Fluoroscopy-guided high-intensity focused ultrasound neurotomy of the lumbar zygapophyseal joints: a prospective, open-label study

OBJECTIVE

The objective of this study is to investigate safety and effectiveness of a fluoroscopy-guided high-intensity focused ultrasound (HIFU) system for thermal ablation of the lumbar medial branch nerves.

METHODS

This dual center prospective cohort study enrolled 30 participants with lumbar zygapophyseal joint syndrome. Each participant previously had a positive response to either a single diagnostic analgesic block or radiofrequency ablation (RFA). The primary effectiveness outcome was individual responder rate, defined as a reduction of two points or more on the pain intensity numerical rating scale without an increase in opioid intake, or a reduction in opioid intake without an increase in pain at 6 months after the intervention. The primary safety outcome was procedure-related or device-related adverse events (AEs). Secondary outcome variables included MRI evidence of tissue ablation, Oswestry Disability Index, 12-Item Short Form Health Survey, Brief Pain Inventory, and Patient Global Impression of Change.

RESULTS

The individual responder rate was 89.7% at 2 days, 89.7% at 7 days, 72.4% at 14 days, 82.1% at 30 days, 59.3% at 90 days and 82.6% at 180 days. The average Numeric Rating Scale for pain severity decreased from 7.1 at baseline to 3.0 (N=29) after 2 days, 3.0 (N=29) after 7 days, 3.1 (N=29) after 14 days, 3.2 (N=28) after 30 days, 4.3 (N=27) after 90 days, and 3.3 (N=23) after 180 days. All participants tolerated the procedure well with no significant side effects or complications.

CONCLUSIONS

Fluoroscopy-guided HIFU neurotomy achieved clinical responses comparable with RFA, and there were no significant device-related or procedure-related AEs.

TRIAL REGISTRATION NUMBER

NCT04129034.

Incomplete sensorimotor paresis after upper abdominal surgery with TEA and spinal epidural lipomatosis: a case report

INTRODUCTION

This case report documents a postoperative, incomplete sensorimotor paraparesis from thoracic vertebral body 6 (Th6) after combined anesthesia for upper abdominal surgery in a patient who had a thoracic localization of spinal epidural lipomatosis (SEL).

CASE PRESENTATION

The patient was treated in our clinic with a thoracic epidural catheter (TEA) for perioperative analgesia during a partial duodenopancreatectomy. Paraparetic symptoms occurred 20 hours after surgery. Initial MRI did not show bleeding, infection or spinal cord damage and the neurosurgeon consultants recommended observation. The neurological examination and the third follow-up MRI on 15th postoperative day showed ventrolateral damage of the spinal cord at level Th6. It is possible that local anesthetic compressed the spinal cord in addition to the existing lipomatosis and the thoracic kyphosis. The paraparesis improved during follow-up paraplegiologic treatment.

CONCLUSION

So far, only two uncomplicated lumbar epidural catheter anesthesias have been described in patients who had a lumbar SEL. Epidural catheter anesthesia is a safe and effective method of pain control. But it is important to carefully identify and stratify patients with risk factors during the premedication visit. In patients who had kyphosis and thoracic localization of SEL, TEA may only be used after a risk-benefit assessment.

Updated guidelines for prescribing opioids to treat patients with chronic non-cancer pain in Korea: developed by committee on hospice and palliative care of the Korean Pain Society

There are growing concerns regarding the safety of long-term treatment with opioids of patients with chronic non-cancer pain. In 2017, the Korean Pain Society (KPS) developed guidelines for opioid prescriptions for chronic non-cancer pain to guide physicians to prescribe opioids effectively and safely. Since then, investigations have provided updated data regarding opioid therapy for chronic non-cancer pain and have focused on initial dosing schedules, reassessment follow-ups, recommended dosage thresholds considering the risk-benefit ratio, dose-reducing schedules for tapering and discontinuation, adverse effects, and inadvertent problems resulting from inappropriate application of the previous guidelines. Herein, we have updated the previous KPS guidelines based on a comprehensive literature review and consensus development following discussions among experts affiliated with the Committee on Hospice and Palliative Care in the KPS. These guidelines may assist physicians in prescribing opioids for chronic non-cancer pain in adult outpatient settings, but should not to be regarded as an inflexible standard. Clinical judgements by the attending physician and patient-centered decisions should always be prioritized.

Five-Fraction High-Conformal Ultrahypofractionated Radiotherapy for Primary Tumors in Metastatic Breast Cancer

PURPOSE

To report on the local control and toxicity of 5-fraction, high-conformal ultrafractionated radiation therapy (RT) for primary tumors in patients with metastatic breast cancer (MBC) who did not undergo planned surgical intervention.

METHODS

We retrospectively reviewed 27 patients with MBC who underwent 5-fraction high-dose ultrafractionated intensity-modulated RT for their primary tumors between 2017 and 2022 at our institution. A median dose of 66.8 Gy (range, 51.8-83.6 Gy) was prescribed to the gross tumor, calculated in 2-Gy equivalents using an α/β ratio of 3.5, along with a simultaneous integrated boost of 81.5%. The primary endpoint of this study was local control.

RESULTS

The median tumor size and volume were 5.1 cm and 112.4 cm3, respectively. Treatment was generally well tolerated, with only 15% of the patients experiencing mild acute skin toxicity, which resolved spontaneously. The best infield response rate was 82%, with the objective response observed at a median time of 10.8 months post-RT (range, 1.4-29.2), until local progression or the last follow-up. At a median follow-up of 18.3 months, the 2-year local control rate was 77%. A higher number of prior lines of systemic therapy was significantly associated with poorer 2-year local control (one-two lines, 94% vs three or more lines, 34%; p = 0.004). Post-RT, 67% of the patients transitioned to the next line of systemic therapy, and the median duration of maintaining the same systemic therapy post-RT was 16.3 months (range, 1.9-40.3).

CONCLUSION

In our small dataset, 5-fraction, high-conformal ultrahypofractionated breast RT offered promising 2-year local control with minimal toxicity. Further studies are warranted to investigate the optimal dose and role in this setting.

India Hypertension Control Initiative: Blood Pressure Control Using Drug and Dose-Specific Standard Treatment Protocol at Scale in Punjab and Maharashtra, India, 2022

Background

Hypertension treatment coverage is low in India. A stepwise simple treatment protocol is one of the strategies to improve hypertension treatment in primary care. We estimated the effectiveness of various protocol steps to achieve blood pressure (BP) control in public sector health facilities in Punjab and Maharashtra, India, where the India Hypertension Control Initiative (IHCI) was implemented.

Methods

We analyzed the records of people enrolled for hypertension treatment and follow-up under IHCI between January 2018 and December 2021 in public sector primary and secondary care facilities across 23 districts from two states. Each state followed a different treatment protocol. We calculated the proportion with controlled BP at each step of the protocol. We also estimated the mean decline in BP pre- and post-treatment.

Results

Of 281,209 patients initiated on amlodipine 5 mg, 159,292 continued on protocol drugs and came for a follow-up visit during the first quarter of 2022. Of 33,450 individuals who came for the follow-up in Punjab and 125,842 in Maharashtra, 70% and 76% had controlled BP, respectively, at the first step with amlodipine 5 mg. In Punjab, at the second step with amlodipine 10 mg, the cumulative BP control increased to 75%. A similar 5% (76%-81%) increase was seen in the second step after adding telmisartan 40 mg in Maharashtra. Overall, the mean (SD) systolic blood pressure (SBP) decreased by 16 mmHg from 148 (15) mmHg at the baseline in Punjab. In Maharashtra, the decline in the mean (SD) SBP was about 15 mmHg from the 144 (18) mmHg baseline.

Conclusion

Simple drug- and dose-specific protocols helped achieve a high control rate among patients retained in care under program conditions. We recommend treatment protocols starting with a single low-cost drug and escalating with the same or another antihypertensive drug depending on the cost and availability.

Neurophysiological outcomes that sustained clinically significant improvements over 3 years of physiologic ECAP-controlled closed-loop spinal cord stimulation for the treatment of chronic pain

INTRODUCTION

A novel, spinal cord stimulation (SCS) system with a physiologic closed-loop (CL) feedback mechanism controlled by evoked compound action potentials (ECAPs) enables the optimization of physiologic neural dose and the accuracy of the stimulation, not possible with any other commercially available SCS systems. The report of objective spinal cord measurements is essential to increase the transparency and reproducibility of SCS therapy. Here, we report a cohort of the EVOKE double-blind randomized controlled trial treated with CL-SCS for 36 months to evaluate the ECAP dose and accuracy that sustained the durability of clinical improvements.

METHODS

41 patients randomized to CL-SCS remained in their treatment allocation and were followed up through 36 months. Objective neurophysiological data, including measures of spinal cord activation, were analyzed. Pain relief was assessed by determining the proportion of patients with ≥50% and ≥80% reduction in overall back and leg pain.

RESULTS

The performance of the feedback loop resulted in high-dose accuracy by keeping the elicited ECAP within 4µV of the target ECAP set on the system across all timepoints. Percent time stimulating above the ECAP threshold was >98%, and the ECAP dose was ≥19.3µV. Most patients obtained ≥50% reduction (83%) and ≥80% reduction (59%) in overall back and leg pain with a sustained response observed in the rates between 3-month and 36-month follow-up (p=0.083 and p=0.405, respectively).

CONCLUSION

The results suggest that a physiological adherence to supra-ECAP threshold therapy that generates pain inhibition provided by ECAP-controlled CL-SCS leads to durable improvements in pain intensity with no evidence of loss of therapeutic effect through 36-month follow-up.

Outcomes of polymyalgia rheumatica in real-world practice: a longitudinal cohort study

Background: Polymyalgia rheumatica (PMR) is an inflammatory condition closely linked with giant cell arteritis, which is a large vessel vasculitis. To provide real-world evidence on PMR outcomes and their determinants, we conducted a longitudinal study focusing on symptom relief and acute phase reactant normalization. Methods: We followed patients with PMR who were registered in Tabriz University of Medical Sciences Vasculitis Registry (TUOMS-VR) until February 2023. We measured sustained remission (primary outcome) and secondary outcomes including glucocorticoids (GCs)-free remission, medication-free remission, relapse rate and disease-induced damage. Results: We identified eighty-one patients with PMR and followed them for a median time of 57 months. In a median duration of 3 weeks, 98.8% of patients achieved symptom control, with 86.4% achieving sustained remission in a median duration of 9 weeks. Sustained remission was more common in non-smokers and adherent to therapy patients. Relapse occurred in 22.1% of patients, primarily due to non-adherence. Medication-free remission was observed in 30.9% of patients, especially among females and those with an initial prednisolone dose > 15 mg/d. Damage occurred in 42.0% of patients. Conclusion: Although sustained remission in PMR is not an unattainable goal in daily practice and most patients are in remission at the last visit, two-thirds of patients require long-term treatment.

Intraoperative neurophysiological monitoring and spinal cord stimulator implantation

INTRODUCTION

Spinal cord injury (SCI) is one of the most dreaded complications after spinal cord stimulation (SCS) implantation surgery. As a result, intraoperative neurophysiological monitoring (IONM) has been proposed to avoid accidental damage to nervous structures under anesthesia and confirm positioning for optimal stimulation. Our study uses a large administrative claims database to determine the 30-day risk of SCI after SCS implantation.

METHODS

This retrospective cohort study used the IBM MarketScan Commercial and Medicare Supplemental Databases from 2016 to 2019. Adult patients undergoing SCS surgical procedures with at least 90 days of follow-up, IONM use, the type of sedation used during the procedure, and subsequent SCI were identified using administrative codes. In addition, logistic regression was used to examine the relationship between various risk factors and subsequent SCI.

RESULTS

A total of 9676 patients underwent SCS surgery (64.7% percutaneous implants) during the study period. Nine hundred and forty-four (9.75%) patients underwent SCS implantation with IONM. Conscious sedation, Monitored Anesthesia Care anesthesia, and general anesthesia were used in patients with 0.9%, 60.2%, and 28.6%, respectively. Eighty-one (0.8%) patients developed SCI within 30 days after SCS implant surgery. The SCI rate was higher in the group that underwent IONM (2% vs 0.7%, p value <0.001) during the implantation procedure, reflecting the underlying risk. After adjustment for other factors, the OR of SCI is 2.39 (95% CI: 1.33 to 4.14, p value=0.002) times higher for those with IONM than those without IONM.

CONCLUSIONS

Increased SCI risk among patients with IONM likely reflects higher baseline risk, and further research is needed for risk mitigation.

Difference Between Cardiopulmonary Bypass Time and Aortic Cross-Clamping Time as a Predictor of Complications After Coronary Artery Bypass Grafting

INTRODUCTION

Along with cardiopulmonary bypass time, aortic cross-clamping time is directly related to the risk of complications after heart surgery. The influence of the time difference between cardiopulmonary bypass and cross-clamping times (TDC-C) remains poorly understood.

OBJECTIVE

To assess the impact of cardiopulmonary bypass time in relation to cross-clamping time on immediate results after coronary artery bypass grafting in the Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) II.

METHODS

Analysis of 3,090 patients included in REPLICCAR II database was performed. The Society of Thoracic Surgeons outcomes were evaluated (mortality, kidney failure, deep wound infection, reoperation, cerebrovascular accident, and prolonged ventilation time). A cutoff point was adopted, from which the increase of this difference would affect each outcome.

RESULTS

After a cutoff point determination, all patients were divided into Group 1 (cardiopulmonary bypass time < 140 min., TDC-C < 30 min.), Group 2 (cardiopulmonary bypass time < 140 min., TDC-C > 30 min.), Group 3 (cardiopulmonary bypass time > 140 min., TDC-C < 30 min.), and Group 4 (cardiopulmonary bypass time > 140 min., TDC-C > 30 min.). After univariate logistic regression, Group 2 showed significant association with reoperation (odds ratio: 1.64, 95% confidence interval: 1.01-2.66), stroke (odds ratio: 3.85, 95% confidence interval: 1.99-7.63), kidney failure (odds ratio: 1.90, 95% confidence interval: 1.32-2.74), and in-hospital mortality (odds ratio: 2.17, 95% confidence interval: 1.30-3.60).

CONCLUSION

TDC-C serves as a predictive factor for complications following coronary artery bypass grafting. We strongly recommend that future studies incorporate this metric to improve the prediction of complications.

Impact of temperature on the magnitude and duration of relief after lumbar facets medial branch nerves radiofrequency ablation: a randomized double-blinded study

INTRODUCTION

There are numerous studies appraising the variables that may influence the clinical outcomes after lumbar thermal radiofrequency ablation (RFA). Expanding the lesion size may increase the likelihood of capturing the target nerves in the lesion, thereby increasing the technical success rate of RFA. However, our literature search has failed to identify a consensus on the optimal target temperature. A retrospective study demonstrated that there seems to be significant functional improvement associated with the temperature of 90°C compared with 80°C. The authors prospectively studied the subject in a double-blinded randomized fashion.

METHODS

Patients undergoing RFA for lumbar facetogenic pain were randomized in two cohorts (80°C and 90°C). Physicians and patients were blinded to the temperature used. The primary outcome was self-reported pain scores up to 12 months. Secondary outcomes included: self-reported functional improvement, duration of relief as measured by the time before repeat ablation of the same medial branches nerves, opioids' consumption, and patient satisfaction.

RESULTS

Both groups reported pain improvement in all follow-up time points. Overall, both groups achieved statistically significant pain reduction (p<0.05). The median time to repeat RFA in the 80°C group was 112 (49-252) days, while it was 217 (198-348) days in the 90°C group (p<0.04). The univariate analysis emphasized that the RFA temperature is a statistically significant factor for pain improvement of more than 50%, OR 2.7 (1.1 to 6.6) p value=0.031.

CONCLUSION

RFA has been demonstrated as an effective therapeutic modality for lumbar facetogenic back pain. Yet, the several factors involved in determining a favorable outcome of this procedure require further research and optimization. This prospective double-blinded randomized trial demonstrated that RFA at both temperatures (80°C, 90°C) provided significance at all the time periods examined. However, RFA at 90°C was superior to 80°C in regard to the duration of relief.

Cooled versus conventional radiofrequency treatment of the genicular nerves for chronic knee pain: 12-month and cost-effectiveness results from the multicenter COCOGEN trial

BACKGROUND

Radiofrequency (RF) treatment of the genicular nerves reduces chronic knee pain in patients with osteoarthritis (OA) or persistent postsurgical pain (PPSP) after total knee arthroplasty (TKA). The objective of this study is to compare long-term outcomes of cooled and conventional RF and perform an economic evaluation.

METHODS

The COCOGEN trial is a double-blinded, non-inferiority, pilot, randomized controlled trial that compared the effects up to 12 months of cooled and conventional RF in patients with chronic knee pain suffering from OA or PPSP after TKA following a 1:1 randomization rate. Outcomes were knee pain, functionality, quality of life, emotional health, medication use, and adverse events. A trial-based economic evaluation was performed with a 12-month societal perspective. Here, the primary outcome was the incremental costs per quality-adjusted life year (QALY).

RESULTS

41 of the 49 included patients completed the 12-month follow-up. One patient in the PPSP cooled RF group had substantial missing data at 12-month follow-up. The proportion of patients with ≥50% pain reduction at 12 months was 22.2% (4/18) in patients treated with conventional RF versus 22.7% (5/22) in patients treated with cooled RF (p>0.05). There was a statistically significant difference in the mean absolute numerical rating scale at 12 months after cooled RF and conventional RF in patients with PPSP (p=0.02). Differences between other outcomes were not statistically significant. The health economic analysis indicated that cooled RF resulted in lower costs and improved QALYs compared with conventional RF in PPSP but not in OA. There were no serious adverse events.

CONCLUSIONS

Both RF treatments demonstrated in approximately 22% of patients a ≥50% pain reduction at 12 months. In patients with PPSP, contrary to OA, cooled RF seems to be more effective than conventional RF. Additionally, cooled RF has in patients with PPSP, as opposed to OA, greater effectiveness at lower costs compared with conventional RF.

TRIAL REGISTRATION NUMBER

NCT03865849.

Impact of psychosocial factors on the success of neuromodulation treatment for patients with persistent pain

INTRODUCTION

Significant interindividual variability in spinal cord stimulation (SCS) outcomes exists. Due to its high cost and risks of complications, criteria to guide patient selection for SCS trials and their outcomes would be helpful. With increased focus on the use of patient-reported outcomes to improve care, we aim to evaluate the National Institute of Health Patient Reported Outcome Measurement Information System measures for an association with successful SCS trials in patients with persistent pain.

METHODS

Our prospective, observational study enrolled 60 patients with persistent pain who underwent an SCS trial. Patients completed demographic and Patient Reported Outcome Measurement Information System computer adaptive test (PROMIS CAT) assessments to measure self-reported pain interference, depression, anxiety, physical functioning, and sleep disturbance at the time they presented for placement of their trial device.

RESULTS

Of the 58 patients who underwent successful electrode placement, 11 had an unsuccessful trial. There were no differences in patient demographics between patients with a successful and an unsuccessful trial. Patients who had a successful SCS trial reported lower pre-trial levels of anxiety, depression, and sleep disturbance and decreased post-trial levels of depression, sleep disturbance, and pain interference.

CONCLUSIONS

We found that patients with high levels of depression, anxiety, and sleep disturbance using the PROMIS CAT were predictive of unsuccessful trials. In addition, we found that patients with successful SCS trials reported lower levels of these domains on PROMIS CAT administered at the end of the trial.

Real-time ultrasound-guided mid-thoracic epidural access using a novel paramedian cross (PX) view and drip infusion technique: a brief technical report

BACKGROUND

Real-time ultrasound guidance (USG) has been applied for lower thoracic epidural access, but the more challenging mid-thoracic epidural (MTE) access remains underexplored. This report presents a technique of real-time US guidance with a novel paramedian cross view, termed "the PX view," for securing MTE catheters, along with an outcome analysis from a retrospective case series.

METHODS

Medical records of patients who underwent USG-MTE catheter placement with the PX view and drip infusion technique from January to December 2022 were reviewed. All catheters were placed with patients in the prone position under mild to moderate procedural sedation. The process of acquiring the PX view, in-plane needling technique, and the use of drip infusion to identify loss of resistance were detailed. The incidence of successful PX view attainment, the number of attempts, redirections, failures, and any technique-related complications were recorded.

RESULTS

Fifty-one patients underwent USG-MTE catheter attempts, (42 with median sternotomy, 3 fractured ribs, 3 upper abdominal laparotomies, 2 modified radical mastectomies, and 1 thoracotomy). A satisfactory PX view was obtained in all patients, and the epidural space was identified during the first needle entry in 49 cases, resulting in a 96% first-attempt success rate. Seven patients required needle redirections, while two patients needed a second needle entry. No technique-related complications were documented.

CONCLUSION

The combination of the PX view and the drip infusion method proved effective for real-time ultrasound-guided MTE catheter placement.

Real-World Effectiveness and Safety of Glecaprevir/Pibrentasvir for the Treatment of Chronic Hepatitis C: A Prospective Cohort Study in Portugal

INTRODUCTION

Information about pan-genotypic treatments for hepatitis in Portugal is scarce. We aimed to evaluate the effectiveness and safety of glecaprevir plus pibrentasvir (GLE/PIB) treatment for hepatitis C virus (HCV) infection in real-world clinical practice.

METHODS

An observational prospective study was implemented in six hospitals with 121 adult HCV patients who initiated treatment with GLE/PIB between October 2018 and April 2019, according to clinical practice. Eligible patients had confirmed HCV infection genotype (GT) 1 to 6 and were either treatment-naïve or had experience with interferon-, ribavirin- or sofosbuvir-based regimens, with or without compensated cirrhosis. Baseline sociodemographic and safety data are described for the total population (N = 115). Effectiveness [sustained virologic response 12 weeks after treatment (SVR12)] and patient-reported outcomes are presented for the core population with sufficient follow-up data (n = 97).

RESULTS

Most patients were male (83.5%), aged < 65 years (94.8%), with current or former alcohol consumption (77.3%), illicit drug use (72.6%), and HCV acquisition through intravenous drug use (62.0%). HIV co-infection occurred in 22.6% of patients. The prevalence of each GT was: GT1 51.3%, GT2 1.7%, GT3 30.4%, GT4 16.5%, and GT5.6 0%. Most patients were non-cirrhotic (80.9%) and treatment-naïve (93.8%). The SVR12 rates were 97.9% (95% CI: 92.8 - 99.4), and > 95% across cirrhosis status, GT, illicit drug use, alcohol consumption, and HCV treatment experience. The adverse event rate was 2.6%, and no patient discontinued treatment due to adverse events related to GLE/PIB.

CONCLUSION

Consistent with other real-world studies and clinical trials, treatment with GLE/PIB showed high effectiveness and tolerability overall and in difficult-to-treat subgroups (ClinicalTrials.gov: NCT03303599).

Optimizing drug regimens and supplementation in orthognathic surgery: A comprehensive and practical guide

OBJECTIVE

This study aimed to comprehensively review the literature and provide a practical guide for optimizing drug regimens and supplementation related to orthognathic surgery.

METHODS

The authors conducted a thorough review of the existing literature, following the PRISMA-ScR guidelines. Various types of studies except case reports and reviews were included. The study applied specific inclusion criteria, focusing on perioperative and/or postoperative drugs, medications, or supplementation related to orthognathic surgery.

RESULTS

This guide included 78 studies on various medications in orthognathic surgery. It encompasses clinical trials, cohort studies, cross-sectional studies, prospective and retrospective studies. The topics covered include antibiotics, analgesics, corticosteroids, antiemetics, hemostatic agents, local anesthetics, herbal medicine, and botulinum toxin. Pain and edema control involved specific medications, while local anesthesia utilized ropivacaine and bupivacaine. The guide also discusses mineral and vitamin supplementation. The effectiveness of hemostatic agents and antiemetics was highlighted.

CONCLUSION

Pain management, reduced swelling, enhanced wound healing, and faster recovery are among the advantages. In addition to the standard drugs and medications, the inclusion of vitamin and mineral supplements, tranexamic acid, postoperative anesthetic blocks, and preemptive antiemetics is anticipated to offer various benefits in orthognathic surgery, despite the limited available evidence.

Genetic and epigenetic alterations in DNA repair genes and treatment outcome of chemoradiotherapy in cervical cancer

Cervical cancer (CaCx) is the deadliest malignancy among women which is caused by human papillomavirus (HPV) and anthro-demographical/clinicopathological factors. HPV oncoproteins E6 and E7 target p53 and RB (retinoblastoma) protein degradation, Ataxia telangiectasia mutated (ATM), ATM-RAD3-related (ATR) inactivation and subsequent impairment of non-homologous end joining (NHEJ), homologous recombination, and base excision repair pathways. There is also an accumulation of genetic and epigenetic alterations in Tumor Growth Suppressors (TGS), oncogenes, and DNA repair genes leading to increased genome instability and CaCx development. These alterations might be responsible for differential clinical response to Cisplatin-based chemoradiotherapy (CRT) in patients. This review explores HPV-mediated DNA damage as a risk factor in CaCx development, the mechanistic role of genetic and epigenetic alterations in DNA repair genes and their association with CRT and outcome, It also explores new possibilities for the development of genetic and epigenetic-based biomarkers for diagnostic, prognostic, and molecular therapeutic interventions.

Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracoscopic surgery: a prospective randomized open-label non-inferiority trial

BACKGROUND AND OBJECTIVES

The evolving surgical techniques in thoracoscopic surgery necessitate the exploration of anesthesiological techniques. This study aimed to investigate whether incorporating a continuous erector spinae plane (ESP) block into a multimodal analgesia regimen is non-inferior to continuous thoracic epidural analgesia (TEA) in terms of quality of postoperative recovery for patients undergoing elective unilateral video-assisted thoracoscopic surgery.

METHODS

We conducted a multicenter, prospective, randomized, open-label non-inferiority trial between July 2020 and December 2022. Ninety patients were randomly assigned to receive either continuous ESP block or TEA. The primary outcome parameter was the Quality of Recovery-15 (QoR-15) score, measured before surgery as a baseline and on postoperative days 0, 1, and 2. Secondary outcome parameters included pain scores, length of hospital stay, morphine consumption, nausea and vomiting, itching, speed of mobilization, and urinary catheterization.

RESULTS

Analysis of the primary outcome showed a mean QoR-15 difference between the groups ESP block versus TEA of 1 (95% CI -9 to -12, p=0.79) on day 0, -1 (95% CI -11 to -8, p=0.81) on day 1 and -2 (95% CI -14 to -11, p=0.79) on day 2.

CONCLUSIONS

The continuous ESP block is non-inferior to TEA in video-assisted thoracoscopic surgery.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (NL6433).

Role of supplemental regional blocks on postoperative neurocognitive dysfunction after major non-cardiac surgeries: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/IMPORTANCE

Postoperative neurocognitive dysfunction (PNCD) is a frequent and preventable complication after surgery. The large high-quality evidence for the efficacy of supplemental regional analgesia blocks (RAB) for preventing PNCD is still elusive.

OBJECTIVE

The objective of this meta-analysis was to evaluate the effect of RAB versus standard anesthesia care on the incidence of PNCD in adult patients undergoing major non-cardiac surgery.

EVIDENCE REVIEW

PubMed, EMBASE, Scopus, and the Cochrane Central Registers of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) from 2017 until June 2022. The primary outcome was the incidence of PNCD within 1 month of surgery. A random-effects model with an inverse variance method was used to pool results, and OR and mean differences were calculated for dichotomous and continuous outcomes. Various exploratory subgroup analyses were performed to explore the possibility of the association between the various patient, technique, and surgery-related factors. Grading of Recommendation, Assessment, Development, and Evaluation guidelines were used to determine the certainty of evidence.

FINDINGS

Twenty-six RCTs comprizing 4414 patients were included. The RAB group was associated with a significant reduction in the incidence of PNCD with an OR of 0.46 (95% CI 0.35 to 0.59; p<0.00001; I2=28%) compared with the control group (moderate certainty). Subgroup analysis exhibited that the prophylactic efficacy of RAB persisted for both delirium and delayed neurocognitive recovery.

CONCLUSIONS

Current evidence suggests that supplemental RAB are beneficial in preventing PNCD in patients after major non-cardiac surgery.

PROSPERO REGISTRATION NUMBER

CRD42022338820.

Comparative outcomes of catheter-directed thrombolysis versus AngioJet pharmacomechanical catheter-directed thrombolysis for treatment of acute iliofemoral deep vein thrombosis

OBJECTIVE

The objective of this study was to compare the outcomes of pharmacomechanical thrombolysis and thrombectomy (PCDT) plus catheter-directed thrombolysis (CDT) vs CDT alone for the treatment of acute iliofemoral deep vein thrombosis (DVT) and summarize the clinical experience, safety outcomes, and short- and long-term efficacy.

METHODS

We performed a 4-year retrospective, case-control study. A total of 95 consecutive patients with acute symptomatic iliofemoral deep vein thrombosis (DVT) with a symptom duration of ≤7 days involving the iliac and/or common femoral veins underwent endovascular interventions. The patients were divided into two groups according to their clinical indications: PCDT plus CDT vs CDT alone. Statistical analyses were used to compare the clinical characteristics and outcomes between the two groups. Additionally, the patients were followed up for 3 to 36 months after treatment, and the proportions of post-thrombotic syndrome (PTS) and moderate to severe PTS were analyzed using the Kaplan-Meier survival method.

RESULTS

A total of 95 consecutive patients were analyzed in this retrospective study, of whom, 51 underwent CDT alone and 44 underwent PCDT plus CDT. Between the two groups, in terms of immediate-term efficacy and safety, significant differences were found in the catheter retention time (60.64 ± 12.04 hours vs 19.42 ± 4.04 hours; P < .001), dosages of urokinase required (5.82 ± 0.81 million units vs 1.80 ± 0.64 million units; P < .001), the detumescence rate at 24 hours postoperatively (48.46% ± 8.62% vs 76.79% ± 7.98%; P = .026), the descent velocity of D-dimer per day (2266.28 ± 1358.26 μg/L/D vs 3842.34 ± 2048.02 μg/L/D; P = .018), total hospitalization stay (6.2 ± 1.40 days vs 3.8 ± 0.70 days; P = .024), number of postoperative angiograms (2.4 ± 0.80 vs 1.2 ± 0.30; P = .042), and grade III venous patency (>95% lysis: 54.5% vs 68.6%; P = .047). Furthermore, during the follow-up period, significant differences were found in the incidence of PTS (Villalta scale ≥5 or a venous ulcer: 47.0% vs 27.7%; P = .037), and the incidence proportion of moderate to severe PTS at 12 months (15.7% vs 4.5%; P = .024) and 24 months (35.3% vs 11.4%; P = .016).

CONCLUSIONS

Compared with CDT alone, in the iliofemoral DVT subgroup with a symptom duration of ≤7 days, PCDT plus CDT could significantly relieve early leg symptoms, shorten the hospitalization stay, reduce bleeding complications, promote long-term venous patency, and decrease the occurrence of PTS and the incidence proportion of moderate to severe PTS. Thus, the short- and long-term outcomes both support the superiority of PCDT plus CDT vs CDT in this subgroup.

Cooled radiofrequency ablation of genicular nerves for knee osteoarthritis

Knee osteoarthritis (OA) is a prevalent and debilitating musculoskeletal condition that significantly affects the quality of life of millions of individuals worldwide. In recent years, cooled radiofrequency ablation (CRFA) has become a viable treatment option for knee OA. This review thoroughly evaluated the existing literature on CRFA therapy for knee OA. It delved into the mechanisms behind CRFA, evaluated its clinical efficacy, and investigated potential avenues for future research and application. The insights gained from this review are crucial for healthcare professionals, researchers, and policymakers, offering an updated perspective on CRFA's role as a viable therapeutic option for knee OA.

Salvage re-irradiation in non-melanoma skin cancers: A multicenter analysis

BACKGROUND AND PURPOSE

We conducted a multicentre real-world study to assess the outcomes of radical salvage re-irradiation for non-melanoma skin cancer (nMSC) recurrences following definitive or postoperative radiotherapy.

MATERIALS AND METHODS

Data on patients treated between 2006 and 2022 with re-irradiation for nMSCs were retrospectively collected from five high-volume brachytherapy centers. The primary endpoint was local control (LC). Secondary endpoints included overall survival, progression-free survival, and adverse events (AEs). The Kaplan-Meier estimator and Cox Proportional-Hazards Model were utilised in the analysis.

RESULTS

A total of 58 patients with a median age of 78.4 years with recurrences of previously irradiated nMSC in the head and neck region were included in the analysis. The majority had cutaneous basal cell carcinoma (BCC; 91.4%), and were irradiated with high-dose-rate brachytherapy (HDR-BT; 91.4%). The most common locations included the nasal region (36.2%) and external ear (18.9%). The 1-year LC was 73.1% and decreased to 41.7% at three years. The size of the re-irradiated lesion was the single independent prognostic factor in Cox analysis (per mm; HR 1.07; 95% CI 1.04-1.11; p < 0.001). Grade 3 or worse AEs were reported in 7 cases (12.1%).

CONCLUSION

Re-irradiation for nMSCs, predominantly administered with brachytherapy for radiorecurrent BCC, is associated with high recurrence rates, and the risk of failure significantly increases with the size of the treated lesion. Re-irradiation could be an option for selected elderly patients with small, localised, inoperable recurrences after RT to achieve local control or defer systemic treatment; however, prospective trials are necessary to confirm its safety and efficacy.

Real-world study of intranasal ketamine for use in patients with refractory chronic migraine: a retrospective analysis

INTRODUCTION

Subanesthetic ketamine infusion has been used for managing refractory headache in inpatient or outpatient infusion settings. Intranasal ketamine may be an alternative option for outpatient care.

METHODS

A retrospective study was conducted at a single tertiary headache center to assess the clinical effectiveness and tolerability of intranasal ketamine in patients with refractory chronic migraine. Candidates who received intranasal ketamine between January 2019 and February 2020 were screened through an electronic medical record query. Manual chart reviews and structured telephone interviews were conducted on obtaining informed consent.

RESULTS

Of 242 subjects screened, 169 (79.9% women) of median (IQR) age 44 (22) years were interviewed. They reported a median (IQR) of 30 (9) monthly headache days and tried 4 (1) classes of preventive medications. Overall, they used 6 (6) sprays per day, with a median (IQR) of spray use of 10 (11) days per month. Intranasal ketamine was reported as 'very effective' in 49.1% and the quality of life was considered 'much better' in 35.5%. At the time of the interview, 65.1% remained current intranasal ketamine users and 74.0% reported at least one adverse event.

CONCLUSION

In this descriptive study, intranasal ketamine served as an acute treatment for refractory chronic migraine by reducing headache intensity and improving quality of life with relatively tolerable adverse events. Most patients found intranasal ketamine effective and continued to use it despite these adverse events. Given the potential for overuse, it should be reserved for those clearly in need of more effective rescue treatment with appropriate safety precautions. Well-designed prospective placebo-controlled trials are necessary to demonstrate the efficacy and safety of intranasal ketamine in patients with migraine.

The Effect of Elastic Eyelid Band Application on Bilateral Severe Ptosis in a Patient With Bilateral Incomplete Claude's Syndrome: A Case Report

Patients with brainstem stroke can present with various oculomotor disorders, including ptosis. Neurogenic ptosis, which results from total or partial dysfunction of the third cranial nerve and/or the Müller muscle, can significantly restrict activities of daily living and participation in rehabilitation. Therefore, surgical intervention is an effective therapeutic strategy. However, owing to complications associated with incomplete eyelid closure, such as exposure keratitis and corneal injury, patients with neurogenic ptosis should first be observed, as natural recovery without surgery can be expected despite a poor prognosis. We reported the case of a 66-year-old woman with bilateral Claude syndrome who presented with severe bilateral ptosis, quadriparesis, and cognitive impairment after a bilateral midbrain infarction. After 3 months of intensive rehabilitation using soft elastic eyelid bands, her ptosis improved without the need for eyelid bands and visual field significantly increased, with improved functional level to the point of walking independently without assistance. This report demonstrates the potential advantages of the simple yet effective nonsurgical intervention of a soft elastic eyelid band for ptosis to restore significant functional gains in patients with severe bilateral ptosis after acute stroke.

Early use of high efficacy therapies in pediatric forms of relapsing-remitting multiple sclerosis: A real-life observational study

BACKGROUND

Pediatric forms of multiple sclerosis are more active than those in adults. Yet, the effectiveness of different therapeutic approaches is not well studied in this population. Our objective was to compare the effectiveness of the early use of high efficacy therapies (HETs) with the effectiveness of moderate efficacy therapies (METs) in children with MS.

METHODS

This observational study included patients diagnosed with pediatric MS, at 4 hospital centers in France, during a 10-year period. METs included: interferon β-1a, glatiramer acetate, dimethyl fumarate, teriflunomide; HETs included: fingolimod, natalizumab, ocrelizumab, alemtuzumab. The primary endpoint was the occurrence of a new relapse, the secondary endpoint was EDSS worsening.

RESULTS

Sixty-four patients were included in the analysis (80% women; mean age 15.5 years, 81% treated with MET) with a median follow-up of 22.5 months. At baseline, 52 patients were on MET (interferon β-1a, glatiramer acetate, dimethyl fumarate, teriflunomide) and 12 patients were on HET (natalizumab, ocrelizumab). The cumulative probability of being relapse-free at 6.5 years was 23.3% on MET, vs 90.9% on HET (p = 0.013). The cumulative probability of no EDSS worsening did not differ between the 2 groups.

CONCLUSION

Patients starting with METs had much higher clinical disease activity than those starting early with HETs. Rapid initiation of more aggressive treatment may allow better disease control; however, the data on EDSS worsening are not conclusive.

Image-guided Thermal Ablation as a Promising Approach to Both Nontoxic and Toxic Autonomously Functioning Thyroid Nodules

RATIONALE AND OBJECTIVES

Although thermal ablation has been recommended as an alternative therapy option for autonomously functioning thyroid nodules (AFTN), current clinical evidence mainly focuses on toxic AFTN. This study aims to evaluate and compare the efficacy and safety of thermal ablation (percutaneous radiofrequency ablation or microwave ablation) in treating nontoxic and toxic AFTN.

MATERIALS AND METHODS

AFTN patients who received a single session of thermal ablation with a follow-up period ≥12 months were recruited. Changes in nodule volume and thyroid function, and complications were evaluated. Technical efficacy was defined as the maintenance or restoration of euthyroidism with a volume reduction rate (VRR) ≥80% at the last follow-up.

RESULTS

In total, 51 AFTN patients (age: 43.8±13.9 years, female: 88.2%) with a median follow-up period of 18.0 (12.0-24.0) months were included, where 31 were nontoxic (nontoxic group), and 20 were toxic (toxic group) before ablation. The median VRR was 96.3% (80.1%-98.5%) and 88.3% (78.3%-96.2%) in the nontoxic and toxic groups, respectively, and the respective euthyroidism rates were 93.5% (29/31, 2 evolved to toxic) and 75.0% (15/20, 5 remained toxic). The corresponding technical efficacy was 77.4% (24/31) and 55.0% (11/20, p=0.126). Except for one case of stress-induced cardiomyopathy in the toxic group, no permanent hypothyroidism or other major complications occurred in both groups.

CONCLUSION

Image-guided thermal ablation is efficacious and safe in treating AFTN, both nontoxic and toxic. Recognition of nontoxic AFTN would be helpful for treatment, efficacy evaluation, and follow-up.

Hepatobiliary tuberculosis in the developing world

BACKGROUND

Hepatobiliary tuberculosis is a challenging disease that poses diagnostic difficulties due to its resemblance to other etiologies. Delayed diagnosis may lead to inadequate treatment, thus necessitating an urgent need for accurate diagnosis and appropriate management.

AIM

To systematically review case reports on hepatobiliary tuberculosis, focusing on symptomatology, diagnostic procedures, management, and outcomes to provide patient safety and ensure an uneventful recovery.

METHODS

A systematic search was conducted on PubMed from 1992 to 2022, using keywords such as hepatobiliary, liver, tuberculosis cholangitis, cholangiopathy, and mycobacterium. Only case reports or case series in English were included in the study, and research papers published as abstracts were excluded. The search yielded a total of 132 cases, which were further narrowed down to 17 case studies, consisting of 24 cases of hepatobiliary tuberculosis.

RESULTS

The 10 most common symptoms observed in these cases were fever, abdominal pain, weight loss, jaundice, anorexia, generalized weakness, pruritus, chills, fatigue, and chest pains. Objective findings in these cases included hepatomegaly, hepatic nodules, elevated liver enzymes, and elevated bilirubin. Computed tomography scan and ultrasound of the abdomen were the most useful diagnostic tools reported. Histologic demonstration of Mycobacterium tuberculosis confirmed the cases of hepatobiliary tuberculosis. Treatment regimens commonly used included Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol. Out of the 24 cases, 18 presented improvements while 4 had completely recovered.

CONCLUSION

Hepatobiliary tuberculosis is a disease that requires accurate diagnosis and appropriate management to avoid complications.

Use of Octopus™ Tissue Stabilizer for Minimal Manipulation Approach of Bronchial Anastomosis in Lung Transplant

Bronchial anastomotic complications are a cause of grave concern for surgeons that perform lung transplantations. There are several risk factors that may lead to this complication, being inadequate surgical technique one of them, specifically regarding adequate exposure and manipulation of the bronchial stump and anastomosis. Here we report the use of Octopus™ Tissue Stabilizer as a mean to allow for a better exposure of the stump and facilitate a "no-touch" approach towards anastomosis. Systematic application of devices that facilitate the employment of the correct surgical techniques can have an effect in reducing the incidence of bronchial anastomotic complications.

Fate of the Patent False Lumen of the Descending Aorta After Surgical Treatment for Acute Type 1 Aortic Dissection

INTRODUCTION

This study aimed to investigate the factors affecting false lumen patency in the descending thoracic aorta among patients who underwent surgery for acute type 1 aortic dissection.

METHODS

A total of 112 patients with acute type 1 aortic dissection, with the flap below the diaphragm level, underwent surgery between January 2010 and September 2019. Of these, 60 patients who were followed up for ≥ 12 months and whose computed tomography scans were available were included in this study. The patients were divided into two groups: group I, consists of patent false lumen (n=36), and group II, consists of thrombosed false lumen (n=24). Demographic data, operative techniques, postoperative descending aortic diameters, reintervention, and late mortality were compared between the two groups.

RESULTS

The mean follow-up period of all patients was 37.6±26.1 months (range: 12-104). The diameter increase in the proximal and distal descending aorta was significantly higher in the patent false lumen group (5.3±3.7 mm vs. 3.25±2.34 mm; P=0.015; 3.1±2.52 mm vs. 1.9±1.55 mm; P=0.038, respectively). No significant difference in terms of hypertension was found between the two groups during the follow-up period (21 patients, 58.3% vs. 8 patients, 33.3%; P=0.058). A total of 29 patients (48.3%) were found to be hypertensive in the postoperative period.

CONCLUSION

After surgical treatment for acute type 1 aortic dissection, patients should be monitored closely, regardless of whether the false lumen is patent or thrombosed. Mortality and reintervention can be seen in patients with patent false lumen during follow-up.

Thoracic sympathetic ganglion blocks: real-world outcomes in 207 chronic pain patients

BACKGROUND

Thoracic sympathetic ganglion block (TSGB) is a procedure to manage sympathetically maintained upper extremity pain (sympathetically maintained pain). To date, only a few studies have evaluated the clinical effectiveness of TSGB in pain medicine. This study investigated (1) the relationship between technical success of TSGB and pain reduction in patients with chronic upper extremity pain and (2) relevant clinical factors for a positive TSGB outcome.

METHODS

We retrospectively reviewed medical data in 232 patients who received TSGB from 2004 to 2020. Technical success and a positive outcome of TSGB were defined as a temperature increase of ≥1.5°C at 20 min and a pain reduction with ≥2 points on the 11-point Numerical Rating Scale at 2 weeks post-TSGB, respectively. Correlations were assessed using correlation coefficients (R), and multivariable regression model was used to identify factors relevant to TSGB outcomes.

RESULTS

207 patients were ultimately analyzed; among them, 115 (55.5%) patients positively responded to TSGB, and 139 (67.1%) achieved technical success after TSGB. No significant relationship existed between the pain reduction and the temperature increase after TSGB (R=0.013, p=0.855). Comorbid diabetes (OR 4.200) and adjuvant intake (OR 3.451) were positively associated, and psychiatric comorbidity (OR 0.327) and pain duration (OR 0.973) were negatively associated with TSGB outcome.

CONCLUSIONS

We found no significant association between the temperature increase and pain reduction after TSGB. Further studies are warranted to identify significant factors associated with TSGB outcomes in patients with complex regional pain syndrome and neuropathic pain diseases.

[Results and complications of knee arthroplasty in patients with obesity]

Introduction

In México, many patients undergoing total knee arthroplasty (TKA) are obese, which has medical and financial consequences. The functional outcomes and the incidence of complications of these patients remain uncertain due to the inconsistency between studies.

Objective

To determine the association between obesity, complications and functional results of patients undergoing TKA.

Material and methods

Descriptive, cross-sectional, prospective, observational, cohort study in which patients who underwent TKA between September 1, 2021, and August 30, 2022, were studied. Patients were divided by their body mass index (BMI) in < 30kg/m2 and > 30kg/m2 and their demographic characteristics, Oxford Knee Score (OKS), and incidence of complications were compared.

Results

Out of the 102 patients, 59 presented a BMI < 30 kg/m2 and 43 a BMI > 30 kg/m2. No difference was found in their postoperative OKS (p = 0.12) and delta OKS (p = 0.07). A significant increase in trans-surgical (p = 0.02) and post-surgical (p = 0.04) complications was found in the group with BMI > 30 kg/m2, presenting a risk 5.03 times higher.

Conclusion

A BMI > 30kg/m2 does not affect the functional results after a TKA; however, it is associated with a risk 5.03 times higher of suffering complications during and after surgical intervention.

Daring discourse: artificial intelligence in pain medicine, opportunities and challenges

Artificial intelligence (AI) tools are currently expanding their influence within healthcare. For pain clinics, unfettered introduction of AI may cause concern in both patients and healthcare teams. Much of the concern stems from the lack of community standards and understanding of how the tools and algorithms function. Data literacy and understanding can be challenging even for experienced healthcare providers as these topics are not incorporated into standard clinical education pathways. Another reasonable concern involves the potential for encoding bias in healthcare screening and treatment using faulty algorithms. And yet, the massive volume of data generated by healthcare encounters is increasingly challenging for healthcare teams to navigate and will require an intervention to make the medical record manageable in the future. AI approaches that lighten the workload and support clinical decision-making may provide a solution to the ever-increasing menial tasks involved in clinical care. The potential for pain providers to have higher-quality connections with their patients and manage multiple complex data sources might balance the understandable concerns around data quality and decision-making that accompany introduction of AI. As a specialty, pain medicine will need to establish thoughtful and intentionally integrated AI tools to help clinicians navigate the changing landscape of patient care.

Coronary Artery Bypass Grafting: A Comparative Exercise between Patients from the BYPASS Registry and Patients from a University Hospital

INTRODUCTION

The coronary artery bypass grafting (CABG) data provided by the Brazilian Registry of Cardiovascular Surgeries in Adults (BYPASS) Registry is a Brazilian reality.

OBJECTIVE

To carry out a comparative exercise between the BYPASS Registry published data and data from patients operated on in a randomly chosen period (2013-2015) at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP).

METHODS

This is a retrospective study reviewing 173 electronic medical records of CABG patients from the HCFMRP-USP. These data were compared with the BYPASS Registry published data. Chi-square test was used to verify the changes within the prevalence of adequate/inadequate biochemical tests before and after surgery. The sample was divided into groups consistent with cardiopulmonary bypass (CPB) time (CPB ≤ 120 minutes and CPB > 120 minutes). For the complications, prevalence by the chi-square test was adopted. Significant P-values are < 0.05.

RESULTS

The comparative operative data of the BYPASS Registry and the HCFMRP-USP patients were quite similar, except for the isolate use of only arterial grafts, which was more frequent on HCFMRP-USP patients (30.8% vs. 15.9%), and the use of radial artery, also more frequent on HCFMRP-USP patients (48.8% vs. 1.1%).

CONCLUSION

The comparative study suggested that the BYPASS Registry should be a reference for CABG quality control.

Sex-Based Differences in One-Year Outcomes After Mitral Valve Repair for Infective Endocarditis

INTRODUCTION

This study was aimed to evaluate the sex-based differences in baseline characteristics and one-year outcomes of men and women undergoing mitral valve repair for infective endocarditis.

METHODS

This cross-sectional study was performed at Imam Ali Hospital affiliated with the Kermanshah University of Medical Science. From March 21, 2014, to October 21, 2021, all patients who underwent mitral valve repair for infective endocarditis were enrolled in this study. Data were obtained using a checklist developed based on the study's objectives. Independent samples t-tests, paired samples t-tests, and chi-squared test (or Fisher's exact test) were used to assess the differences between subgroups.

RESULTS

Of 75 patients, 26 were women (34.7%) and 49 were men (65.3%). Women were more likely to have diabetes mellitus (20.4% vs. 57.7%, P=0.0001), hypertension (49% vs. 80.8%, P=0.007), and hypercholesterolemia (55.1% vs. 80.8%, P=0.027). Conversely, men were more likely to have a history of smoking (38.8% vs. 7.7%, P=0.004). After one year, women had significantly higher mortality (0% vs. 7.7%, P=0.049), major adverse cardiac and cerebrovascular events (51.0 vs. 76.9, P=0.029), mitral valve reoperation (8.1% vs. 34.6%, P=0.003), and treatment failure (30.6% vs. 61.5%, P=0.009) rates than men.

CONCLUSION

Mortality, major adverse cardiac and cerebrovascular events, mitral valve reoperation, and treatment failure rates were higher in women than in men. The worse outcomes in women may be explained by their more adverse clinical risk profile.

There remains a role for neuraxial anesthesia for hip fracture surgery in the post-REGAIN era

Two recent, large-scale, randomized controlled trials comparing neuraxial anesthesia with general anesthesia for patients undergoing surgical fixation of a hip fracture have sparked interest in the comparison of general and neuraxial anesthesia. These studies both reported non-superiority between general and neuraxial anesthesia in this patient cohort, yet they have limitations, like their sample size and use of composite outcomes. We worry that that if there is a perception among surgeons, nurses, patients and anesthesiologists that general and spinal anesthesia are equivalent (which is not what the authors of the studies conclude), it may become difficult to argue for the resources and training to provide neuraxial anesthesia to this patient population. In this daring discourse, we argue that despite the recent trials, there remain benefits of neuraxial anesthesia for patients who have suffered hip fractures and that abandoning offering neuraxial anesthesia to these patients would be an error.

Congenital aural atresia: hearing rehabilitation using active middle-ear implants

OBJECTIVE

To assess hearing rehabilitation in patients with congenital aural atresia using an active middle-ear implant (Vibrant Soundbridge).

METHODS

Of a cohort of 70 microtia and atresia patients, 10 underwent Vibrant Soundbridge implantation between 2008 and 2021. Two of the 10 patients had binaural implantation, resulting in 12 ears for analysis. Pre- and post-operative audiometry data were analysed, and patient satisfaction was evaluated. Surgical issues regarding coupling sites and outcomes were analysed.

RESULTS

Pure tone average (0.5, 1, 2 and 4 kHz) improved from a pre-operative mean (standard deviation) of 65.3 (8.7) dB HL to a post-operative mean of 26.8 (4.9) dB HL. This resulted in a mean pure tone average gain of 38.5 dB HL. The results indicate no obvious difference between stapes (n = 8) and incus (n = 4) coupling. The mean effective gain for 0.5, 1, 2 and 4 kHz was -17.8 dB HL (standard deviation = 4.3). Concerning effective gain, Vibrant Soundbridge performed best at 2 kHz. Patients reported high overall satisfaction, good sound quality and strongly improved directional hearing.

CONCLUSION

An active middle-ear implant (Vibrant Soundbridge) allows hearing rehabilitation in selected atretic ears, and provides long-term hearing stability in children and adults.

Radiographic lead migration in percutaneous spinal cord stimulator trials

INTRODUCTION

Lead migration during spinal cord stimulator (SCS) trials is relatively neglected in the literature and presents a different set of challenges compared with fully implanted leads. There is no consensus on what constitutes a clinically significant amount of radiographic lead migration during SCS trials. We wished to evaluate the incidence and extent of radiographic lead migration during percutaneous SCS trials, to investigate the risk factors for lead migration and whether this has impacted on trial success.

METHODS

This prospective observational study of percutaneous SCS trials took place in a tertiary referral center in the UK between April 2021 and January 2022. Radiographs of SCS lead position were taken at baseline and prior to lead removal. Lead migration ≥50% of a vertebral level was deemed significant.

RESULTS

One hundred trials were included comprising 162 leads. Mean migration distance was 0.55 vertebral levels (SD 0.85) or 12.5 mm (SD 18.2) in a caudal direction. Significant radiographic migration occurred in 50% of all leads (81 of 162 leads), at least one lead in 62% of cases and all leads in 44% of cases. Radiographic lead migration was not found to be associated with reduced trial success. A single lead and mechanical anchors were associated with greater incidence of lead migration.

CONCLUSION

Radiographic lead migration of approximately half of a vertebral level in a caudal direction can be expected during percutaneous SCS trials and this can be anticipated by siting leads half of a vertebral level higher to accommodate for this. Additional factors should be considered in the setting of radiographic lead migration to determine whether this can be considered clinically significant.

Investigating Causes of Medical Errors in Intensive Care Units in Iran: A Cross-sectional Study

Background

Medical errors cause disability and mortality in intensive care units (ICUs). We aimed to determine the occurrence and causes of medical errors in the ICUs of Iran.

Methods

In this cross-sectional study, data from the family complaint files referred to The disciplinary authority of Iran Medical Council was retrospectively reviewed to explore the causes of medical errors. Statistical analysis was performed in SPSS Version 26.0.

Results

A total of 293 complaint files were referred to the disciplinary commission from 2014 to 2019, of which 95 files were related to medical errors in ICUs. The median age of patients was 62 years (46-74 years) and 52 (54.7%) patients were men. Also, 37 (38.9%) patients had decreased levels of consciousness and 42 (42.2%) patients had cardiovascular disease. A total of 40 (42.1%) patients experienced a single medical error and 55 (57.9%) patients experienced more than 1. Causes of medical errors in patients were physician's or nurse's negligence in 53 (55.8%) patients, weak interaction of physician and nurse with the patient and family members in 11 (11.6%) patients, weak interprofessional interaction among physicians in 7 (7.4%) patients, equipment and structure of ICUs in 7 (7.4 patients, nature of ICUs and patients in 6 (6.3%) patients, weak physician-nurse interprofessional interaction in 5 (5.2%) patients) patients, low attention of the physician and the nurse to medication safety in 6 (6.3%) patients.

Conclusion

Patient safety is impacted by a variety of medical mistakes. Interprofessional strategies can be developed and put into action to mitigate medical errors in ICUs.

Prognosis and outcome in patients with chronic inflammatory demyelinating polyradiculoneuropathy in a tertiary center in Oman

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated condition with variable clinical characteristics and different treatment modalities. We aim to present different clinical and demographic features of all patients with CIDP presented to the neuromuscular clinic within four years and their follow-up results. Methods: A retrospective study from a hospital database of 23 patients met the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) diagnostic criteria for CIPD. Complete demographic and clinical data were collected. Progress and outcome were assessed using two clinical score systems at regular intervals at 6, 12, and 18 months. Results: Mean age of patients was 43.4 ± 20.9 years (male-to-female ratio was 1.6:1). Age of onset was 39.7 ± 18.0 years. At the presentation, the Medical Research Council sum score (MRCss) was 50 (39.7-51.3), and the modified Rankin Scale (mRS) was 3 (2.2-3.4). There was a significant improvement in MRCss during four periods (P < 0.001). Multiple comparisons revealed a significant difference in MRCss between the baseline and 12 and 18 months but no significant change between the baseline and 6 months. Likewise, mRS showed a significant improvement between the baseline and 18 months (no significant change between the baseline and 6 months or 12 months). Conclusion: The clinical characteristics of CIDP in our cohort were similar to other reported studies, and most of the studied patients had good outcomes. Our results could be utilized as baseline data for a better understanding of the characteristics of CIDP in Oman and, consequently, for better management of the disease.

Association between fatty infiltration in the cervical multifidus and treatment response following cervical interlaminar epidural steroid injection

Background

Recent attention has been directed towards fatty infiltration in the cervical extensor muscles for predicting clinical outcomes in several cervical disorders. This study aimed to investigate the potential association between fatty infiltration in the cervical multifidus and treatment response following cervical interlaminar epidural steroid injection (CIESI) in patients with cervical radicular pain.

Methods

The data of patients with cervical radicular pain who received CIESIs between March 2021 and June 2022 were reviewed. A responder was defined as a patient with a numerical rating scale decrease of ≥ 50% from the baseline to three months after the procedure. The presence of fatty infiltration in the cervical multifidus was assessed, along with patient characteristics, and cervical spine disease severity. To assess cervical sarcopenia, fatty infiltration in the bilateral multifidus muscles was evaluated at the C5-C6 level using the Goutallier classification.

Results

Among 275 included patients, 113 (41.1%) and 162 (58.9%) were classified as non-responders and responders, respectively. The age, severity of disc degeneration, and grade of cervical multifidus fatty degeneration were significantly lower in responders. Multivariate logistic regression analysis revealed that pre-procedural symptoms (radicular pain with neck pain, odd ratio [OR] = 0.527, P = 0.024) and high-grade cervical multifidus fatty degeneration (Goutallier grade 2.5-4, OR = 0.320, P = 0.005) were significantly associated with an unsuccessful response to CIESI.

Conclusions

These results suggest high-grade cervical multifidus fatty infiltration is an independent predictor of poor response to CIESI in patients with cervical radicular pain.

Effect of ultrasound parameters of benign thyroid nodules on radiofrequency ablation efficacy

BACKGROUND AND AIM

Ultrasound-guided radiofrequency ablation (RFA) is a minimally invasive therapy for thyroid nodules (TNs). Understanding the determinants of RFA efficacy can improve treatment and prognosis. This study aims to investigate the relationship between ultrasound parameters of benign TNs and the efficacy of RFA.

METHODS

A pretest-posttest interventional study was conducted in 2021 on 250 randomly sampled patients with benign TNs, receiving RFA. For this purpose, the volume reduction (VR) and the VR ratio (VRR) of the nodules were measured at the 1-, 3-, 6-, and 12-month follow-up periods after the RFA completion. The technical success rate (TSR) of this procedure was then categorized into four states, including low (VRR < 25%), moderate (VRR = 25-49%), high (VRR = 50-74%), and very high (VRR ≥ 75). Ordered logistic regression (OLR) was further utilized to investigate the effect of the ultrasound parameters of TNs on the TSR. The analyses were notably performed using Stata 14.2.

RESULTS

The VRR at the 1-, 3-, 6-, and 12-month follow-up periods were 38.7%, 53.6%, 59.3%, and 59.9%, respectively. The mean VR was also statistically significant at all follow-ups (p < 0.001). At the 1-, 3-, and 6-month follow-up periods, the VR of over 50% was observed in 28.2%, 52.1%, and 65.2% of the nodules, respectively. The odds ratios (ORs) of the RFA success were found to be 4.3 times higher for the nodules in the left lobe compared to the right lobe (OR: 4.31, p = 0.002), 6.3 times greater for isoechoic nodules compared to hyperechoic nodules (OR: 6.39, p < 0.001), 6.2 times higher for hyper-vascular nodules compared to hypo-vascular nodules (OR: 6.25, p = 0.005), and 2.3 times greater for mixed nodules compared to solid ones (OR: 2.37, p = 0.049).

CONCLUSION

The ultrasound parameters of TNs had a statistically significant effect on the efficacy of RFA. Small-sized, isoechoic, and hyper-vascular nodules, as well as those with mixed tissue, were observed to respond better to RFA, leading to a better prognosis in terms of VR after treatment.

Trends and outcomes of emergency general surgery in elderly and highly elderly population in a single regional emergency center

Purpose

The number of elderly patients, especially aged ≥80 years, undergoing emergency surgery is gradually increasing. The aim of this study was to find out the trends and results of emergency general surgery for elderly patients over 9 years in an emergency medical center in South Korea, where the population is aging most rapidly.

Methods

The clinical characteristics, outcomes, and medical expenses of emergency general surgery for the elderly (aged 65-79 years) and highly elderly (aged ≥80 years) patients who visited to a regional emergency medical center from 2012 to 2020 were analyzed.

Results

The number of highly elderly patients increased with each 3-year interval, whereas the proportion of patients aged 19-79 years was similar, and that of pediatric patients was decreasing. The higher the age group, the higher the mortality (young adult vs. elderly vs. highly elderly: odds ratio [OR], 1 vs. 3.689 vs. 11.293; P < 0.001) and complication rates (OR, 1 vs. 2.840 vs. 4.633; P < 0.001), and longer length of hospital stay (β = 0.949, P = 0.001) even after adjusting for the type of surgery and the American Society of Anesthesiologists physical status classification. Non-covered medical expenses were significantly related to the age groups (β = 151,608.802, P < 0.001).

Conclusion

The higher age group was associated with increased number of unfavorable outcomes after emergency general surgery, along with increased medical cost. Efforts to prevent emergency surgery for elderly patients and a specialized treatment system are needed.

Recurrence of Invasive Cervical Resorption after six years of Nonsurgical and Surgical management by Bioceramic-Material

Invasive cervical resorption (ICR) is a phenomenon of unknown etiology that results in the loss of hard dental tissue. To have a successful outcome for a tooth affected by ICR, correct diagnosis and management are needed. With the introduction of new biocompatible materials and the advancement of CBCT imaging, these pathologies can be identified and treated with precision, resulting in promising outcomes. This case report aims to present the management of maxillary central incisors diagnosed with external ICR, treated with bioceramic root repair material, and followed-up to six years.

Outcomes for the first four lines of therapy in patients with HER2-positive advanced breast cancer: results from the SONABRE registry

PURPOSE

We assessed the systemic treatment choices and outcomes in patients diagnosed with human epidermal growth factor receptor-2-positive (HER2 +) advanced breast cancer (ABC), for the first four lines of systemic therapy and by hormone receptor (HR) status.

METHODS

We identified 330 patients diagnosed with HER2 + ABC in 2013-2018 in the Southeast of The Netherlands, of whom 64% with HR + /HER2 + and 36% with HR-/HER2 + disease. Overall survival (OS) from start of therapy was calculated using the Kaplan-Meier method.

RESULTS

In real world, 95% of patients with HR + /HER2 + and 74% of patients with HR-/HER2 + disease received systemic therapy. In HR + /HER2 + disease, use of endocrine, chemo- and HER2-targeted therapy was , respectively, 64%, 46% and 60% in first line, and 39%, 64% and 75% in fourth line. In HR-/HER2 + disease, 91-96% of patients received chemotherapy and 77-91% HER2-targeted therapy, irrespective of line of therapy. In patients with HR + /HER2 + disease, median OS was 34.9 months (95%CI:25.8-44.0) for the first line and 12.8 months (95%CI:10.7-14.9) for the fourth line. In HR-/HER2 + disease, median OS was 39.9 months (95%CI:23.9-55.8) for the first line and 15.2 months (95%CI:10.9-19.5) for the fourth line. For patients treated with first-line pertuzumab, trastuzumab plus chemotherapy, median OS was not reached at 56.0 months in HR + /HER2 + disease and 48.4 months (95%CI:32.6-64.3) in HR-/HER2 + disease.

CONCLUSION

Survival times for later lines of therapy are surprisingly long and justify the use of multiple lines of systemic therapy in well-selected patients with HER2 + ABC. Our real-world evidence adds valuable observations to the accumulating evidence that within HER2 + ABC, the HR status defines two distinct disease subtypes.

Acute Type A Aortic Dissection and Late Pregnancy: What Should We Do?

INTRODUCTION

Acute type A aortic dissection (AAAD) in late pregnancy is a rare but severe disease. Lack of clinical experience is the main cause of high mortality. This study tries to investigate the multidisciplinary therapeutic strategy for these patients.

CASE PRESENTATION

We reported three patients with AAAD in late pregnancy. Sudden chest pain was the main clinical symptom before operation. All three patients and their newborns survived through multidisciplinary approach in diagnosis and treatment. No serious complications occurred during the mid-term follow-up.

CONCLUSION

Multidisciplinary diagnosis and treatment strategy play a crucial role in saving the lives of pregnant women with AAAD.

Nationwide Treatment Outcomes of Patients With Multidrug/Rifampin-Resistant Tuberculosis in Korea, 2011-2017: A Retrospective Cohort Study (Korean TB-POST)

BACKGROUND

The treatment outcomes of patients with multidrug/rifampin-resistant (MDR/RR) tuberculosis (TB) are important indicators that reflect the current status of TB management and identify the key challenges encountered by TB control programs in a country.

METHODS

We retrospectively evaluated the treatment outcomes as well as predictors of unfavorable outcomes in patients with MDR/RR-TB notified from 2011 to 2017, using an integrated TB database.

RESULTS

A total of 7,226 patients with MDR/RR-TB were included. The treatment success rate had significantly increased from 63.9% in 2011 to 75.1% in 2017 (P < 0.001). Among unfavorable outcomes, the proportion of patients who failed, were lost to follow up, and were not evaluated had gradually decreased (P < 0.001). In contrast, TB-related death rate was not significantly changed (P = 0.513), while the non-TB related death rate had increased from 3.2% in 2011 to 11.1% in 2017 (P < 0.001). Older age, male sex, immigrants, low household income, previous history of TB treatment, and comorbidities were independent predictors of unfavorable outcomes. Of the 5,308 patients who were successfully treated, recurrence occurred in 241 patients (4.5%) at a median 18.4 months (interquartile range, 9.2-32.4) after completion treatment.

CONCLUSION

The treatment outcomes of patients with MDR/RR-TB has gradually improved but increasing deaths during treatment is an emerging challenge for MDR-TB control in Korea. Targeted and comprehensive care is needed for vulnerable patients such as the elderly, patients with comorbidities, and those with low household incomes.

An update of oncologic and obstetric outcomes after abdominal trachelectomy using the FIGO 2018 staging system for cervical cancer: a single-institution retrospective analysis

OBJECTIVE

To apply the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system to all patients who underwent trachelectomy in our previous study and to update the oncologic and obstetric results.

METHODS

We retrospectively reviewed the medical records of patients in whom abdominal trachelectomy was attempted between June 2005 and September 2021. The FIGO 2018 staging system for cervical cancer was applied to all patients.

RESULTS

Abdominal trachelectomy was attempted for 265 patients. Trachelectomy was converted to hysterectomy in 35 patients, and trachelectomy was completed successfully in 230 (conversion rate: 13%). Applying the FIGO 2018 staging system, 40% of the patients who underwent radical trachelectomy had stage IA tumors. Among 71 patients who had tumors measuring ≥2 cm, 8 patients were classified as stage IA1 and 14 as stage IA2. Overall recurrence and mortality rates were 2.2% and 1.3%, respectively. One hundred twelve patients attempted to conceive after trachelectomy; 69 pregnancies were achieved in 46 patients (pregnancy rate: 41%). Twenty-three pregnancies ended in first-trimester miscarriage, and 41 infants were delivered between gestational weeks 23 and 37; 16 were deliveries at term (39%) and 25 were premature deliveries (61%).

CONCLUSION

This study suggested that patients judged to be ineligible for trachelectomy and patients receiving overtreatment will continue to appear using the current standard eligibility criteria. With the revisions to the FIGO 2018 staging system, the preoperative eligibility criteria for trachelectomy, which were based on the FIGO 2009 staging system and tumor size, should be changed.