Awake intradural spinal tumour resection

Background Meningioma is a common slow growing spinal tumour with a predilection for intradural occurrence. Patients usually present with pain followed by ataxia and sensory and sphincter problems. The gold standard treatment in these cases is gross total microsurgical resection under general anaesthesia. However, there exist high anaesthetic risk patients unsuitable for general anaesthesia. Performing spinal surgeries under local anaesthesia and sedation has been reported albeit rarely for mostly minimally invasive procedures but not for open intradural pathologies. Case description We report a 63-year-old woman with critical aortic stenosis, coronary artery disease and severe chronic obstructive airways disease (COAD) who presented with ten months’ history of worsening back pain and bilateral leg pains, ataxia, hyperreflexia in lower limbs as well as altered lower limb sensation. Magnetic resonance imaging (MRI) revealed a contrast enhancing intradural lesion at T6/7 with severe spinal cord compression. However, the patient was ASA class IV and her cardiac disease was not amenable to intervention. She underwent thoracic laminectomy and excision of the tumour under local anaesthesia and sedation with no significant complications and clinical improvement. Conclusion Our illustrative case and literature review suggest that utilising local anaesthesia and sedation to perform spinal surgeries including intradural tumours is possible even in high-risk patients with good outcome. Our ASA class IV patient tolerated the surgery well with gross total tumour resection and subsequent resolution of the symptoms

Resources, race and rights: A case study of Native Title and the Adani Carmichael coal mine

This thesis examines the extent to which state institutions and government have taken into account Indigenous rights and interests during the approval process for a large mining development. This case study focuses on the various phases of approval for the proposed Adani Carmichael Coal Mine, a significant development that has challenged the native title system in Australia. It assesses the extent to which the rights and interests of the Wangan and Jagalingou people, the traditional owners that possess a native title claim over the region, have been upheld by the National Native Title Tribunal and the State and Federal Government. This thesis employs multiple theoretical perspectives to explain the outcomes of the approval process. While this study aims to critically review the existing literature, the application of two liberal culturalist perspectives and the broader framework of critical race theory contribute added insights in the area of native title and resource developments

Microsurgical resection of giant T11/T12 conus cauda equina schwannoma

In this video, we highlight the anatomy involved with microsurgical resection of a giant T11/T12 conus cauda equina schwannoma. Spinal schwannoma remains the third most common intradural spinal tumor. Tumors undergoing gross total resection usually do not recur. To our knowledge, this is the first video case report of giant cauda equina schwannoma resection. A 55-year-old female presented with paraparesis and urinary retention. Lumbar spine MRI revealed a contrast-enhancing intradural extramedullary tumor at the T11/T12 level. Surgery was performed in the prone position with intraoperative neurophysiology monitoring (somatosensory and motor evoked potentials—SSEPs and MEPs). T11/T12 laminectomies were performed. After opening the dura and arachnoid, the tumor was found covered with cauda equina nerve roots. We delineated the inferior pole of the tumor, followed by opening of the capsule and debulking the tumor. Subsequently, the cranial pole was dissected from the corresponding cauda equina nerve roots. Finally, the tumor nerve origin was identified and divided after nerve stimulation confirmed the tumor arose from a sensory nerve root. The tumor was removed; histological analysis revealed a schwannoma (WHO Grade I). Postoperative MRI revealed complete resection. The patient fully recovered her neurological function. This case highlights the importance of careful microsurgical technique and gross total resection of the tumor in the view of favorable postoperative neurological recovery of the patient. Intraoperative use of ultrasound is helpful to delineate preoperatively tumor extension and confirm postoperative tumor resection

Mechanical Circulatory Support in Management of Cardiogenic Shock and Myxedema Coma.

The cardiovascular system is a major target of thyroid hormone action and the two systems are closely interlinked. It can be greatly impacted even with subtle alterations in thyroid function. Caution is needed when implementing thyroid hormone replacement in patients with severe hypothyroidism, especially in the setting of ischemic coronary artery disease. If not properly treated, myxedema may ensue. Given the high mortality of myxedema coma, supportive care may not always suffice and patients may require more invasive interventions. We present a challenging case of a patient with overt hypothyroidism with concurrent acute coronary syndrome which subsequently lead to myxedema coma and cardiogenic shock. A transcaval approach for the delivery of an Impella 5.0 (Abiomed Inc., Danvers, MA) was utilized in supporting this patient. To our knowledge, this is the first reported case that describes the use of a mechanical circulatory support in treating myxedema-induced cardiovascular collapse

Grundlagen der Robotic Process Automation. Stand der Forschung und Diskussion in der Praxis

Große Teile der Arbeitswelt stecken aktuell in der Transformation zur Industrie 4.0. Ziel dieser vierten industriellen Revolution ist eine wirtschaftliche Produktion durch dezentral gesteuerte, autonome Prozesse, unterstützt durch Digitalisierung und Automatisierung sowie durch die Vernetzung von Maschinen, Robotern, Werkstücken und Mitarbeitenden. Die Auswirkungen dieser Entwicklung auf die Arbeitswelt werden kontrovers diskutiert; Szenarien von der Vernichtung von Millionen von Arbeitsplätzen in den nächsten fünf Jahren bis hin zur Schaffung praktisch ebenso vieler neuer Beschäftigungsmöglichkeiten mit veränderten Qualifikationsanforderungen über alle Branchen hinweg stehen in Literatur und Praxis einander gegenüber. Robotic Process Automation stellt in dieser Entwicklung einen ersten Schritt auf dem Weg zu einer intelligenten Prozessautomation dar und bietet Unternehmen den Einstieg in die Digitalisierung und Automatisierung von Prozessen sowie in die Kollaboration von Menschen und Softwarerobotern

Miksopapilarni ependimom kralježnične moždine u odraslih: prikaz osobne serije i pregled literature

Myxopapillary ependymomas (MPE) of the spinal cord are slow-growing benign tumors most frequently found in adults between 30 and 50 years of age. They arise from the ependyma of the filum terminale and are located in the area of the medullary conus and cauda. The recommended treatment option is gross total resection, while patients undergoing subtotal resection usually require radiotherapy. Complete resection without capsular violation can be curative and is often accomplished by simple resection of the filum above and below the tumor mass. Nevertheless, dissemination and distant treatment failure may occur in approximately 30% of the cases. In this paper, we propose an original MPE classification, which is based upon our personal series report concerned with tumor location and its correlation with the extent of resection. We also provide literature review, discussing surgical technique, tumor recurrence rate and dissemination, and adjuvant treatment. In conclusion, our findings suggest that MPE management based on the proposed 5-type tumor classification is favorable when total surgical resection is performed in carefully selected patients. Yet, further studies on a much broader model is obligatory to confirm this.Miksopapilarni ependimomi (MPE) kralježnične moždine sporo su rastući, dobroćudni tumori najčešće zastupljeni u odraslih u dobi između 30 i 50 godina života. Nastaju iz ependima filuma terminale, a pretežito su smješteni u području medularnoga konusa i kaude. Kirurško uklanjanje tumora u cijelosti preporučena je metoda liječenja, dok u bolesnika u kojih to nije moguće učiniti u obzir dolazi subtotalna resekcija nakon koje je potrebno zračenje. Potpuno uklanjanje tumora uz očuvanje cjelovitosti tumorske kapsule postiže se jednostavnom resekcijom filuma terminale iznad i ispod tumorske mase, što može dovesti do izlječenja. Unatoč tomu, tumorska diseminacija uzduž neuralne osi može se javiti u oko 30% slučajeva. U ovom radu predlažemo originalnu klasifikaciju MPE koja prosuđuje smještaj tumora i obujam tumorske resekcije, a temeljena je na osobnoj seriji operiranih bolesnika. Također raspravljamo o kirurškoj tehnici, o mogućnostima recidiva i širenja ovakvih tumora, kao i o oblicima pomoćnog liječenja, koristeći se pregledom literature. Zaključujemo kako naši rezultati zagovaraju kirurško liječenje temeljeno na predloženoj originalnoj tumorskoj klasifikaciji, koje može biti uspješno u pažljivo odabranih bolesnika u kojih je tumor uklonjen u cijelosti. Naknadna istraživanja na znatno većem uzorku potrebna su za potvrdu naših rezultata

Lindex - En studie om varumärkesföryngring i praktiken

Sammanfattning Titel: Lindex – en studie om varumärkesföryngring i praktiken. Uppsatsnivå: Kandidatuppsats, 15 hp. Författare: Orhan Arnautovic, Mediha Besic och Samir Nurovic. Utbildning: Magisterprogrammet i Service Management vid Lunds Universitet, Campus Helsingborg. Handledare: Richard Ek och Christian Fuentes. Syfte: Syftet med vår uppsats är att undersöka hur ett varumärke föryngras i praktiken. Frågeställningar: 1.) Hur föryngras varumärket i butiken? 2.) Hur föryngras varumärket i reklamen? 3.) Hur föryngras varumärket på hemsidan? Metod: Den etnografiska observationen har bidragit till en unik insamling av material av det som återfinns i butikerna. Som komplement till detta har vi använt oss av kvalitativa intervjuer med butikschefer för att få bekräftelse på våra egna tolkningar. Utöver Lindex butiker har vi analyserat varumärkesföryngringen på andra plan såsom reklambroschyrer och hemsida i form av bildanalyser. Slutsatser: Varumärket har föryngrats med hjälp av att Lindex anpassat sig till den rådande konkurrensen på marknaden med hjälp av marknadsföringen. Lindex når idag en bredare och yngre kundkrets som numera tilltalas av det nya och trendanpassade sortimentet. Design, sortiment, marknadsföring och personal skapar genom samverkan nya, fräscha och moderna butiker. Märkesinnehavaren Lindex och dess centrala intressenter konsumenterna, populärkultur och övriga intressenter så som konkurrenter och leverantörer, utgör en central roll i varumärkesföryngringen. Dessa har format det nya Lindex och är på så sätt dess varumärkesförfattare. Nyckelord: Varumärke, varumärkesföryngring, varumärkesförfattare, värde, livscykel, marknadsföring

Surgical anatomy of microsurgical 3-level anterior cervical discectomy and fusion C4–C7

Anterior cervical discectomy and fusion (ACDF) is one of the most common spinal procedures, frequently used for the treatment of cervical spine degenerative diseases. It was first described in 1958. Interestingly, to our knowledge, 3-level ACDF has not been previously published as a peer-reviewed video case with a detailed description of intraoperative microsurgical anatomy. In this video, we present the case of a 33-year-old male who presented with a combination of myelopathy (hyperreflexia and long tract signs in the upper and lower extremities) and bilateral radiculopathy of the upper extremities. He had been previously treated conservatively with physical therapy and pain management for 6 months without success. We performed 3-level microsurgical ACDF from C4 to C7. All 3 levels were decompressed, and bone allografts were placed to achieve intervertebral body fusion. A titanium plate was utilized from C4 to C7 for internal fixation. The patient was discharged home on the first postoperative day. His pain, numbness and tingling resolved, as well as his myelopathy. No perioperative complications were encountered. Herein we present the surgical anatomy of our operative technique including ertain technical tips. Written consent was obtained directly from the patient. VIDEO https://vimeo.com/user128225853 VIDEO ANNOTATIONS 01:13 — opening the surgery site 02:29 — positioning of retractors 03:02 — start of 3-level discectomy 06:04 — allograft placement and fixation 08:20 — drain placement and closur