, jobb inguinalis terime miatt került átvételre. CT-vizsgálat femoralis sérvbe kizárt abscedáló appendix vermiformist ábrázolt. Inguinalis metszésből, illetve alsó median laparotomiából a féregnyúlványt a hasüregbe reponáltuk, majd appendectomia és inguinalis necrectomia történt. Posztoperatív adhéziós ileus és hasfali disruptio miatt egy alkalommal reoperáltuk, adhaesiolysist és hasfali resuturát végeztünk. Ezt követően lágyéki sebén negatív nyomásos sebkezelést alkalmaztunk, a beteget a 22. napon otthonába bocsájtottuk. Az appendix szövettana low grade mucinosus neoplasiát igazolt. Megbeszélés: A femoralis sérvbe szorult appendix vermiformis de Garengeot-sérvként ismeretes, extrém ritka incidenciájú sérvtípus, ennél is ritkább az appendix mucinosus neoplásiájával szövődő variánsa. E sérv klinikai megjelenése széles spektrumon mozoghat, pontos preoperatív diagnózisa CT-vizsgálat nélkül kifejezetten nehéz. A műtéti megoldásra többféle lehetőség választható, mely nagyban függ az esetleges komplikációktól, a rendelkezésre álló eszközöktől, az intraoperatív lelettől, valamint az operáló sebész jártasságától. Summary. Case reports: a 66-year-old woman was admitted to our Department due to a painful inguinal lump. During examinations an incarcerated femoral hernia was found with an inflamed vermiform appendix inside the hernial sac. Appendectomy and femoral hernioplasty was performed from inguinal approach. The patient was discharged home without complications. Pathological examinations of the specimen showed signs of acute appendicitis. A few weeks later a 76-year-old man with severe comorbidities was admitted to our unit due to painful gangraenous inguinal skin lesion. CT scan showed an incarcerated femoral hernia containing the appendix with subcutaneous abscess. Appendectomy, hernioplasty, and inguinal necrosectomy was performed from an inguinal and low median approach. Another operation was necessary due to postoperative obstruction and subcutaneous dehiscence. After intraabdominal adhaesiolysis and abdominal wall reconstruction negative pressure wound therapy was applied to the inguinal wound, the patient was discharged 22 days after the primary operation. Pathological examinations of the appendix showed low grade mucinous neoplasm. Discussion: The femoral hernia containing the appendix is called de Garengeot’s hernia and is one of the rarest types of inguinofemoral hernias. The clinicopathology of this type of hernia can cover a wide range of symptoms. The definitive preoperative diagnosis is relatively difficult to find without a CT-scan. The surgical approach and treatment depends on the manifestation, clinical findings and on the available equipment and the expertise of the surgeon.

Achieving large and distant ancestral genome inference by using an improved discrete quantum-behaved particle swarm optimization algorithm

Background Reconstructing ancestral genomes is one of the central problems presented in genome rearrangement analysis since finding the most likely true ancestor is of significant importance in phylogenetic reconstruction. Large scale genome rearrangements can provide essential insights into evolutionary processes. However, when the genomes are large and distant, classical median solvers have failed to adequately address these challenges due to the exponential increase of the search space. Consequently, solving ancestral genome inference problems constitutes a task of paramount importance that continues to challenge the current methods used in this area, whose difficulty is further increased by the ongoing rapid accumulation of whole-genome data. Results In response to these challenges, we provide two contributions for ancestral genome inference. First, an improved discrete quantum-behaved particle swarm optimization algorithm (IDQPSO) by averaging two of the fitness values is proposed to address the discrete search space. Second, we incorporate DCJ sorting into the IDQPSO (IDQPSO-Median). In comparison with the other methods, when the genomes are large and distant, IDQPSO-Median has the lowest median score, the highest adjacency accuracy, and the closest distance to the true ancestor. In addition, we have integrated our IDQPSO-Median approach with the GRAPPA framework. Our experiments show that this new phylogenetic method is very accurate and effective by using IDQPSO-Median. Conclusions Our experimental results demonstrate the advantages of IDQPSO-Median approach over the other methods when the genomes are large and distant. When our experimental results are evaluated in a comprehensive manner, it is clear that the IDQPSO-Median approach we propose achieves better scalability compared to existing algorithms. Moreover, our experimental results by using simulated and real datasets confirm that the IDQPSO-Median, when integrated with the GRAPPA framework, outperforms other heuristics in terms of accuracy, while also continuing to infer phylogenies that were equivalent or close to the true trees within 5 days of computation, which is far beyond the difficulty level that can be handled by GRAPPA.

Clinical Features, Prognostic Factors, and Treatment Strategy of Osteoblastoma-like Osteosarcoma: A Case Report and Review of the Literature

Background： Osteoblastoma-like osteosarcoma is a very rare tumor and the diagnosis and the treatment can be challenging and controversial. Herein, we presented a case occurring in the occipital bone firstly and summarized all of the previously published cases to delineate the clinical characteristics, prognostic factors and treatment strategy of osteoblastoma-like osteosarcoma. Case presentation: A 34-year-old man presented with a headache with bitter and dull for 6 months, underwent a suboccipital posterior median approach to remove the lesion without intra-operative complications. Computerized tomography revealed osteogenic bone destruction on the occipital protuberance involving inner and outer table of the skull. Preoperative Magnetic Resonance Venogram revealed that the tumor invades sinus convergence, disappeared sinus convergence, narrowed bilateral transverse sinus, and abundant tumor blood vessels. Re-examination on the day after operation revealed that the post-operative changes of the occipital bone and the tumor were resected completely. The pathologic examination identified the Osteoblastoma-like osteosarcoma. The postoperative course was uneventful. Patient was discharged home 7 days after operation. By four months, re-examination Magnetic Resonance Imaging scan revealed that there was no evidence of recurrence and was not leaded to any problem. Conclusion: For patients with presumed osteoblastoma-like osteosarcoma, gross total resection should be recommended. If tolerable, radiotherapy or chemotherapy could be an alternative treatment modality. Patients with areas of conventional osteosarcoma had poor progression-free survival and tumors with metastasis had a poor overall survival. The lung was the most frequently involved regions of metastasis. Trial registration: CRD, CRD42019121880. Registered 13 February 2019, https://www.crd.york.ac.uk/PROSPERO

Comparison of different approaches to combined spinal epidural anesthesia (CSEA) under the guidance of ultrasound in cesarean delivery obese patients: A randomized controlled trial

Background: Combined spinal epidural anesthesia (CSEA) is commonly performed in cesarean deliveries. However, it is difficult to perform in obese parturients because of positioning challenges. The aim of this study was to compare the effect of different approaches to CSEA under the guidance of ultrasound.Methods: One hundred obese patients (BMI≧30 kg/m2) who underwent elective cesarean section were randomly enrolled. Patients were assigned to a median approach group and a paramedian approach group randomly. Clinical characteristics were compared between groups. First puncture success rate, ultrasonic time needed for positioning and puncture time, ultrasonic predicted anesthesia puncture depth, actual puncture depth, adverse reactions to anesthesia, complications after anesthesia, and patient satisfaction with the epidural puncture were recorded.Results: The first puncture success rate was significantly different between the two groups (92% vs 86%, P <0.05). The positioning time and total puncture time in the paramedian approach group were higher than those in the median approach group (217.7 s vs 201.6 s, P <0.05; 251.3 s vs 247.4 s, P＞0.05). The incidence of postanesthesia complications in the paramedian approach group was significantly lower than that in the median approach group (2% vs 12%, P <0.05), and patient satisfaction was higher in the paramedian approach group than in the median approach group (P <0.05).Conclusion: The ultrasound-guided paracentesis approach for intrauterine spinal anesthesia for cesarean section patients is time-consuming, but it can effectively improve the success rate of the first puncture, reduce the incidence of anesthesia-related adverse reactions, and improve patient satisfaction.Trial registration: This study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024722) on July 24, 2019.