Retrosternal goiter: The need for thoracic approach based on CT findings: Surgeon’s view

Background and purposeThe incidence of retrosternal goiter (RSG) varies from 2% to 26% of all thyroidectomies, depending on the defining criteria. There are no clear guidelines to identify patients that require an intrathoracic approach. So, we tried to correlate, between the size and/or anatomical site of the RSG based on preoperative CT findings and the surgical approaches used, aiming at defining those patients with RSG who are in need for thoracic approach.Patients and methodsOut of 1481 patients underwent thyroidectomy at the National Cancer Institute (NCI), Cairo University, between January 2000 and December 2009, only 73 (4.93%) of them had retrosternal extension. Demographic, clinical, operative, anatomical, and pathological data of patients with RSG were recorded and analyzed.ResultsThe intraoperative extension of the goiter correlated with the extension seen in the CT in all except two patients. Laterality and longitudinal extension found in preoperative CT, correlated well with the surgical findings. The approach used was cervical in 66 cases (90.4%); combined approach in six patients (8.2%). Pure thoracic (full sternotomy) was used alone in one case (1.4%). Extension of the RSG down to or below the arch was associated with an increased risk of using a thoracic approach p < 0.0001.ConclusionPreoperative CT, can be used effectively to guide the indications for using a thoracic approach. Reaching the aortic arch or beyond and loss of fat planes in CT, recurrent and malignant disease, are significant risk factors for using a thoracic approach.     

Laparoscopic right hemicolectomy

Over the past 20 years, laparoscopic colectomy has become a well-established technique in the surgical armamentarium of colorectal operations, with proven reductions in postoperative pain, time to return of bowel function, and length of hospital stay. After early concerns over its oncologic effects, large prospective, multicenter trials have proven its safety in colorectal adenocarcinoma, with equivalence in nodal harvest, recurrence rates, disease-free survival, and overall survival. Laparoscopic right hemicolectomy in particular is a relatively accessible technique which may be performed by a single surgeon and an assistant/camera operator; this operation serves as an excellent method to develop laparoscopic skills for more complicated colorectal procedures. In this article, we describe the technical aspects of our approach to laparoscopic right hemicolectomy, which utilizes a medial-to-lateral, no-touch technique and either an intracorporeal or extracorporeal anastomosis.     

Ensuring cultural sensitivity for Muslim patients in the Australian ICU: Considerations for care

Australia is a diverse and multicultural nation, made up of a population with a predominant Christian faith. Islam, the second largest religion in the world, has demonstrated significant growth in Australia in the last decade. Coming from various countries of origin and cultural backgrounds, Muslim beliefs can range from what is considered ‘traditional’ to very ‘liberal’.It is neither possible nor practical for every intensive care clinician to have an intimate understanding of Islam and Muslim practices, and cultural variations amongst Muslims will mean that not all beliefs/practices will be applicable to all Muslims. However, being open and flexible in the way that care is provided and respectful of the needs of Muslim patients and their families is essential to providing culturally sensitive care.This discussion paper aims to describe the Islamic faith in terms of Islamic teachings, beliefs and common practices, considering how this impacts upon the perception of illness, the family unit and how it functions, decision-making and care preferences, particularly at the end of life in the intensive care unit.     

Pharmacotherapeutic options for kidney disease in HIV positive patients

ABSTRACT

Introduction

Since the developmentof combined antiretroviral therapy (cART), HIV-associated mortality and the incidence of HIV-associated end-stage kidney disease (ESKD) has decreased. However, in the United States, an increase in non-HIV-associated kidney diseases within the HIV-positive population is expected.     

Making health systems more equitable

Health systems are consistently inequitable, providing more and higher quality services to the well-off, who need them less, than to the poor, who are unable to obtain them. In the absence of a concerted effort to ensure that health systems reach disadvantaged groups more effectively, such inequities are likely to continue. Yet this situation need not be accepted as inevitable, for there are many promising measures that might be pursued: establishment of goals for improved coverage in the poor, rather than in entire populations, and use of those goals to direct planning toward the needs of the disadvantaged; use of one or more of the several techniques that seem to have been effective in at least some of the settings where they have been tried; and empowerment of poor clients to have a more central role in health system design and operation.     

Effect of completion of cardiac rehabilitation on heart rate recovery

To evaluate the effects of a cardiac rehabilitation program on heart rate recovery after percutaneous transluminal coronary angioplasty, a historical cohort study was performed on 436 patients of whom 285 were grouped on completion of 5, 10, or 24 training sessions. All 3 groups showed significant improvements in heart rate recovery, peak heart rate during treadmill testing, and end-training heart rate, from baseline to follow-up. Heart rate recovery on follow-up correlated significantly with the number of completed exercise sessions. The number of sessions, baseline ejection fraction, and age were independent predictors of mean post-training heart rate recovery. The cardiac rehabilitation program had a significant effect on peak heart rate and heart rate recovery, regardless of the underlying characteristics of the patients.