Elective surgery patients walk to operating room instead of wheeled in on trolley: patient centered care

Introductions: Habits and beliefs of earlier practitioners influence medicine. We continue to wheel in the elective surgery patients to operating room (OR) which makes them feel not in self-control and increases anxiety. With few exceptions of heavily sedated, in severe pain or frail patients, most prefer to walk to the OR accompanied by nurse and family, if given the opportunity, in line with patient centered care. We aim to assess feasibility to allow elective surgery patients walk to OR accompanied by nurse and family member. Methods:This was a cross-sectional observation of 100 consecutive elective surgery patients admitted at surgery department, Patan Hospital, Nepal. Adult patients of 15 years or above were allowed to walk to OR accompanied by a nurse and family members. Demographic profile, patient satisfaction, anxiety on arriving to OR, patient feeling of autonomy were recorded to assess patient centered care. Microsoft Excel was used to descriptively analyze the data. Ethical approval was obtained. Results:Of 100 consecutive patients, 62 were female and 38 male, average age 52 years (range 15 to 72), and abdomen surgery 62 (62%). Two patients did not want to walk. The 98 patients who walked to the OR, all were satisfied and 89 were not anxious. Conclusions: Elective surgery patients (98 out of 100) accompanied by nurse and family members walked to operating room satisfied and were not anxious.  Keywords: elective surgery, patient autonomy, patient-centered care, patient satisfaction, walking to operating roo

Direct Liver Invasion from a Gastric Adenocarcinoma as an Initial Presentation of Extranodal Tumor Spread

Gastric cancer often carries a poor prognosis, with an estimated 740,000 deaths from the malignancy occurring yearly worldwide (Dicken et al., 2005). The mortality of disease is largely dependent on the extent of tumor spread, as gastric cancer has a predilection to metastasize to other visceral secondaries via hematogenous and lymphatic dissemination. Direct invasion of a gastric adenocarcinoma to adjacent organs secondary to gastric wall perforation does occur; however, it is often present in the setting of advanced disease. Rarely does direct tumor invasion to adjacent organs from a gastric adenocarcinoma present as the initial manifestation of extranodal tumor spread. We present a case of a 40-year-old male with direct tumor extension to the liver as an initial presentation of extranodal tumor spread from a gastric adenocarcinoma. Clinicians should be aware of such an occurrence, as treatment modalities in direct liver extension from a gastric adenocarcinoma vary and may be directed towards palliation rather than curative intent

Odontoblast markers and dentine reactions in carious primary molars with and without hypomineralised enamel defects

Background: Wnt/β-Catenin signalling and DMP1 have key roles in tertiary dentinogenesis. Aim: To compare the relationship between remaining dentine thickness (RDT), tertiary dentine thickness (TDT), β-catenin and dentine matrix protein 1 (DMP1) in carious second primary molar teeth with normal (SPM) and hypomineralised enamel (HSPM). Design: Extracted carious SPM and HSPM were fixed, sectioned (5 μm) and stained with haematoxylin and eosin or with indirect immunofluorescence for β-catenin and DMP1. Image analysis was performed to determine RDT, TDT, β-catenin and DMP1 intensity in the odontoblast layer and dentine-pulp complex. Results: Carious SPM (n = 11; mean RDT = 1536.1 μm) and HSPM (n = 12; mean RDT = 1179.9 μm) had mean TDT 248.6 μm and 518.1 μm, respectively (P =.02). There were no significant differences in intensity values in the odontoblast layer and dentine-pulp complex for β-catenin and DMP1 for both groups. Conclusion: There was no observable variation in Wnt/β-catenin and DMP1 expression between HSPM and SPM despite a statistically significant twofold increased TDT in HSPM compared with SPM that had similar RDT. Thus, the observed increased TDT in HSPM is more likely due to an earlier onset of repair processes rather than an amplified response to caries

Our experience with Athens protocol - simultaneous topo-guided photorefractive keratectomy followed by corneal collagen cross linking for keratoconus

Background: Corneal collagen cross linking (CXL) has become an established modality of treatment for progressive Keratoconus. Aim of the study was to analyze visual outcome, refractive status and changes in corneal curvature following simultaneous topography-guided photorefractive keratectomy (PRK) followed by corneal collagen cross-linking with riboflavin (C3R) for keratoconus in a tertiary eye care hospital.Methods: All patients underwent manifest refraction, uncorrected visual acuity (UCVA), Best corrected visual acuity (BCVA), slit lamp examination, corneal topography, ultrasound pachymetry and fundus evaluation pre operatively. 39 eyes of 27 patients with keratoconus underwent simultaneous topo guided PRK + CXL were followed up upto 6 months.Results: Mean UCVA improved from 0.81 log mar units pre-operatively to 0.43 log mar units at the end of 6 months. Preoperative BCVA was maintained or improved in 37 eyes (94.87%) and BCVA decreased by more than 1 line in 2 eyes (5.12%) post-operatively. The mean BCVA improved from 0.2 log mar units pre-operatively to 0.1 log mar units at the end of 6 months. The mean preoperative manifest refraction spherical equivalent reduced from -3.1±2.3D to -1.4±1.3D postoperatively. The mean steepest K reading decreased from 47.8±4.2D pre-op to 45±3.3D at the end of 6 month. Similarly, mean flat keratometry readings reduced significantly from 44.8±3.5D preoperatively to 42.2±2.8D at the last follow-up visit postoperatively.Conclusions: Combined topo-guided PRK+CXL is an effective approach in treating patients with keratoconus. It biomechanically stabilizes the cornea, improves the corneal contour, reduces irregular astigmatism and offers a better quality of vision

Assessment of the biomechanical properties of the cornea with the ocular response analyzer in normal and keratoconic eyes

PURPOSE. To compare hysteresis, a novel measure of ocular rigidity (viscoelasticity) in normal and keratoconic eyes. METHODS. The study consisted of 207 normal and 93 keratoconic eyes. Eyes were diagnosed as keratoconic based on clinical examination and corneal topography. The hysteresis was measured by the Ocular Response Analyzer (ORA; Reichert Ophthalmic Instruments, Buffalo, NY). The data were recorded by Generation 3 software for the ORA. Central corneal thickness (CCT) was measured with a handheld ultrasonic pachymeter in the midpupillary axis. RESULTS. The mean hysteresis was 10.7 ± 2.0 (SD) mm Hg (range, 6.1-17.6) in normal eyes compared with 9.6 ± 2.2 mm Hg (range, 4.7-16.7) in keratoconic eyes. The difference was statistically significant (P < 0.0001, unpaired t-test). Mean CCT in the normal and keratoconic eyes was 545.0 ± 36.4 μm (range, 471-650) and 491.8 ± 54.7 μm (range, 341-611), respectively; the difference was significant (P < 0.0001, unpaired t-test). CONCLUSIONS. Hysteresis was significantly higher in normal than in keratoconic eyes. It may be a useful measurement in addition to CCT, when assessing ocular rigidity, and may be of particular importance when trying to correct intraocular measurements for increased or decreased ocular rigidity. Long-term studies of change in hysteresis may provide information on the progression of keratoconus

Lower Extremity Cutaneous Lesions as the Initial Presentation of Metastatic Adenocarcinoma of the Colon

Cutaneous metastases from colorectal cancers are rare and are usually present on the abdominal wall or previous surgical incision sites. Remote cutaneous lesions have been reported, however, often occur in the setting of widespread metastatic disease including other visceral secondaries. We present a case of lower extremity cutaneous metastases as the first sign of metastatic disease in a patient with adenocarcinoma of the colon. This case illustrates that new skin lesions may be the initial presentation of metastatic disease in a patient with a history of cancer

Complete Corpus Callosotomy Using a Frameless Navigation Probe through a Minicraniotomy in Children with Medically Refractory Epilepsy: A Case Series and Technical Note

BACKGROUND: Medically refractory epilepsy constitutes up to one-third of the epilepsy pediatric patients. Corpus callosotomy (CC) has been used for the treatment of medically refractory epilepsy in children with atonic seizures and generalized tonic-clonic (GTC) seizures. In this case series study, we are describing a novel technique for CC using the frameless navigation probe through a minicraniotomy. METHODS: Thirteen pediatric patients with the diagnosis of medically refractory epilepsy predominantly GTC with drop attack who underwent extensive Phase I. An L-shape was done, then through a 4 × 3 cm craniotomy, we were able to open the interhemispheric fissure until the corpus callosum is visualized. The Stealth probe is then used to go down to the midline raphe which is followed anteriorly then traced posteriorly to the anterior border of the vein of Galen. Finally, the Stealth probe is used to confirm the completeness of the callosotomy. RESULTS: The procedure was accomplished successfully with no intraoperative complications; mean surgical time is 3 h:07 m. The mean follow-up was 31.5 months. All patients achieved significant seizure control. No patients experienced worsening of their atonic seizures after surgery compared with their preoperative state; however, six patients achieved Engel Class I, four patients achieved Engel Class II, and three patients achieved Engel Class III. CONCLUSION: Complete CC using a frameless navigation probe is a novel and effective technique for the treatment of medically refractory epilepsy with a very good surgical and seizure outcomes, minimal neurological morbidity, minimal blood loss, and short OR time

National or population level interventions addressing the social determinants of mental health - an umbrella review

Background: Social circumstances in which people live and work impact the population’s mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198). Results: We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk. Conclusion: This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health

Single-Cell Phenotyping within Transparent Intact Tissue through Whole-Body Clearing

Understanding the structure-function relationships at cellular, circuit, and organ-wide scale requires 3D anatomical and phenotypical maps, currently unavailable for many organs across species. At the root of this knowledge gap is the absence of a method that enables whole-organ imaging. Herein, we present techniques for tissue clearing in which whole organs and bodies are rendered macromolecule-permeable and optically transparent, thereby exposing their cellular structure with intact connectivity. We describe PACT (passive clarity technique), a protocol for passive tissue clearing and immunostaining of intact organs; RIMS (refractive index matching solution), a mounting media for imaging thick tissue; and PARS (perfusion-assisted agent release in situ), a method for whole-body clearing and immunolabeling. We show that in rodents PACT, RIMS, and PARS are compatible with endogenous-fluorescence, immunohistochemistry, RNA single-molecule FISH, long-term storage, and microscopy with cellular and subcellular resolution. These methods are applicable for high-resolution, high-content mapping and phenotyping of normal and pathological elements within intact organs and bodies