Hemorrhagic Risks of Percutaneous Dilated Tracheotomy in Thrombocytopenia

The objective: to assess the incidence and influence of platelets level on the hemorrhagic complications during percutaneous dilated tracheotomy (PDT) in patients with thrombocytopenia.Subjects and Methods. The study included 85 consecutive patients with varying degrees of thrombocytopenia at the stages of hematopoietic stem cell transplantation. The control group included 56 patients who underwent classical tracheotomy. The study group included 29 patients who underwent PDT (Griggs method). The operations were performed for prolonged artificial pulmonary ventilation. When the platelets level was below 20 × 109/L, platelet concentrate transfusion was performed before the operation.Results. The incidence of hemorrhagic complications in patients with thrombocytopenia during PDT was 13.8% (95% CI 9.13–18.45%). In open tracheotomy, the bleeding rate was 3.8% (95% CI 2.65–4.49%). These results are comparable to the incidence of hemorrhagic complications in patients with normal platelet counts. The influence of the platelet level on the presence of hemorrhagic complications in both groups was not established.Conclusion. Thrombocytopenia is not a contraindication to performing PDT. However, platelet concentrate transfusion should be performed in patients with platelet counts less than 20 × 109/L. An experienced team of anesthesiologists and endoscopists can reduce the incidence of other complications.

Prolonged non-invasive respiratory support in a COVID-19 patient with severe acute hypoxemic respiratory failure

A pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 was declared in 2020. Severe cases were characterized by the development of acute hypoxemic respiratory failure (AHRF) requiring advanced respiratory support. However, intensive care units (ICU) were saturated, and many patients had to be treated out of ICU. This case describes a 75-year-old man affected by AHRF due to Coronavirus Disease 2019 (COVID-19), hospitalized in a high-dependency unit, with PaO2/FiO2 <100 for 28 consecutive days. An experienced team with respiratory physiotherapists was in charge of the noninvasive ventilatory support (NIVS). The patient required permanent NIVS with continuous positive airway pressure, non-invasive ventilation, high flow nasal oxygen and body positioning. He was weaned from NIVS after 37 days and started exercise training afterwards. The patient was discharged at home with low-flow oxygen therapy. This case represents an example of a successful treatment of AHRF with the still controversial noninvasive respiratory support in one patient with COVID-19.

A laser management in cases of laryngeal stenosis due to corrosive poisoning

Background: Post corrosive poisoning result in serious chemical injuries and complications to the gastrointestinal tract and a high mortality rate. Post corrosive Complications that include respiratory injuries are especially significant for determining the severity of acute corrosive poisonings. Mortality is most often caused by tracheal necrosis, perforation of esophagus or stomach, followed by Mediastinitis or peritonitis. Results: Herewith presenting nine cases of laryngotracheal stenosis following corrosive poisoning ingestion. The purpose of this study is to upper aerodigestive tract complications and its Management. Stricture can be managed by endoscopic dilatation, oesophageal Stents, surgery. In our experience we planned for laser release of cricopharyngeal stricture with oesophageal dilatation. Diode laser isused for release of cricopharyngeal. Conclusions: Good postoperative outcome can be achieved and patient can be without tracheostomy for life long living near normal life. Pre and post operative psychological analysis and counselling is also very important for better functional outcome.Giving general anaesthesia is challenging in these cases hence experienced Team of anaesthetist is required to prevent mortality.

Applying Health-Six-Sigma Principles Helps Reducing the Variability of Length of Stay in the Emergency Department

ABSTRACT Background Reducing length of stay (LOS) is one of the urgent problems in health care systems worldwide. Popular methods that are used to reduce LOS are the Lean and the 6 Sigma, which in practice result in limited improvements. In this paper we introduce and test a tailored method for implementing the 6 Sigma principles in healthcare (we call H-6S). Methods The study took place within the emergency department (ED) of the "Josephtal Medical Center" in Eilat, Israel. Our analysis focused on the processes of examining and treating patients from admission to ED until discharge home. The analysis was done during the second quarter of 2018. The implementation of the recommendations took place during Q3 2018. The reported results are from Q3 2018 to Q2 2019, compared to the corresponding period in 2017 (experienced team). Results In Q2 2017 LOS was 2.42h ± 2.07h (experienced team, N=9928). In Q2 2018, the LOS was 2.62h± 7.04h (before the H-6S, inexperienced team, N=9484). In Q2 2019 following the intervention it reached 2.3h±1.74h (N=7647). The differences between the SDs of the three periods are significant. Conclusion Implementing H-6S dropped variance of LOS within 3 months and remained low for the whole year. Each new team of physicians who enters the emergency department should be thoroughly instructed as to the routines and expectations of the system from them, which should narrow the differences of previous education between them.

A Case Series Describing the Recurrence of COVID-19 in Patients Who Recovered from Initial Illness in Bangladesh

To date, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has infected over 80 million people globally. We report a case series of five clinically and laboratory confirmed COVID-19 patients from Bangladesh who suffered a second episode of COVID-19 illness after 70 symptom-free days. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), is a leading public health research institution in South Asia. icddr, b staff were actively tested, treated and followed-up for COVID-19 by an experienced team of clinicians, epidemiologists, and virologists. From 21 March to 30 September 2020, 1370 icddr,b employees working at either the Dhaka (urban) or Matlab (rural) clinical sites were tested for COVID-19. In total, 522 (38%) were positive; 38% from urban Dhaka (483/1261) and 36% from the rural clinical site Matlab (39/109). Five patients (60% male with a mean age of 41 years) had real-time reverse transcription-polymerase chain reaction (rRT-PCR) diagnosed recurrence (reinfection) of SARS-CoV-2. All had mild symptoms except for one who was hospitalized. Though all cases reported fair risk perceptions towards COVID-19, all had potential exposure sources for reinfection. After a second course of treatment and home isolation, all patients fully recovered. Our findings suggest the need for COVID-19 vaccination and continuing other preventive measures to further mitigate the pandemic. An optimal post-recovery follow-up strategy to allow the safe return of COVID-19 patients to the workforce may be considered.

Recipes for a Successful Exit for Clean- and Hard-tech Startups

This study demonstrates the combinations of multiple causal factors that formulate a startup’s strategy to successfully “exit”, namely “recipes for a successful exit,” in the clean- and hard-tech sector. We identify seven key causal factors (i.e., causal conditions) that impact startup success, including commercial readiness, investor interactions, favorable industry, non-financial support, straightforward development path, experienced team, and visibility to investors. We also investigate the combinations of selective causal conditions that can provide further synergetic impact. We conduct the fuzzy-set qualitative comparative analysis (fsQCA) on seven US clean and hard-tech startups that exited between 2005 and 2016. The successful companies all demonstrate distinctive characteristics based on three general categories (1) robust ecosystem; (2) heavy-lifting team; or (3) external opportunity. Across these three categories, commercial readiness and strong investor interactions are necessary conditions for all exit cases. But there are important differences that drive success in each category, such as the interaction with non-financial support (in the robust ecosystem case), experienced team (in the heavy-lifting team case), and favorable industry (in the external opportunity case). Our findings are meant to support entrepreneurs in reaching an exit by optimizing the given internal and external circumstances, and policymakers to build a robust ecosystem that can increase the success rate of the clean- and hardtech development.

Peripartum Hysterectomy: Is There Any Difference Between Emergent versus Planned Surgery ?

Aim: The aim of the study was to compare the outcomes of emergent and planned peripartum hysterectomy. Methods: This retrospective cross-sectional study was conducted in two hospitals. Maternal and neonatal outcomes were compared according to the emergent and planned peripartum hysterectomy. Results: Totally 34020 deliveries were evaluated retrospectively and 66 peripartum hysterectomy cases were analyzed. Of these patients, 31 cases were planned surgery and 35 cases were emergent surgery. The patients who underwent planned peripartum hysterectomy had lower rate of blood transfusion (83.9% vs. 100%, p=0.014), higher postoperative hemoglobin levels (9.9±1.3 vs. 8.3±1.3, p<0.001) compared with the emergent hysterectomy group. The birth weight was lower although the apgar scores were higher in the planned surgery compared with the emergent cases. Conclusion: The planned peripartum hysterectomy with a experienced team provide less need for transfusion and improved neonatal outcomes in regard to the emergent peripartum hysterectomy.

The Value of Using a Dedicated Vascular Lab in Managing and Treating Diabetic Critical Limb Ischemia Patients

Critical limb ischemia (CLI) is a debilitating end stage of advanced peripheral vascular disease. Treating CLI, particularly in the diabetic patient, is a multifaceted process that requires an experienced team of providers. The CLI model employs practitioners from interventional cardiology, vascular surgery, wound care, endocrinology, nephrology, internal medicine, and podiatry. The main treatment goal is to improve quality of life and reduce the number of limb amputations and the subsequent complications. Often, multiple endovascular procedures are needed to restore perfusion to the lower leg and foot to prevent limb loss. The overall health care savings are significant if limb loss is avoided despite requiring multiple procedures. The number of patients, particularly diabetics, who will need this advanced level of care is only expected to rise.

Translated Article: Resection of a Rare Proximal Radius Malignant Chondrosarcoma (Grade III) Bone Tumor and Reconstruction of the Forearm Functionality: A Case Report

Background: Chondrosarcoma is one of the common malignant bone tumors and is characterized by thin tumors. The cells produce tumor cartilage. It occur usually 3rd decade of life, affected more men than women. Objectives: To perform alternate surgical procedures for remove tumor and obtain fully forearm functionality by reconstruction. Methods: A patient affected by a rare proximal radius chondrosarcoma bone tumor and it became malignant (grade III). Resection the tumor along with chemotherapy and radiotherapy was done. Surgical treatments are mainly recommended for most types of chondrosarcoma treatment. However, the treatment of chondrosarcoma clinically and surgically is controversial due to different techniques. Results: Patients was fully recovered with excellent wrist and elbow joint functionality. Reconstruction of bones were fused by the support of metallic implants. There was no tumor recurrence occur during post-operative follow-up period. Conclusion: Chondrosarcoma of bone generally has an excellent prognosis when optimal diagnosed and treated by an experienced team of specialists. Its clinical treatment is always challenging due to of the rarity of these lesions and few institutions having enough patients to study about it.

From Da Vinci Si to Da Vinci Xi: realistic times in draping and docking the robot

Robot-assisted surgery is assumed to be time consuming partially due to extra time needed in preparing the robot. The objective of this study was to give realistic times in Da Vinci Xi draping and docking and to analyse the learning curve in the transition from the Si to the Xi in an experienced team. This prospective study was held in a hospital with a high volume of robot-assisted surgery in general surgery, urology and gynaecology. Times from the moment patients entered the operating room until the surgeon took place behind console were precisely recorded during the first 6 weeks after the implementation of the Xi. In total, 65 procedures were performed and documented. The learning curve for the process of draping and docking the robot was reached after 21 and 18 cases, respectively. Mean times after completion of the learning curve were 5 min for draping and 7 min for docking and were statistically different from mean times before completion of the learning curve (p values < 0.01). In dedicated teams netto extra time needed for preparing the Xi can even be reduced to just the time needed for docking. Thus, setting up the robot should have limited impact on overall time spent in the operation room.