Edward Hospital

BackgroundFlow-diverter stents (FDS) have become the standard of care for a wide range of intracranial aneurysms, but their efficacy/safety in the context of recurrent/recanalized aneurysms following stent-assisted coiling (SAC) is not well established. We evaluate the outcomes of FDS retreatment in a large multicenter cohort.MethodsWe retrospectively analyzed data from 118 patients across 22 institutions who underwent FDS retreatment for recurrent/persistent aneurysms after SAC (2008–22). The primary outcome was angiographic occlusion status at last follow-up, categorized as complete (100%), near-complete (90–99%), or incomplete (<90%) occlusion. Secondary outcomes included procedural complications and clinical outcomes measured by the modified Rankin Scale (mRS).ResultsA total of 118 patients (median age 57, 74.6% female) with median follow-up of 15.3 months were identified. Complete occlusion was achieved in 62.5% and near-complete occlusion in 25%. FDS deployment within the pre-existing stent was successful in 98.3% of cases. Major complications occurred in 3.4% of cases, including postoperative aneurysmal rupture with resultant mortality (1.6%) and thromboembolic events with long-term disability (1.6%). Favorable clinical outcomes (mRS 0–2) were observed in 95.1% of patients. Wider aneurysm neck diameter was a significant predictor of incomplete occlusion (adjusted OR (aOR) 1.23 per mm, P=0.044), with male sex trending towards association with non-occlusion (aOR 3.2, P=0.07), while baseline hypertension was associated with complete occlusion (aOR 0.32, P=0.048).ConclusionsFDS treatment for recurrent/residual aneurysms after SAC represents a viable treatment option for these challenging cases with acceptable safety and reasonable occlusion rates, although lower than de novo FDS occlusion rates.

BackgroundThe ethical component in midwifery education is governed by international professional values, codes, and ethical principles. The aim of midwifery education is to encourage students to develop a lifelong commitment to ethical practice within their midwifery role and scope. However, little evidence is available on the experiences of midwifery students and how they navigate ethical issues in maternity systems. AimTo present a case study from a midwifery students' perspective that demonstrates observed ethical issues and to provide analysis of the ethical issues identified. DesignA Single explanatory case study design with a feminist lens applied. Explanatory case studies present the ‘how and why’ of a phenomenon and contributes to understanding phenomena in a holistic and real-life context. SettingThis project was set at a West Australian university from which pre-registration midwifery courses are delivered. ParticipantsA solitary case study is presented from a midwifery students' clinical placement. MethodsEthics were approved 2023-04805. Edith Cowan University HREC. The source of data for this case study was direct observation by the primary author (Priya, 2021) and the Joanna Briggs Methods for Case study reporting guide followed. Thematic analysis with a feminist lens was applied to the data. ResultsThree themes were generated ‘Through the looking glass; observing ethical issues’; ‘Whose body Is It? The Erosion of Maternal Consent’ and ‘Relational care versus defensive practice’. These themes explain the antecedents and consequences of the ethical issues identified by the midwifery student, the findings are supported by ethical theory and midwifery philosophy to highlight some of the underlying causes that contribute to ethical issues. ConclusionMidwifery students experience ethical distress when they observe ethical issues and are powerless to support birth people in a way that aligns with midwifery philosophy of relational, woman-centred care. Further research is required to better understand how midwifery students may be better supported to foster ethical care.

A retrospective chart review. The authors aim to investigate the role of clinical and radiographic parameters in patients who underwent posterior cervical surgery, and their association with C5 palsy severity and time to recovery. Postoperative C5 palsy affects 1%-30% of patients undergoing posterior decompression, with or without fusion. Causation and avoidance of this complication remain widely debated. A single institution review of patients who underwent posterior cervical spine surgery was focused on using specific Common Procedural Technology codes associated with the patient population of interest. Patients were excluded if they had inadequate pre and postoperative imaging, as well as a history of prior cervical spine surgery, concurrent anterior surgery, intradural pathology, spinal tumor, or spinal trauma. Radiographic measurements of the pre and postoperative images were completed with subsequent intraclass correlation coefficient analysis to confirm the precision of measurements. Out of 105 total patients, 35 (33%) patients developed a C5 palsy. Twenty-four (69%) of those palsies completely resolved, with a median time to recovery of 8 months. Preoperative demographics and radiographic parameters demonstrated heterogeneity among those patients who did and did not have a resolution of palsy. Patients with increased change in C2-C7 lordosis ( P = 0.011) after surgery were associated with decreased likelihood of recovery. Patients without a smoking history ( P = 0.009) had an increased likelihood of recovering from C5 palsy. The degree of increased lordosis in the treatment of degenerative cervical disease plays a role in the rate of recovery from C5 palsy. This should be considered during preoperative planning in determining the amount of lordosis desired. In addition, patients without a smoking history were associated with a higher rate of recovery. Level IV.

Based on the assumed inverse implications of exercising psychological distance, the existing body of knowledge concludes that not exercising psychological distance correlates with the romanticization of the COVID-19 pandemic. This study aimed to determine the extent of this correlation. Data was collected from January to February 2023 using an anonymous online survey that took a primarily quantitative approach but included qualitative questions. Respondents were asked questions relating to facts about the COVID-19 pandemic in addition to their personal experiences during that time. The survey yielded 174 responses from a variety of demographics. The results aligned with the hypotheses and the existing body of knowledge, showing a positive correlation between not exercising psychological distance and romanticizing the COVID-19 pandemic. Furthermore, the results showed that not exercising psychological distance can negatively affect adolescents. This study further revealed the negative effects of the COVID-19 pandemic on adolescents, allowing these effects to be remedied and avoided in other mentally distressing situations. Future research should be conducted on the correlation of the research variables with other variables, the use of romanticization as a coping mechanism, and the application of this study’s results to other demographics.

Introduction: Upper GI pseudomelanosis is a rare, benign condition of unknown etiology and unrevealed significance. It presents endoscopically as speckled black pigmentation of the mucosa and histologically as dark inclusions within macrophages of the lamina propria. To date, around 10 cases of the combined occurrence of gastric and duodenal pseudomelanosis have been reported. We present a case of concurrent gastric and duodenal pseudomelanosis incidentally diagnosed on upper GI endoscopy. Case Description/Methods: A 59-year-old-woman with a medical history of esophageal stricture, non-ischemic cardiomyopathy, and iron deficiency anemia being treated with furosemide and oral iron supplementation was hospitalized for an acute episode of diverticulitis. After her condition improved, she developed non-bloody emesis. Upper GI endoscopy was performed to investigate the possibility of esophageal stricture. Endoscopy demonstrated dark pigmentation of the entire gastric mucosa with mild diffuse involvement of the duodenum. Cold forceps biopsies were taken at the pre-pyloric area of the stomach and the duodenum for the histopathological examination of the lesions. The biopsy specimen revealed pigment-laden macrophages in the lamina propria, confirming the combined presentation of gastric and duodenal pseudomelanosis (Figure 1). Discussion: Upper GI pseudomelanosis has been linked to various comorbidities, including upper GI bleeding, chronic renal disease, hypertension, and medications such as oral iron, furosemide, hydrochlorothiazide, propranolol, and hydralazine. The present case shows a similar association with iron and furosemide but without the presence of chronic kidney disease, in contrast to all the previously reported cases that suggest a very strong association with iron therapy or chronic renal failure with pseudomelanosis. In addition, women have been reported to have the most cases compared to men. It has been postulated that drug-based sources of sulfur, such as furosemide, disrupt iron transport and cause iron accumulation within macrophages. While the pathogenesis is not clearly understood, no clinical or prognostic significance has been described and no surveillance or follow-up guidelines have been identified. Therefore, it is essential to diagnose patients early on histopathology findings and to avoid unnecessary testing and interventions.Figure 1.: Gastric antral type mucosa with pigment-laden macrophages. The mucosa shows nonspecific reactive gastropathy.

This study sought to determine whether adjuvant chemotherapy (AC) compared to no AC (noAC) after neoadjuvant chemoradiation (CRT) and resection for rectal adenocarcinoma prolongs survival. Current guidelines from expert groups are conflicting, and data to support administering AC to patients who received neoadjuvant CRT are lacking. A total of 19,867 patients met inclusion/exclusion criteria. Mean age was 58.6 ± 12.0years, and 12,396 (62.4%) were males. Complete response (CR) was documented in 3801 (19.1%) patients and 8167 (41.1%) received AC. The cohort was stratified into pathological complete (pCR, N = 3801) and incomplete (pIR, N = 16,066) subgroups, and pIR further subcategorized into ypN0 (N = 10,191) and ypN + (N = 5875) subgroups. After propensity score matching, AC was associated with improved OS in the pCR subgroups (mean 139.1 ± 1.9 vs. 134.0 ± 2.2months; p < 0.001), in pIR ypN0 subgroup (141.6 ± 1.5 vs. 129.9 ± 1.2months, p < 0.001), and in pIR ypN + subgroup (155.9 ± 5.4 vs. 126.5 ± 7.6months; p < 0.001). AC was associated with improved OS in patients who received neoadjuvant CRT followed by proctectomy for clinical stages II and III rectal adenocarcinoma. This effect persisted irrespective of pathological response status. AC following neoadjuvant CRT and surgery is associated with improved OS in patients with rectal adenocarcinoma. These findings warrant adoption of AC after neoadjuvant CRT and surgery for clinical stage II and III rectal adenocarcinoma.

: Social media (SM) has dramatically changed the way surgeons interact and communicate in both private and public spheres. Similar to other medical specialties, novel technologies and techniques (NTTs) are continually being introduced. In this respect, SM provides an avenue for surgeons to communicate in an unimpeded manner. In particular, the ability to exchange clinical vignettes and videos has paved the way for rapid developments in laparoscopic and robotic-assisted surgery. These practices are evident through events such as grand rounds, morbidity and mortality conferences, and national symposia which are now increasingly hosted online. Overall, this ability to engage in global discourse, incorporate diverse perspectives, and foster collaboration increases accessibility and enhances professional development, which in turn improves patient care. Exciting new advancements taking advantage of recent developments in virtual reality (VR) and augmented reality (AR) are also being applied to further lower logistical and geographical barriers to increase surgical knowledge and benefit health outcomes. Beyond the clear advantages and opportunities afforded by SM, however, lie practical and ethical concerns, some of which pertain to bias and misinformation as well as professionalism. Ultimately, while SM may not entirely replace in-person interactions, it holds significant promise to change how surgeons connect in the future.

Introduction:The coronavirus disease 2019 (COVID-19) pandemic has caused significant global disruption, especially for chronic care like hemodialysis treatments. Approximately 10,000 end-stage kidney disease (ESKD) patients are receiving maintenance hemodialysis (MHD) at 174 dialysis centers in Greater Mumbai. Because of the fear of transmission of infection and inability to isolate patients in dialysis centers, chronic hemodialysis care was disrupted for COVID-19-infected patients. Hence, we embarked on a citywide initiative to ensure uninterrupted dialysis for these patients.Materials and Methods:The Municipal Corporation of Greater Mumbai (MCGM) designated 23 hemodialysis facilities as COVID-positive centers, two as COVID-suspect centers, and the rest continued as COVID-negative centers to avoid transmission of infection and continuation of chronic hemodialysis treatment. Nephrologists and engineers of the city developed a web-based-portal so that information about the availability of dialysis slots for COVID-infected patients was easily available in real time to all those providing care to chronic hemodialysis patients.Results:The portal became operational on May 20, 2020, and as of December 31, 2020, has enrolled 1,418 COVID-positive ESKD patients. This initiative has helped 97% of enrolled COVID-infected ESKD patients to secure a dialysis slot within 48 hours. The portal also tracked outcomes and as of December 31, 2020, 370 (27%) patients died, 960 patients recovered, and 88 patients still had an active infection.Conclusions:The portal aided the timely and smooth transfer of COVID-19-positive ESKD patients to designated facilities, thus averting mortality arising from delayed or denied dialysis. Additionally, the portal also documented the natural history of the COVID-19 pandemic in the city and provided information on the overall incidence and outcomes. This aided the city administration in the projected resource needs to handle the pandemic.