From the time of Hippocrates to the early 19th century, knowledge advanced but that was an uneven process. Anatomy was basically defined by Galen and remained cast in stone until the early 16th century. Neuroanatomy was described by Galen but had little practical value, as brain surgery was not possible. The anatomy of the cranium was known and was largely correct. Care was taken to avoid the frontal air sinuses and the venous sinuses and the temporal region. The role of the brain in consciousness was not understood. It was considered the seat of the soul but there was a lack of understanding that damage to it could induce clinical symptoms such as stupor or paralysis. These were variously attributed to injuries to the meninges or the bone. This error was finally corrected in the 18th century when the brain was identified as responsible for much of the clinical disturbance following cranial trauma. All awareness that post traumatic neurological deficit was contralateral was ignored until the late 18th century, although several authors noted it. Likewise, the presence of CSF had to wait until the 18th century until it was recognized. Fissures were treated with trepanation, because of a perceived risk of infection developing between the bone and the dura. Depressed fracture fragments were elevated, replaced, or removed according to the details of the injury. Finally, for centuries surgeons blocked patients ears to reduce the sound of drilling, despite the fact that such a blocking would amplify the noise.

Recommendations for surgical repair of a congenital heart defect in children with trisomy 13 or trisomy 18 remain controversial, are subject to biases, and are largely unsupported with limited empirical data. This has created significant distrust and uncertainty among parents and could potentially lead to suboptimal care for patients. A working group, representing several clinical specialties involved with the care of these children, developed recommendations to assist in the decision-making process for congenital heart defect care in this population. The goal of these recommendations is to provide families and their health care teams with a framework for clinical decision making based on the literature and expert opinions.
This project was performed under the auspices of the AATS Congenital Heart Surgery Evidence-Based Medicine Taskforce. A Patient/Population, Intervention, Comparison/Control, Outcome process was used to generate preliminary statements and recommendations to address various aspects related to cardiac surgery in children with trisomy 13 or trisomy 18. Delphi methodology was then used iteratively to generate consensus among the group using a structured communication process.
Nine recommendations were developed from a set of initial statements that arose from the Patient/Population, Intervention, Comparison/Control, Outcome process methodology following the groups\' review of more than 500 articles. These recommendations were adjudicated by this group of experts using a modified Delphi process in a reproducible fashion and make up the current publication. The Class (strength) of recommendations was usually Class IIa (moderate benefit), and the overall level (quality) of evidence was level C-limited data.
This is the first set of recommendations collated by an expert multidisciplinary group to address specific issues around indications for surgical intervention in children with trisomy 13 or trisomy 18 with congenital heart defect. Based on our analysis of recent data, we recommend that decisions should not be based solely on the presence of trisomy but, instead, should be made on a case-by-case basis, considering both the severity of the baby\'s heart disease as well as the presence of other anomalies. These recommendations offer a framework to assist parents and clinicians in surgical decision making for children who have trisomy 13 or trisomy 18 with congenital heart defect.

BACKGROUND:  Tonsillectomy is a surgical procedure that involves removing the tonsils, often performed alongside adenoidectomy. Dating back to ancient times, it improves quality of life and can be life-saving when done for appropriate reasons. Common indications in children include recurrent tonsillitis and sleep-disordered breathing (SDB). Evidence suggests it reduces how often and how severe sore throats are in highly affected children. Symptoms such as lymphadenopathy, tonsillar pus, fever, or signs of streptococcal infection should be present for diagnosis of tonsillitis. Polysomnography (PSG) is essential to diagnose obstructive sleep apnea (OSA) and confirm airway obstruction.
OBJECTIVE: Our aim in this study is to determine the reasons for tonsillectomy in Taif, Saudi Arabia, since it is not well established before in this city.
METHODS:  A nine-year retrospective analysis of case records of patients aged 0-18 years who have had tonsillectomy performed in a tertiary hospital. Data was analyzed using SPSS (IBM Corp., Armonk, NY, USA).
RESULTS:  The research study involved analyzing data from 361 participants. Among the participants, 16.9% (n = 61) underwent tonsillectomy alone, while the majority (83.1%; n = 300) underwent tonsillectomy in combination with other procedures. The most common combined procedure was adenotonsillectomy (71.7%; n = 259). Additionally, adenotonsillectomy and insertion of grommets in other combinations was observed and was equal to 11.4% (n = 41) of the total percentage of our sample. The primary indications for tonsillectomy alone were chronic tonsillitis (42.6%; n = 26) and recurrent tonsillitis (49.2%; n = 30).  Conclusion: This research study provides valuable information on the types of procedures performed and the indications for surgery in pediatric patients. The results highlight the prevalence of chronic and recurrent tonsillitis and adenotonsillitis as primary indications for tonsillectomy, either alone or in combination with other procedures. These findings contribute to our understanding of the clinical decision-making process and can aid healthcare professionals in providing optimal care for pediatric patients with tonsillar and adenotonsillar pathologies.

The correct indications for surgical treatment of primary splenic tumors as well as metastases of the spleen are challenging due to the rarity of the various entities. Primary solid splenic tumors include benign lesions, such as hemangiomas, hamartomas and sclerosing angiomatous nodular transformation (SANT) of the spleen. In these cases, surgical treatment is indicated only in the case of inconclusive imaging and after careful consideration of the risk-benefit ratio, even in the case of pronounced symptoms. In contrast, primary angiosarcoma or undifferentiated pleomorphic sarcoma as highly malignant tumors represent an urgent indication for surgery. Although more frequent than primary splenic malignancies, secondary splenic tumors are also not that frequent. Solitary splenic metastases are rare; however, from an oncological point of view they can be treated by resection. In the case of oligometastasis with splenic involvement, splenectomy is used only as part of a palliative concept in cases of pronounced symptoms or in the context of cytoreductive surgery. In general, the laparoscopic approach is to be preferred when the operation is technically feasible as it is associated with fewer pulmonary and infectious complications and a shorter hospital stay. In addition, to reduce the risk of severe infections after splenectomy, the option of partial splenectomy should be considered, especially for benign lesions. A thorough informing of the patient regarding both intraoperative and perioperative risks as well as potential long-term sequelae, especially severe infectious diseases, is an essential component of informed consent before surgery.
UNASSIGNED: Die korrekte Indikation zur chirurgischen Therapie von primären Milztumoren sowie Metastasen der Milz ist aufgrund der Seltenheit der verschiedenen Entitäten anspruchsvoll. Zu den primären soliden Milztumoren zählen benigne Läsionen wie Hämangiome, Hamartome und die sklerosierende angiomatöse noduläre Transformation (SANT) der Milz. Hier besteht lediglich bei nicht eindeutiger Bildgebung sowie unter einer sorgfältigen Nutzen-Risiko-Abwägung auch bei einer ausgeprägten Symptomatik eine Indikation zur chirurgischen Therapie. Demgegenüber stellen das primäre Angiosarkom oder das undifferenzierte pleomorphe Sarkom als hochmaligne Tumoren eine dringende Operationsindikation dar. Wenngleich häufiger als primäre Milzmalignome, so sind auch sekundäre Milztumoren vergleichsweise selten. Solitäre Milzmetastasen stellen eine Rarität dar, scheinen jedoch auch aus onkologischer Sicht sinnhaft mittels Resektion therapiert werden zu können. Im Falle einer Oligometastasierung mit Milzbefall kommt eine Splenektomie nur im Rahmen eines palliativen Konzepts bei ausgeprägter Symptomatik oder im Rahmen zytoreduktiver Chirurgie zum Einsatz. Generell ist das laparoskopische Vorgehen, wenn operationstechnisch möglich, zu bevorzugen, da dieses mit weniger pulmonalen und infektiösen Komplikationen und mit einem kürzeren Krankenhausaufenthalt einhergeht. Um das Risiko schwerwiegender Infektionen nach Splenektomie zu verringern, sollte zudem insbesondere bei benignen Läsionen die Möglichkeit einer partiellen Splenektomie erwogen werden. Die sorgfältige Information der Patient:in sowohl über intra- und perioperative Risiken als auch potenzielle Langzeitfolgen, insbesondere schwere infektiöse Erkrankungen, ist essenzieller Bestandteil der Aufklärung vor der Operation.

BACKGROUND: Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting.
METHODS: A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting.
RESULTS: Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion.
CONCLUSIONS: Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.

BACKGROUND: Arthroplasty care delivery is facing a growing supply-demand mismatch. To meet future demand for joint arthroplasty, systems will need to identify potential surgical candidates prior to evaluation by orthopaedic surgeons.
METHODS: Retrospective review was conducted at two academic medical centers and three community hospitals from March 1 to July 31, 2020 to identify new patient telemedicine encounters (without prior in-person evaluation) for consideration of hip or knee arthroplasty. The primary outcome was surgical indication for joint replacement. Five machine learning algorithms were developed to predict likelihood of surgical indication and assessed by discrimination, calibration, overall performance, and decision curve analysis.
RESULTS: Overall, 158 patients underwent new patient telemedicine evaluation for consideration of THA, TKA, or UKA and 65.2% (n = 103) were indicated for operative intervention prior to in-person evaluation. The median age was 65 (interquartile range 59-70) and 60.8% were women. Variables found to be associated with operative intervention were radiographic degree of arthritis, prior trial of intra-articular injection, trial of physical therapy, opioid use, and tobacco use. In the independent testing set (n = 46) not used for algorithm development, the stochastic gradient boosting algorithm achieved the best performance with AUC 0.83, calibration intercept 0.13, calibration slope 1.03, Brier score 0.15 relative to a null model Brier score of 0.23, and higher net benefit than the default alternatives on decision curve analysis.
CONCLUSIONS: We developed a machine learning algorithm to identify potential surgical candidates for joint arthroplasty in the setting of osteoarthritis without an in-person evaluation or physical examination. If externally validated, this algorithm could be deployed by various stakeholders, including patients, providers, and health systems, to direct appropriate next steps in patients with osteoarthritis and improve efficiency in identifying surgical candidates.
METHODS: III.

Due to the increasing research into familial clustering of cancer entities, more and more genes are being identified in which mutations explain this clustering. Mutations in the cadherin 1 (CDH1) and catenin alpha 1 (CTNNA1) genes are considered to be causative for the occurrence of hereditary diffuse gastric cancer. Those affected show an incidence of gastric cancer of around 40% up to the age of 80 years and affected women show an incidence of 55% for the occurrence of lobular breast cancer. In 2020 updated international guidelines were published for the clinical management of patients with hereditary diffuse gastric cancer. When the specific test criteria are fulfilled, patients should undergo genetic testing for mutations in the CDH1 and CTNNA1 genes. In cases of the familial occurrence of diffuse gastric cancer and detection of a pathological mutation, a prophylactic total gastrectomy with D1 lymphadenectomy is recommended. Alternatively, or when pathological mutations are not detected, a gastroscopy should be performed annually with targeted and random biopsies. The occurrence of lobular breast cancer should be monitored annually by magnetic resonance imaging (MRI) from the age of 30 years onwards. A bilateral mastectomy for risk reduction should be discussed in a multidisciplinary setting.
UNASSIGNED: Durch die zunehmende Erforschung familiärer Häufungen von Tumorerkrankungen, werden immer weitere Gene identifiziert, deren Mutationen diese Häufungen erklären. Mutationen im CDH1- oder CTNNA1-Gen werden als ursächlich für das Auftreten des hereditären diffusen Magenkarzinoms angesehen. Die Betroffenen zeigen eine Magenkarzinominzidenz von ungefähr 40 % bis zum 80. Lebensjahr. Gleichzeitig zeigen weibliche Betroffene eine Inzidenz von 55 % für das Auftreten des lobulären Mammakarzinoms. 2020 wurden aktualisierte internationale Leitlinien publiziert, die den klinischen Umgang mit diesem Patientengut beschreiben. Bei Erfüllung spezifischer Testkriterien sollte eine genetische Testung der zwei aufgeführten Gene erfolgen. Bei dem Nachweis einer pathologischen Mutation sowie dem familiären Auftreten diffuser Magenkarzinome kann eine prophylaktische totale Gastrektomie mit D1-Lymphadenektomie empfohlen werden. Alternativ oder bei fehlendem Nachweis pathologischer Mutationen sollten jährliche Gastroskopien mit gezielten sowie zufälligen Biopsien erfolgen. Das Auftreten des lobulären Mammakarzinoms sollte ab dem 30. Lebensjahr mittels jährlicher magnetresonanztomographischer Untersuchungen gemonitort werden. Eine risikoreduzierende beidseitige Mastektomie kann erwogen werden.

Hysterectomy is an essential part of the treatment armamentarium for patients with malignant disease, severe prolapse, massive fibroids, with genetic mutations that predispose to endometrial cancer, and in selected patients with severe symptomatic endometriosis and adenomyosis. For patients with abnormal uterine bleeding unresponsive to non-surgical measures, there is high-level evidence that hysterectomy, particularly minimally invasive hysterectomy, is associated with higher rates of satisfaction and quality of life, comparable rates of serious adverse events and a lower incidence of further surgery, than endometrial resection or ablation. A \'net zero\' hysterectomy is not an appropriate goal in contemporary gynaecological practice.

A 49-year-old female presented to the hospital with complaints of generalized weakness, subjective fevers, and chills. In the emergency department (ED), she was found to be hypotensive and tachycardic and met the sepsis criteria. A CT scan of the abdomen and pelvis (CT A/P) with contrast revealed a liver abscess and a foreign body (FB) that was suspected to be the cause of the liver abscess. Of note, the patient had undergone a recent dental procedure due to an infected root canal, which had involved a dental screw. The patient was uncertain whether the dental screw had been removed, but she felt as though it was no longer there. At this time, the clinical suspicion was high for FB secondary to this dental procedure. The patient underwent interventional radiology (IR)-guided liver abscess drainage and magnetic resonance cholangiopancreatography (MRCP) for the evaluation of the FB. An esophagogastroduodenoscopy (EGD) was performed, but no evidence of the FB was found. This warranted an exploratory laparotomy (EL) to ensure the successful removal of the FB. Upon gross visualization by surgery, the FB was revealed to be a bone that the patient did not recall ingesting. However, surgical pathology evaluation revealed that the FB was actually a plastic stick. This rare case highlights the clinical approach to FB ingestion when complicated by liver abscess, as well as successful treatment with EL as opposed to laparoscopy which is the procedure of choice.

Congenital heart disease (CHD) is the most common predisposing factor for pediatric infective endocarditis (IE). Although patients with unrepaired ventricular septal defects (VSDs) are at greater risk of IE than those without CHD, the American Heart Association (AHA) considers VSDs to be relatively low risk and therefore does not recommend antibiotic prophylaxis against IE. Even among patients with VSDs who develop IE, current AHA and European Society for Cardiology (ESC) guidelines do not recommend surgical VSD closure, despite the potential for a second IE event. We present a case series of four children with small, restrictive, perimembranous VSDs who developed tricuspid valve (TV) IE. All four experienced delayed diagnosis and secondary complications, including three with septic pulmonary emboli. All four patients ultimately underwent surgical VSD closure. These cases highlight the importance of recognizing IE as a possible cause of prolonged fever in children, even among those with even \'low-risk\' CHD. The cases also draw attention to the potential benefits of VSD closure in patients who develop IE.