The authors describe a case of pneumocephalus following epidural anaesthesia for total knee arthroplasty. Multiple attempts in locating the epidural space for the anaesthesia and the use of loss of resistance to air (LORA) technique were identified as the source of air entry. Supportive management was given including high flow oxygenation therapy and spontaneous reabsorption of air was noted five days after surgery. The presence of pneumocephalus should be kept in mind if patient develops neurological complications postoperatively following epidural anaesthesia.
Pneumocephalus ; Anesthesia, Cardiac Procedures

INTRODUCTIONNasopharnygeal carcinoma (NPC) is characterised by early metastases with the skeleton being the most common site of metastases. The ability to prognosticate survival is crucial in the decision whether or not to offer surgery to these patients and the choice of surgery offered. We aimed to evaluate the scoring systems namely: Bauer, Katagiri and Scandinavian Sarcoma Group (SSG) in NPC patients with skeletal metastases.

MATERIALS AND METHODSA total of 92 patients with skeletal metastases from NPC were studied. We retrospectively analysed the actual survival of these patients and compared with predicted survival according to the 3 scoring systems. The predicted survival according to each system was calculated and labelled as A scores. These were then re-scored by assigning NPC as a better prognostic tumour and labelled as B scores. The predicted survival of scores A and B were compared to actual survival. Univariate and multivariate Cox regression analyses were performed. The predictive values of each scoring were calculated.

RESULTSThe median overall survival for the whole cohort was 13 months (range: 1 to 120 months). In multivariate analysis, general condition and visceral metastases showed significant effect on survival. There were statistically significant differences (P <0.001) between the subgroups of the SSG B as well as Katagiri B scoring systems where NPC was classified as a better prognostic tumour. SSG B provided the highest predictive value (0.67) as compared to the other 2 scoring systems.

CONCLUSIONThe SSG and Katagiri score could be used to prognosticate NPC with a statistically significant association with actual survival.

Bone Neoplasms ; mortality ; secondary ; Carcinoma ; mortality ; secondary ; Humans ; Multivariate Analysis ; Nasopharyngeal Neoplasms ; mortality ; pathology ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Survival Rate

INTRODUCTIONOutcomes of bariatric surgery for super obese Asians are not well reported. We aimed to compare short-term outcomes of laparoscopic sleeve gastrectomy (LSG) in Asian patients with body mass index (BMI) <47.5 kg/m to those with BMI •••••• ≥47.5 kg/m.

MATERIALS AND METHODSA total of 272 patients from Singapore university hospital who underwent LSG from 2008 to 2015 with a follow-up of at least 6 months were included in the study. Primary endpoint was weight loss at 1-year and 3-years. Morbid obesity (Group 1, G1) was defined as BMI <47.5 kg/m and super obesity (Group2, G2) was defined as BMI ≥47.5 kg/m.

RESULTSThere were 215 patients in G1 and 57 patients in G2 (mean preoperative weight: 107.3 kg and 146.8 kg; mean follow-up: 27.9 and 26.8 months, respectively). Mean total weight loss at 3-year of 41.9 kg for G2 was significantly higher ( = 0.003) than 27.2 kg for G1. Mean percentage excess weight loss (EWL) did not differ at 3-years. There was no difference in operating time, blood loss, length of stay, 30-day morbidity and readmission. There were no conversions and mortality in both groups. Remission of herpertension ( - 0.001) and dyslipidaemia ( = 0.038) were significantly associated with achieving EWL percentage (%EWL) >50 in G1.

CONCLUSIONLSG is an equally safe and effective operation in Asians with BMI ≥47.5 kg/m2 when compare to patients with BMI <47.5 kg/m in achieving significant weight loss and improvement in comorbidities. Super obese lose more weight but have lower %EWL.

Asian Continental Ancestry Group ; Gastrectomy ; methods ; Humans ; Laparoscopy ; instrumentation ; methods ; Obesity, Morbid ; surgery ; Outcome Assessment (Health Care) ; Patient Safety ; Retrospective Studies ; Singapore

Nonalcoholic fatty liver disease (NAFLD) is a leading cause of liver disease worldwide. The estimated global incidence of NAFLD is 47 cases per 1,000 population and is higher among males than females. The estimated global prevalence of NAFLD among adults is 32% and is higher among males (40%) compared to females (26%). The global prevalence of NAFLD has increased over time, from 26% in studies from 2005 or earlier to 38% in studies from 2016 or beyond. The prevalence of NAFLD varies substantially by world region, contributed by differing rates of obesity, and genetic and socioeconomic factors. The prevalence of NAFLD exceeds 40% in the Americas and South-East Asia. The prevalence of NAFLD is projected to increase significantly in multiple world regions by 2030 if current trends are left unchecked. In this review, we discuss trends in the global incidence and prevalence of NAFLD and discuss future projections.

Aged ; Atherosclerosis ; Case-Control Studies ; Coronary Artery Bypass ; methods ; Coronary Artery Disease ; surgery ; Female ; Hemodynamics ; physiology ; Humans ; Male ; Mammary Arteries ; physiology ; transplantation ; Middle Aged ; Pulsatile Flow ; Radial Artery ; physiology ; transplantation ; Rheology ; Saphenous Vein ; physiology ; transplantation ; Shear Strength ; Stress, Mechanical ; Vascular Patency ; physiology

Objective: Ovarian clear cell carcinoma (OCCC) is associated with chemoresistance. Limited data exists regarding the efficacy of targeted therapies such as immune checkpoint inhibitors (ICI) and bevacizumab, and the role of secondary cytoreductive surgery (SCS). Methods: We retrospectively analyzed genomic features and treatment outcomes of 172 OCCC patients treated at our institution from January 2000 to May 2022. Next-generation sequencing (NGS) was performed where sufficient archival tissue was available. Results: 64.0% of patients were diagnosed at an early stage, and 36.0% at an advanced stage.Patients with advanced/relapsed OCCC who received platinum-based chemotherapy plus bevacizumab followed by maintenance bevacizumab had a median first-line progressionfree survival (PFS) of 12.2 months, compared with 9.3 months for chemotherapy alone (hazard ratio=0.69; 95% confidence interval [CI]=0.33, 1.45). In 27 patients who received an ICI, the overall response rate was 18.5% and median duration of response was 7.4 months (95% CI=6.5, 8.3). In 17 carefully selected patients with fewer than 3 sites of relapse, median PFS was 35 months (95% CI=0, 73.5) and median overall survival was 96.8 months (95% CI=44.6, 149.0) after SCS. NGS on 58 tumors revealed common mutations in ARID1A (48.3%), PIK3CA (46.6%), and KRAS (20.7%). Pathogenic alterations in PIK3CA, FGFR2, and NBN were associated with worse survival outcomes. Median tumor mutational burden was 3.78 (range, 0–16). All 26 patients with available loss of heterozygosity (LOH) scores had LOH <16%. Conclusion Our study demonstrates encouraging outcomes with bevacizumab and ICI, and SCS in select relapsed OCCC patients. Prospective trials are warranted.

Objective: Ovarian clear cell carcinoma (OCCC) is associated with chemoresistance. Limited data exists regarding the efficacy of targeted therapies such as immune checkpoint inhibitors (ICI) and bevacizumab, and the role of secondary cytoreductive surgery (SCS). Methods: We retrospectively analyzed genomic features and treatment outcomes of 172 OCCC patients treated at our institution from January 2000 to May 2022. Next-generation sequencing (NGS) was performed where sufficient archival tissue was available. Results: 64.0% of patients were diagnosed at an early stage, and 36.0% at an advanced stage.Patients with advanced/relapsed OCCC who received platinum-based chemotherapy plus bevacizumab followed by maintenance bevacizumab had a median first-line progressionfree survival (PFS) of 12.2 months, compared with 9.3 months for chemotherapy alone (hazard ratio=0.69; 95% confidence interval [CI]=0.33, 1.45). In 27 patients who received an ICI, the overall response rate was 18.5% and median duration of response was 7.4 months (95% CI=6.5, 8.3). In 17 carefully selected patients with fewer than 3 sites of relapse, median PFS was 35 months (95% CI=0, 73.5) and median overall survival was 96.8 months (95% CI=44.6, 149.0) after SCS. NGS on 58 tumors revealed common mutations in ARID1A (48.3%), PIK3CA (46.6%), and KRAS (20.7%). Pathogenic alterations in PIK3CA, FGFR2, and NBN were associated with worse survival outcomes. Median tumor mutational burden was 3.78 (range, 0–16). All 26 patients with available loss of heterozygosity (LOH) scores had LOH <16%. Conclusion Our study demonstrates encouraging outcomes with bevacizumab and ICI, and SCS in select relapsed OCCC patients. Prospective trials are warranted.

Objective: Ovarian clear cell carcinoma (OCCC) is associated with chemoresistance. Limited data exists regarding the efficacy of targeted therapies such as immune checkpoint inhibitors (ICI) and bevacizumab, and the role of secondary cytoreductive surgery (SCS). Methods: We retrospectively analyzed genomic features and treatment outcomes of 172 OCCC patients treated at our institution from January 2000 to May 2022. Next-generation sequencing (NGS) was performed where sufficient archival tissue was available. Results: 64.0% of patients were diagnosed at an early stage, and 36.0% at an advanced stage.Patients with advanced/relapsed OCCC who received platinum-based chemotherapy plus bevacizumab followed by maintenance bevacizumab had a median first-line progressionfree survival (PFS) of 12.2 months, compared with 9.3 months for chemotherapy alone (hazard ratio=0.69; 95% confidence interval [CI]=0.33, 1.45). In 27 patients who received an ICI, the overall response rate was 18.5% and median duration of response was 7.4 months (95% CI=6.5, 8.3). In 17 carefully selected patients with fewer than 3 sites of relapse, median PFS was 35 months (95% CI=0, 73.5) and median overall survival was 96.8 months (95% CI=44.6, 149.0) after SCS. NGS on 58 tumors revealed common mutations in ARID1A (48.3%), PIK3CA (46.6%), and KRAS (20.7%). Pathogenic alterations in PIK3CA, FGFR2, and NBN were associated with worse survival outcomes. Median tumor mutational burden was 3.78 (range, 0–16). All 26 patients with available loss of heterozygosity (LOH) scores had LOH <16%. Conclusion Our study demonstrates encouraging outcomes with bevacizumab and ICI, and SCS in select relapsed OCCC patients. Prospective trials are warranted.

Introduction: To evaluate the clinical relevance of the painful anterior apprehension test in shoulder instability. Materials and methods: We performed a retrospective study of 155 patients that underwent arthroscopic anterior Bankart repair between 2014–2016. Exclusion criteria were previous ipsilateral shoulder surgery, bony Bankart lesions, glenohumeral osteoarthritis and concomitant surgery involving rotator cuff tears, biceps tendon pathology and superior labrum from anterior to posterior (SLAP) lesions. The study cohort was divided into three groups: apprehension test with apprehension only, apprehension test with pain only, and apprehension test with both apprehension and pain. Patient demographics, clinical characteristics, radiological imaging, arthroscopy findings and surgical outcomes (Constant, American Shoulder and Elbow Surgeons (ASES), SF-36 scores) were evaluated. Results: A total of 115 (74.2%) had apprehension only, 26 (16.8%) had pain only and 14 (9.0%) had pain and apprehension with the apprehension test. Univariate analysis showed significant differences between the groups in patients with traumatic shoulder dislocation (p=0.028), patients presenting with pain (p=0.014) and patients presenting with recurrent dislocations (p=0.046). Patients with a purely painful apprehension test were more likely to have a traumatic shoulder dislocation, more likely to present only with pain, and less likely to present with recurrent shoulder dislocations. Multivariate analysis showed that none of these factors alone were significant as single predictors for shoulder instability. All three groups were otherwise similar in patient profile, MRI and arthroscopic assessments, and clinical outcomes of surgery. Excellent clinical outcomes were achieved in all groups with no difference in pre-operative and post-operative scores across all groups at all time points. Conclusion: The painful apprehension test may suggest underlying shoulder instability.