Is Pathological Exam for Disorders of the Appendix Testis Necessary?

Testicular appendages are remnants of embryologic structures commonly encountered during pediatric operations. The literature is vague on the management of incidentally discovered testicular appendages found intraoperatively. We performed a retrospective review of 93 pediatric patients who were found to have an incidental testicular appendage during inguinal hernia repair, cryptorchidism, or testicular torsion cases from December 2017 to June 2020. 100% of the incidental testicular appendage pathology results were benign. All of the specimens were 1.0 cm or less in their largest dimension. Removal of these specimens is considered the standard of care at our institution to help prevent torsion of the testicular appendage, which is one of the leading causes of acute scrotum in children. The authors of this study argue that pathological analysis is unnecessary and may result in excessive use of resources without proven benefit.

Host Directed Therapies for Tuberculous Meningitis

A dysregulated host immune response significantly contributes to morbidity and mortality in tuberculous meningitis (TBM). Effective host directed therapies (HDTs) are critical to improve survival and clinical outcomes. Currently only one HDT, dexamethasone, is proven to improve mortality. However, there is no evidence dexamethasone reduces morbidity, how it reduces mortality is uncertain, and it has no proven benefit in HIV co-infected individuals. Further research on these aspects of its use, as well as alternative HDTs such as aspirin, thalidomide and other immunomodulatory drugs is needed. Based on new knowledge from pathogenesis studies, repurposed therapeutics which act upon small molecule drug targets may also have a role in TBM. Here we review existing literature investigating HDTs in TBM, and propose new rationale for the use of novel and repurposed drugs. We also discuss host variable responses and evidence to support a personalised approach to HDTs in TBM.

Robotic Surgery for the Thoracic and Vascular Surgeon

In the last two decades, robotic-assisted approaches have gained popularity as alternatives to conventional open and minimal-invasive surgery (MIS). The robotic approach combines the concepts of the traditional MIS with the latest technological advancements, enabling the surgeon to control the instrumentation using a robotic device connected to a remote console. With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception and hand-eye coordination. Since its introduction, numerous robotic-assisted procedures have been developed and tested across nearly all surgical fields. Data from previous studies have shown that a great majority of these techniques are feasible and have favourable treatment outcomes. In the field of thoracic and vascular surgery, two disciplines often combined in Belgium, robotic approaches have been implemented in the treatment of a wide array of disorders including lung cancer, mediastinal tumours, thoracic outlet syndrome, diaphragmatic paralysis, sympathectomy, aortobifemoral bypass surgery and division of the arcuate ligament for median arcuate ligament syndrome (MALS). Despite this increasing popularity, there are still a number of controversies regarding robotic surgery. There are only limited data on the cost-effectiveness of robotic surgery and its objective proven benefit over conventional MIS. In this review, we summarise the latest data on robotic approaches for the most relevant thoracic and vascular disorders.

1013 Preoperative Nasopharyngeal Swab Testing and Postoperative Pulmonary Complications in Patients Undergoing Elective Surgery During The SARS-Cov-2 Pandemic

Introduction This study aimed to evaluate the association between preoperative SARS-CoV-2 testing and postoperative pulmonary complications in patients undergoing elective cancer surgery. Method International cohort study including adult patients undergoing elective surgery for cancer in areas affected by SARS-CoV-2 up to 19 April 2020 (NCT04384926). Patients suspected preoperatively of SARS-CoV-2 infection were excluded. The primary outcome measure was postoperative pulmonary complications at 30 days after surgery. Results Of 8784 patients (432 hospitals, 53 countries), 2303 patients (26.2%) underwent preoperative testing: 1458 (16.6%) had a swab test, 521 (5.9%) CT only, and 324 (3.7%) swab and CT. The overall pulmonary complication rate was 3.9% and SARS-CoV-2 infection rate was 2.6%. After risk adjustment, only a nasopharyngeal swab test (adjusted odds ratio 0.68, 95% confidence interval 0.68-0.98, p = 0.040) was associated with lower rates of pulmonary complications. Swab testing remained beneficial before major surgery and in high SARS-CoV-2 population risk areas but not before minor surgery in low incidence areas. Conclusions Preoperative nasopharyngeal swab testing was beneficial before major surgery and in high SARS-CoV-2 incidence areas. There was no proven benefit of swab testing before minor surgery in low incidence areas.

Systemic corticosteroids for management of COVID-19: Saving lives or causing harm?

The underlying cause of many complications associated with severe COVID-19 is attributed to the inflammatory cytokine storm that leads to acute respiratory distress syndrome (ARDS), which appears to be the leading cause of death in COVID-19. Systemic corticosteroids have anti-inflammatory activity through repression of pro-inflammatory genes and inhibition of inflammatory cytokines, which makes them a potential medical intervention to diminish the upregulated inflammatory response. Early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the role of corticosteroids was unclear. Corticosteroid use in other indications such as ARDS and septic shock has proven benefit while its use in other respiratory viral pneumonias is associated with reduced viral clearance and increased secondary infections. This review article evaluates the benefits and harms of systemic corticosteroids in patients with COVID-19 to assist clinicians in improving patient outcomes, including patient safety. Dexamethasone up to 10 days is the preferred regimen to reduce mortality risk in COVID-19 patients requiring oxygen support, mechanical ventilation, or extracorporeal membrane oxygenation. If dexamethasone is unavailable, other corticosteroids can be substituted at equivalent doses. Higher doses of corticosteroids may be beneficial in patients who develop ARDS. Corticosteroids should be avoided early in the disease course when patients do not require oxygen support because of potential harms.

Host Directed Therapies for Tuberculous Meningitis

A dysregulated host immune response significantly contributes to morbidity and mortality in tuberculous meningitis (TBM). Effective host directed therapies (HDTs) are critical to improve survival and clinical outcomes. Currently only one HDT, dexamethasone, is proven to improve mortality. However, there is no evidence dexamethasone reduces morbidity, how it reduces mortality is uncertain, and it has no proven benefit in HIV co-infected individuals. Further research on these aspects of its use, as well as alternative HDTs such as aspirin, thalidomide and other immunomodulatory drugs is needed. Based on new knowledge from pathogenesis studies, repurposed therapeutics which act upon small molecule drug targets may also have a role in TBM. Here we review existing literature investigating HDTs in TBM, and propose new rationale for the use of novel and repurposed drugs. We also discuss host variable responses and evidence to support a personalised approach to HDTs in TBM.

Mature Versus Registration Studies of Immuno‐Oncology Agents: Does Value Improve With Time?

PURPOSE: A unique feature of immuno-oncology agents is the potential for durable survival for a subset of patients; however, this benefit usually cannot not be seen in the early published data used for regulatory approval. Value frameworks developed by ASCO and the European Society for Medical Oncology (ESMO) assess the clinical benefit demonstrated in clinical trials. Proven benefit may change with time as more mature data are available. Our objective was to evaluate the impact of mature data for immuno-oncology agents on ASCO and ESMO scores and to examine the concordance of these frameworks using more mature data. METHODS: We reviewed Food and Drug Administration (FDA) approvals for immuno-oncology agents between 2011 and 2017, calculated the ASCO-Net Health Benefit (NHB) score and ESMO-Magnitude of Clinical Benefit Score (MCBS), checked which agents fulfilled the criteria of being rewarded for durable survival, assessed the concordance between models using the Spearman correlation test, and compared the initial results of registration studies with mature follow-up data from the same studies. RESULTS: The FDA approved 27 solid tumor indications for immuno-oncology agents between 2011 and 2017. The correlation between ASCO-NHB score and ESMO-MCBS was high (0.88). Mature follow-up data were available for 13 of these indications, in which 6 studies were found to have improved in the grade of ASCO and/or ESMO value frameworks, whereas 2 cases were downgraded in the scale. CONCLUSION: Despite different approaches, the high concordance between ASCO and ESMO value frameworks indicates that both models reward treatments as beneficial for the same immuno-oncology agents. Mature data with longer follow-up reaffirmed most of the findings found in the evaluation in the initially published registration studies.

Endovascular thrombectomy: 31 hours from symptom onset

Endovascular thrombectomy is an effective intervention for symptomatic intracranial large-vessel occlusion. This treatment has proven benefit up to 24 hours following onset in selected patients with prestroke functional independence. Limited case reports suggest that thrombectomy beyond 24 hours may also be effective. We describe a young woman managed with endovascular thrombectomy beyond 24 hours.

Navigating through the maze of caesarean myomectomy: generating evidence

Management of myomas during pregnancy and labor is a contested subject so far. Currently no recommended national or international guidelines are in place resulting in conflicted opinion and management variation across the globe. Many obstetricians still discourage its practice due to fear of uncontrolled haemorrhage which may lead to unwanted hysterectomy in a reproductive age. However, some researchers have challenged the conventional perspective and argue that caesarean myomectomy (CM) is a safe procedure. The aim of this study is to examine all aspects of CM with an evaluative lens and to weigh its risk-benefit ratio. For this purpose, we conducted a literature review of studies, including those from low-resource countries indexed in scientific databases like PubMed, Google Scholar and Scopus. Most recent articles that reported benefits, complications and different techniques to safely perform caesarean myomectomy with proven benefit for the patient were examined thoroughly so that solid evidence on pros and cons of caesarean myomectomy could be generated. There is a dire need to conduct large sample size studies or randomized controlled trials for the risk-benefit evaluation of CM and to produce evidence-based clinical conclusion.

The use of perioperative chemotherapy in patients undergoing radical cystectomy for bladder cancer in Quebec (Canada), 2000-2016

Introduction: Despite its proven benefit, studies have reported poor use of perioperative chemotherapy (POC) in bladder cancer (BC) patients undergoing radical cystectomy (RC). We evaluated POC use in Quebec between January 2000 and September 2016. Methods: Using provincial health administrative databases, data were retrospectively collected from patients from two years before RC until December 2016 or death. Logistic regression was used to identify variables predicting POC use. Survival analyses were conducted using Cox regression. Analyzed covariates were age, sex, comorbidities, year of RC, residence and hospital region, distance to hospital, hospital type and size, and hospital’s and surgeon’s RC volume. Results: A total of 790/4656 patients (17.0%) received POC. Neoadjuvant chemotherapy (NAC) use increased in recent years: 3.5% (2009), 11.2% (2012), and 20.7% (2015). POC use was increased in patients with recent surgery, a younger age, less comorbidities, residing closer to the hospital of surgery, and a high surgeon’s RC volume (p<0.05). For patients treated between 2013 and 2016, a younger age (odds ratio [OR] 0.71; 95% confidence interval [CI] 0.64–0.80 per five years), shorter distance to the hospital (OR 0.88; 95% CI 0.77–0.99 per 50 km), surgery in an academic hospital (OR 1.86; 95% CI 1.06–3.29), and recent surgery (OR 1.34; 95% CI 1.14–1.58 per year) independently predicted NAC use. These NAC users had a significantly higher OS rate than patients without POC (hazard ratio 0.73; 95% CI 0.55–0.97). Limitations include missing data on pathological staging. Conclusions: NAC/POC use increased in Quebec but was lower compared to most developed countries. Its use was lower in patients residing further from the hospital and in those treated in non-academic hospitals.