以症状为主线的教学模式在耳鼻咽喉头颈外科规范化培训教学中的应用

耳鼻咽喉头颈外科住院医师规范化培训教学对临床思维的要求日益提高,传统以理论授课为主的教学模式难以使学生对耳鼻咽喉头颈外科形成系统的临床思维,本文探讨了“以症状为主线,充分培养临床思维”的教学模式在耳鼻咽喉头颈外科基地住院医师规范化培训培养中的应用及心得体会.     

Smoking as an independent risk factor for severe skin reactions due to adjuvant radiotherapy for breast cancer

Risk factors for severe acute radiation skin reactions (ARSR) have been described with conflicting results. The aim of this study was to identify risk factors for the development of severe ARSR in women undergoing adjuvant radiotherapy (RT) for breast cancer.390 women were assessed at the first and final RT sessions and at followup. ARSR were measured by the Radiation Therapy Oncology Group/The Organization for Research and Treatment of Cancer, Acute Radiation Morbidity Scoring Criteria (RTOG/EORTC scale). Patients reported symptoms using visual analogue scale (VAS). Health related quality of life was assessed by EORTC QLQ-C30 and sleep disturbances by the MOS-Sleep questionnaire. Clinical data included smoking status (carbon monoxide in expired air), body mass index (BMI) and treatment data.RT dose, ≥50 Gy (mean difference 1.9 CI: 1.0 to 3.5, p = 0.040), high BMI (mean difference 4.3 CI: 2.2 to 8.3, p < 0.001) and smoking (mean difference 2.5 CI. 1.1 to 5.7, p = 0.027) were the factors strongest related to severe ARSR. Patients' with severe ARSR reported higher levels of pain and increased sleeping problems.To stop smoking during RT is the best decision patients can make to reduce the risk for severe ARSR since smoking is an independent risk factor.     

Outcomes of basal ganglia and thalamic cavernous malformation surgery: A meta-analysis

Surgical resection of basal ganglia (BG) and thalamic cavernous malformations (CMs) has not yet become standardized in the field of neurosurgery due to the eloquent location of these lesions and the relative paucity of literature on the subject. This review presents a consolidation of the available literature on outcomes and complication rates after surgical resection of these lesions. A systematic literature review was performed via PubMed database for articles published between 1985 and 2019. Studies comprising ≥2 patients receiving surgery for BG or thalamic CMs with available follow-up data were included. Pooled data included patient demographics, CM preoperative characteristics, and surgical outcomes Twenty studies comprising 227 patients were included for analysis. Complete resection was achieved in 94.7% (fixed-effects pooled estimate [FE]: 94.9%[91.0%–97.8%]; random-effects pooled estimate [RE]: 90.0%[79.8%–96.9%]), and hemorrhage of incompletely resected CMs occurred in 50% (FE: 55.9%[25.9%–83.6%]; RE: 55.9%[25.9%–83.6%]) of patients. Early morbidity was observed in 24.0% (FE: 24.9%[17.8%–32.6%]; RE: 24.9%[17.8%–32.6%]). At final follow-up, 67.3% (FE: 67.7%[58.8%–76.0%]; RE: 67.8%[52.2%–81.6%]) and 20.6% (FE: 20.6%[13.6%–28.6%]; RE: 20.9%[9.8%–34.9%]) had improvement and stability of preoperative symptoms, respectively. Mortality rate was 1.3% (FE: 2.3%[0.6%–5.1%]; RE: 2.3%[0.6%–5.1%]). Therefore, high cure rates with low rates of postoperative morbidity can be achieved in BG or thalamic CM surgery. Most patients had improved neurological function at final follow-up. Complete resection should be attempted to reduce rates of repeat hemorrhage.     

Clinical presentation and prognosis of adenosquamous carcinoma of the pancreas – Matched-pair analysis with pancreatic ductal adenocarcinoma

IntroductionAdenosquamous carcinoma of the pancreas (ASCP) is a rare subtype of pancreatic adenocarcinoma. The aim of this study was to investigate the characteristics and outcomes of ASCP in comparison to pancreatic ductal adenocarcinoma (PDAC).Materials and methodsAll patients with ASCP treated between December 2001 and December 2017 were identified from a prospective database. Clinicopathological and follow-up data were analyzed. A nested case-control-study with matched-pair analysis was performed to compare overall survival of ASCP and PDAC.ResultsOf 4009 patients undergoing surgery for pancreatic adenocarcinoma 91 patients had ASCP. Compared to PDAC ASCP were larger (4.0 vs. 3.2 cm; p < 0.0001), more frequently involved lymph nodes (88% vs. 78%; p = 0.0216), more frequently showed poor differentiation (G3: 79% vs. 36%; p < 0.0001) and more frequently were located in the pancreatic tail (19% vs. 10%; p = 0.0179). Overall median post-resection-survival was shorter in ASCP (10.8 vs. 20.5 months in PDAC; p = 0.0085), but 5-year survival rates were comparable (18.2% vs. 17.5%). After matching for the unevenly distributed prognostic factors survival after resection of ASCP and PDAC was comparable (p = 0.8301). Localization in the head or several parts of the pancreas, high CA 19-9 levels, and M1 disease were independent predictors of survival in patients with ASCP.ConclusionASCP is more aggressive with poorer differentiation and higher rates of lymph node metastases compared to PDAC. In spite of a shorter median survival, 5-year survival rates after surgical resection of about 18% can be expected in ASCP and support resection as part of a multimodal therapy as the treatment of choice in this rare cancer.     

Acute osteomyelitis of the distal fibula in children: Treatment options and long-term follow-up

IntroductionAcute osteomyelitis of the distal fibula is a rare disease in children and is characterized by special features compared with other sites. The objective of this study was to report the functional outcome at long-term follow-up.MethodsWe reviewed retrospectively, between January 2000 and December 2010, all cases of acute osteomyelitis of the distal fibula. Epidemiological and bacteriological data as well as therapy and outcome factors were analyzed. At the last follow-up, functional outcome was studied based on ankle motion, growth disturbance, and radiological sequelae.ResultsSeven cases of acute osteomyelitis of the distal fibula were found. The mean age was patients was 7.71 years and the sex ratio was 2.5. The portal of entry of the pathogen was a skin injury in 57% of cases. Staphylococcus aureus was identified in 71% of cases. The mean duration of antibiotic therapy was 33.2 days. At a mean of 12.85 years of follow-up, no growth disturbance was found. The mean plantar and dorsal flexion was 41° and 27.7°, respectively. The mean postoperative American Orthopedics Foot and Ankle score (AOFAS) was 96.71 points.ConclusionAcute osteomyelitis of the distal fibula in children is scarce and rarely reported in the literature. It occurs more often in boys at an average age of 7 years. Local symptoms are usually more obvious than general symptoms. Surgical debridement of the subperiosteal abscess without bone trepanation seems to lead to a satisfactory outcome.Level of evidenceLevel IV – case series.IRBSahloul Hospital Human Research Ethics Committee.     

Collateral augmentation treatment with a combination of acetazolamide and head-down tilt in a rat ischemic stroke model

Cerebral collaterals is crucially important in the pathophysiology of acute ischemic stroke and associated with outcome after reperfusion therapy. We explored the effectiveness of collateral augmentation treatment with a combination of acetazolamide (ACZ) and head-down tilt (HDT) in the transient middle cerebral artery occlusion (MCAO) rat model. Transient MCAO was induced in all animals for 1.5 h, followed by reperfusion for 22.5 h. Seventy-two male Wistar rats were divided into four treatment groups: control, ACZ, HDT, and combination. Twenty sham rats, which underwent surgery, were randomly allocated to these groups. Twenty-four hours after MCAO or sham surgery, we measured the infarction volume, brain edema (aquaporin-4 [AQP4], and brain water content), and neurological deficits (Garcia and Longa tests). Collateral augmentation treatments were associated with reduced infarction volume, less brain edema, and better neurological outcomes compared with untreated animals. More specifically, ACZ and HDT treatments resulted in small infarction volumes, and HDT was associated with a low AQP4 expression and improved neurological score, while the combination of ACZ and HDT improved neurological scores and reduced brain water content. This study shows that collateral augmentation treatments are associated with a better stroke prognosis compared with untreated animals after transient MCAO. The combination of ACZ and HDT seems to have some synergistic effect, but was not proven to be superior to HDT treatment alone.