BACKGROUND & AIMS: :Using a combined general anesthesia/epidural technique, two cases of intraoperative malfunctioning epidural catheters in obese patients are presented. After the epidural was found to be malfunctioning, the anesthesiologist placed the palm of both hands underneath the patients' lumbar and thoracic area. The epidural catheter with tape and subcutaneous tissue was pulled in both cases towards the head. In each case, this simple maneuver made the catheter function again. In conclusion, this simple corrective maneuver should be attempted prior to discarding the epidural anesthetic technique.

背景与目标： ：介绍了使用全身麻醉/硬膜外联合技术，在肥胖患者中出现两例术中硬膜外导管发生故障的情况。在发现硬膜外出现故障后，麻醉医师将双手的手掌放在患者的腰椎和胸廓区域下方。在两种情况下，将带有胶带和皮下组织的硬膜外导管拉向头部。在每种情况下，这种简单的操作都使导管再次起作用。总之，应该在放弃硬膜外麻醉技术之前尝试进行这种简单的矫正操作。

BACKGROUND & AIMS: PURPOSE:To evaluate outcomes among early-stage breast cancer patients after conservative surgery and full-dose intraoperative radiotherapy electrons (ELIOT) by applying the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) recommendations for partial breast irradiation (APBI). MATERIALS AND METHODS:One-thousand eight-hundred and twenty-two patients were stratified into the three GEC-ESTRO categories of "good candidates", "possible candidates" and "contraindication" in order to assess outcomes. RESULTS:All the 1822 cases except 7 could be classified according to GEC-ESTRO groups: 573 patients met the criteria to be included in the "good candidates" group, 468 patients in the "possible candidates" group and 767 patients in the "contraindication" group. Median and mean follow-up length was 3.5 years (range 0-10.5 years) and 3.8 years (SD 2.2), respectively. The 5-year rate of in-breast tumor reappearances for "good candidates", "possible candidates" and "contraindication" groups were 1.9%, 7.4% and 7.7%, respectively (p 0.001). While the regional node relapse showed no difference, the rate of distant metastases was significantly different in the "contraindication" group compared to the other two categories, having a significant impact on survival. CONCLUSIONS:Among the ELIOT population, the GEC-ESTRO recommendations enabled the selection of the good candidates with a low rate of local recurrence, but failed to differentiate the "possible candidates" and the "contraindication" groups.

背景与目标： 目的：通过应用GroupeEuropéendeCuriethérapie-欧洲放射治疗和肿瘤学学会（GEC-ESTRO）建议对保守性手术和全剂量术中放疗电子（ELIOT）进行评估，以评估早期乳腺癌患者的结局（APBI）。
材料与方法：将128例患者分为GEC-ESTRO的“好候选人”，“可能候选人”和“禁忌症”三个类别，以评估结果。
结果：除7例外，其余1822例均可以根据GEC-ESTRO组进行分类：573例符合“好候选者”组的标准，468例“可能候选”组的患者，767例“禁忌症”的患者“ 团体。中位和平均随访时间分别为3。5年（0-10。5年）和3。8年（SD 2.2）。 “好候选者”，“可能候选者”和“禁忌症”组的5年乳腺肿瘤复发率分别为1.9％，7.4％和7.7％（p 0.001）。尽管区域淋巴结复发无差异，但“禁忌”组中远处转移的发生率与其他两类相比有显着差异，对生存率有显着影响。
结论：在ELIOT人群中，GEC-ESTRO的建议使得能够选择局部复发率低的好候选者，但未能区分“可能候选者”和“禁忌症”人群。

BACKGROUND & AIMS: INTRODUCTION:Fatiguing of respiratory muscles reduces peripheral muscle perfusion. Further, acute hypoxia enhances respiratory muscle fatigue. This study investigated the effects of inspiratory muscle loading (IML) on resting locomotor muscle perfusion in hypoxia compared to normoxia. METHODS:Ten subjects completed two study days of fatiguing IML (blinded, randomized) in normobaric hypoxia (targeted oxygen saturation 80%) and normoxia, respectively. Contrast-enhanced ultrasound (CEUS) of the gastrocnemius muscle and popliteal doppler ultrasonography were used to monitor muscle perfusion. Based on CEUS and monitored cardiac output, perfusion surrogate parameters (CLPaer and CLPap) were established. RESULTS:Muscle perfusion declines early during IML in normoxia (CLPaer: -54±25%, p<0.01; CLPap: -58±32%, p<0.01) and hypoxia (CLPaer: -43±23%, p<0.01; CLPap: -41±20%, p<0.01). Hypoxia compared to normoxia increased cardiac output before (+23±19%, p<0.01 ANOVA) and during (+22±20%, p<0.01 ANOVA) IML, while local muscle perfusion during IML remained unchanged (CLPaer: p=0.41 ANOVA; CLPap: p=0.29 ANOVA). CONCLUSION:Acute hypoxia compared to normoxia does not affect locomotor muscle perfusion during fatiguing IML.

背景与目标： 引言：呼吸肌疲劳会减少周围肌肉的灌注。此外，急性缺氧会增强呼吸肌疲劳。这项研究调查了吸氧量（IML）与低氧相比低氧对静息运动肌灌注的影响。
方法：十名受试者分别在常压低氧（目标血氧饱和度为80％）和常氧下完成了对IML（盲，随机）疲劳训练的两个研究日。腓肠肌的造影增强超声（CEUS）和pop肌多普勒超声检查可监测肌肉灌注情况。基于CEUS和监测的心输出量，建立灌注替代参数（CLPaer和CLPap）。
结果：常氧（CLPaer：-54±25％，p <0.01; CLPap：-58±32％，p <0.01）和缺氧（CLPaer：-43±23％，p <0.01）在IML早期肌肉灌注下降。 CLPap：-41±20％，p ＜0.01）。与常氧相比，低氧增加了IML之前（23±19％，p <0.01 ANOVA）和期间（22±20％，p <0.01 ANOVA）的心输出量，而IML期间的局部肌肉灌注保持不变（CLPaer：p = 0.41 ANOVA; CLPap：p ＝ 0.29 ANOVA）。
结论：与常氧相比，急性缺氧并不影响IML疲劳期间运动肌的灌注。

BACKGROUND & AIMS: PURPOSE:To demonstrate the utility of a new concept of intraoperative use of high frequency ultrasound (hfioUS) in maximizing the extent of resection (EOR) of intracerebral high-grade tumors. MATERIALS AND METHODS:22 Patients harboring an intracerebral high-grade tumor were retrospectively included in this study (14 primary tumors, 8 metastasis). 14 of them had a perilesional edema equal or greater to lesion volume, 3 had previously received radiotherapy. Following macroscopic tumor debulking, the small (11 × 31 mm) L15 - 7io (Philips, Bothell, USA) high-frequency probe (7 - 15 MHz) was introduced into the resection cavity and its walls were meticulously scanned to search for tumor remnants. Postoperative MR scan was evaluated by a board-certified independent neuroradiologist, who assessed the EOR. RESULTS:Gross total resection was achieved in 21 patients (95.5 %). One patient had a small tumor remnant (6 × 4 × 3 mm) of a very large (80 × 60 × 74 mm) anaplastic astrocytoma, detected in the postoperative MR scan. A permanent postoperative hemiparesis was diagnosed in one patient with a metastasis in the motor area, while the other patients recovered without permanent neurological deficits from the surgery. CONCLUSION:The hfioUS probe allowed in this study a precise detection of the tumor and a detailed discrimination between normal, pathological and edematous tissue in all 22 cases. :ZIEL:: Darstellung eines neuen intraoperativen Konzepts basierend auf Hochfrequenz-Ultraschall (hfioUS) zur Maximierung der Resektion hochgradiger intrazerebraler Tumoren. MATERIAL UND METHODEN:22 Patienten mit hochgradigen intrazerebralen Tumoren (14 primäre Tumoren, 8 Metastasen) wurden retrospektive in diese Studie eingeschlossen. 14 dieser Patienten zeigten ein perifokales Ödem gleich oder größer als das Läsionsvolumen, 3 Patienten erhielten präoperativ bereits Radiotherapie. Nach der makroskopischen Tumorentfernung wurde die hfioUS-Messsonde L15 – 7io (Philips, Bothell, USA) mit einer Größe von 11 × 31 mm in die Tumorhöhle eingeführt und die Wände dieser nach Tumorresten untersucht. Postoperative MRTs wurden von einem unabhängigen Neuroradiologen bezüglich Resektionsgrad ausgewertet. ERGEBNISSE:Eine makroskopische Totalresektion wurde bei 21 Patienten (95.5 %) erreicht. Ein Patient mit einem großen anaplastischen Astrozytom (80 × 60 × 74 mm) zeigte einen kleinen Resttumor (6 × 4 × 3 mm) im postoperativen MRT. Eine permanente postoperative Hemiparese zeigte sich bei einem Patient mit einer Metastase im motorischen Areal, die restlichen Patienten erholten sich postoperative ohne permanentes neurologisches Defizit von der Operation. SCHLUSSFOLGERUNG:In dieser Studie erlaubte die hfioUS-Messsonde bei allen 22 Fällen eine präzise Darstellung des Tumors und eine detaillierte Unterscheidung zwischen regelrechtem, pathologischem und ödematösem Hirnparenchym.

背景与目标： 目的：证明术中使用高频超声（hfioUS）这一新概念在最大限度地扩大脑内高级别肿瘤的切除范围（EOR）方面的实用性。
材料与方法：本研究回顾性纳入了22例脑内高度肿瘤患者（14例原发肿瘤，8例转移瘤）。其中14例病灶周围水肿等于或大于病灶体积，3例以前接受过放射治疗。在宏观肿瘤消灭之后，将小的（11×31 mm）L15-7io（Philips，Bothell，USA）高频探头（7-15 MHz）引入切除腔，并对其壁进行仔细扫描以寻找肿瘤残留物。术后MR扫描由经董事会认证的独立神经放射科医生评估，该医师评估了EOR。
结果：21例患者全切除了（95.59％）。一名患者在术后MR扫描中发现了一个很小的肿瘤残留（6××4××3×mm）很大的（80××60××74×mm）间变性星形细胞瘤。在一名运动区域转移的患者中，诊断出永久性术后偏瘫，而其他患者在手术后没有永久性神经功能缺损的情况下康复。
结论：在本研究中，hfioUS探针可对所有22例患者的肿瘤进行精确检测，并对正常，病理和水肿组织进行详细区分。
：ZIEL :: Darstellung eines neuenneuopern Konzepts basierend auf Hochfrequenz-Ultraschall（hfioUS）zur Maximierung der Resektion hochgradiger intrazerebraler Tumoren。
材料和方法：22顽固性复发性脑卒中患者是图斯雷布雷伦·图莫伦（14 primture Tumoren，8 Metastasen）。 14位患者的抗癌药和放射线治疗的3位患者，放疗的药物为3位患者。 US-Messsonde L15 – 7io（菲利普斯，美国博塞尔）的Nach der makroskopischen Tumorentfernung战争发生在Tumorhöhleeingeführt和Wänt死者中。术后的MRT会引起神经放射。
ERGEBNISSE：21位患者（Eat makroskopische Totalresektion wurde beeren）（95.5％）。术后进行MRT时，患者应接受astroplasttom（80×60×74 mm）和zeigte einen kleinen Resttumor（6×4×3 mm）的手术。永久性手术后半永久患者的脑部转移，再进行永久性患者永久性神经外科手术后永久性手术。
SCHLUSSFOLGERUNG：在Dieser Studie erlaubte die HfioUS-Messsonde bei allen中，在肿瘤与细节研究方面的进展，以及在病理学和病理学上的发展。

BACKGROUND & AIMS: OBJECT:The purpose of this study was to provide an evidence-based algorithm for the design, development, and implementation of a new checklist for the response to an intraoperative neuromonitoring alert during spine surgery. METHODS:The aviation and surgical literature was surveyed for evidence of successful checklist design, development, and implementation. The limitations of checklists and the barriers to their implementation were reviewed. Based on this review, an algorithm for neurosurgical checklist creation and implementation was developed. Using this algorithm, a multidisciplinary team surveyed the literature for the best practices for how to respond to an intraoperative neuromonitoring alert. All stakeholders then reviewed the evidence and came to consensus regarding items for inclusion in the checklist. RESULTS:A checklist for responding to an intraoperative neuromonitoring alert was devised. It highlights the specific roles of the anesthesiologist, surgeon, and neuromonitoring personnel and encourages communication between teams. It focuses on the items critical for identifying and correcting reversible causes of neuromonitoring alerts. Following initial design, the checklist draft was reviewed and amended with stakeholder input. The checklist was then evaluated in a small-scale trial and revised based on usability and feasibility. CONCLUSIONS:The authors have developed an evidence-based algorithm for the design, development, and implementation of checklists in neurosurgery and have used this algorithm to devise a checklist for responding to intraoperative neuromonitoring alerts in spine surgery.

背景与目标： 目的：本研究的目的是提供一种基于证据的算法，用于设计，开发和实施针对脊柱手术中对术中神经监测警报的反应的新清单。
方法：对航空和外科文献进行了调查，以获取成功设计，开发和实施清单​​的证据。审查了清单的局限性以及实施清单的障碍。在此基础上，开发了神经外科检查清单创建和实现的算法。使用此算法，一个多学科团队对文献进行了调查，以获取有关如何对术中神经监测警报做出反应的最佳实践。然后，所有利益相关者都对证据进行了审查，并就列入清单的项目达成了共识。
结果：设计了对术中神经监测警报反应的清单。它强调了麻醉师，外科医生和神经监测人员的具体作用，并鼓励团队之间的沟通。它着重于对识别和纠正神经监测警报的可逆原因至关重要的项目。在初步设计之后，检查清单草稿经过了利益相关者的意见审查和修订。然后在小规模试验中对清单进行评估，并根据可用性和可行性进行修订。
结论：作者开发了一种基于证据的算法，用于神经外科检查清单的设计，开发和实施，并已使用该算法设计了对脊柱手术中术中神经监测警报做出反应的检查清单。

BACKGROUND & AIMS: :The purpose of this study is to compare the effects of spinal and epidural anesthesia on a rat transverse rectus abdominus myocutaneous flap ischemia-reperfusion injury model.Forty Sprague-Dawley rats were divided into 4 experimental groups: group I (n = 10), sham group; group II (n = 10), control group; group III (n = 10), epidural group; and group IV (n = 10), spinal group. After the elevation of the transverse rectus abdominus myocutaneous flaps, all groups except for the sham group were subjected to normothermic no-flow ischemia for 4 hours, followed by a reperfusion period of 2 hours. At the end of the reperfusion period, biochemical and histopathological evaluations were performed on tissue samples.Although there was no significant difference concerning the malonyldialdehyde, nitric oxide, and paraoxonase levels in the spinal and epidural groups, the total antioxidant state levels were significantly increased, and the total oxidative stress levels were significantly decreased in the epidural group in comparison to the spinal group. The pathological evaluation showed that findings related to inflammation, nuclear change rates and hyalinization were significantly higher in the spinal group compared with the epidural group.Epidural anesthesia can be considered as a more suitable method that enables a decrease in ischemia-reperfusion injuries in the muscle flaps.

背景与目标： ：本研究的目的是比较脊髓麻醉和硬膜外麻醉对大鼠横直肌腹肌皮瓣缺血再灌注损伤模型的影响。40只Sprague-Dawley大鼠分为4个实验组：I组（n = 10），假小组第二组（n = 10），对照组；第三组（n = 10），硬膜外组；第四组（n = 10），脊柱组。腹直肌横肌皮瓣抬高后，除假手术组外，其余各组均进行常温无血流缺血4小时，然后再灌注2小时。在再灌注期结束时，对组织样本进行了生化和组织病理学评估。尽管在脊髓和硬膜外组中丙二酰二醛，一氧化氮和对氧磷酶水平没有显着差异，但总抗氧化剂状态水平却明显升高，与硬膜外组相比，硬膜外组的总氧化应激水平显着降低。病理评估显示，与硬膜外组相比，脊髓组炎症，核变化率和透明质化相关的发现显着更高。硬膜外麻醉被认为是一种更合适的方法，可以减少肌肉的缺血再灌注损伤襟翼。

BACKGROUND & AIMS: :Bioabsorbable internal fixation has become an established part of the surgeons' armamentarium. There are several unique aspects of bioabsorbable polymers that can enhance their versatility. One of these is the application of heat to adapt the implant. Hot-tip cautery has been used for years to cut and otherwise customize bioabsorbable implants intraoperatively. As the tips of these devices can reach temperatures of over 1,000 degrees C, there is the potential that such practice can modify the degradation properties of these polymers. This study was performed to better understand the extent to which this potential exists. Screw heads of an 82:18 poly-L-lactic acid and poly-glycolic acid copolymer were modified by repeated passage of a hot-tip cautery wire, deforming the hex geometry to that of a ball. There was no significant difference between the glass transition temperature (approximately 59 degrees C) and inherent viscosity (approximately 1.45 dL/g) of treated and untreated screw heads, indicating no overall change in these properties throughout the mass of the screw head. Additionally, these properties were measured and comparisons made between the treated screw heads and untreated plates made of the same polymer during 28-day exposure to an in vitro bath (pH 7.4, 37 degrees C). The glass transition temperature and inherent viscosity exhibited declines during this period, with no significant differences between the two groups. Collectively, these results suggest that hot-tip cautery results in no substantial changes in the degradation characteristics of this polymer.

背景与目标： ：可生物吸收的内固定已成为外科医生武器库中的固定部分。生物可吸收聚合物有几个独特的方面，可以增强它们的多功能性。其中之一是施加热量以适应植入物。热尖烧灼术已经被使用了很多年，以在手术中切割和定制可生物吸收的植入物。由于这些设备的尖端可以达到超过1000摄氏度的温度，因此这种做法有可能改变这些聚合物的降解性能。进行这项研究是为了更好地了解这种潜力的存在程度。 82:18聚L-乳酸和聚乙醇酸共聚物的螺钉头通过热尖头烧灼线的反复通过进行了修饰，从而使六角形几何形状变形为球形。处理和未处理的螺钉头的玻璃化转变温度（大约59摄氏度）和固有粘度（大约1.45 dL / g）之间没有显着差异，表明在整个螺钉头的质量中，这些性能没有整体变化。另外，在暴露于体外浴（pH 7.4，37摄氏度）的28天期间，测量了这些性能并比较了处理过的螺钉头和由相同聚合物制成的未处理板。在此期间，玻璃化转变温度和比浓对数粘度下降，两组之间没有显着差异。总的来说，这些结果表明，热尖烧灼不会导致该聚合物的降解特性发生实质性变化。

BACKGROUND & AIMS: :A scar flap is formed with the pedicle at the lateral part of the columella base at the cleft side, that is, in the center of the affected region. It enables flap placement according to individual need. A prospective evaluation was performed in a group of 76 patients with cleft lip and palate, all operated on by the same plastic surgeon. The flap was used to improve the height of the columella and the extent of nasal mucosa on the frontal septum and on the nostril base in the vestibule. In the lip, the flap raised its height and improved proportionality. The average area of flap used in a unilateral deformity was 42 mm. Both flaps in a bilateral deformity were 77 mm. The average follow-up was 22.4 months. Neither local nor general complications were noted apart from a recurrence of the deformity of the nasal septum in 7.9% of patients. The nasal passage was improved in 59.9% of patients and normalized in 19.6% upon follow-up rhinomanometry, but nevertheless, only one third of patients overcame their dynamic stereotype of breathing by the mouth. Anthropometric measurements showed an absence of statistically significant differences between patients after surgery and healthy individuals in crucial parameters (nasal tip projection, length of columella, nasolabial angle, nasal angle, and lip angle). The loss of the stigmatizing deformity is based on rotation of the nasolabial angle in relation to the aesthetic axis of the face. Direct examination proved aesthetic and functional improvement as statistically significant in 92.1% of patients.

背景与目标： ：瘢痕皮瓣的形成是在小腿小腿底部的外侧，即患部的中央，以椎弓根为蒂。它可以根据个人需要放置襟翼。对一组由同一整形外科医生进行手术的76例唇left裂患者进行了前瞻性评估。皮瓣用于改善前额隔和前庭鼻孔基部的小肠高度和鼻粘膜范围。在唇部，皮瓣提高了高度并提高了比例。单侧畸形使用的皮瓣平均面积为42毫米。双侧畸形的两个皮瓣均为77 mm。平均随访22.4个月。除7.9％的患者鼻中隔畸形复发外，未发现局部或一般并发症。随访鼻测压法后，有59.9％的患者改善了鼻腔通气，并在19.6％的水平上恢复了正常，但是，只有三分之一的患者克服了他们通过口呼吸的动态刻板印象。人体测量显示，手术后患者与健康个体之间在关键参数（鼻尖投影，小柱长度，鼻唇角，鼻角和唇角）之间没有统计学上的显着差异。耻辱性畸形的丧失是基于鼻唇沟角相对于面部的美学轴的旋转而引起的。直接检查证明92.1％的患者的美学和功能改善具有统计学意义。

BACKGROUND & AIMS: :Old and frail patients with advance breast malignancy require mastectomy which often results in large defects requiring soft tissue cover. We present three cases of large fasciocutaneous perforator based V-Y advancement flaps for reconstruction of large post-mastectomy wounds in older patients with large tumours. This technique reduces the morbidity of patients who have severe co-existing morbidity factor in addition to the advance breast disease.

背景与目标： ：患有乳腺恶性肿瘤的老弱患者需要进行乳房切除术，这通常会导致较大的缺陷，需要软组织覆盖。我们介绍了三例基于大型筋膜皮肤穿刺器的V-Y推进瓣，用于在患有大肿瘤的老年患者中重建大型乳房切除术后伤口。该技术可降低患有严重乳腺疾病并存的严重发病因素的患者的发病率。

BACKGROUND & AIMS: BACKGROUND:The utility of frozen section (FS) examination in the intraoperative management of breast lesions is well established. The accuracy of FS in the diagnosis of borderline noninvasive or preinvasive breast lesions is uncertain.

METHODS:The authors retrospectively reviewed the results of intraoperative consultations/frozen section examinations of 181 ductal carcinomas in situ (DCIS) of the breast. Various clinical and pathologic factors were analyzed and correlated with FS diagnosis.

RESULTS:FS examination was performed on 153 cases (85%) and only macroscopic examination on 28 cases (15%). FS diagnoses were as follows: DCIS in 76 cases (50%), atypical ductal hyperplasia/suspicious for DCIS in 8 cases (5%), benign in 55 cases (36%), deferred in 13 cases (8%), and invasive carcinoma in 1 case. FS accuracy, false-negative rate, and false-positive rate were 55%, 36%, and 0.6%, respectively. Sampling error was the main reason for the low detection rate, and technical inadequacy was a major factor contributing to interpretive problems. In multivariate regression analysis, FS accuracy was significantly associated with the clinical presentation of a palpable mass (odds ratio [OR] = 4.16, 95% confidence interval [CI]: 2.04-8.45), the macroscopic finding of a mass (OR = 3.03, 95% CI: 1.45-6.67), and necrosis (OR = 3.13, 95% CI: 1.4-6.67).

CONCLUSIONS:The authors concluded that the accuracy of FS diagnosis of DCIS was low, mainly due to sampling error. In general, FS examination should not be performed when no lesion/mass is identified by macroscopic examination.

背景与目标： 背景：冰冻切片（FS）检查在乳腺病变术中处理中的效用已得到很好的确立。 FS在诊断边缘性非浸润性或浸润性乳腺病变中的准确性尚不确定。

方法：作者回顾性分析了181例导管癌的术中咨询/冷冻切片检查的结果。乳房的原位（DCIS）。分析了各种临床和病理因素，并将其与FS诊断相关联。

结果：对153例（85％）进行了FS检查，仅对28例（15％）进行了肉眼检查。 。 FS诊断如下：DCIS 76例（50％），非典型性导管增生/可疑DCIS 8例（5％），良性55例（36％），延缓13例（8％）和侵入性癌1例。 FS准确性，假阴性率和假阳性率分别为55％，36％和0.6％。抽样误差是导致检出率低的主要原因，技术不足是导致解释性问题的主要因素。在多元回归分析中，FS准确性与可触及肿块的临床表现显着相关（比值比[OR] = 4.16，95％置信区间[CI]：2.04-8.45），肉眼可见肿块（OR = 3.03） ，95％CI：1.45-6.67）和坏死（OR = 3.13，95％CI：1.4-6.67）。

结论：作者得出结论：FS诊断的准确性DCIS的值较低，主要是由于采样误差。通常，当肉眼检查未发现病变/肿块时，不应进行FS检查。