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Statement of problem Rehabilitation of edentulous patients with severe maxillary atrophy is a clinical challenge. Although several treatment options are available, the implant-supported overdenture has been widely advocated. However vertical insertion implant-supported overdentures have drawbacks, including wear, aging, and the continuous maintenance of retention systems. Whether an implant-supported overdenture with a horizontal insertion pathway can overcome these problems is unclear. Purpose The purpose of this observational study was to determine the clinical and biological behavior of a new type of implant-supported overdenture with a horizontal insertion pathway over a mean clinical follow-up period of 6 years. Material and methods Ten study participants with an atrophic maxilla underwent rehabilitation with horizontal overdentures supported by 6 implants. Follow-up visits were scheduled at 3 months, 6 months, and annually thereafter. The variables analyzed were implant and prosthetic survival, peri-implant tissue behavior, mechanical complications, and patient satisfaction. Results The follow-up period ranged from 5 to 8 years, mean ±standard deviation 6.3 ±1.2 years. A total of 60 implants and 10 horizontal overdentures were placed. The clinical survival of the implants was 98.3% (mean peri-implant bone loss, 1.3 ±0.4 mm) and was 80% of the prostheses. Overall, mean patient satisfaction as assessed with a visual analog scale was 7.4, with 8.5 for esthetics and 9.5 for function. Conclusions The horizontal implant-supported overdenture provided a functional alternative to conventional prostheses.

Narcolepsy and idiopathic hypersomnia cannot be cured; all available treatments are symptomatic. It is of paramount importance for patients, and their relatives, to be informed about the consequences of these chronic diseases and to become ready to accept the consequences of the diagnosis before starting any treatment. This facilitates the implementation of behavioral modifications and the proper use of medication to decrease the disease burden. A supportive social environment (eg, family members, friends, employer, colleagues, and patient support groups) is instrumental. Current treatment options are discussed with a focus on pharmacologic treatment, including future directions.

Hemolytic-Uremic Syndrome (HUS) is a clinical syndrome with a triad of non-immune Microangiopathic Hemolytic Anemia (MAHA), thrombocytopenia and renal failure. Together with the Thrombotic Thrombocytopenic Purpura (TTP), it belongs to a group of diseases characterized as the Thrombotic Microangiopathy (TMA), which represents a microvascular occlusive disorder with the formation of a predominantly thrombocytic thrombus in the renal and/or systemic circulation. In the period starting from 2001 to 2017, 14 patients with a HUS were diagnosed at the Clinic for Nephrology (unfortunately ADAMTS 13 could not have been done due to technical reasons). In a retrospective clinical laboratory analysis and monitoring, we obtained the following results. Out of 14 patients, 10 were female (or 71.43%) and 4 were male (28.57%), the youngest patient was aged 17 and the oldest one 78, the average age of our patients was 55.33 years, the annual number of patients with the diagnosis of HUS was 0.93 patients per year, or 0.00116 in relation to the total number of patients treated. After monitoring the patients individually for the period ranging from 1 to 14 years, a stable remission was achieved in 5 patients, while a chronic renal insufficiency occurred in 3 patients. In two of our patients, a percutaneous kidney biopsy was performed with pathohistological findings described in references. Having done this retrospective analysis, we can conclude that the survival and complications of this rare, but serious disease correspond to the available world data.

A 49-year-old woman presented to the hospital with shortness of breath 2 weeks after a left total hip replacement. She was found to have a submassive pulmonary embolism (PE), with her case complicated by the detection of a large mobile clot in transit extending through a patent foramen ovale between the right and left atria. The presence of this free-floating right heart thrombus (FFRHT) increases her risks of stroke and mortality, yet the optimal approach to her treatment was unclear. Ultimately, intravenous tissue plasminogen activator was administered with resolution of the clot. Treatment was complicated by haemodynamically insignificant bleeding at the site of recent surgery. Herein, we further discuss the implications and treatment options for patients with an FFRHT in the setting of an acute PE.

Introduction Although several combination therapies for acute myeloid leukemia (AML) have emerged recently, there has been a lack of published surveys and educational projects focused on these important treatment options. We aimed to improve the oncology team members’ knowledge and awareness of several FDA approved combination therapies for AML, including glasdegib (DAURISMO®), venetoclax (VENCLEXTA®), GO (MYOLOTARG®),CPX-351 (VYXEOS®), and midostaurin (RYDAPT®). Additionally, we aimed to examine these teams’ perspectives, views, and attitudes towards these topics and finally identify barriers to the implementationof such therapies in clinical practice. Method Initially, we developed booklets and then distributed them to each participating oncology and hematology office. Subsequently, all participating oncology and hematology team members were asked to complete an anonymous online survey to test their knowledge of and attitudes toward the subjects. Main results There was a total of 52 survey respondents. The correct answer regarding various combination therapies for AML was identified by nearly 70% or more of survey takers. The level of awareness of project subjects significantly improved after reading our printing materials. Many survey respondents were motivated to learn more about combination therapies for AML as well as discuss these topics with others. Conclusions Our booklets effectively improved understanding and awareness of combination therapies for AML. Future studies should explore awareness, knowledge, and perception of other new and emerging combination therapies for AML among oncology and hematology team members in other areas.

Melasma is a common chronic refractory disorder of pigmentation affecting people with darker skin types. Overall prevalence varies between 8.8% and 40%, depending on the ethnicity of the population and the geographical area. Therapeutic management of melasma is challenging, with high recurrence rates which significant impacts on the quality of life. No single treatment is universally efficacious. Systemic treatments with tranexamic acid and polypodium leucotmatous had promising results, although the former was related to systemic side effects. Microneedling and peeling were also efficacious, although their superiority to topical hydroquinone, the gold standard in melasma treatment, remains to be established. Similarly, laser and light devices have been beneficial. However, recurrence rates remain high in all treatment groups. Combination therapies, either in double or triple combinations yielded the best results when compared to single terapies. Treatment choice should be made after Wood's lamp examination, as well as dermatoscopic evaluation, in order to select the best treatment option, targeted at each melasma subtype.

Statement of problem Implant-supported and implant-retained extraoral prostheses are reliable treatment options for patients with craniofacial defects. They provide stable retention and therefore enhance the patient's appearance and quality of life. Despite studies on survival rates of extraoral implants, little attention has been paid to the design of the implants used to support and retain extraoral prostheses. Purpose The purpose of this longitudinal clinical study was to assess the long-term survival rate (1 to 12 years, mean 6 years) of 2 different designs of implants (disk: single, double, and triple and screw-type) used for extraoral epithesis anchorage. Material and methods Twenty-six participants with orbital and nasal defects, 10 of whom had had radiation treatment, were included in the study. Disk implants and extraoral (EO) screw implants were used and placed in the periorbital (15 participants) and perinasal regions (11 participants). Data were analyzed by using the Chi-square test and the Fisher Exact test for qualitative variables and the Mann-Whitney U test for comparison of quantitative variables. Implant survival rates were calculated by Kaplan-Meier analysis. Results The overall 12-year survival rate of all implants was 90.3% (mean=79 months), with 92.9% for nasal (mean=84 months) and 88.2% for orbital (mean=75 months) implants. Related to the implant design, survival rates were as follows: for single-disk implants, 90.2%; for double disks, 94.6%; for triple disks, 88.3%; and for screw implants, 83.3%. In nonradiated participants, the implant survival rate was 97.6%, and for radiated participants, 76.1%. Conclusions Survival rates for implant-retained craniofacial prostheses are limited. The nasal site seems to be a more predictable implant site than the orbital site, with a higher overall survival rate. Also, implants inserted in radiated tissues have lower survival rates for both anatomic sites, with statistically significantly lower results in the orbital region. The most reliable type of implant among the disk implants used was the double disk in the orbital site and the single disk in the nasal site, which may indicate the advantages of some designs in specific areas.

Graphical abstract, Highlights • Importance of disaggregation mechanism and innate disaggregation in living systems. • Different types and mechanism of disaggregation reported in literature. • Structural details of the interactions and the disaggregation mechanisms. • Amyloid disaggregation in protein aggregation disorders as a potential treatment. • Proposed amyloid disaggregation mechanism of an ATP-independent chaperone (L-PGDS)., Introduction Protein aggregation and deposition of uniformly arranged amyloid fibrils in the form of plaques or amorphous aggregates is characteristic of amyloid diseases. The accumulation and deposition of proteins result in toxicity and cause deleterious effects on affected individuals known as amyloidosis. There are about fifty different proteins and peptides involved in amyloidosis including neurodegenerative diseases and diseases affecting vital organs. Despite the strenuous effort to find a suitable treatment option for these amyloid disorders, very few compounds had made it to unsuccessful clinical trials. It has become a compelling challenge to understand and manage amyloidosis with the increased life expectancy and ageing population. Objective While most of the currently available literature and knowledge base focus on the amyloid inhibitory mechanism as a treatment option, it is equally important to organize and understand amyloid disaggregation strategies. Disaggregation strategies are important and crucial as they are present innately functional in many living systems and dissolution of preformed amyloids may provide a direct benefit in many pathological conditions. In this review, we have compiled the known amyloid disaggregation mechanism, interactions, and possibilities of using disaggregases as a treatment option for amyloidosis. Methods We have provided the structural details using protein-ligand docking models to visualize the interaction between these disaggregases with amyloid fibrils and their respective proposed amyloid disaggregation mechanisms. Results After reviewing and comparing the different amyloid disaggregase systems and their proposed mechanisms, we presented two different hypotheses for ATP independent disaggregases using L-PGDS as a model. Conclusion Finally, we have highlighted the importance of understanding the underlying disaggregation mechanisms used by these chaperones and organic compounds before the implementation of these disaggregases as a potential treatment option for amyloidosis.

End stage ankle joint arthritis is a debilitating condition. Surgical treatment, most commonly ankle arthrodesis or fusion, can be highly effective. The authors outline the nature and prevalence of ankle arthritis and show that the frequency of each type of procedure varies geographically. They present data supporting the hypothesis that units performing ankle replacement more frequently tend to have better outcomes, both clinically and financially. Adoption of country-wide Ankle Arthritis Networks is proposed, ensuring that every patient seeing a foot and ankle orthopaedic surgeon has potential access to all treatment options whether their surgeon chooses to perform replacement or not. The case is made that establishment of Ankle Arthritis Networks will avoid the need for units to perform a low number of replacements per year, homogenise treatment availability across the country and enables the right patient to receive the right treatment first time. LEVEL OF EVIDENCE: IV.

Treatment of bacterial septic arthritis in the native adult hip joint can be challenging. Prompt diagnosis and treatment decisions can reduce the associated morbidity and mortality. For this systematic review of the literature, we asked: (1) What are the treatment options? (2) What are the success rates and the outcomes after treatment? (3) Which antibiotic and duration of therapy are optimal? We searched the electronic databases PubMed, Scopus, and Embase using the search terms “hip” or “native hip” and “septic arthritis” or “coxitis”. Studies were included if they reported on: (1) bacterial infection of the hip, (2) treatment, (3) success rate/outcomes, (4) follow-up. The final review included 19 studies. The quality of study reporting was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. Three treatment options are: arthroscopy, single open surgery, and two-stage total hip arthroplasty (THA). A high success rate in infection eradication was reported for all three. Intravenous antibiotic therapy should be promptly initiated to eradicate septic arthritis and minimize potential sequelae and complications. Arthroscopy, single open or two-stage THA were reported to be effective in treating bacterial septic arthritis of the native hip. The key to optimal outcome is early diagnosis and timely treatment. Cite this article: EFORT Open Rev 2021;6:164-172. DOI: 10.1302/2058-5241.6.200082

PURPOSE Diagnosis of AIDS lymphoma in low-resource settings, like South Africa, is often delayed, leaving patients with limited treatment options. In tuberculosis (TB) endemic regions, overlapping signs and symptoms often lead to diagnostic delays. Assessment of plasma cell-free DNA (cfDNA) by next-generation sequencing (NGS) may expedite the diagnosis of lymphoma but requires high-quality cfDNA. METHODS People living with HIV with newly diagnosed aggressive B-cell lymphoma and those with newly diagnosed TB seeking care at Chris Hani Baragwanath Academic Hospital and its surrounding clinics, in Soweto, South Africa, were enrolled in this study. Each participant provided a whole blood specimen collected in cell-stabilizing tubes. Quantity and quality of plasma cfDNA were assessed. NGS of the immunoglobulin heavy chain was performed. RESULTS Nine HIV+ patients with untreated lymphoma and eight HIV+ patients with TB, but without lymphoma, were enrolled. All cfDNA quantity and quality metrics were similar between the two groups, except that cfDNA accounted for a larger fraction of recovered plasma DNA in patients with lymphoma. The concentration of cfDNA in plasma also trended higher in patients with lymphoma. NGS of immunoglobulin heavy chain showed robust amplification of DNA, with large amplicons (> 250 bp) being more readily detected in patients with lymphoma. Clonal sequences were detected in five of nine patients with lymphoma, and none of the patients with TB. CONCLUSION This proof-of-principle study demonstrates that whole blood collected for cfDNA in a low-resource setting is suitable for sophisticated sequencing analyses, including clonal immunoglobulin NGS. The detection of clonal sequences in more than half of patients with lymphoma shows promise as a diagnostic marker that may be explored in future studies.

Myocardial infarction in a nonagenarian is a morbid cardiac illness that can lead to significant mortality unless properly dealt with management aspects. Many comorbid or family-related issues might be part of holdbacks in management of such a group of patients. Hence, myocardial infarction in a nonagenarian where intervention is better treatment option forms an uncommon combination and has many preprocedural, periprocedural and postprocedural difficulties related to multiple issues. Here, we present a case of nonagenarian who presented with extensive anterior wall MI and was successfully dealt with primary percutaneous coronary intervention despite periprocedural and intraprocedural difficulties.

Нами було обстежено 56 хворих із фармакорезистентними лицьовими симпаталгіями різного ступеня вираженості больового синдрому, в сироватці крові яких спектрофотометричним методом визначено базовий вміст глутамату, аспартату та гамма-аміномасляної кислоти для вивчення їх впливу на формування і вираженість больового синдрому. В даній роботі показано, що у хворих із фармакорезистентними лицьовими симпаталгіями з найбільш вираженим больовим синдромом відзначається найбільш значущі зміни вмісту нейроамінокислот, а саме зростання рівня глутамату, зменшення рівня гальмівних амінокислот, зокрема гамма-аміномасляної кислоти, при порівнянні з контролем, що свідчить про неефективність гальмівних механізмів у даної категорії пацієнтів. Необхідним є подальше вивчення особливостей нейроамінокислотного дисбалансу у хворих із фармакорезистентними лицьовими симпаталгіями для розробки диференціально-діагностичних і прогностичних критеріїв перебігу та нових шляхів лікування.

ObjectivesRheumatoid arthritis (RA) in patients undergoing immunosuppressive therapy (IS) is sometimes involved with other iatrogenic immunodeficiency-associated lymphoproliferative disorders (LPD). We aimed to clarify the effects of LPD treatment on RA and the current status of RA treatment options after LPD onset and subsequent IS withdrawal.MethodsWe retrospectively analyzed data of patients who had RA with LPD and examined the relationship between LPD course and RA treatment as well as that between RA relapse and LPD treatment.ResultsLPD patients were categorized into two groups: patients who regressed spontaneously (n = 19) and those who needed chemotherapy (n = 12). The chemotherapy group had significantly less RA relapse than the spontaneous regression group (p = .041). RA almost relapsed early in the spontaneous regression group and needed treatment for RA. Chemotherapy with rituximab prevented long-term RA relapse, and RA did not relapse for long even after rituximab monotherapy. The total dose of rituximab in monotherapy correlated with the time to RA relapse. Six patients with RA relapse received biologics and had no LPD relapse for more than 1 year.ConclusionsRituximab in chemotherapy for LPD may help prevent RA relapse with LPD. Large-scale studies are required in the future for verification.

Objectives. The aims of this study were to investigate the effect of intratympanic injection of isosorbide on the vestibular function in animal models with endolymphatic hydrops and to find a new treatment option for the acute onset of vertigo in Ménière’s disease (MD).Methods. Seventy male guinea pigs were used. Intratympanic injection of isosorbide (IT-ISB) was applied. The animals were divided into three study groups, namely the control, chronic hydrops model, and acute hydrops model groups. The intracochlear drug concentration was measured using high-performance liquid chromatography (HPLC). Vestibular function was analyzed using an animal rotator test with bidirectional sinusoidal harmonic acceleration (SHA) before and after IT-ISB. The histological change was also investigated.Results. ISB successfully permeated the perilymph through the round window membrane (RWM) at all three different concentrations of IT-ISB (25%, 50%, and 100%). In the chronic hydrops model, while IT-ISB histologically induced a reduction of endolymphatic hydrops, vestibular function was unchanged. In the acute hydrops model, no endolymphatic hydrops was histologically observed, and vestibular symmetry was also preserved after IT-ISB.Conclusion. ISB passed through the RWM into the perilymphatic space even at the lower concentrations. IT-ISB histologically reduced the hydrops in the chronic model and preserved the symmetrical vestibular function in the acute model. IT-ISB could be a treatment candidate for the acute attack of vertigo in MD.

The present case series, based on dental literature, aimed to identify factors that influence the final treatment decision for patients affected by mandibular canine transmigration using individual data from case reports in the literature. The protocol used for data synthesis was prepared following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. An online search was conducted and included studies published up until September of 2019 (MEDLINE, Google Scholar, Scielo, and Conricyt). A chi squared test was used to evaluate associations between the treatment choice and gender, age, Mupparapu classification, and the presence of oral pathologies or dental anomalies (p < 0.05). A multinomial logistic regression was used to evaluate the individual case report data to determine the effect of the explanatory variables for treatment selection. Seventy-six papers fulfilled the inclusion criteria. Surgical removal (46.71%) and radiographic monitoring (38.16%) were the most common treatments reported. Age, Muppararu classification, and the presence of oral pathologies were significantly associated with the treatment option (p < 0.05). In conclusion, surgical removal and radiographic monitoring are the most frequently reported treatments for mandibular canine transmigration. Age, Mupparapu type, presence of oral pathologies, and qualitative aspects such as emotional reasons are relevant for the decision regarding treatment approach.

RATIONALE: New advanced bronchoscopic treatment options for patients with severe COPD have led to increased interest for COPD phenotyping, including fissure completeness.OBJECTIVES: We investigated clinical, environmental, and genetic factors contributing to fissure completeness in patients with and without COPD.METHODS: We used data of 9926 participants of the COPDGene study who underwent chest computed tomography (CT). Fissure completeness was calculated from CT scans following quantitative CT analysis at baseline and five-year follow-up. The clinical and environmental factors sex, race, smoking, COPD, emphysema, maternal smoking during pregnancy and maternal COPD were tested for impact on fissure completeness. Genome-wide association analyses were performed separately in non-Hispanic whites and African-Americans.MEASUREMENTS AND MAIN RESULTS: African-Americans had significant higher fissure completeness than non-Hispanic whites for all three fissures (pCONCLUSIONS: Fissure completeness is genetically determined and not dependent on age, sex, smoking status, the presence and severity of COPD including exacerbation frequency, maternal smoking during pregnancy, or maternal COPD.

Rugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices.A survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test.Ninety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p 0.05), but not recurrent dislocation (p 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p 0.05), but not following conservative treatment or the Latarjet procedure (p 0.05).There remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety.Level 4 (case series).

Recent improvements in chemoimmunotherapies, targeted agents, hematopoietic stem cell transplants, and cellular therapies have revolutionized treatment paradigms for patients with diffuse large B-cell lymphoma (DLBCL). Even in the relapsed or refractory setting, contemporary treatment options are delivered with curative intent and can lead to lasting remissions. Although such therapies have improved overall outcomes, they have increasingly led to a wide variety of presentations of recurrent tumors in need of palliation. Here, we review the use of radiotherapy (RT) in the palliation of DLBCL. We draw particular attention to the evolving role for hypofractionated RT and low-dose RT for DLBCL. We review the available literature on these topics and focus on commonly encountered clinical scenarios.

Background Uterus transplantation (Utx) has achieved clinical success but little is known about motivations and experiences of UTx recipients. Methods We conducted semi-structured interviews with 20 UTx recipients in addition to collecting quantitative demographic and clinical data. Closed-ended interview questions were treated as categorical variables. Thematic analysis was performed on qualitative data. Bivariate analysis tested associations between categorical variables. Results Themes that emerged included: the decision to pursue UTx is a process, primary motivations for UTx are specific to the experience of gestation, and alternative options did not offer the same value as UTx. There was no association between disease etiology, clinical status, or perception of UTx risk with information needs or donor preference. Conclusions Our findings suggest that UTx is a unique treatment option that some women with AUFI find preferable to adoption and surrogacy and, as such, should be discussed as a parenthood option with women diagnosed with AUFI.

Introduction For children with haemophilia, early initiation of prophylaxis is crucial to prevent life-threatening bleeds and maintain joint health throughout life. Options for prophylaxis have recently increased from replacement therapy with standard or extended half-life coagulation factor products to include other haemostasis products, such as the non-replacement therapy emicizumab. Aim To review key factors that determine the choice of prophylaxis in young children. Methods Key clinical questions on the implementation of prophylaxis for haemophilia in children were identified and PubMed was searched for evidence supporting guidance on the implementation of prophylaxis. Results The results of the literature search and the practical experience of the authors were used to build consensus on when to start prophylaxis, the pros and cons of the products available to guide the choice of product, and practical aspects of starting prophylaxis to guide the choice of regimen. Conclusions In this era of increasing therapeutic choices, available information about the range of treatment options must be considered when initiating prophylaxis in young children. Parents or care givers must be sufficiently informed to allow informed shared decision making. Although plentiful data and clinical experience have been gathered on prophylaxis with clotting factor replacement therapy, its use in young children brings practical challenges, such as the need for intravenous administration. In contrast, our relatively brief experience and limited data with subcutaneously administered non-replacement therapy (i.e., emicizumab) in this patient group imply that starting emicizumab prophylaxis in young children requires careful consideration, despite the more convenient route of administration.

Background. The purpose was to evaluate the presence of risk factors and underlying disorders in patients with confirmed and unconfirmed diagnosis of non-alcoholic fatty liver disease (NAFLD); the bene­fits of practicing physicians regarding pharmacological and non-pharmacological treatments of NAFLD under conditions of real clinical practice. Materials and methods. The study included 5,000 patients (an average of 50 patients from 100 research centers), 2,450 women (49.00 %) and 2,550 men (51.00 %), middle age — (52.83 ± 12.33) years. To conduct research in Ukraine, 100 gastroenterological departments were selected. The list of research centers included departments with qualified staff, provided with proper materials and technical equipment, with the obligatory presence of the local Ethics Committee. The data used in the study were obtained during one regular patient’s visit to the center included in the study. During the visit, the basic data of the patient, data of instrumental examination (ultrasound of the liver), results of laboratory tests, data on the application of treatment methods (pharmacological and non-pharmacological) were recorded. Diagnosis of NAFLD was established or excluded on the basis of laboratory and instrumental data entered into medical cards. Results. Ove­rall, the risk factors for NAFLD were detected in 4,650 (93.00 %) patients. Most often, overweight (91.90 %), hypercholesterolemia (61.44 %), and hyperlipidemia (41.23 %) were found. The frequency of virtually all investigated risk factors (with the exception of hypercholesterolemia) is significantly higher (p < 0.05) in the group of patients with a confirmed diagnosis of NAFLD than in those with an unconfirmed diagnosis of NAFLD. Non-pharmacological and pharmacological treatment methods were used in most patients (90.44 and 93.82 %, respectively). Most non-pharmacological and pharmacological treatments were significantly more frequently used in patients with a confirmed diagnosis of NAFLD (p

Objective The long-term success of endovascular aneurysm repair (EVAR) is limited by complications, most importantly endoleaks. In case of (persistent) type I endoleak (T1EL), secondary intervention is indicated to prevent secondary aneurysm rupture. Different treatment options are suggested for T1ELs, such as endo anchors, (fenestrated) cuffs, embolization, or open conversion. Currently, the treatment of T1EL with liquid embolic agents is available; however, results are not yet addressed. This review presents the safety and efficacy of embolization with liquid embolic agents for treatment of T1ELs after EVAR. Methods A systematic literature search was performed for all studies reporting the use of liquid embolic agents as monotherapy for treatment of T1ELs after EVAR. Patient numbers, technical success (successful delivery of liquid embolics in the T1EL) and clinical success (absence of aneurysm related death, endoleak recurrence or additional interventions during follow-up) were examined. Results Of 1604 articles, 10 studies met the selection criteria, including 194 patients treated with liquid embolics; 73.2% of the patients were male with a median age of 71 years. The overall technical success was 97.9%. Clinical success was 87.6%. Because the median follow-up was only 13.0 months (range, 1-89 months), data on long-term success are almost absent. Four cases (2.1%) of secondary aneurysm rupture after embolization owing to endoleak recurrence were reported. All ruptures occurred in aneurysms exceeding initial treatment diameter of 70 mm. Conclusions Initial technical success after liquid embolization for T1EL is high, although long-term clinical success rates are lacking. Within this review, the risk of secondary rupture is comparable with untreated T1EL at 2% with a median follow-up of 13 months, regardless of the initial success of embolization. In general, no decrease in secondary aneurysm rupture after embolization of T1EL after EVAR is demonstrated, although the results of late embolization are debated.

We report the case of a 60-year-old female patient with a contained rupture of a proximal anastomotic pseudoaneurysm after previous open repair of a type IV thoracoabdominal aneurysm. A repeat open repair was considered to be too risky. We performed an urgent endovascular repair with a thoracic stent-graft and a surgeon-modified fenestrated aortic cuff with two fenestrations. The final angiogram and postoperative imaging studies showed complete aneurysm exclusion without any endoleak. Surgeon-modified fenestrated endovascular aortic repair is a feasible treatment option for emergency cases for which repeat open repair or custom-made complex endovascular repair is not an option.

Objective: Is the level of shared decision-making (SDM) higher after introduction of a SDM package (including encounter decision aids on treatment options for heavy menstrual bleeding and training for clinicians) than before?. Methods: This before-after study, performed in OB-GYN practice, compared consultations before and after introduction of a SDM package. The target sample size was 25 patients per group. Women seeking treatment for heavy menstrual bleeding were eligible. After their appointments, patients filled out a three-item patient-reported SDM measure. Treatment discussions were audio-recorded and rated for SDM using Observer OPTION 5. Consultation transcripts in the ‘after’ group were checked for adherence to the steps required for intended use of decision aids. Results: 16 gynaecologists participated. 25 patients participated before introduction of the decision aids and 28 after. The proportion of women reporting optimal SDM was higher after introduction (75 %) than before (50 %;p < 0.001). The mean observer-rated level of SDM was also significantly higher after than before (MD = 12.50,95 % CI 5.53–19.47). Conclusion: The level of SDM was higher after the introduction of the package than before. Practice implications: This study was conducted in a real-life setting in three clinics, both large academic and small rural, offering opportunities for implementation in different type of organizations.

Objective To assess practicing urologists’ attitudes and perceptions of active surveillance (AS) and other treatment options for low-risk prostate cancer. Methods This was a cross-sectional survey of urologists practicing in Michigan and Georgia. Urologists were asked about perceptions and practices pertaining to AS. Results Overall, 225 urologists completed the survey; 147 (65%) were from Michigan and 78 (35%) were from Georgia. Most urologists reported they provided (99%), discussed (97%), and offered (61%) AS to all of their low-risk patients. Most believed AS is effective (97%) and underused (90%), while 80% agreed that curative therapy (surgery, radiation) is overused in the United States. Although most (79%) endorse that Black men are more likely to have aggressive low-risk disease, 89% reported feeling comfortable recommending AS to Black men. In multivariable analysis, significant provider-related predictors of AS recommendation were practice location, number of years in practice, beliefs pertaining to survival benefit of prostatectomy and effectiveness of AS, and expectation that patients are not interested in AS. The patient characteristics of race, age, life expectancy, fear of cancer progression, and fear of treatment side effects were also significant predictors of AS recommendations. Conclusion Most urologists surveyed stated that AS is effective and underused for low-risk prostate cancer . Overall, urologists are much less likely to recommend AS to younger men and slightly less to Black men. AS recommendations varied by practice location and by years in practice. These findings indicate targeted educational efforts in the US are needed to influence urologists toward greater acceptance of AS.

PURPOSEEffective treatment options are limited for patients with advanced (metastatic or unresectable) melanoma who progress after immune checkpoint inhibitors and targeted therapies. Adoptive cell therapy using tumor-infiltrating lymphocytes has demonstrated efficacy in advanced melanoma. Lifileucel is an autologous, centrally manufactured tumor-infiltrating lymphocyte product.METHODSWe conducted a phase II open-label, single-arm, multicenter study in patients with advanced melanoma who had been previously treated with checkpoint inhibitor(s) and BRAF ± MEK targeted agents. Lifileucel was produced from harvested tumor specimens in central Good Manufacturing Practice facilities using a streamlined 22-day process. Patients received a nonmyeloablative lymphodepletion regimen, a single infusion of lifileucel, and up to six doses of high-dose interleukin-2. The primary end point was investigator-assessed objective response rate (ORR) per RECIST, version 1.1.RESULTSSixty-six patients received a mean of 3.3 prior therapies (anti–programmed death 1 [PD-1] or programmed death ligand 1 [PD-L1]: 100%; anticytotoxic T-lymphocyte-associated protein-4: 80%; BRAF ± MEK inhibitor: 23%). The ORR was 36% (95% CI, 25 to 49), with two complete responses and 22 partial responses. Disease control rate was 80% (95% CI, 69 to 89). Median duration of response was not reached after 18.7-month median study follow-up (range, 0.2-34.1 months). In the primary refractory to anti–PD-1 or PD-L1 therapy subset, the ORR and disease control rate were 41% (95% CI, 26 to 57) and 81% (95% CI, 66 to 91), respectively. Safety profile was consistent with known adverse events associated with nonmyeloablative lymphodepletion and interleukin-2.CONCLUSIONLifileucel demonstrated durable responses and addresses a major unmet need in patients with metastatic melanoma with limited treatment options after approved therapy, including the primary refractory to anti–PD-1 or PD-L1 therapy subset.

Objective Open repair surgery (ORS) for an abdominal aortic aneurysm (AAA) remains an important treatment option, but the incidence of para-anastomotic aneurysms is unclear. The purpose of this study was to estimate the incidence of para-anastomotic aneurysms and reveal secondary complications through routine annual computed tomography (CT) imaging. Methods One hundred and forty-seven patients who underwent ORS for AAA between January 2006 and December 2015 and received routine CT imaging surveillance were enrolled. Results The follow up period was 7.1 ± 2.7 years. The total follow up time of all patients was 1 041.1 years, and 958 CT images were collected (0.92 CT scans/year/patient). A proximal para-anastomotic aneurysm was detected in five patients (3.4%). Four of the five patients had aneurysmal dilation at the initial ORS (proximal diameter >25 mm), which enlarged during follow up; thus, a de novo proximal para-anastomotic aneurysm was observed in one patient (0.7%). The time between surgery and the diagnosis of all proximal para-anastomotic aneurysms was 5.7 ± 1.4 years, and the de novo proximal para-anastomotic aneurysm was detected at 11.8 years. The incidence of all para-anastomotic aneurysms at five and 10 years was 2.2% and 3.6%, and the incidence of the de novo para-anastomotic aneurysm was 0% at five and 10 years. Nine synchronous thoracic aortic aneurysms (TAAs) and seven metachronous TAAs were detected, and 16 patients (10.9%) had a TAA. Neoplasms were detected in 18 of 147 patients (12.2%), and the most dominant neoplasm was lung cancer. Conclusion The incidence of para-anastomotic aneurysms was low; thus, abdominal and pelvic CT imaging every five years may be sufficient and consistent with the current AAA guidelines. In contrast, TAAs were diagnosed in a high percentage of patients, and based on these observations, routine CT imaging should be expanded to include the chest.

Hemorrhagic rupture is a very rare and life-threatening hepatic cyst complication. Several treatment methods have been used for hepatic cyst hemorrhage and/or rupture; however, transcatheter arterial embolization for hepatic cyst hemorrhage has been poorly documented. An 80-year-old man receiving dual antiplatelet therapy was diagnosed with hemorrhagic rupture of a hepatic cyst. Transcatheter arterial embolization using a coil was performed for A6 branch confirmed active extravasation. His condition improved promptly after treatment, and the hepatic cyst gradually became smaller as compared to the size before hemorrhage. Transcatheter arterial embolization is suitable for hepatic cyst hemorrhage and might be a minimally invasive treatment option for a symptomatic hepatic cyst.

Background: Transcatheter mitral valve replacement (TMVR) offers a valuable treatment option for inoperable patients suffering from a degenerated mitral valve after previous ring annuloplasty. Dynamic obstruction of the left ventricular outflow tract(LVOT) is a procedural risk with detrimental consequences and can be estimated upfront using a multi-slice computed tomography(MSCT) derived 3D computational model(3DCM). This study explored the accuracy of pre-procedural neo-LVOT prediction in TMVR using 3DCMs of multiple cardiac phases. Methods: We obtained both pre- and post-procedural MSCT scans of a patient who underwent uncomplicated TMVR and derived 3DCMs from each cardiac phase. Virtual implantations of the deployed valve were performed and neo-LVOT dimensions were semi-automatically calculated in the pre-procedural models and matched with the post-procedural models. Predicted and post-procedural neo-LVOTs were compared between 3DCMs. Results: From cardiac phases 20–70%, 11 matched 3DCM pairs were generated. The mean difference between predicted and post-TMVR neo-LVOT area was 3 ± 23 mm2. The intra-class correlation coefficient for absolute agreement between predicted and post-procedural neo-LVOT area was 0.86 (95%CI 0.56–0.96, p < 0.001). Conclusion: 3DCMs could accurately predict post-TMVR neo-LVOT dimensions in a patient with a pre-existing mitral annular ring. Prospective research is warranted to demonstrate the accuracy of these models in larger samples and different mitral annular phenotypes.

Current treatment options for men with metastatic castration-resistant prostate cancer (mCRPC) are noncurative, and median survival upon development of mCRPC is approximately 3 years. The novel hormonal agent enzalutamide has an established role in the mCRPC treatment paradigm, and emerging evidence suggests potential synergism with enzalutamide and the PD-1 inhibitor pembrolizumab in men with mCRPC. Here, we describe the design and rationale for the multicenter, randomized, double-blind, Phase III KEYNOTE-641 study, which will be conducted to compare the efficacy and safety of pembrolizumab plus enzalutamide with that of enzalutamide plus placebo in mCRPC. Clinical trial registration: NCT03834493 ( ClinicalTrials.gov )

Objective To understand the impact of cost conversations on the following decision-making outcomes: patients’ knowledge about their conditions and treatment options, decisional conflict, and patient involvement. Patients and Methods In 2020 we performed a secondary analysis of a randomly selected set of 220 video recordings of clinical encounters from trials run between 2007 and 2015. Videos were obtained from eight practice-based randomized trials and one pre–post-prospective study comparing care with and without shared decision-making (SDM) tools. Results The majority of trial participants were female (61%) and White (86%), with a mean age of 56, some college education (68%), and an income greater than or equal to $40,000 per year (75%), and who did not participate in an encounter aided by an SDM tool (52%). Cost conversations occurred in 106 encounters (48%). In encounters with SDM tools, having a cost conversation lead to lower uncertainty scores (2.1 vs 2.6, P=.02), and higher knowledge (0.7 vs 0.6, P=.04) and patient involvement scores (20 vs 15.7, P=.009) than in encounters using SDM tools where cost conversations did not occur. In a multivariate model, we found slightly worse decisional conflict scores when patients started cost conversations as opposed to when the clinicians started cost conversations. Furthermore, we found higher levels of knowledge when conversations included indirect versus direct cost issues. Conclusion Cost conversations have a minimal but favorable impact on decision-making outcomes in clinical encounters, particularly when they occurred in encounters aided by an SDM tool that raises cost as an issue.

Rotator cuff tears are common shoulder injuries expected to increase with the growth of the aging population. Although a small subset of patients with low functional demands can be treated nonoperatively, surgical intervention is a cost-effective solution, which can restore shoulder function and help patients return to activity sooner. While multiple surgical options are available, rotator cuff repair is a highly utilized procedure with varying success. Due to a large proportion of rotator cuff repairs still failing to completely heal, this procedure requires careful planning to achieve anatomical and biomechanically stability. New technology and techniques are being explored to help increase the success of rotator cuff repairs with an increasing focus on augmentation. The current article gives a brief overview of pertinent anatomy, treatment options, and challenges in healing of rotator cuff repairs. Thereafter, the merits of different types of rotator cuff repair augmentation available will be discussed as well as the authors’ experience in utilizing biologic augmentation and surgical technique.

Summary Background Carpometacarpal osteoarthritis of the thumb (CMC OA) is treated with various therapeutic approaches. However, the literature remains inconclusive regarding the ideal procedure for each disease stage. In this study, we assessed the international application of surgical treatment options including CMC I implants and non-surgical treatment options for CMC OA depending on the disease stage, with a strong focus on the detection of geographical disparities. Methods We conducted a large international online survey with members of hand surgical societies of the International Federation of Societies for Surgery of the Hand (IFSSH). The first part of the survey asked about general therapy options of CMC OA depending on the severity of the disease, whereas the second part specifically dealt with the use of prostheses. Results We could include 10 of 56 IFSSH member societies (6807 surgeons) and received answers from 1138 members (16.7%). Significant differences were detected in an increased use of corticosteroid injections in the USA, and a growing frequency of fat injections in Europe. Regarding use and frequency of the resection arthroplasty, we found similar results in all participating countries. Prosthetic implantation showed a significant difference between the USA and Europe, with far larger numbers stated by European hand surgeons. Conclusion CMC OA is treated differently in the participating countries depending on the stage of the disease. We give an insight into geographical differences in treatment paradigms, with corticosteroid injections being more prevalent in the USA, and prosthesis implantation being more frequently chosen in the selected European countries.

Rapid eye movement (REM) behavior disorder (RBD) is characterized by loss of skeletal muscle atonia that can lead to dream enactment. This condition can cause harm to patients and their bed partners if appropriate safety measures are not ensured. This condition is often the initial presenting symptom in a group of complex neurodegenerative processes. Definitive diagnosis requires a thorough history and an in-laboratory polysomnogram to look for evidence of REM sleep without atonia. Treatment options are limited but consist of sleep safety measures and pharmacotherapy. Patients diagnosed with idiopathic RBD associated with alpha-synucleinopathy are likely to have progression of disease.

Patients with advanced cancer from Saudi Arabia are often not well informed about diagnoses, prognoses, and treatment options. Poor communication can lead to health-care decisions that insufficiently meet patients’ preferences, concerns, and needs and that subsequently affect patients’ quality of life. Objectives: The purpose of this study is to examine the relationship between provider communication behaviors and the quality of life of patients with advanced cancer. Method: A cross-sectional, correlation design was used in the present study, in which 159 patients with confirmed diagnoses of stage III or IV solid cancer were surveyed. Results: The mean summary score of the patients’ quality of life was 57.31. We found a significant relationship between provider communication behaviors and patient quality of life (β = 0.18, b = 0.35, SE = 0.15, p = 0.021). In addition, R2 shows that only 3.4% of variance in patient quality of life is predicated on provider communication behaviors. Conclusions: The relationship between provider communication behaviors and patient quality of life was low (r = 0.18). A possible reason for this is that provider communication behaviors are not the only factor that affects patient quality of life, other variables, such as the patient’s age, cancer type, and level of awareness, can also have an effect. Another possible explanation is that communication behaviors between patients and providers may vary depending on the level of cultural contact.

The most common types of CTCL are mycosis fungoides (MF) and Sézary syndrome (SS). In both MF and SS, complete responses to treatment are uncommon. Recent developments and understanding of the biology of MF/SS have led to novel agents which may offer prolonged responses with less toxicity compared to conventional chemotherapy approaches.In this review, we discuss the efficacy and safety of new nonchemotherapy treatment options including antibody agents, small molecule inhibitors, fusion proteins, and CAR T-cell therapy. We also reflect on older immunomodulatory treatments including retinoids and histone deacetylase inhibitors.Patients with MF/SS who require systemic therapy often progress through multiple agents sequentially, thus the need for additional novel agents in the treatment armamentarium. Antibody-based therapies such as alemtuzumab are highly effective in the blood compartment of disease, while brentuximab vedotin has shown higher activity in skin and lymph nodes. Checkpoint inhibitors may play a role in treating MF/SS but may induce hyperprogression, and engineered T cells and bispecific antibodies recruiting immune effectors are being developed and may show promise in the future.

Introduction The incidence of acetabular fractures in the elderly population is ever increasing. While management of acetabular fractures in young patients following high-energy trauma is well described, treatment of the elderly patient subgroup is complex and requires a unique, individualized approach. A variety of treatment strategies including operative and non-operative approaches exists to manage this vulnerable patient group. Conservative management of acetabular fractures in the elderly continues to play an important role in treatment of both stable fracture patterns and those medically unfit for surgery. Aim This review assessing the current literature was undertaken with the purpose of summarising the challenges of management in this at-risk cohort as well as quantifying the role and outcomes following conservative management in the elderly. Conclusion Our recommendation is that conservative management of acetabular fractures in the elderly can be considered as a treatment option on a case-by-case basis accounting for patient, injury, and surgical factors. If it is to be pursued, we advise a multidisciplinary approach focused on early mobility, minimisation of risk and regular follow-up to optimise patient outcomes.

Negative symptoms in schizophrenia remain a clinical challenge with small effect sizes and evidence for pharmacological or psychotherapeutic treatment approaches. Studies suggest that electroconvulsive therapy (ECT) holds some promise as a treatment option of often persistent negative symptoms with clinically meaningful effects. This review summarizes the existing evidence on the efficacy of ECT on negative symptoms in patients with schizophrenia. Thirty-five publications were included in this literature review comprising 21 studies, two meta-analyses, eight reviews and four case reports. Conclusions should be interpreted cautiously, given the small number and methodological shortcomings of the included publications with a variation of study designs and missing standardized protocols. Implications for future research and practice are critically discussed. Recommendations are given to provide more evidence that will meet the clinical challenge of reducing the negative symptoms in schizophrenia. Study designs that focus explicitly on negative symptoms and assess patients over longer follow up periods could be helpful. Future research should include control groups, and possibly establish international multicentered studies to get a sufficient study population. Findings suggest that patients with schizophrenia resistant to pharmacological treatment might benefit from ECT. A risk and benefit assessment speaks in favour of the ECT treatment. Future practice of ECT should include a combination treatment with antipsychotics. Whereas the use of anaesthetics and electrode placement does not seem to play a role, the recommendation regarding frequency of ECT treatments is currently three times a week, For the assessment of negative symptoms the assessment tool should be chosen carefully.

Urinary tract infection is one of the common infection encountered in day to day practice. Due to emergence of drug resitance among uropathogens treatment options have become limited. Fosfomycin being a safe oral antibiotic is being used widely to treat multidrug resistant uropathogens. In the present study 831 (48.45%) samples that yielded significant growth were processed out of 1715 sample for ESBL detection by double disc synergy and phenotypic confirmatory method. E.coli constituted the predominant isolate (60.4%) followed by K.pneumoniae. 256 (30.80%) samples yielding growth were from out patients and 575 from inpatients. Over all 44% of isolates in the present study were ESBL producers. 50% of Ecoli were ESBL producers. 70.64% of ESBL isolates were susceptible to fosfomycin in vitro. Present study finding suggest that resistance to fosfomysin is on rise even though majority of ESBLs were sensitive to it. The current study recommends to use fosfomycin only after testing susceptibility among uropathogens. Keywords : Ecoli, ESBL, Fosfomysin, Kpneumoniae

Contains fulltext : 248734.pdf (Publisher’s version ) (Open Access) Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. For many years guidelines have listed optimal preventive therapy. More recently, novel therapeutic options have broadened the options for state-of-the-art CV risk management (CVRM). In the majority of patients with CVD, risk lowering can be achieved by utilising standard preventive medication combined with lifestyle modifications. In a minority of patients, add-on therapies should be considered to further reduce the large residual CV risk. However, the choice of which drug combination to prescribe and in which patients has become increasingly complicated, and is dependent on both the absolute CV risk and the reason for the high risk. In this review, we discuss therapeutic decisions in CVRM, focusing on (1) the absolute CV risk of the patient and (2) the pros and cons of novel treatment options.

Introduction Salivary gland neoplasms (SGNs) respond poorly to the traditional chemotherapy agents limiting the availability of systemic treatment options in the metastatic setting. The recent identification of actionable molecular targets in SGNs has led to the evaluation of targeted therapies in non-approved advanced SGNs. Case Report We present the case of an elderly male with HER-2 Neu overexpressing metastatic mucoepidermoid carcinoma (MEC) who demonstrated a prompt and sustained disease response to targeted therapies directed against HER-2 Neu with long survival interrupted by hepatoxicity to Trastuzumab emtansine (TDM-1) treatment. Management and Outcome: The patient was started on Trastuzumab and Pertuzumab on a clinical trial and resulted in an objective improvement sustained over 3 years. Following the disease progression, TDM-1 was started with a response until the patient developed severe hepatotoxicity as an adverse effect of TDM-1 therapy resulting in its discontinuation. Close follow-up post-treatment-discontinuation demonstrated continued clinical improvement until 6 months, when the patient developed brain metastasis. He passed away a few months later in hospice care. Discussion The metastatic MEC in our patient overexpressed HER-2 Neu. Owing to Trastuzumab and Pertuzumab response, Trastuzumab emtansine (TDM-1) was initiated on a compassionate basis which further extended the survival but had to be terminated owing to adverse effects. Given the paucity of data on targeted therapies in the treatment of metastatic SGNs and the safety, tolerability, and efficacy of TDM-1 therapy among the elderly, further studies are warranted to answer these important questions and to identify eligible patients for this novel treatment option.

The article deals with the current issues of the etiology, pathogenesis and clinical course of Peyronie's disease. The diagnostic possibilities of using ultrasound sonography are demonstrated. The international data on known treatment options for Peyronie's disease are reviewed. The author describes his own user experience of the Peyroflex® at an early stage of the disease and gives a preliminary assessment of its effectiveness.

Zusammenfassung Klinisches/methodisches Problem Technische Fortschritte auf dem Gebiet der spinalen interventionellen Neuroradiologie ermöglichen es, eine breite Palette an gezielten, minimal-invasiven Behandlungsoptionen einschließlich der spinalen Ozontherapie beim Rückenschmerz anzuwenden. Dieser Beitrag gibt eine Übersicht der biochemischen, molekularen, immunologischen und pharmazeutischen Mechanismen sowie Applikationstechniken der gezielten Ozontherapie. Radiologische Standardverfahren Zum Einsatz kommen die Computertomographie (CT) sowie konventionelle Röntgenaufnahmen (Durchleuchtung). Leistungsfähigkeit Die CT-gesteuerten Interventionen (epidural, periradikuläre, Facettengelenk und intradiskal) haben den höchsten Stellenwert und haben sich historisch durchgesetzt. Durchleuchtungsgesteuerte Verfahren können ebenfalls eingesetzt werden. Schlussfolgerung Die Ozontherapie liefert vielversprechende Ergebnisse. Der Beitrag soll dazu dienen, Informationen über die Grundlagen dieser Technik(en) zu vermitteln.

Background Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors releasing catecholamines. Metastatic pheochromocytomas/paragangliomas (PPGLs) occur in about 5–26% of cases. To date, the management of patients affected by metastatic disease is a challenge in the absence of guidelines. Aim The aim of this study was to evaluate the overall survival (OS) and the progression-free survival (PFS) in metastatic PPGLs. Methods Clinical data of 20 patients referred to the Careggi University Hospital (Florence, Italy) were retrospectively collected. Follow-up ranged from 1989 to 2019. Site and size of primary tumor, biochemical activity, genetic analysis and employed therapies were considered. Data were analyzed with SPSS version 27. Results Nine PHEOs (45%) and 11 PGLs (55%) were enrolled. Median age at diagnosis was 43.5 years [30–55]. Mean follow-up was 104.6 ± 89.3 months. Catecholamines were released in 70% of cases. An inherited disease was reported in 50% of patients. OS from the initial diagnosis (OSpt) and from the metastatic appearance (OSmtx) were lower in older patients (OSpt p = 0.028; OSmtx p p = 0.007; OSmtx p = 0.041), larger tumors (OSpt p = 0.008; OSmtx p = 0.025) and sporadic disease (OSpt p = 0.013; OSmtx p = 0.008). Conclusion Our data showed that older age at the initial diagnosis, sympathetic extra-adrenal localization, larger tumors and wild-type neoplasms are related to worse prognosis. Notably, the employed therapies do not seem to influence the survival of our patients. At present, effective treatments for metastatic PPGLs are missing and a multidisciplinary approach is indispensably required.

Chronic graft-versus-host disease (cGVHD) is one of the major causes of late mortality after allogenic hematopoietic stem cell transplantation. Moderate-to-severe cGVHD is associated with poor health-related quality of life and substantial disease burden. While corticosteroids with or without calcineurin inhibitors comprise the first-line treatment option, the prognosis for patients with steroid-refractory cGVHD (SR-cGVHD) remains poor. The mechanisms underlying steroid resistance are unclear, and there are no standard second-line treatment guidelines for patients with SR-cGVHD. In this review, we provide an overview on current treatment options of cGVHD and use a series of theoretical case studies to elucidate the rationale of choices of second- and third-line treatment options for patients with SR-cGVHD based on individual patient profiles.

Distraction osteogenesis is a viable treatment option for patients with a cleft associated with severe maxillary retrusion. A rigid external distraction device and a hybrid internal maxillary distractor have been used to advance the maxilla allowing for predictable and stable results. These techniques can be applied by itself or as an adjunct to traditional orthognathic procedures. The technical aspects are presented. These procedures tend to be simpler and demonstrate great stability compared to traditional surgical methods. The reasons for stability are discussed.

Treatment options for dialysis access steal syndrome (DASS) include distal revascularization with interval ligation (DRIL), proximalization of arterial inflow (PAI), access banding, and access ligation. This study examines the efficacy of DRIL in treating DASS and reports short-term bypass patency, access patency, and wound infection rates.A retrospective analysis was performed on adults diagnosed with DASS following hemo-dialysis access creation who underwent DRIL procedures between January 1, 2009 and May 11, 2017. Patients18 years and those with lower extremity accesses or HeRO grafts that developed DASS were excluded. Data was obtained using electronic medical records and analyzed using SPSS software. Residual steal was defined as reintervention for DASS within 60 days of DRIL. Recurrent steal was defined as reintervention beyond 60 days.Eighty-nine DRIL procedures were performed for correction of DASS. Population included 59.6% female (n = 53), 47.2% current/former smokers (n = 42), 76.4% diabetic (n = 68), and 79.8% AVF (n = 71). Symptom resolution was complete for 69.7% (n = 62), and partial for 25.8% (n = 23), with no improvement in 4.5% (n = 4). Following DRIL, mean DBI improved from 0.43 to 0.67 (P= 0.002). Mean steal classification improved from 3.04 to 0.64 (P0.001). Five patients required a subsequent procedure for DASS symptoms - 3 for residual steal and 2 for recurrent steal. Bypass patency at 6 months post DRIL was 93.3% (n = 83) primary, 97.8% (n = 87) primary-assisted, and 100% (n = 89) secondary patency. Access patency at 6 months post DRIL was 78.7% (n = 70) primary, 91% (n = 81) primary-assisted, and 94.4% (n = 84) secondary. Twenty-one patients (23.5%) had 24 cases of surgical site infections, with 70.8% (n = 17) occurring at the saphenectomy site. Wound infections re-solved within 60 days postoperatively in 23 out of 24 patients.DRIL is highly effective in relieving symptoms of DASS and has excellent rates of short-term access and bypass patency. However, consideration must be given to the high wound infection rate and the potential need for subsequent procedures.

The current recommendation to stop colorectal cancer screening for older adults is based on a lack of evidence due to systematic exclusion of this population from trials. Older adults are a heterogenous population with many available strategies for patient-centered assessment and decision-making. Evolutions in management strategies for colorectal cancer have made safe and effective options available to older adults, and the rationale to screen for treatable disease more reasonably, especially given the aging Canadian population. In this commentary, we review the current screening guidelines and the evidence upon which they were built, the unique considerations for screening older adults, new treatment options, the risks and benefits of increased screening and potential considerations for the new guidelines.

Objective To propose a first-aid management protocol for myiasis in neglected cutaneous squamous cell carcinoma (SCC) in the ED based on a recent literature review. Data sources PubMed. Study selection Inclusion criteria were all series and case reports of primary/secondary cutaneous SCC with myiasis of the head and neck, including orbital SCC cases, published after 2005. Data extraction A total of 14 articles including 15 patients were included. Data synthesis Demographics, socioeconomic situation, site of the lesion, larvae species with bacterial suprainfection, and first-aid treatment options were discussed. Two representative cases are described. Conclusions Large, ulcerated, necrotic, myiasis-burdened SCC lesions in the head and neck area present a challenge for treatment, and to date, no consensus regarding first-aid management exists. The authors' proposed four-pillar first-aid management scheme may be a valid option to rapidly improve wound condition through disinfection, pain relief, and malodor and discharge eradication as a bridge to surgery.