The effect of respiratory activity,non-invasive respiratory support and facemasks on aerosol generation and its relevance to COVID-19

Respirable aerosols (< 5 µm in diameter) present a high risk of SARS-CoV-2 transmission. Guidelines recommend using aerosol precautions during aerosol-generating procedures, and droplet (> 5 µm) precautions at other times. However, emerging evidence indicates respiratory activities may be a more important source of aerosols than clinical procedures such as tracheal intubation. We aimed to measure the size, total number and volume of all human aerosols exhaled during respiratory activities and therapies. We used a novel chamber with an optical particle counter sampling at 100 l.min^-1 to count and size-fractionate close to all exhaled particles (0.5–25 µm). We compared emissions from ten healthy subjects during six respiratory activities (quiet breathing; talking; shouting; forced expiratory manoeuvres; exercise; and coughing) with three respiratory therapies (high-flow nasal oxygen and single or dual circuit non-invasive positive pressure ventilation). Activities were repeated while wearing facemasks. When compared with quiet breathing, exertional respiratory activities increased particle counts 34.6-fold during talking and 370.8-fold during coughing (p < 0.001). High-flow nasal oxygen 60 at l.min^-1 increased particle counts 2.3-fold (p = 0.031) during quiet breathing. Single and dual circuit non-invasive respiratory therapy at 25/10 cm.H₂O with quiet breathing increased counts by 2.6-fold and 7.8-fold, respectively (both p < 0.001). During exertional activities, respiratory therapies and facemasks reduced emissions compared with activities alone. Respiratory activities (including exertional breathing and coughing) which mimic respiratory patterns during illness generate substantially more aerosols than non-invasive respiratory therapies, which conversely can reduce total emissions. We argue the risk of aerosol exposure is underappreciated and warrants widespread, targeted interventions.     

Duodenopancreatectomía cefálica y tutorización externa del conducto de Wirsung. Resultados de una serie de 80 casos consecutivos

IntroductionThere is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique.Patients and methodsA retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting.ResultsMean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively.ConclusionsAlthough our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.     

Endoscopic Anterior Transposition of Ulnar Nerve (EATUN) for Treatment of Tardy Ulnar Nerve Palsy

BackgroundTardy ulnar nerve palsy is the development of late onset ulnar nerve dysfunction and is usually treated by open anterior transposition of ulnar nerve. Open technique is done using a longitudinal incision about 6–8 inch. in length with chances of development of medial antebrachial cutaneous nerve neuromas.PurposeIn this study, we describe the technique of Endoscopic Anterior Transposition of Ulnar Nerve (EATUN procedure) to treat tardy ulnar nerve palsy and analyze the results.MethodsSeven patients diagnosed to have tardy ulnar nerve palsy was treated by EATUN. The humerus-elbow-wrist angle (HEW), pre- and post-operative intrinsic muscle power and sensory assessment, Dellon scores, and the Q-DASH was analyzed.ResultsThe minimum follow-up was 12 months (Mean 27.4 months, Range 12–36 months). Improvement in Dellon and Q-DASH scores following EATUN procedure was statistically significant. There was objective improvement of intrinsic muscle power and sensation on follow-up, though not statistically significant. No instance of neuroma of the medial cutaneous nerve of forearm was noted.ConclusionsThe endoscopic anterior transposition of the ulnar nerve is a good option in surgical management of tardy ulnar nerve palsy.Level of evidenceTherapeutic Level IV.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00366-w.     

Eden-Hybinette Procedure for Revision Surgery in Recurrent Anterior Shoulder Instability in Epilepsy

AimsThe purpose of this study was to analyze the clinical outcomes after Eden-Hybinette procedure for revision surgery in recurrent anterior shoulder instability in patients with epilepsy.Materials and MethodsWe retrospectively evaluated eight such patients between 2015 and 2018. Four patients had failed Latarjet/Bristow procedure and two had failed arthroscopic Bankart procedure, while two had history of both the procedures. After medical control of epilepsy, Eden-Hybinette procedure was performed in all patients. WOSI score and Rowe shoulder score was recorded preoperatively and in subsequent post-operative follow-up. A paired t test was used to analyze and compare preoperative and postoperative outcomes and was considered significant if p value was < 0.05.ResultsThe average follow-up was 30 months (range 24–48 months). There was no recurrence of shoulder instability. The mean WOSI score before surgery was 77.3 (range 70–83), which improved to 24.2 (range 19–30) at 24-month follow-up. The mean Rowe score before surgery was 11.3 (range 5–15), which improved to 81.8(range 65–90) at 24-month follow-up. The improvement in WOSI and Rowe score was found to be statistically significant [p value < 0.05]ConclusionsWe conclude that Eden-Hybinette is a useful revision procedure to manage recurrent anterior shoulder dislocation in patients with epilepsy. Optimum medical control of seizure is also an important factor in preventing recurrent shoulder instability     

经跗骨窦入路微创锁定钢板治疗跟骨关节内骨折疗效对比研究

目的:比较经跗骨窦入路使用微创锁定钢板与解剖型锁定钢板治疗跟骨关节内骨折的临床疗效。方法:回顾性分析2016年7月至2017年6月采用跗骨窦入路治疗的48例跟骨关节内骨折患者的临床资料,根据内固定方式不同分为微创锁定钢板组和解剖型锁定钢板组,每组24例。微创锁定钢板组,男14例,女10例;年龄27～46(38.70±5.58)岁;骨折Sanders分型,Ⅱ型18例,Ⅲ型6例。解剖型锁定钢板组,男17例,女7例;年龄26～46(37.10±6.44)岁;骨折Sanders分型,Ⅱ型16例,Ⅲ型8例。观察并比较两组患者手术时间,视觉模拟评分(visual analague scale,VAS),术后并发症情况,比较术后1周及末次随访时B?hler角、Gissane角、跟骨宽度和高度变化情况,采用Maryland足部功能评分进行功能评价。结果:所有患者获得随访,时间12～18(14.10±1.94)个月。48例患者获得骨性愈合,愈合时间8～16(10.60±2.25)周。微创锁定钢板组手术时间、VAS评分、并发症分别为(69.50±7.51) min、(2.80±1.07)分、2例,解剖型锁定钢板组分别为(77.50±7.15) min、(3.80±1.09)分、8例,两组比较差异有统计学意义(P0.05)。两组术后1周及末次随访时B?hler角、Gissane角、跟骨宽度、高度比较差异无统计学意义(P0.05)。两组Maryland足部功能评分比较差异无统计学意义(P0.05)。结论:对于SandersⅡ、Ⅲ型跟骨关节内骨折,经跗骨窦入路使用微创锁定钢板治疗可以达到与解剖型锁定钢板相似的牢靠固定及功能恢复,其操作更简便,手术时间更短,术后早期疼痛更轻,术后并发症更少。     

Clinical characteristics and risk factors for fatal outcome of patients receiving Sun's procedure after previous cardiac surgery

BackgroundCardiac reoperation has always been a difficult problem in clinical practice. Because of the difficulty of operation, the incidence of complications and mortality rate is high. Secondary aortic surgery, especially the reoperation involving arch, has higher risk and is more difficult for patients with renal failure. Sun's operation (total arch replacement + stent elephant nose) has achieved good results in the treatment of diseases involving aortic arch, and occupies an important position in the treatment of patients with secondary arch lesions after cardiac surgery.MethodsA total of 395 patients with a history of cardiac surgery were recorded in our center from January 1, 2009 to December 31, 2017, among whom 118 (30.1%) patients underwent aortic reoperation via the original incision using Sun's aortic procedure owing to postoperative great vessel disease. We analyzed the clinical data and survival time, and used Cox regression to analyze the risk factors for 30-day mortality as well as long term mortality.ResultsThe interval between the last operation and the present operation was 0.08–19 years. Sixteen patients died within 30 days after operation and the average mortality rate was 13.6%. During the follow-up period, 28 patients died, with the mortality rate of 23.7%. As of December 31, 2017, the longest survival time was 9.36 years, and the survival time of 70 patients was more than 3.05 years. The main risk factor associated with the 30-day survival was cardiopulmonary bypass (CPB) time. The longer the CPB time was, the greater the risk of death was. The main risk factors associated with the long-term survival were CPB time and 24-h bleeding volume. The longer the CPB time was, the more the 24-h bleeding volume was, the higher long-term mortality rate was.ConclusionThe second Sun's operation, as a surgical treatment after cardiac surgery, showed a high survival rate, with long survival time and good curative effect. CPB is the main risk factor for the 30-day survival state after operation, and CPB time and 24-h bleeding volume are the main risk factors for the long-term survival state after operation.     

Aortic homograft implantation after Ozaki procedure: Case report

Introduction and importanceThe infective endocarditis incidence data for patients undergoing aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium (Ozaki procedure) are rare, and the optimal surgical treatment strategy remains unclear.Case presentationThis is the first case report of surgical treatment of infective endocarditis of aortic valve with cryopreserved homograft in an athlete with previously performed Ozaki procedure.Clinical discussionThe choice of homograft was dictated by the young age of the patient; professional activity as an athlete; refusal of anticoagulants and the need for wide excision of compromised tissues to mitigate potential risk of spread of infection as well as its recurrence.ConclusionThe use of the aortic homograft allowed us to radically remove the infected tissues and achieve hemodynamic characteristics similar to the native valve. This is probably the first case report of use of homograft to treat aortic valve endocarditis following Ozaki procedure.     

急性重症胆管炎的救治体会

目的：探讨急性重症胆管炎的有效治疗方法。方法：回顾性分析１５４例急性重症胆管炎（ＡＣＳＴ）的临床资料。结果：单纯胆总管外引流术９２例,死亡１０例（１０．９％）;胆总管外引流附加胆囊造瘘或胆囊切除或肝脓肿引流术共３２例,死亡６例（１８．８％）;胆道内引流术３０例（胆肠吻合２４例,奥狄括约肌切开成形术６例）,死亡８例（２６．７％）。全组治愈１３０例,死亡２４例,总病死率为１５．６％。结论：ＡＣＳＴ诊断明确后及早手术是提高疗效的关键,手术方式的选择以简单、有效为原则,积极防治休克和多器官功能衰竭是改善预后的重要措施。