Angal Hospital

Introduction: The Ventilator Rounding Tool (VRT) is an evidence-based practice tool promoting ICU liberation by addressing pain, sedation & delirium. The COVID-19 pandemic created a setback for care with many patients needing deep sedation, leading nurses to learning the misconception that deep sedation is “standard of care.” The aim of this study was to evaluate outcomes pre and post re-introduction of the VRT and nursing education. Methods: Adult patients in the Medical/Surgical/Trauma ICU (MSTICU) who required mechanical ventilation were included. Baseline data from October 2023-July 2024 was compared to post-intervention from August 2024-June 2025. In our MSTICU, nurses utilize an institution specific sedation algorithm for titrating sedatives. The intervention of this study was pharmacist-led education on the institution sedation algorithms with a focus on light sedation in concordance with a multidisciplinary team plan to reinforce the VRT. The primary outcome was total duration of continuous infusion (CI) sedatives (propofol and/or fentanyl). Additional outcomes included ICU length of stay (LOS), ventilator days, amount of as needed sedative administration, & the incidence of delirium. Results: The study included 573 patients, 239 in the pre-intervention group and 334 in the post intervention group. The median duration of CI sedatives was 32 (14 -71) hours in the pre-intervention group vs. 25 (11 – 54.3) hours in the post intervention group (p=0.037). The median amount of as-needed sedative (fentanyl & hydromorphone) was 120 mg (45 –262.5) mg in morphine equivalent dose (MED) in the pre-intervention group vs. 105 (45 -232.5) mg in MED in the post intervention group (p=0.53). Median number of ventilator days was 1.8 days in the pre-intervention group vs. 1.63 days in the post intervention group (p=0.095). Median ICU LOS was 5 (3 –7) days in the pre group vs. 4 (3 – 7) days in the post group (p=0.027). The incidence of delirium was 62.3% in the pre group vs. 53.3% in the post group (p=0.031). Conclusions: Re-engaging nurses with education on promoting light sedation & the VRT led to significantly reduced time on continuous sedatives & ICU LOS. It was also associated with lower rates of delirium. Study results support the positive impact of multidisciplinary teamwork on patient outcomes.

Ever since the first hybrid prosthesis was used for a total aortic arch replacement, many other techniques have been developed to comply with the need for the treatment of a wide spectrum of patients and their clinical pictures. We hereby provide an overview of the most popular surgical techniques to perform a frozen elephant trunk, including our tailored approach revolving around the antegrade deployment of a Gore C-TAG endovascular stent graft sutured to a four-branched vascular prosthesis. This technique was applied to three cases of acute type A aortic dissection. Although our small series of patients consists of acute aortic dissections only, this technique could be applied to any other aortic arch pathology, such as chronic dissections or aneurysms. Moreover, we believe that, because of the individually tailored approach and widespread availability of the necessary materials, this technique can reveal itself useful in many different operative scenarios.

We report the case of a G4P2 of 41 years of age presenting a bulky fibromatous uterus of size 22-24 weeks, having undergone a polymyomectomy under cervical-isthmic tourniquet for desire of maternity after an injection of LHRH agonist.The post-operative complications were complicated by acute intestinal obstruction.An exploratory laparotomy has objectified a residual hemoperitoneum of low abundance and a solid adhesion between the posterior surface of the uterus and the ileum at the level of post myomectomy hysterorraphy.The conservative treatment consisted of a lifting of the occlusion by careful adhesiolysis, without intestinal resection.This case illustrates the morbidity of post myomectomy bleeding linked to the adhesiogenic activity of fibrin.

Abstract Background: Neoadjuvant Therapy (NAT) permits less aggressive breast and axillary surgery and better assessment of systemic response. Establishing accurate and early predictors of NAT response would help limit morbidity of ineffective regimens through modification of treatment regimens and thereby optimize clinical outcomes. The purpose of the study was to assess the utility of tumor biomarkers, ultrasound (US) and US-guided diffuse optical tomography (DOT) in early prediction of breast cancer response to NAT.MethodsThis prospective HIPAA compliant study was approved by the institutional review board. Forty one patients were imaged with US and US-guided DOT prior to NAT, at completion of the first three treatment cycles, and prior to definitive surgery from February 2017 to January 2020. Miller-Payne grading was used to assess pathologic response. Receiver operating characteristic curves (ROCs) were derived from logistic regression using independent variables, including: tumor biomarkers, US maximum diameter, percentage reduction of the diameter (%US), pretreatment maximum total hemoglobin concentration (HbT) and percentage reduction in HbT (%HbT) at different treatment time points. Resulting ROCs were compared using area under the curve (AUC). Statistical significance was tested using two-sided two-sample student t-test with P<0.05 considered statistically significant. ResultsThirty-eight patients (mean age =47, range 24-71 years) successfully completed the study, including 15 HER2+ of which 11 were ER+; 12 ER+ or PR+/HER2-, and 11 triple negative. The combination of HER2 and ER biomarkers, %HbT at the end of cycle 1 (EOC1) and %US (EOC1) provided the best early prediction, AUC = 0.941 (95% CI: 0.869­–1.0). Similarly an AUC of 0.910 (95% CI: 0.810–1.0) with %US (EOC1) and %HbT (EOC1) can be achieved independent of HER2 and ER status. The most accurate prediction, AUC = 0.974 (95% CI: 0.933–1.0), was achieved with %US at EOC1 and %HbT (EOC3) independent of biomarker status. ConclusionThe combined use of tumor HER2 and ER status, US, and US-guided DOT may provide accurate prediction of NAT response as early as the completion of the first treatment cycle. Clinical Trial Registration number: NCT02891681Registration time: September 7, 2016https://clinicaltrials.gov/ct2/show/NCT02891681

La osteonecrosis mandibular relacionada con medicamentos (ONMRM), es un síndrome asociado al uso de fármacos antirresortivos (bifosfonatos), inhibidores de ligando RANK-L y de angiogénesis, administrados para el tratamiento de enfermedades como cáncer y osteoporosis. Objetivos: actualizar contenidos respecto a etiopatogenia y tratamientos de ONMRM, enfatizando el rol del factor “infección”, y en la perspectiva de que el tratamiento, pueda ser implementado por el odontólogo general. Materiales y métodos: se realiza un scoping review mediante acceso a las bases de datos MEDLINE (Pubmed) y Cochrane library, de artículos publicados desde el año 2010 en adelante, en inglés y castellano, empleando palabras claves incluidas en los medical subject headings (MeSH). Conclusiones: La evidencia recogida demuestra que, teniendo en cuenta los factores de riesgo individuales, no existen en general contraindicaciones para llevar a cabo exodoncias, bajo específicos protocolos quirúrgicos, en pacientes con terapias antiresortivas o antiangiogénicas, ya que al parecer, el origen de la ONMRM se asocia a contaminación por biofilm, más que al uso o efecto de estos fármacos. En el caso del tratamiento de una ONMRM ya instalada, las terapias quirúrgicas resultan ser más eficaces que las paliativas en la remisión del cuadro.

Introduction: With limited intensive care unit (ICU) beds at many hospitals, patients with acute myocardial infarction (MI) may be triaged into ICUs with less experience managing MI. To our knowledge, volume-outcome relationships have not been studied according to an ICU’s annual MI volume. Hypothesis: We hypothesized that MI patients admitted to ICUs with low annual MI volume would have lower rates of MI quality indicators and worse clinical outcomes when compared to ICUs with high MI volume. Methods: We used data from the eICU— a telemedicine system for ICU patients at >400 US hospitals— to examine MI management in ICUs with low vs high annual MI volume in 2008. In order to focus on ICU triage between specialty ICUs, hospitals with <250 beds were excluded. Low MI volume was defined as =50th (=16 pts/yr) and high MI volume was defined as =90th (=96 pts/yr) percentile of ICUs managed by eICU programs. Performance measures were compared and modified Poisson regression was used to assess the association between mortality and admission to an ICU with low MI volume. Results: Of 7482 patients with a primary ICU admission diagnosis of MI, 5313 were admitted to ICUs with high and 288 to ICUs with low MI volume. Patients in the low MI volume group were slightly older, more likely to be female, and had more comorbidities and worse vital signs and labs at ICU admission. These patients had less frequent coronary revascularization (70% vs 77%), less early aspirin (74% vs 86%) and?blocker use (81% vs 90% among pts without contraindications), and longer length-of-stay in the ICU (2.8 vs 2.4 days) and overall (6.3 vs 5.2 days) when compared to MI patients in high MI volume ICUs (all p=0.05). ICU mortality (6% vs 3%, p<0.001) and hospital mortality (10% vs 4%, p<0.001) were higher in the low MI volume group. After adjustment for 24 patient-level characteristics, admission to an ICU with low annual MI volume was independently associated with higher hospital mortality (RR 1.46, 95% CI 1.02-2.09, p=0.038). Conclusions: Among unselected patients with acute MI, admission to an ICU with less experience treating MI is associated with less application of evidence-based therapies and higher rates of in-hospital mortality.