Survival of a Patient with Amniotic Fluid Embolism Based on Multidisciplinary Team Training: A Case Report of a Swiss University Hospital

Amniotic fluid embolism (AFE) is a rare, unpredictable and unpreventable event with high maternal and fetal morbidity and mortality. Its clinical presentation is nonspecific ranging from moderate organ dysfunction to cardiovascular collapse with disseminated intravascular coagulation (DIC), which can lead to death. In a situation of severe systemic disease, maternal survival is largely dependent on the combined efficacy of gynecological and anesthetic teams. We report a case of AFE in a healthy woman admitted to the delivery room for labor induction. Due to a loss of consciousness soon after epidural anesthesia associated to fetal bradycardia, an emergency caesarean section was performed which was complicated by uterine atony and DIC requiring hysterectomy. The outcome was favorable due to fast and efficient multidisciplinary care, emphasizing the benefit of having been trained for such situations through simulation and team training programs for obstetrical emergency management.

Using an Interprofessional Lens to Analyze Serious Adverse Events in a Teaching Hospital: An Analysis with the TeamSTEPPS® Framework

This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS® framework. Adverse events are the undesirable events that are not due to the natural course of a disease;they are considered serious when they prolong a hospital stay, lead to a physical disability or to death. Failures in teamwork, particularly with interprofessional teams, can lead to potential risks to patient safety. Using a dataset of de-identified reports of serious adverse events in 2016 in a tertiary teaching hospital, we explored the contribution of teamwork skills according to the TeamSTEPPS® framework to these adverse events. We found that 61% of the 41 analyzed events involved failures in teamwork skills, with 80% of these involving communication, 52% in situation monitoring and team structure, 44% in mutual support and 40% in leadership. Sixty-four percent of the events involved more than one teamwork component. Our findings emphasize the need to improve teamwork training in healthcare, focusing not only on communication, but also on other teamwork skills as they often contribute together in adverse events. Future analyses of serious adverse events should include a focus on teamwork competencies, to guide the development of future quality and safety training programs.

Pacemaker post transcatheter aortic valve replacement:A multifactorial risk?

Pacemaker post-transcatheter aortic valve replacement is related to multifactorial risk.Nwaedozie et al brought to the body of evidence electrocardiogram and clinical findings.However,procedural characteristics have at least as much impact on the final need for a permanent pacemaker and potentially on the pacing rate.In this regard,long-term follow-up and understanding of the impact of long-term stimulation is of utmost importance.

Epidural anesthesia improves pancreatic perfusion and decreases the severity of acute pancreatitis

AIM: To study the safety of epidural anesthesia(EA),its effect on pancreatic perfusion and the outcome of patients with acute pancreatitis(AP).METHODS: From 2005 to August 2010,patients with predicted severe AP [Ranson score ≥ 2,C-reactive protein > 100 or necrosis on computed tomography(CT)] were prospectively randomized to either a group receiving EA or a control group treated by patientcontrolled intravenous analgesia. Pain management was evaluated in the two groups every eight hours using the visual analog pain scale(VAS). Parameters for clinical severity such as length of hospital stay,use of antibiotics,admission to the intensive care unit,radiological/clinical complications and the need for surgical necrosectomy including biochemical data were recorded. A CT scan using a perfusion protocol was performed on admission and at 72 h to evaluate pancreatic blood flow. A significant variation in blood flow was defined as a 20% difference in pancreatic perfusion between admission and 72 h and was measured in the head,body and tail of the pancreas.RESULTS: We enrolled 35 patients. Thirteen were randomized to the EA group and 22 to the control group. There were no differences in demographic characteristics between the two groups. The Balthazar radiological severity score on admission was higher in the EA group than in the control group(mean score 4.15 ± 2.54 vs 3.38 ± 1.75,respectively,P = 0.347) and the median Ranson scores were 3.4 and 2.7 respectively(P = NS). The median duration of EA was 5.7 d,and no complications of the epidural procedure were reported. An improvement in perfusion of the pancreas was observed in 13/30(43%) of measurements in the EA group vs 2/27(7%) in the control group(P = 0.0025). Necrosectomy was performed in 1/13 patients in the EA group vs 4/22 patients in the control group(P = 0.63). The VAS improved during the first ten days in the EA group compared to the control group(0.2 vs 2.33,P = 0.034 at 10 d). Length of stay and mortality were not statistically different between the 2 groups(26 d vs 30 d,P = 0.65,and 0% for both respectively).CONCLUSION: Our study demonstrates that EA increases arterial perfusion of the pancreas and improves the clinical outcome of patients with AP.

Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer:A review

Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds.Such large wounds are prone to infection and perineal herniation,and their closure is a major concern to most surgeons.Different approaches to the perineal repair exist,varying from primary or mesh closure to myocutaneous flaps.Each technique has its own associated advantages and potential complications and the ideal approach is still debated.In the present study,we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure.Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction.In addition,the rate of perineal hernia is lower in early follow-up,while long-term hernia occurrence appears to be similar between the different techniques.Finally,it is an easy and quick reconstruction method.Although more expensive than primary closure,the cost associated with the use of a biological mesh is at least equal,if not less,than flap reconstruction.

Health-related quality of life outcomes after cholecystectomy

Gallbladder diseases are very common in developed countries. Complicated gallstone disease represents the most frequent of biliary disorders for which surgery is regularly advocated. As regards, cholecystectomy represents a common abdominal surgical intervention; it can be performed as either an elective intervention or emergency surgery, in the case of gangrene, perforation, peritonitis or sepsis. Nowadays, the laparoscopic approach is preferred over open laparotomy. Globally, numerous cholecystectomies are performed daily; however, little evidence exists regarding assessment of post-surgical quality of life (QOL) following these interventions. To assess post-cholecystectomy QOL, in fact, documentation of high quality care has been subject to extended discussions, and the use of patientreported outcome satisfaction for quality improvement has been advocated for several years. However, there has been little research published regarding QOL out-comes following cholecystectomy; in addition, much of the current literature lacks systematic data on patientcentered outcomes. Then, although several tools have been used to measure QOL after cholecystectomy, diffi culty remains in selecting meaningful parameters in order to obtain reproducible data to reflect postoperative QOL. The aim of this study was to review the impact of surgery for gallbladder diseases on QOL. This review includes Medline searches of current literature on QOL following cholecystectomy. Most studies demonstrated that symptomatic patients profi ted more from surgery than patients receiving an elective intervention. Thus, the gain in QOL depends on the general conditions before surgery, and patients without symptoms profi t less or may even have a reduction in QOL.

The contribution of Asian scientists to global research in andrology

Aim: To present a personal account of the involvement of the World Health Organization (WHO) in the collaborativedevelopment in Asia of those areas of andrology concerned with male contraception and reproductive health.Methods: The andrology training through workshops and institution support undertaken by the WHO HumanReproduction Programme (HRP) and how they contributed to the strengthening of andrology research in Asia aresummarised. Results: The author's experience and the Asian scientific contributions to the global research in thefollowing areas are reviewed: the safety of vasectomy and the development of new methods of vas occlusion; gossypoland its failure to become a safe, reversible male antifertility drag; Tripterygium and whether its pure extracts will passthrough the appropriate toxicology and phased clinical studies to become acceptable contraceptive drugs; hormonalmethods of contraception for men. Conclusion: The WHO policy of research capacity building through training andinstitution strengthening, together with the collaboration of Asian andrologists, has created strong National institutionsnow able to direct their own programmes of research in clinical and scientific andrology.

Perforated duodenal diverticulum, a rare complication of a common pathology: A seven-patient case series

Duodenal diverticula (DD) are frequently encountered and are usually asymptomatic, with an incidence at autopsy of 22%. Perforation of DD is a rare complication (around 160 cases reported) with potentially dramatic consequences. However, little evidence regarding its treatment is available in the literature. The aim of this study was to review our experience of perforated DD, with a focus on surgical management. Between January 2001 and June 2011, all perforated DD were retrospectively reviewed at a single centre. Seven cases (5 women and 2 men; median age: 72.4 years old, rang: 48-91 years) were found. The median American Society of Anesthesiologists' score in this population was 3 (range: 3-4). The perforation was located in the second portion of duodenum (D2) in six patients and in the third portion (D3) in one patient. Six of these patients were treated surgically: five patients underwent DD resection with direct closure and one was treated by surgical drainage and laparostomy. One patient was treated conservatively. One patient died and one patient presented a leak that was successfully treated conservatively. The median hospital stay was 21.1 d (range: 15-30 d). Perforated DD is an uncommon presentation of a common pathology. Diverticular excision with direct closure seems to offer the best chance of survival and was associated with a low morbidity, even in fragile patients.

Non-occlusive mesenteric ischemia: Diagnostic challenges and perspectives in the era of artificial intelligence

Acute mesenteric ischemia(AMI)is a severe condition associated with poor prognosis,ultimately leading to death due to multiorgan failure.Several mechanisms may lead to AMI,and non-occlusive mesenteric ischemia(NOMI)represents a particular form of AMI.NOMI is prevalent in intensive care units in critically ill patients.In NOMI management,promptness and accuracy of diagnosis are paramount to achieve decisive treatment,but the last decades have been marked by failure to improve NOMI prognosis,due to lack of tools to detect this condition.While real-life diagnostic management relies on a combination of physical examination,several biomarkers,imaging,and endoscopy to detect the possibility of several grades of NOMI,research studies only focus on a few elements at a time.In the era of artificial intelligence(AI),which can aggregate thousands of variables in complex longitudinal models,the prospect of achieving accurate diagnosis through machine-learning-based algorithms may be sought.In the following work,we bring you a state-of-the-art literature review regarding NOMI,its presentation,its mechanics,and the pitfalls of routine work-up diagnostic exams including biomarkers,imaging,and endoscopy,we raise the perspectives of new biomarker exams,and finally we discuss what AI may add to the field,after summarizing what this technique encompasses.

Selection of patients with hepatocellular carcinoma before liver transplantation:need to combine alpha-fetoprotein with morphology?

Liver transplantation is the best treatment for selected patients with unresectable hepatocellular carcinoma (HCC). While candidate selection has been historically based on the restrictive Milan

Role of near-infrared fluorescence in colorectal surgery

Near-infrared fluorescence(NIRF)is a technique of augmented reality that,when applied in the operating theatre,allows the colorectal surgeon to visualize and assess bowel vascularization,to identify lymph nodes draining a cancer site and to identify ureters.Herein,we review the literature regarding NIRF in colorectal surgery.

Recent advances in the management of autoimmune pancreatitis in the era of artificial intelligence

Autoimmune pancreatitis(AIP)is a type of immune-mediated pancreatitis subdivided into two subtypes,type 1 and type 2 AIP.Furthermore,type 1 AIP is considered to be the pancreatic manifestation of the immunoglobulin G4(IgG4)-related disease.Nowadays,AIP is increasingly researched and recognized,although its diagnosis represents a challenge for several reasons:False positive ultrasound-guided cytological samples for a neoplastic process,difficult to interpret levels of IgG4,the absence of biological markers to diagnose type 2 AIP,and the challenging clinical identification of atypical forms.Furthermore,60%and 78%of type 1 and type 2 AIP,respectively,are retrospectively diagnosed on surgical specimens of resected pancreas for suspected cancer.As distinguishing AIP from pancreatic ductal adenocarcinoma can be challenging,obtaining a definitive diagnosis can therefore prove difficult,since endoscopic ultrasound fine-needle aspiration or biopsy of the pancreas are suboptimal.This paper focuses on recent innovations in the management of AIP with regard to the use of artificial intelligence,new serum markers,and new therapeutic approaches,while it also outlines the current management recommendations.A better knowledge of AIP can reduce the recourse to surgery and avoid its overuse,although such an approach requires close collaboration between gastroenterologists,surgeons and radiologists.Better knowledge on AIP and IgG4-related disease remains necessary to diagnose and manage patients.

Risk of colorectal cancer in patients with diverticular disease

Colorectal cancer constitutes an important burden on the healthcare system. Screening at-risk populations to reduce colorectal cancer-related morbidity and mortality has become part of good clinical practice. However, recommendations regarding subgroups of patients with diverticular disease are subject to controversy. Herein, we review the most recent literature regarding the prevalence of colorectal cancer in patients with diverticular disease, diverticulitis and uncomplicated diverticulitis. The recent literature does not identify diverticular disease as a long-term risk factor for colorectal cancer. However, the risk of colorectal cancer is increased in the short-term period after hospitalization related to diverticular disease. According to a recent systematic review and meta-analysis, the prevalence of colorectal cancer is 1.6% in patients with acute diverticulitis who underwent colonoscopy. The risk of having colorectal cancer after an episode of acute diverticulitis is 44-fold higher than that of an age-and gender-adjusted reference population. Despite lower among patients with uncomplicated episode, the risk of colorectal cancer remains 40-fold higher in that subpopulation than that in the reference population. To conclude, the recent literature describes an increased risk of colorectal cancer among patients with acute diverticulitis compared to the reference population. Colonoscopy is therefore recommended in patients with diverticulitis to exclude colorectal cancer.

Diagnostic accuracy of a new point-of-care screening assay for celiac disease

AIM: To determine the diagnostic accuracy of a new point-of-care assay detecting anti-deamidated gliadin peptides in celiac disease(CD) patients.METHODS: One-hundred-and-twelve patients(age range: 1.8-79.2 years old) with clinical symptoms suggestive of CD and/or first-degree relatives(FDR) of CD patients(n = 66),and confirmed CD on a gluten-free diet(GFD)(n = 46),were prospectively enrolled in the study at Gastroenterology outpatient clinics for adult patients and from the Gastroenterology Consultation Ward at the Pediatric Department of the University Hospital of Geneva.Written informed consent was obtained from all subjects enrolled.The study received approval from the local ethics committee.The original CD diagnosis had been based on serum-positive IgA anti-tissue transglutaminase enzyme-linked immunosorbent assay(ELISA)(QuantaLite,Inova Diagnostics,San Diego,CA,United States) and on biopsy results.Serum samples from all study participants were tested by the new CD lateral flow immunochromatographic assay(CD-LFIA) device,Simtomax Blood Drop(Augurix SA,BioArk,Monthey,Switzerland) to detect immunoglobulin(Ig)A and IgG antibodies against deamidated gliadin peptides.The diagnostic performance was evaluated using receiver operating characteristic curves with 95%CIs.A cut-off of 2 on the Rann colorimetric scale was used to calculate the device's sensitivity and specificity.RESULTS: CD-LFIA was highly accurate in detecting untreated celiac patients.In the group of patients with CD symptoms and/or FDR,eight new cases of CD were detected by ELISA and biopsy.All of these new cases were also correctly identified by CD-LFIA.The test yielded four false positive and four false negative results.The false positive results were all within the groups with clinical symptoms suggestive of CD and/or FDR,whereas the false negative results were all within the GFD group.The test yeld a sensitivity of 78.9%(95%CI: 54.4-93.9) and specificity of 95.7%(95%CI: 89.4-98.8),and the area under the curve reached 0.893(95%CI: 0.798-0.988).The Kappa coefficient,calculated according to the values obtained by two readers from the same device,was of 0.96(SE: 0.06).When the GFD patients were excluded from the analysis,the area under the curve reached 0.989(95%CI: 0.971-1.000) and the Kappa coefficient,calculated according to the values obtained by two readers from the same device,became 0.96(SE: 0.07).Furthermore,using the Rann scale cut-off of 2 without the GFD patients,sensitivity was 100% and specificity was 93.1%(95%CI: 83.3-98.1).CONCLUSION: The new CD-LFIA rapid screening test shows good diagnostic accuracy,sensitivity and specificity,and may rule out CD in patients with CD-related symptoms.

Natural history of uncomplicated sigmoid diverticulitis

While diverticular disease is extremely common, the natural history(NH) of its most frequent presentation(i.e., sigmoid diverticulitis) is poorly investigated. Relevant information is mostly restricted to populationbased or retrospective studies. This comprehensive review aimed to evaluate the NH of simple sigmoid diverticulitis. While there is a clear lack of uniformity in terminology, which results in difficulties interpreting and comparing findings between studies, this review demonstrates the benign nature of simple sigmoid diverticulitis. The overall recurrence rate is relatively low, ranging from 13% to 47%, depending on the definition used by the authors. Among different risk factors for recurrence, patients with C-reactive protein > 240 mg/L are three times more likely to recur. Other risk factors include: Young age, a history of several episodes of acute diverticulitis, medical vs surgical management, male patients, radiological signs of complicated first episode, higher comorbidity index, family history of diverticulitis, and length of involved colon > 5 cm. The risk of developing a complicated second episode(and its corollary to require an emergency operation) is less than 2%-5%. In fact, the old rationale for elective surgery as a preventive treatment, based mainly on concerns that recurrence would result in a progressively increased risk of sepsis or the need for a colostomy, is not upheld by the current evidence.

Comment on: Should a colonoscopy be offered routinely to patients with CT proven acute diverticulitis? A retrospective cohort study and meta-analysis of best available evidence

Latest evidence indicates that patients with acute diverticulitis have higher prevalence of colorectal cancer than reference patients.Therefore,colonoscopy should be offered after an episode of acute diverticulitis.

Approaches to Improving Nursing Handoffs in Surgical Wards

Objective: To propose approaches to improve nursing handoffs for surgical patients, including standardization. Background: Handoffs, or the transfer of accountability and patient information, can generate potential risks for patient safety. Standardization has been proposed to help improve handoffs. Methods: After observing 333 nursing handoffs in the surgical wards of our institution, we conducted a thematic content analysis, comparing and contrasting the observations. Results: Handoff processes, including the use of support tools, varied among the observations. Common themes in the handoff content suggested possibilities of standardization. About half of the 51 interruptions occurring during the observed handoffs were by healthcare professionals. Conclusions: Standardization to improve handoffs should address both the content and the process. Interruptions were common and should be avoided whenever possible. Future studies should also consider the use of mobile applications to support handoffs and clinical documentation.

Compassionate Use of Midostaurin in Myeloid and Lymphoid Neoplasia with FGFR1 Abnormality

Background: Patients with stem cell myeloproliferative disorders have a particularly poor prognosis and limited treatment options, i.e. mainly aggressive chemotherapy or allogeneic stem cell transplantation. In 2004, Chen et al. reported a patient presenting a t(8;13) (p11;q12) cytogenic anomaly who responded positively to treatment with PKC412 (midostaurin), an oral multi-targeted tyrosine kinase inhibitor. Here, we report a second case treated with the above-mentioned drug. Patient: A 71-year-old woman was diagnosed as having chronic myelogenous leukaemia with eosinophilia secondary to t(8;13) with FGFR1 involvement. Due to her age, an allogeneic stem cell transplantation was not possible. Treatment: A treatment combining aggressive chemotherapy and midostaurin was explored. The patient received one cycle of hyper-CVAD chemotherapy followed by maintenance therapy with midostaurin. A relapse occurred after six months, and she was treated with four more cycles of hyper-CVAD chemotherapy. The patient entered a complete clinical, haematological and cytogenetic remission. A maintenance therapy with midostaurin continued for four months until she developed a chemoresistant relapse followed by acute leukaemia. Conclusion: This is the second case of a t(8;13) myeloid and lymphoid neoplasm with FGFR1 abnormalities treated successfully with midostaurin. Midostaurin is administered orally, allows for outpatient care and in this case showed only occasional and minimal side effects. The combination of hyper-CVAD and midostaurin extended survival by 21 months without allogeneic transplantation. This case further supports the possibility of using midostaurin for the treatment of other diseases with FGFR1 dysregulations;however, specific clinical trials are needed to confirm this hypothesis.

Phase I/II Study of Gefitinib and Concomitant Preoperative Radiotherapy in Patients with Locally Advanced Rectal Cancer

Objective: To determine the recommended dose (RD) of gefitinib when combined with concomitant radiotherapy (RT) in a preoperative setting in patients with locally advanced rectal cancer. Secondary objectives were to evaluate acute toxicities, pathological response rate, progression-free and overall survival (OS). Materials and Methods: 20 patients with cT3-4 or cN+ cM0 tumors were enrolled. The planned RT consisted in 50 Gy given in 2 daily fractions of 1.25 Gy in 4 weeks. During RT, gefitinib was planned to be given orally once daily with 2 successive dose levels: 250 mg and 500 mg. Rectal surgery was scheduled 5 - 6 weeks after completion of RT. The median follow-up for all patients was 57 months. Results: Among the first cohort of 6 patients, 1 patient presented a dose limiting toxicity (DLT) (Grade 3 diarrhea/dehydration). In the second cohort, 2/6 patients presented with the same DLT so that 250 mg was considered as the RD. Main acute toxicities consisted in diarrhea (grade 2 - 3, 63%), and skin reaction (in RT fields grade 2 - 3 in 42%). The 5-year actuarial OS and loco-regional control rates were of 80% and 84% respectively. Conclusion: The concomitant daily administration of 250 mg of gefitinib with 50 Gy preoperative RT is feasible with manageable toxicity. The major pathologic response rate is encouraging, though it needs further confirmation. Distant metastasis still represents a concern and new strategies to overcome this issue are warranted.

Vascular invasion in pancreatic cancer:Imaging modalities,preoperative diagnosis and surgical management

Pancreatic cancer is associated with a poor prognosis,and surgical resection remains the only chance for curative therapy.In the absence of metastatic disease,which would preclude resection,assessment of vascular invasion is an important parameter for determining resectability of pancreatic cancer.A frequent error is to misdiagnose an involved major vessel.Obviously,surgical exploration with pathological examination remains the"gold standard"in terms of evaluation of resectability,especially from the point of view of vascular involvement.However,current imaging modalities have improved and allow detection of vascular invasion with more accuracy.A venous resection in pancreatic cancer is a feasible technique and relatively reliable.Nevertheless,a survival benefit is not achieved by curative resection in patients with pancreatic cancer and vascular invasion.Although the discovery of an arterial invasion during the operation might require an aggressive management,discovery before the operation should be considered as a contraindication.Detection of vascular invasion remains one of the most important challenges in pancreatic surgery.The aim of this article is to provide a complete review of the different imaging modalities in the detection of vascular invasion in pancreatic cancer.