Pediatric surgery during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on pediatric surgery. The infection is often asymptomatic and atypical in children, while overlapping presentations with other infectious diseases generate additional diagnostic challenges. The high probability of missed pediatric cases and the invasive nature of surgery generate great concern for widespread transmission in this setting. Current guidelines suggest that triage of cases should be made on a case-by-case basis by a multidisciplinary team of experts. Decision-making can be assisted by classifying cases as elective, urgent, or an emergency according to the risks of delaying their surgical management. A workflow diagram should ideally guide the management of all cases from admission to discharge. When surgery is necessary, all staff should use appropriate personal protective equipment, and high-risk practices, such as aerosol-generating tools or procedures, should be avoided if possible. Furthermore, carefully designed organizational protocols should be established to minimize transmission while ensuring the uninterrupted operation of pediatric surgery units. For example, surgical teams can be divided into small weekly rotating groups, and healthcare workers should be continuously monitored for COVID-19 symptoms. Additionally, team protocols in the operating room can optimize communication and improve adherence to personal protective equipment use. Isolated operating rooms, pediatric intensive care units, and surgical wards should be specifically designed for suspected or confirmed COVID-19 cases. Finally, transportation of patients should be minimal and follow designated short routes. All these measures can help mitigate the effects of the COVID-19 pandemic on pediatric surgery units.     

Cavotricuspid isthmus ablation guided by force‐time integral – A randomized study

BackgroundForce‐time integral (FTI) is an ablation marker of lesion quality and transmurality. A target FTI of 400 gram‐seconds (gs) has been shown to improve durability of pulmonary vein isolation, following atrial fibrillation ablation. However, relevant targets for cavotricuspid isthmus (CTI) ablation are lacking.HypothesisWe sought to investigate whether CTI ablation with 600 gs FTI lesions is associated with reduced rate of transisthmus conduction recovery compared to 400 gs lesions.MethodsFifty patients with CTI‐dependent flutter were randomized to ablation using 400 gs (FTI400 group, n = 26) or 600 gs FTI lesions (FTI600 group, n = 24). The study endpoint was spontaneous or adenosine‐mediated recovery of transisthmus conduction, after a 20‐min waiting period.ResultsThe study endpoint occurred in five patients (19.2%) in group FTI400 and in four patients (16.7%) in group FTI600, p = .81. First‐pass CTI block was similar in both groups (50% in FTI400 vs. 54.2% in FTI600, p = .77). There were no differences in the total number of lesions, total ablation time, procedure time and fluoroscopy duration between the two groups. There were no major complications in any group. In the total population, patients not achieving first‐pass CTI block had significantly higher rate of acute CTI conduction recovery, compared to those with first‐pass block (29.2% vs. 7.7% respectively, p = .048).ConclusionsCTI ablation using 600 gs FTI lesions is not associated with reduced spontaneous or adenosine‐mediated recurrence of transisthmus conduction, compared to 400 gs lesions.     

Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging,alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.     

The relationship between Rarebit perimetry and OCT‐derived retinal nerve fibre layer thickness in glaucoma

Purpose: To examine the association between measures of neuroretinal matrix integrity as determined with Rarebit perimetry and optical coherence tomography (OCT)‐derived retinal nerve fibre layer thickness. Methods: One randomly selected eye of 30 White primary open‐angle glaucoma patients (age: 60.9 ± 11.7 years; MD: ?3.2 ± 5.1 dB) and 16 healthy White individuals (age: 33.2 ± 6.4 years; MD: ?0.8 ± 0.8 dB) were included in the study. Participants underwent Rarebit perimetry testing (central field, software version 4) and an OCT fast retinal nerve fibre layer (RNFL) scan. Correlation was investigated between hemifield Rarebit scores and the corresponding RNFL values, as well as between global Rarebit scores and the respective RNFL measures. Results: Statistically significant correlations of average hit rate (HR) < 90 and mean hit rate (MHR) were detected with Max–Min and average thickness (Pearson’s r ranging from 0.393 to 0.474). Number HR < 90 showed a moderate correlation only with Max–Min (r = ?0.396, P = 0.030). Regarding the association between hemifield hit rates and the corresponding OCT thickness parameters, only inferior maximum correlated moderately with HR superior (r = 0.385, P = 0.035). A tendency was detected for the relationship of superior maximum with HR inferior (r = 0.345, P = 0.062). For the control group, no significant correlation was found for any of the global or hemifield indices and the corresponding thickness values. Conclusion: Although Rarebit perimetry is based on a physiological principle distinctly different from conventional perimetry, it provides global indicators of neuroretinal matrix integrity that correlate with some OCT‐derived RNFL thickness measures.     

A pooled analysis of case-control studies of thyroid cancer¶ I. Methods

Objective: Because the etiology of thyroid cancer is not well described, we conducted a pooled analysis of all published case- control studies, as well as two identified unpublished studies. This paper describes the major characteristics of the 14 studies included in the analysis, as well as the statistical methods employed. Four studies were conducted in the United States (1 each in Washington State, California, Connecticut and Hawaii), 8 in Europe (3 in Sweden, 2 in Norway, 1 in Switzerland, 1 in Italy and 1 in Greece), and 2 in Asia (1 in China and 1 in Japan).Methods: The original datasets were obtained and restructured in a uniform format. Data on socio-demographic characteristics, anthropometric measures, smoking and alcohol consumption, history of benign thyroid diseases and of other selected medical conditions and treatments, family history of cancer and of benign thyroid conditions, occupation, residence in endemic goitre areas, and dietary habits were analyzed. For women, we also analyzed menstrual and reproductive factors and use of female hormones. Radiotherapy and, in Japan, exposure to the A-bombs were considered as potential confounding factors.Results: A total of 2,725 cases (2,247 females and 478 males) and 4,776 controls (3,699 females and 1,077 males) were included in this study. Of the cases, 79% were classified as papillary thyroid carcinomas, 14% as follicular, 2% medullary, 1% anaplastic, 1% other histologies, and 3% histological type unknown. Each of the datasets was checked for outliers and consistency. Data were analysed separately by study center, gender, and the two major histologic types (papillary, follicular). Frequency tables and simple statistics were computed for each variable under study. Conditional logistic regression was used to compute odds ratios. For matched studies, the original matching was preserved, whereas, for unmatched ones, five-year age groups were used for matching. Study-specific analyses were computed, and then the data from all the studies were pooled conditioning on study. Heterogeneity between studies, geographic areas and study designs was assessed, and the modifying effect of age was also evaluated.     

The importance of inspection in clinical cardiology: Frank's sign

The Frank''s sign (FS) is a diagonal earlobe crease running from the tragus to the edge of the auricle. In this case, we describe a 71 years‐old male patient with FS who presented to the emergency department complaining of epigastric pain. A non‐ST elevation myocardial infarction was diagnosed.     

Evaluation of the genetic damage to workers in a Greek shipyard

Shipyards are industrial areas where workers are likely exposed to environmental pollutants such as welding fumes, fine organic solvent and dye dust, that render the occupational environment a high risk one. Assessing the risk that workers are exposed to is a high critical factor in improving their working conditions. The present study aims to investigate the potential genetic damage to workers exposed to a harsh environment in a Greek shipyard. It is focused on assessing the percentage of induced micronuclei, as well as on changes in the various cell types of shipyard workers’ oral mucosa epithelium by implementing the buccal micronucleus cytome assay. Exposed workers appeared with statistically significant induced micronuclei as compared to office employees. Statistically, significant cell lesions were detected and are related to workers’ exposure to environmental conditions. The workers’ smoking habit contributed as well to the observed buccal epithelial cell alterations. The observed data signify the high-risk workers are exposed; resulting in the shipyard’s management the need to implement measures improving the working environment conditions and to reevaluate the workers’ personal protective equipment requirements.