*pasok si Sisa, na para bang nagdarasal*

Ah, *tingin sa audience*, magdasal na kayong lahat! Hindi niyo ba alam na Araw ng
Patay ngayon? Tignan niyo, kita niyo ba yung ilaw na iyon sa kampanaryo? Anak ko
iyon, si Basilio! Si Crispin naman yung nasa simbahan.

*manginginig kaunti, tila nalulungkot* Hindi ko nga lang sila mabisita sa kumbento.
May sakit kasi yung kura eh, at baka raw mawala ang onsang ginto. *tatawa bigla at
ngingiti* Binibigyan ko ng gulay ang kura; marami ring bulaklak sa aking bakuran at
dalawa ang aking anak.

*tatakbo palayo* Basilio! Crispin! Mga anak ko, nasaan na kayo! *tuturo sa
audience* Ikaw, nakita mo ba ang anak ko? *hahagulgol at tatakbo ulit sa ibang
pwesto*

*titigil at titingin sa isang tao sa audience* Basilio, ikaw ba iyan? H-hindi, hindi
ikaw*hihikbi* Hindi ikaw ang anak ko!

*tatakpan ang mukha tapos tatawa* Ahh, kilala niyo ba ang asawa ko? Mahal na
mahal ko siya, si Pedro. *tutungo* Dapat talagang mahalin ang isang tao, kahit ano
man ang kanyang pagkukulang. *tatawa bigla* Kaya nga naman tinatawag na pag-
ibig!

*aawit ng pabulong* Hmm, ayaw ni Doa Consolacion ang aking mga awitin. *kikibit
ang balikat kakaunti, tapos tatawa* Ang galing niyang sumayaw *titingin sa
audience* alam niyo ba iyon? *tatawa lalo*

*hihikbi bigla* Masakit yung latigo, masakit. *manginginig* Paano na kaya ang aking
mga anak? *iiyak* Basilio! Crispin!

*Exeunt*
 MARCH 10, 2017
Opioid pain medications may affect liver transplant patients' survival
Saint Louis University Health News

In a recent paper published in the journal Liver Transplantation, researchers reported that the use of
opioid pain medications may play a significant role in patient outcomes following liver transplantation,
according to Saint Louis University nephrologist and senior author Krista Lentine, MD, PhD.

An analysis of nearly 30,000 patients undergoing liver transplantation in the United States between 2008
and 2014 found elevated death and organ loss rates in the first five years after transplantation among
recipients with the highest use of opioid pain medications while on the waiting list.

Higher risks mainly emerged after the first transplant anniversary, a pattern that may in part reflect
sustained opioid use. Sixty five percent of those with the highest level of opioid use on the waiting list
continued moderate to high level use in the first year after transplantation.

The findings indicate that transplant candidates who require high levels of opioids should be carefully
assessed and monitored before and after transplantation.

Concerns for an epidemic of complications related to use of prescription opioids has not spared the
population with endstage liver disease, Lentine said. Risks of opioidrelated toxicities may be even
greater in patients with organ failure, due to altered drug metabolism and excretion. First author and
associate professor of surgery at Saint Louis University Henry Randall, MD, concurred, noting More
work is needed to identify underlying mechanisms of mortality, determine the impact of decreasing opioid
use before transplant, and design pain management strategies that improve patient outcomes.
 The Congenital Heart Collaborative performs Ohio's first fetal cardiac intervention
Nationwide Children's Hospital

A mother and her 29weekold unborn child are doing well after a team of physicians performed a
successful in utero procedure at University Hospitals Rainbow Babies & Children's Hospital (UH
Rainbow) last week. Known as fetal aortic valvuloplasty, this is the first heart procedure done before birth
in Ohio.

This rare approach helps prevent the progression of hypoplastic left heart syndrome (HLHS) in about half
of all treated patients. Babies born with HLHS are sometimes referred to as having half a heart, because
the left chambers of the heart are too small to pump blood to the body. The minimally invasive procedure
may make the baby healthier and more stable at birth and may decrease the number of openheart
surgeries for the child later in life. 'Right now, mom and baby are doing well, and we noted improvement
in the way the blood flows through the heart prior to mom's discharge,' says James Strainic, MD, Director,
Fetal Heart Program at UH Rainbow.

The procedure took place at UH Rainbow through the Congenital Heart Collaborative's Fetal Heart
Program, which offers cardiac interventions for unborn babies with developing HLHS and other critical,
congenital heart conditions.

The fetal valvuloplasty uses ultrasound guidance and a catheterbased approach to gain access to the fetal
heart and to open the aortic valve using a tiny inflated balloon. This increases blood flow through the left
ventricle of the heart to help its development.

Aimee K. Armstrong, MD, Director of Cardiac Catheterization and Interventional Therapies at

Nationwide Children's Hospital, has performed fetal heart procedures more than a dozen times in her
career, but this is her first fetal intervention patient since joining the Congenital Heart Collaborative in
2015. Dr. Armstrong built a team of experts from Nationwide Children's, UH Rainbow and UH
MacDonald Women's hospitals, as part of the Congenital Heart Collaborative.

'By performing interventions on the fetal heart, we are able to alter the trajectory of heart and lung disease
development before a baby is born with the goal of making the baby's heart healthier at birth,' said Dr.
Armstrong. 'We ultimately hope to be able to decrease morbidity and mortality for these babies.'

The Congenital Heart Collaborative, formalized two years ago, is a partnership between UH Rainbow
Babies & Children's in Cleveland and Nationwide Children's in Columbus, which brings together expert
physicians, surgeons and teams to provide world class care for patients and families in Northeast Ohio.

'The Fetal Heart Program at UH Rainbow Babies & Children's Hospital is proud to be the first site in
Ohio to offer this stateoftheart care for babies who are diagnosed with a congenital heart condition
before birth,' said David Hackney, MD, Division Chief of Maternal Fetal Medicine at UH MacDonald
Women's Hospital. 'Our goal is to provide comprehensive care, from initial diagnosis through the entire
pregnancy and beyond.'

With UH Rainbow Babies & Children's and UH MacDonald Women's hospitals both under one roof,
Maternal Fetal Medicine specialists and the Congenital Heart Collaborative team can offer the full
continuum of care in rare cases like this, for optimal outcomes.

When the baby is born, he will receive immediate followup care from experts at UH Rainbow Babies &
Children's Hospital and the Congenital Heart Collaborative.
 Sartorius Muscle Flaps: Perioperative Outcomes Based on Surgical Specialty

Presented at: Society for Vascular Surgery, Vascular Annual Meeting, Poster session presentation, June
2016, Washington, DC.
Tammam Obeid, MBBS, Satinderjit Locham, MBBS

Abstract
Objective
Complicated groin wounds often require repair by Sartorius Muscle Flap (SMF). Operating surgical
specialty differs based on SMF indication, hospital, and operating surgeon preference. We aim to assess
the effect of operating surgical specialty, indication for SMF, and other patient-level factors on 30-day
outcomes.

Methods
We collected data on all patients undergoing SMF performed at our institution from 2005-2015, including
age, sex, body mass index, comorbidity index (hypertension, diabetes, dyslipidemia, peripheral arterial
disease, coronary artery disease), smoking status, history of malignancy, indication for SMF (infection,
non-infectious complication, prophylaxis), and operating surgeons specialty (vascular, plastic, general,
other). Primary outcome was any 30-day complications (wound infection, seroma, dehiscence, or
bleeding). Secondary outcome included 30-day surgical re-intervention rate. Univariate analysis and
multivariate logistic regression modeling were used to evaluate primary outcomes.

Results
A total of 170 SMFs were performed during the study period (mean patient age 58 years; 49% male).
Primary indication for SMF was prophylaxis in 116 cases (68%), followed by infection in 36 cases (21%)
and non-infectious complications in 18 cases (11%).

General surgeons performed the highest proportion of SMF (45%) followed by vascular surgeons (26%),
other specialties (15%), and plastic surgeons (14%). Compared to all specialties, vascular surgeons
operated on the severely ill patients (77% of vascular patients had 3 comorbidities; P<0.001).

Surgical re-intervention within 30 days was required in 7 patients (4.1%); 3 by vascular surgeons (6.8%
of total cases by vascular surgery) and 4 by plastic surgeons (17.4% of total cases by plastic surgery),
P<0.001.

Any 30-day complications occurred in 47 patients (28%): 30 general surgery cases (39%); 7 plastic
surgery cases (30%); 7 other specialty cases (27%); and 3 vascular surgery cases (7%) (P<0.001). Out of
all vascular-disease-related cases (56), plastic surgeons performed 21% of SMF, while vascular surgeons
performed 79%. On logistic regression correcting for baseline differences between groups, vascular
surgeon SMF outcomes were compared favorably to those done by other specialties.

Conclusion
Overall, SMFs have low perioperative re-intervention rates but high complication rates. Vascular surgeons
perform SMF on high-risk patients with more comorbidities compared to other specialties. Although
overall morbidity associated with this procedure is high, perioperative outcomes for SMF performed by
vascular surgeons are favorable.
 Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer
Patrick J. McLarenJames P. Dolan

Abstract

Background

The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed
significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can
now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar
survival outcomes without the associated morbidity of a major operation. However, a number of these
cases may still require surgical intervention as the best treatment option.

Methods

The current scientific literature, national and international guidelines were reviewed for recommendations
regarding optimal treatment of early esophageal malignancy.

Results

The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well
as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal
tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy.
In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or
lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal
lesions, tumors within a long segment of Barretts esophagus, tumors adjacent to a hiatal hernia, tumors
that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy.

Conclusions

When performed at high-volume centers in experienced hands, esophagectomy can have consistently
good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a
treatment option.
 Analysis of delayed discharge after day-surgery laparoscopic cholecystectomy
Junning Cao, Bo Liu

Abstract
Background
Delayed discharge is the existing obstacle to further enhancing quality of recovery after Day-surgery
laparoscopic cholecystectomy (LC/DS). This study aims to analyze the reasons for delayed discharge
after LC/DS.

Methods
The 745 patients with delayed discharge after LC/DS were retrospectively studied. The reasons for
delayed discharge and data related to patients were collected and analyzed. Psychosocial reasons were
defined by meeting discharge criteria but refusing to discharge, and complications were defined and
graded using the Clavien-Dindo classification system. Differences were statistically significant when p-
value < 0.01 level.

Results
The reasons for delayed discharge included psychosocial reasons (P, n = 324), conversion to open surgery
(CO, n = 21) and Clavien-Dindo I (n = 72), II (n = 307), IIIa (n = 17), IVa (n = 4) complications. Group P
had a shorter length of postoperative hospital stay (PHT) compared to groups I, II, IIIa, IVa and CO (p <
0.01, respectively). Group II had a longer operation time (p < 0.01) but no longer length of PHT (p =
0.814) compared to group I. The length of PHT in group IIIa was longer than that in groups I and II (p <
0.01, respectively), but the length of PHT in group IVa was no longer than that in groups I, II, and IIIa (p
= 0.047, p = 0.044 and p = 0.849, respectively). Group CO had a longer operation time (p < 0.01,
respectively), a more blood loss (p < 0.01, respectively) and a longer length of PHT (p < 0.01,
respectively) compared to groups P, I, II, and IIIa.

Conclusion
Patients who are delayed discharge due to psychosocial reasons have a rapid postoperative recovery. The
slower postoperative recovery and upgraded complication classifications are related and optimized
medical procedures promote the recovery. It is reasonable for patients who undergo conversion to open
surgery to experience a slow postoperative recovery.