Cureus最新文献

Severe pulmonary conditions in patients undergoing surgery place them at greater risk of adverse outcomes. Alternatives to general anesthesia are encouraged, particularly for emergent interventions, as these procedures can compromise the patients' full recovery postoperatively. We describe an example of an underused anesthetic technique, continuous spinal anesthesia, to circumvent the perioperative risk of major abdominal surgery, successfully avoiding invasive mechanical ventilation in these patients.

Research indicates that poor communication accounts for almost half of errors made during surgery. Despite this, formal training in the cognitive and interpersonal aspects of operating is lacking in the surgical curriculum. Non-Technical Skills for Surgeons (NOTSS) is a behaviour rating system designed to evaluate surgeons on their non-technical skills in the operating room. This rating system splits intraoperative non-technical skills into four domains: situation awareness, decision-making, communication and teamwork, and leadership. Assessors score surgical trainees on each of these domains, using these ratings to inform a structured debrief. NOTSS has been shown to have a robust construct, content and concurrent validity, accurately predicting the risk of adverse events in surgery. Its reliability is threatened by considerable inter-rater variance, particularly in the cognitive domains of the taxonomy, which makes it difficult to defend its use as a summative assessment, but it is relatively procedure-independent as an assessment tool. The feasibility of incorporating NOTSS into the surgical curriculum depends on the viability and financial cost of training assessors across the United Kingdom (UK) in its use, which is currently unknown. It has been received positively by assessors and trainees alike as a formative tool to facilitate a deeper understanding of non-technical skills in theatre, but its acceptability as a barrier to progression has not been examined. Promisingly, a small study has demonstrated NOTSS assessments to have a positive impact on trainees' non-technical proficiency in surgery, but further research is warranted before any definitive conclusions can be drawn about its educational value.

Oral lichen planus (OLP) is a chronic inflammatory condition that affects the mucous membranes of the oral cavity and is characterized by a T-cell-mediated autoimmune response. It presents a therapeutic challenge due to its relapsing nature, causing significantly decreased quality of life and, in some cases, increasing the risk of malignant transformation. While topical corticosteroids have long been the first-line therapy for OLP, their long-term use is associated with adverse effects, such as mucosal atrophy and candidiasis. This has driven interest in alternative therapies, particularly topical calcineurin inhibitors (TCIs), such as tacrolimus, which offer a steroid-sparing approach. This review explores the pathophysiological basis of OLP, examines the role of TCIs in its treatment, and evaluates emerging therapies, with a specific focus on the use of a topical liposomal formulation of tacrolimus. These formulations aim to achieve high local drug concentrations while minimizing systemic absorption. OLP is a complex and multifactorial disease that requires a multifaceted approach to management. While current therapies provide symptomatic relief, there is a need for more effective and safer treatment options. Emerging therapies, including advanced drug delivery systems, biologics, and alternative therapies, hold promise for improving the management of OLP. Future research should focus on identifying novel therapeutic targets and developing strategies that can achieve sustained remission with minimal side effects.

Granulomatosis with polyangiitis (GPA) is an uncommon disorder that causes inflammation of the blood vessels in the nose, throat, lungs, and kidneys. We describe a 20-year-old female who presented to the emergency room with acute left facial paralysis, worsening left-sided otalgia secondary to a hyperemic tympanic membrane with middle ear granulation tissue, nasal obstruction with associated intermittent epistaxis, and cough. A high index of suspicion for GPA helped make an early diagnosis with subsequent initiation of treatment. This case details an unusual presenting symptom for GPA, as well as our treatment plan and the patient's subsequent recovery.

Background Incidental upper gastrointestinal wall thickness (GIWT) is a nonspecific finding often observed on computed tomography (CT) scans performed to investigate patients admitted with various symptoms both gastrointestinal (GI) and non-GI. Its clinical significance is uncertain, and patients often undergo endoscopic evaluation under an urgent cancer pathway to exclude malignancy. We aimed to conduct this study to determine how well the CT findings correlated endoscopically.  Methods  A retrospective data collection was performed for patients who were referred to the endoscopy department between July 2021 and July 2024 for evaluation of GIWT over a period of four years. We analyzed age, gender, reason for initial CT, endoscopic findings, histology findings, and evidence of cancer. Results Our final cohort included 50 patients who underwent endoscopic and subsequent histological examination following abnormal CT findings. The mean age of the included cohort was 71. Thirty-one were males and 19 patients were females. Ninety percent had esophageal wall thickness while 10% had gastric wall thickness. Twenty-six percent of patients had red flag symptoms such as weight loss and iron deficiency anemia as an indication for undergoing CT scans. About 8% of the patients were confirmed to have malignancy on endoscopy of which 6% had red flag symptoms such as weight loss and iron deficiency anemia. Seventy-eight percent of the cohort had gastroscopy within two to four weeks, 10% in four to 12 weeks and 12% after 12 weeks. Conclusion Our results illustrate that a majority of people with incidental GIWT had benign pathologies whereas a small number of patients had malignancy. It is worth noting that malignancy was more common among patients who had red flag symptoms, and therefore urgent endoscopy assessment under the urgent cancer pathway is recommended in these patients. On the contrary, the risk is noted to be low in patients with no red flag symptoms, therefore we recommend assessing such patients individually for the need for endoscopic evaluation based on detailed history and examination. We think further multicenter large studies are required in this area of research and develop standard protocols in relation to investigating incidental upper GIWT with endoscopy.

Introduction Magnetic resonance imaging (MRI) serves as a pivotal tool in the preoperative assessment of rectal cancer. This study aims to evaluate the accuracy of preoperative MRI pelvis in rectal cancer for locoregional staging, circumferential margin (CRM+), and vascular invasion (V1) with postoperative histopathological findings. Methods All patients who underwent preoperative staging MRI pelvis scanning for histology-proven primary rectal adenocarcinoma between January 2020 and July 2022 were included in this study. Preoperative MRI assessment data, including tumor (T), nodal (N) staging, and other prognostic factors, including circumferential margin and vascular invasion, were compared with histopathological reports. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy were calculated. Agreement between MRI and pathology reports was evaluated using the weighted kappa statistic. Results The study included 143 patients. The accuracy of MRI is at its peak for T0 and T4 tumors (T0-97.9%, T4-93.37). The weighted kappa statistic for T staging is 0.401, and for N staging, it is 0.286. The standard kappa statistic for extramural vascular invasion (V) and circumferential resection margin (CRM) is 0.269 and 0.225, respectively. Conclusion MRI demonstrates fair agreement with pathology regarding T and N staging and exhibits high specificity for CRM and V1.

Introduction: In 2019, a new fixed-bearing implant for unicondylar knee arthroplasty (UKA) was introduced that incorporated a round-on-flat design featuring an Oxinium femoral component coupled with a highly crosslinked polyethylene bearing surface. Compared to prior implants, the design featured smaller size increments coupled with medial and lateral-specific tibial baseplates. The objective of this study is to describe our institution's early experience with this UKA implant system by evaluating survivorship, reasons for revision, and patient-reported outcome measures (PROMs).

Methods: The 944 UKAs that comprise the study population, including 814 medial and 130 lateral joint replacements, were performed by six surgeons from September 2019 through the end of December 2023. All UKA components were cemented, the mean age at surgery was 67.1±10.0 years, 57% (537/944) of the UKAs were performed among women, and the mean body mass index was 30.3±6.2 kg/m². Outcome measures included Kaplan-Meier survivorship using reoperation for any reason as an endpoint, reasons for reoperation, range of motion, and PROMs that were collected preoperatively and postoperatively at 4 weeks, 4 months, 1 year, and 2 years.

Results: Using reoperation for any reason as an endpoint, 1-year survivorship was 99.3% (95% CI, 98.7 to 99.9%) and 2-year survivorship was 98.2% (95% CI, 96.9 to 99.5%). There were nine reoperations among the 944 UKAs, including three for infection, two for tibial loosening, one for femoral loosening, one for progression of arthritis, one for patellar instability, and one for recurrent hemarthrosis. The mean time to reoperation was 0.82±0.68 years and all were performed among medial UKAs. Range of motion increased from 117±8 degrees preoperatively to 122±6 degrees at 1-year follow-up. PROMs, including the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Physical score, demonstrated progressive increases from the preoperative assessment through 2-year follow-up. For UKAs with preoperative and 2-year KOOS JR scores, the mean change was 31±17.

Conclusion: As new implants and technologies are introduced, documenting the early outcome from high volume centers can offer valuable insights to validate the effectiveness of implant systems before they are adopted by the broader orthopedic community. This study demonstrates encouraging early outcome data associated with a contemporary UKA system based on survivorship and PROMs. At this early stage, there are no implant-related concerns but obtaining additional follow-up will be important to quantify how revisions and PROMs evolve over time.

This case report describes a 62-year-old male who experienced paradoxical hypothermia following an elective total knee replacement (TKR) performed under spinal anesthesia with intrathecal morphine administration. The patient presented with significant hypothermia, defined as a body temperature below 35°C, approximately 45 minutes following the administration of anesthesia. The condition demonstrated resistance to conventional rewarming techniques. This condition required symptomatic treatment, leading to the administration of naloxone. After receiving two doses of naloxone, the patient's temperature stabilized, and they experienced a reduction in diaphoresis, improved alertness, and less nausea. Given the scarce documentation on non-obstetric paradoxical hypothermic reactions to intrathecal morphine, this case highlights the critical need for careful temperature monitoring when administering spinal anesthesia with intrathecal opioids. Additionally, it highlights the unusual symptoms of hypothermia that can hinder diagnosis and treatment, stressing the need for increased awareness among anesthesiologists to achieve the best possible patient outcomes.

Dyspraxia is a brain pathology that affects an individual's movement, coordination, and motor skills. It makes everyday tasks, such as writing, balancing, or playing sports, more difficult due to problems with motor skills, planning, coordination, and balance. A form of dyspraxia that mainly affects the upper limbs has been recognised as a distinct clinical entity of subcortical strokes, classified as striatocapsular infarction syndrome (SIS). In this case report, a female writer presented with a vague history of right-sided headaches and sudden onset of difficulty with fine motor tasks. She brought in a paper with her typed summary from Jane Austen's Pride and Prejudice, which revealed the disorderliness in her writing and coordination. Examination subsequently revealed visual field defects and finger-nose dyspraxia. A CT head scan confirmed an established infarction in the right parietal lobe, consistent with stroke. Some patterns of these striatocapsular strokes may pose a challenge with early recognition and require comprehensive neurological examination, in addition to relevant neuroimaging for diagnosis. Prognosis varies and is not well defined, with thromboembolic infarction being a common denominator in complications.

Since its first description in 1990, Takotsubo cardiomyopathy (TC) has continued to puzzle physicians and scientists alike as the mechanisms behind the characteristic unique left ventricular dysfunction that marks the condition and its relation to the intense emotional and physiological stressors that usually precede it have remained not fully understood. Since then, several different variants of the condition have been described that do not conform to the conventional narrative of a post-menopausal disease that only affects women of a certain age and is triggered by a preceding event. Of these variants, atypical Takotsubo, which does not assume the typical characteristic apical ballooning that marks the condition has been linked with a younger age group and a more neurological trigger. A strong guideline-based clinical suspicion and an astute knowledge of its clinical, laboratory, and different morphological presentations are often needed to differentiate the case from acute coronary syndromes, which it so closely resembles. This case illustrates an atypical presentation of atypical TC in an otherwise healthy woman and how a guideline-based approach can be utilized to identify and manage the condition while discussing the most recent theories addressing TC.