Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...

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Gallbladder agenesis (GA) is a rare congenital anomaly with conflicting epidemiology described in the literature. When present, it is misinterpreted as cholelitiasis, a highly prevalent condition. Nevertheless, surgeons and radiologists must be aware of it since it can lead to unnecessary invasive procedures. Diagnosis of GA is challenging due to the anatomical structures that sometimes resemble a shrunken gallbladder. We report the case of a 55-year-old man with preoperative diagnosis of cholelitiasis and further intraoperative find of GA. Since cholecystectomy is one of the most common surgeries worldwide, it demonstrates how relevant this case is to emphasize the need to recognize this diagnosis and be aware of its management to avoid unnecessary surgery.

Gastric cancer (GC) ranks fourth in overall cancer mortality. Bariatric surgical procedures, especially the gastric bypass surgery (GBS), raise a concern about the risk of GC in the excluded stomach (ES). Diagnosis of GC in the ES is challenging due to anatomical changes and impossibility of endoscopic access to the ES. There are few reports of GC after GBS, and it occurs more in the gastric stump than in the ES. We report a case of a 54-year-old female with GC in the ES 18 years after GBS. The increasing number of GBS and the aggressiveness of the GC show how relevant this case is to emphasize the need to consider this diagnosis in patients who develop upper abdominal symptoms, anemia or weight loss.

This report describes a therapeutic alternative for correction of severe mitral stenosis causing high-response atrial fibrillation, and consequent syncope in a woman at 8 weeks gestational age. A percutaneous valvuloplasty attempt failed, because the transseptal puncture was not possible, and a definitive resolution was achieved by transapical valvuloplasty, via left thoracotomy through an inframammary incision, with direct access to the mitral valve. Since this was an original and complex procedure, this case is of relevant importance in the treatment of severe mitral stenosis in patients whose conditions render a conventional procedure impossible.

Introdução: O vestibular para ingresso em uma faculdade de medicina exige grande desempenho e dedicação do aluno. Além de competitividade, esse período gera muito estresse e privação de autocuidado. Os distúrbios do sono e níveis elevados de ansiedade podem impactar no desempenho físico, emocional e mental, reduzindo a qualidade de vida e influenciando fortemente na tomada de decisões. Objetivo: Analisar qualidade de sono e nível de ansiedade de jovens durante fase preparatória para ingresso no curso de medicina. Métodos: Pesquisa descritiva transversal com candidatos à vaga para graduação em medicina, em Curitiba-PR. Foram utilizados questionário sócio-demográfico, Índice de Qualidade do Sono de Pittsburgh (IQSP) e Inventário de Ansiedade Beck (BAI). Aplicada estatística descritiva, teste t de Student, teste qui-quadrado, teste de Mann-Whitney, Kruskal-Wallis e análise de variância. Resultados: Amostra com 470 pré-universitários, mulheres (81,9%), entre 18 a 20 anos (82,2%). Distúrbios de sono (IQSP>10) foram detectados em 48,1% dos estudantes e indícios de ansiedade grave em 49,1% (BAI). Não houve diferença significativa dos níveis de ansiedade entre os turnos manhã, tarde e noite (p>5%), porém 60,8% dos estudantes que apresentaram distúrbio do sono estudavam no turno vespertino. O sexo masculino apresentou significativamente mais distúrbio do sono (64,7%) quando comparado ao sexo feminino (44,4%). Contudo, as mulheres mostraram os maiores níveis de ansiedade, com ansiedade grave presente em 55% delas. Cerca de 19,4% desses jovens usavam medicamentos para dormir 3 ou mais vezes na semana; 22,2% apresentavam histórico de uso de drogas ilícitas e 7,4% faziam uso. Apenas 5,3% da amostra não apresentaram nenhuma dificuldade ao se manter entusiasmado nas últimas semanas. Conclusão: Indicadores de distúrbio do sono tiveram predomínio nos turnos da tarde e nos homens, enquanto indícios de ansiedade grave foi mais evidente em mulheres, sem interferência do turno de estudo.

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