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Many lung transplants fail due to chronic lung allograft dysfunction (CLAD). We recently showed that transbronchial biopsies (TBBs) from CLAD patients manifest severe parenchymal injury and dedifferentiation, distinct from time-dependent changes. The present study explored time-selective and CLAD-selective transcripts in mucosal biopsies from the third bronchial bifurcation (3BMBs), compared to those in TBBs.We used genome-wide microarray measurements in 324 3BMBs to identify CLAD-selective changes as well as time-dependent changes and develop a CLAD classifier. CLAD-selective transcripts were identified with linear models for microarray data (limma) and were used to build an ensemble of 12 classifiers to predict CLAD. Hazard models and random forests were then used to predict the risk of graft loss using the CLAD classifier, transcript sets associated with rejection, injury, and time.T cell-mediated rejection and donor-specific antibody were increased in CLAD 3BMBs but most had no rejection. Like TBBs, 3BMBs showed a time-dependent increase in transcripts expressed in inflammatory cells that was not associated with CLAD or survival. Also like TBBs, the CLAD-selective transcripts in 3BMBs reflected severe parenchymal injury and dedifferentiation, not inflammation or rejection. While 3BMBs and TBBs did not overlap in their top 20 CLAD-selective transcripts, many CLAD-selective transcripts were significantly increased in both for example LOXL1, an enzyme controlling matrix remodeling. In Cox models for one-year survival, the 3BMB CLAD-selective transcripts and CLAD classifier predicted graft loss and correlated with CLAD stage. Many 3BMB CLAD-selective transcripts were also increased by injury in kidney transplants and correlated with decreased kidney survival, including LOXL1.Mucosal and transbronchial biopsies from CLAD patients reveal a diffuse molecular injury and dedifferentiation state that impacts prognosis and correlates with the physiologic disturbances. CLAD state in lung transplants shares features with failing kidney transplants, indicating elements shared by the injury responses of distressed organs.

INTRODUCTION Anterior glenohumeral bone loss reconstruction reduces failure rates after soft tissue surgery in patients with large glenoid bone defects. Multiple bone block techniques have been described, most with metal hardware fixation. The objective of this study is to evaluate the safety, as well as the short-term functional and radiological results of an arthroscopic bone block metal-free fixation or bone block cerclage. MATERIAL AND METHODS Retrospective study of patients with glenohumeral instability and>15% glenoid bone loss operated during 2019 with follow-up of at least 12 months. Radiography and computerized tomography studies were performed. Functional outcomes were evaluated before and after surgery with the Western Ontario Shoulder Instability Index and Rowe score. RESULTS A total of 21 patients with a median age of 30.6 (SD 7.1) were included. All showed radiographic consolidation at 3 months follow-up. A percentage of 90.4 of bone grafts presented osteolysis at peripherical areas and 95.2% revealed consolidation in the areas with contact to the glenoid. The median glenoid estimated surface went from 79.3% before surgery to 98.4% at 12 months. Functional scores were statically significant (P

Background Outcomes after lung retransplantation (LRT) remain inferior compared with primary lung transplantation (PLT). This study examined the impact of center volume on 1-year survival after LRT. Methods Using the United Network for Organ Sharing database, the study abstracted patients undergoing PLT and LRT between January 2006 and December 2017, excluding combined heart-lung transplants and multiple retransplants. One-year survival rates after PLT and LRT were compared using propensity score matching. In the LRT cohort, multivariable Cox models with and without time-dependent coefficients were fitted to examine association between transplant center volume and 1-year survival. Center volume was categorized on the basis of inspection of restricted cubic splines. Results A total of 20,675 recipients (PLT 19,853 [96.0%] vs LRT 822 [4.0%]) were included. One-year survival was lower for LRT recipients in the matched cohort (PLT 84.8% vs LRT 76.7%). There was steady improvement in 1-year survival after LRT (2006 to 2009 72.1% vs 2010 to 2013 76.6% vs 2014 to 2017 80.1%). Higher center volume was associated with better 1-year survival after LRT. This survival difference was noted in the initial 30 days after transplantation (intermediate vs low volume hazard ratio, 0.282 [95% confidence interval, 0.151 to 0.526]; high vs low volume hazard ratio, 0.406 [95% confidence interval, 0.224 to 0.737]), but it became insignificant after 30 days. Conclusions Superior 1-year survival after LRT at higher-volume centers is predominantly the result of better 30-day outcomes. This finding suggests that LRT candidates may be referred to higher-volume centers for surgery.

Introduction. Oral mucositis is one of the earliest and most frequent complications of radiation therapy or chemotherapy in patients diagnosed with oropharyngeal cancer. Because of this pathology, therapeutic interventions are most often used, thereby poor treatment is considered an etiological factor of oral mucositis. Now, this issue is being actively studied in the world, but a unified algorithm for treatment and prevention of oral mucositis has not been formed.The study objective – is to evaluate the effect of titanium glycerosolvate aquacomplex in reducing the intensity of radiation induced reactions and reducing the frequency of interruptions.Materials and methods. 52 patients diagnosed with oropharyngeal cancer were included in this study, treated with radiotherapy or chemotherapy. For prophylaxis of severe stages of oral mucositis, 32 patients underwent standard symptomatic therapy (group 1, control group); 20 patients took titanium glycerosolvate aquacomplex in accordance with symptomatic therapy (group 2).Results. In the group 1 only 61.7 % of patients completed treatment. In the group 2 80 % of patients completely underwent antitumor therapy. At the same time, they developed oral mucositis of the I–II degree. Also, in the group of the studied drug, in 100 % of cases, therapy was performed without interruptions.Conclusion. Using titanium glycerosolvate aquacomplex for the prophylaxis of severe stages of oral mucositis during radiotherapy or chemotherapy of oropharyngeal cancer is effective and safe. It is also convenient from the medical and economic side, thanks to the ability to use it on an outpatient basis.

Although the majority of patients with sinus headache do not have rhinosinusitis, many patients will unnecessarily undergo work-up and treatment for rhinosinusitis. This leads to a significant cost burden to the healthcare system. In the era of value-based care, more effective management paradigms need to be developed for sinus headache.Recent efforts to classify nonrhinogenic headache, namely the International Classification of Orofacial Pain, have served as an important step in advancing our understanding of this heterogeneous condition. In addition, a review of the literature points to certain clinical features that may allow for the identification of nonrhinogenic headache based on history.A greater understanding of nonrhinogenic headache as well as innovative tools to differentiate rhinogenic from nonrhinogenic headache are needed to change the paradigm in the management of patients with sinus headache.

Background Endoscopic sinus surgery is a well-established treatment for chronic rhinosinusitis in patients with cystic fibrosis, though its benefits seem to be limited to improving sinonasal symptoms rather than affecting lung function. Objective This study aims to identify clinical and demographic factors that may influence sinonasal and pulmonary outcomes after surgery. Methods This is a six-year retrospective analysis of adult cystic fibrosis patients who underwent endoscopic sinus surgery at a tertiary care center. 22-Item Sino-Nasal Outcomes Test scores and mean forced expiratory volume data at baseline and three to six months after surgery were analyzed using t-test and stepwise regression with the following covariates: age, gender, lung transplant, revision surgery, and pseudomonas on sinus culture. Results 119 surgeries were performed on 88 patients, with 69% on patients with transplant. The overall mean (Standard Deviation) improvement in 22-Item Sino-Nasal Outcomes Test score was 9.42 (18.15) for the entire cohort ( P Conclusion Although surgery was associated with a clinically and statistically significant improvement in sinonasal scores in cystic fibrosis patients, patients with pseudomonas may experience less benefit. Revision surgery and older age may be associated with less favorable pulmonary outcomes. Awareness of such variables may help when deciding which cystic fibrosis patients should undergo surgery.

BACKGROUND: Mechanical ventilation immediately after lung transplantation may impact the development of primary graft dysfunction (PGD), particularly in cases of donor-recipient size mismatch as ventilation is typically based on recipient rather than donor size. METHODS: We conducted a retrospective cohort study of adult bilateral lung transplant recipients at our center between January 2010 and January 2017. We defined donor-based lung protective ventilation (dLPV) as 6 to 8 ml/kg of donor ideal body weight and plateau pressure

Background Pulmonary embolism (PE) is unexpectedly detected in some donor lungs during organ procurement for lung transplantation. Anecdotally, such lungs are usually implanted; however, the impact of this finding on recipient outcomes remains unclear. We hypothesized that incidentally detected donor PE is associated with adverse short-term and long-term outcomes among lung transplant recipients. Methods We analyzed a prospectively maintained database of all lung donors procured by a single surgeon and transplanted at our institution between 2009 and 2018. A standardized approach was used for all procurements and included antegrade and retrograde flush. Pulmonary embolism was defined as macroscopic thrombus seen in the pulmonary artery during the donor procurement operation. Results A total of 501 consecutive lung procurements were performed during the study period. The incidence of donor PE was 4.4% (22 of 501). No organs were discarded owing to PE. Donors with PE were similar to donors without PE in baseline characteristics and Pa o 2. Recipients in the two groups were also similar. Pulmonary embolism was associated with a higher likelihood of acute cellular rejection grade 2 or more (10 of 22 [45.5%] vs 120 of 479 [25.1%], P = .03). Multivariable Cox modeling demonstrated an association between PE and the development of chronic lung allograft dysfunction (hazard ratio 2.02; 95% confidence interval, 1.23 to 3.30; P = .005). Conclusions Lungs from donors with incidentally detected PE may be associated with a higher incidence of recipient acute cellular rejection as well as reduced chronic lung allograft dysfunction-free survival. Surgeons must use caution when transplanting lungs with incidentally discovered PE. These preliminary findings warrant corroboration in larger data sets.

Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality. Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure. A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory. Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface. Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way. An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author’s preferred surgical technique for arthroscopic posterior bone block.

The majority of patients with Crohn's disease and a proportion of patients with ulcerative colitis will ultimately require surgical treatment despite advances in diagnosis, therapy, and endoscopic interventions. The surgical procedures that are most commonly done include bowel resection with anastomosis, strictureplasty, faecal diversion, and ileal pouch. These surgical treatment modalities result in substantial alterations in bowel anatomy. In patients with inflammatory bowel disease, endoscopy plays a key role in the assessment of disease activity, disease recurrence, treatment response, dysplasia surveillance, and delivery of endoscopic therapy. Endoscopic evaluation and management of surgically altered bowel can be challenging. This consensus guideline delineates anatomical landmarks and endoscopic assessment of these landmarks in diseased and surgically altered bowel.

Aims Pre-diabetes is a common condition that affects about 16.4% of Australian adults. Hyperglycaemia is a strong risk factor for the development of stroke. Metformin XR is an approved medication to treat type 2 diabetes in Australia but not pre-diabetes. Additionally, whether it is tolerated following a stroke is unclear. In this pilot study, we aimed to assess the feasibility of Metformin XR in people with stroke and pre-diabetes. Methods In this PROBE design trial, people who had recent stroke (within 3 months) with pre-diabetes were randomized to either the active arm (n = 13) receiving usual care plus Metformin XR (500 mg daily increased to a total daily dose of 1500 mg) or the control group receiving only usual care (n = 13). At baseline & after four months of intervention, clinical and biomedical characteristics, cardiovascular risk factors and medication data were recorded. At one month and 2.5 months into the study, compliance rate and side effects were determined. Results This trial showed that it is feasible to recruit, retain and monitor participants. However, the compliance rate was low. Adherence to metformin XR was 52% (IQR:42% to 61%) based on the remaining tablets in the container after 4 months of intervention. None of the reported side effects were deemed to be related to the study treatment and no significant differences were observed between the metformin XR and the control group. Conclusion Treatment with Metformin XR in participants admitted with stroke and with pre-diabetes is feasible and safe. Strategies are needed to improve adherence in future trials.

Summary Introduction Endonasal dacryocystorhinostomy (DCR) is a surgical procedure that aims to increase tear drainage to treat epiphora caused by nasolacrimal obstruction by creating a bypass through the bone between the lacrimal sac and the nasal cavity. A silicone stent is temporarily put in place for 2 months to avoid early obstruction of the rhinostomy. One of the causes of surgical failure is related to progressive stenosis of intranasal ostium, due to fibrosis and new bone growth, inducing a relapse of epiphora and/or dacryocystitis. Few studies have described changes in the size of the intranasal ostium on direct post-DCR measurement or kinetics of its shrinkage. The purpose of this study is to determine whether changes in the size of intranasal ostium might be a predictor of final functional efficacy. Materials and methods A prospective cohort of eighteen consecutive patients undergoing endonasal DCR for chronic epiphora or chronic dacryocystitis between January 2017 and April 2018 was analyzed. Eight patients who underwent bilateral DCR, and twenty-six intranasal ostia were finally analyzed. Follow-up took place every two months for 1 year, with the silicone tube removed at 2 months. Functional success was defined as absence of recurrent epiphora or dacryocystitis. Ostium size was systematically measured on photos taken during intranasal endoscopy performed every 2 months for 1 year. Results At 2 months after endonasal DCR, 23 of the 26 ostia (88.5%) were functional, but only 19 (73.1%) of them were directly measurable. The mean horizontal diameter at 2 months was 1.44 (SD 0.61) mm, and the mean vertical diameter was 0.86 (SD 0.37) mm, which corresponded to a mean area of 10 (SD 0.84) mm2. We noted a statistically significant decrease in ostium size and area between 2 and 4 months after the procedure (P −0.001), followed by a stabilization period with no statistical correlation between the size of the ostium and its final functional efficacy. At 6 months after DCR, of the 7 ostia that were not initially measurable, 3 were immediately non-functional at 2 months, 3 had a relapse of epiphora at 4 months, and 1 had a relapse of dacryocystitis at 6 months, i.e., 100% clinical failures at 6 months. The other procedures all remained functional after 1 year of follow-up. Conclusion The intranasal ostium of an endonasal DCR shrinks significantly within the 2 months after removal of the silicone tube and remains stable thereafter. There is no correlation between the size or area of intranasal ostium and its final functional efficacy. However, when the ostium is not measurable at the time of 2-month stent removal, all patients experienced a relapse of epiphora or dacryocystitis within 6 months.

Rejection is a major complication following lung transplantation. Acute cellular rejection (ACR), and antibody-mediated rejection (AMR) are risk factors for the subsequent development of chronic lung allograft dysfunction and worse outcomes after transplantation. Although ACR has well-defined histopathologic diagnostic criteria and grading, the diagnosis of AMR requires a multidisciplinary diagnostic approach. This article reviews the identification, clinical and pathologic features of, and therapeutic options for ACR and AMR.

BACKGROUND We previously developed molecular assessment systems for lung transplant transbronchial biopsies (TBBs) with high surfactant and bronchial mucosal biopsies, identifying T-cell‒mediated rejection (TCMR) on the basis of the expression of rejection-associated transcripts, but the relationship of rejection to graft loss is unknown. This study aimed to develop molecular assessments for TBBs and mucosal biopsies and to establish the impact of molecular TCMR on graft survival. METHODS We used microarrays and machine learning to assign TCMR scores to an expanded cohort of 457 TBBs (367 high surfactant plus 90 low surfactant) and 314 mucosal biopsies. We tested the score agreement between TBB–TBB, mucosal–mucosal, and TBB–mucosal biopsy pairs in the same patient. We also assessed the association of molecular TCMR scores with graft loss (death or retransplantation) and compared it with the prognostic associations for histology and donor-specific antibodies. RESULTS The molecular TCMR scores assigned in all the TBBs performed similarly to those in high-surfactant TBBs, indicating that variation in alveolation in TBBs does not prevent the detection of TCMR. Mucosal biopsy pieces showed less piece-to-piece variation than TBBs. TCMR scores in TBBs agreed with those in mucosal biopsies. In both TBBs and mucosal biopsies, molecular TCMR was associated with graft loss, whereas histologic rejection and donor-specific antibodies were not. CONCLUSIONS Molecular TCMR can be detected in TBBs regardless of surfactant and in mucosal biopsies, which show less variability in the sampled tissue than TBBs. On the basis of these findings, molecular TCMR appears to be an important predictor of the risk of future graft failure. Trial registration ClinicalTrials.gov NCT02812290.

Background Endoscopic sinus surgery (ESS) is an effective intervention for patients with medically refractory chronic rhinosinusitis. Frontal sinusotomy is the most challenging part of ESS, with one of the key outcomes being access for topical irrigations. Objective The purpose of this study is to compare irrigation penetration into the frontal sinus following Draf IIa versus modified Draf IIa frontal sinusotomy. Methods Four fresh cadaver heads were used in this experiment. Draf IIa was performed on one side of each head and a modified Draf IIa on the contralateral side. This proposed modification consists of a Draf IIa combined with an agger nasi punch-out procedure and partial trimming of the vertical lamella of the middle turbinate back to the posterior table of the frontal sinus without drilling the beak. Each head was irrigated with methylene blue-dyed water and recorded by rigid endoscopy through an endonasal view (EV) of the frontal sinus and frontal trephination view (TV). Two blinded rhinologists scored the extent of staining (using an ordinal scale of 0 to 3) for each side. A case report where the modified Draf IIa was performed is also described. Results After modified Draf IIa sinuosotomy, the mean score for the EV was 2.125 and for the TV was 2, versus 0.875 and 0.625 for traditional Draf IIa, respectively. There was a statistically significant increase for both EV (p = 0.019) and TV (p = 0.018) after modified Draf IIa. Conclusion In our cadaveric model, this procedural modification improved penetration of postoperative irrigations into the frontal sinus. This simple technique may be easily adapted into frontal ESS when indicated.

The Latarjet technique is a widely used technique for anterior shoulder instability with glenoid bone defects, irreparable capsuloligamentous lesion, or in patients at greater risk of recurrence. The use of this technique has been reported to obtain satisfactory clinical and biomechanical results. Although other methods exist, the coracoid process is typically fixed with 2 metal screws. Complications related to metal fixation are very frequently reported. In an attempt to avoid these complications, we developed this arthroscopically assisted metal-free Latarjet technique in which we fix a coracoid graft using four cerclage tapes to achieve a strong, stable fixation, thus mimicking a plate.

BACKGROUND Keratosis pilaris (KP) is a common hereditary keratinization disorder. Keratosis pilaris rubra and KP atrophicans faciei are less frequent variants of the disease. Topical treatments often yield ineffective and temporary results. OBJECTIVE The objective of this article is to review and assess all the studies that used light and laser devices to treat KP and its variants. MATERIAL AND METHODS On January 15, 2017, an online search of the MEDLINE, Embase, and Cochrane databases was performed using the following combination of keywords: "keratosis pilaris" and "treatment." RESULTS Seventeen studies related to light and laser treatments were retained for analysis. The total number of treated patients was 175. Of which, 22 patients had KP atrophicans faciei, 17 patients had KP rubra, and 136 patients had KP. CONCLUSION Light and laser devices have been emerging as promising therapeutic options for a disfiguring disease that still lacks, until today, an effective long-term treatment.

Introduction: The aim of this article is to describe our technique of bilateral laparoscopic pyelolithotomy (LP) in a 54-year-old patient with bilateral large stones of which one is a staghorn stone (SS). Case Presentation: The patient's legs were extended and spaced from each other; the table was tilted to the right and to the left in a way to use only five trocars for both sides. The calculi were delivered intact at the end of the procedure. Operating time was 208 minutes. Blood loss was 250 mL. Hospital stay was 3 days. Double-J stents were removed 4 weeks later. The patient was stone free with a stable serum creatinine. Conclusion: This case report is the first to describe a bilateral LP for large and SS. This procedure can minimize the postoperative morbidity and is associated with high stone-free rates. It is safe when done by expert surgeons, but further investigations are required to assess its reproducibility.

Background Recent studies have demonstrated a dramatic increase in the use of balloon sinus dilation (BSD) in the United States. However, the use of BSD specifically in revision sinus surgery has not been investigated. This study addresses the question of how BSD is utilized as a tool in revision sinus surgery. Methods Data from MarketScan (Truven Health) over a 5-year period (2012-2016) were analyzed. Patients who underwent a sinus procedure with a minimum of 2 years of follow-up were included. Results A total of 62,304 patients met inclusion criteria; 6847 (10.99%) underwent revision. Age >55 years, the South geographical region, and medical comorbidities increased the odds of revision on multivariate analysis. For patients undergoing revision, BSD was used 11%, 21%, and 13% of the time for revisions of the maxillary, frontal, and sphenoid sinuses, respectively. For a sinus that underwent revision after an initial BSD, a repeat BSD was done close to 40% of the time. Conclusion BSD is used frequently in the revision setting, especially for the frontal sinus and for patients who had already undergone an initial BSD. Our findings highlight the prevalent role of BSD in revision surgery and the need to evaluate such practices.

Renal cell carcinoma with sarcomatoid dedifferentiation is an entity of RCC that has undergone an anaplastic transformation with both a carcinomatous and a sarcomatous component. The standard treatment in metastatic patients is immunotherapy. The aim of this article is to describe our case of metastatic recurrent RCC with sarcomatoid dedifferentiation in a 59 year old male patient treated with nephrectomy and multiple metastasectomies followed by Cabozantinib. Consecutive PET-CT scans showed no evidence of recurrence, three years after the last metastasectomy, and the patient is having currently a normal life. Sarcomatoid dedifferentiation remains a poor prognosis factor in RCC. Surgery for metastases followed by Cabozantinib may be a therapeutic option in metastatic young patients. However, a prospective randomized trial would be the best option to validate this approach.

Highlights • The occurrence of venous invasion in patients with renal angiomyolipoma is a rare and unique phenomenon. • CT scan is the imaging of choice in case of invasion of vena cava. • Collaboration of the urologist and the vascular surgeon is sometimes mandatory for optimal surgical treatment., Introduction Renal angiomyolipomas (AML) are often regarded as benign tumors. This article reports the case of a 47 year old patient with AML associated with a venous invasion of the inferior vena cava. Presentation of case Our 47 year old male patient presented for flank pain and hematuria. CT Scan revealed a 3 cm lobulated low-density lesion in the renal sinus, middle and upper lobes of the right kidney, with evidence of IVC thrombus on angioscan. Right radical nephrectomy and thrombectomy were successfully done with use of cardiopulmonary bypass. On pathology, AML was confirmed. Discussion Renal AML are unilateral and sporadic in most cases, with a female predominance. The occurrence of venous invasion in patients with AML is a rare and unique phenomenon. CT scan is the imaging of choice in such cases and surgery remains the optimal treatment. Conclusion More focus should be put on the ability of AML to invade venous structures. Early imaging and therapeutic planning are necessary for the best outcome in case of vena cava invasion. Collaboration of the urologist with the vascular surgeon can lead to better surgical results.

Background:High-grade gliomas (HGGs) are aggressive tumors that inevitably recur due to their diffusely infiltrative nature. Intraoperative adjuncts such as 5-aminolevulinic acid (5-ALA) have shown promise in increasing extent of resection. As the prospect of increased use of 5-ALA rises, a systematic overview of the health economics of this adjunct is critical.Methods:Medline, EMBASE, Centre for Reviews and Dissemination, EconPapers, and Cochrane databases were searched for keywords relating to glioma, cost-effectiveness, and 5-ALA. Primary studies reporting on the health economics or cost-effectiveness of 5-ALA compared to white light surgery in HGG were included. Quality was assessed using the British Medical Journal guidelines.Results:Three studies were identified. All were European and conducted from the perspective of national healthcare systems. Two studies demonstrated the cost-utility of 5-ALA compared to white light (C$12,817 and C$13,508/quality-adjusted life-years (QALYs)). One assessed the cost-utility per gross total resection (C$6,813). Both these values were below the national cost-effectiveness thresholds for each respective study. The third study demonstrated no significant difference in cost of 5-ALA in glioblastoma resection (C$14,732) compared to prior to its routine use (C$15,936). The quality of these studies ranged from moderate to average. None of these studies considered patient perspective or indirect costs in their analysis.Conclusions:Growing evidence exists examining the health economic benefit of 5-ALA as an intraoperative adjunct for HGG resection. Additional studies within the Canadian context using 5-ALA, specifically incorporating patient and societal perspectives into the cost-utility analyses, are necessary to solidify this line of evidence.

BACKGROUND An association between bariatric surgery and development of de-novo inflammatory bowel disease (IBD) has been observed. AIM To evaluate further the association among bariatric surgery, weight loss medications, obesity and new-onset IBD. METHODS Using Explorys, a population-based Health Insurance Portability and Accountability Act compliant database, we estimated the prevalence of de-novo IBD among patients treated with bariatric surgery (Roux-en-Y gastrojejunostomy, laparoscopic sleeve gastrectomy or gastric banding) (n = 60 870) or weight loss medications (orlistat, phentermine/topiramate, lorcaserin, bupropion/naltrexone and liraglutide) (n = 193 790) compared with obese controls (n = 5 021 210), between 1999 and 2018. RESULTS The prevalence of de-novo IBD was lower among obese patients exposed to bariatric surgery (7.72 per 1000 patients) or weight loss medications (7.22 per 1000 patients) compared with patients with persistent obesity not exposed to these interventions (11.66 per 1000 patients, P < 0.0001). The risk reduction for de-novo IBD was consistent across bariatric surgeries and weight loss medications with the exception of orlistat which was not associated with a reduction in risk for de-novo IBD compared with the persistent obese control cohort. CONCLUSION Obese patients undergoing treatment with bariatric surgery or weight loss medications are at a lower risk for developing de-novo IBD compared with persistently obese controls not exposed to these interventions. These data suggest that obesity and ineffective management of obesity are risk factors for de-novo IBD. Further research is needed to confirm these observations and understand potential mechanisms.

Background Chronic subdural hematoma (cSDH) is an increasingly common condition due to the growing use of anticoagulation. Currently, there remains a lack of evidence to guide the optimal timing of anticoagulant reinitiation for stroke prevention in atrial fibrillation after cSDH evacuation. We aimed to better understand the perceived risks of hemorrhagic and embolic complications along with current practice patterns on restarting anticoagulation after surgical evacuation of cSDH. Methods We conducted a survey of Canadian neurosurgeons and stroke neurologists using a novel self-administered questionnaire using clinical cases that included questions on clinical experience, practice setting, practice patterns, and perceptions on stroke/bleeding risk with anticoagulation reinitiation after cSDH evacuation. The instrument was evaluated for clinical sensibility by 5 neurosurgeons, neurologists, and intensivists. Results The response rate after 4 mailings was 40% for neurosurgeons (55/136) and 21% for stroke neurologists (26/122). Almost all participants would restart anticoagulation for stroke prevention in atrial fibrillation after cSDH evacuation (91.8% in low-risk patients, 98.6% in high-risk patients). Time to reinitiation of anticoagulation varied considerably, particularly for high-risk patients where 36% of participants would restart anticoagulation within 1 week of surgery, 44% between 1 and 4 weeks after surgery, and 19% after 4 weeks postoperatively. The perceived risk of stroke and SDH reaccumulation varied considerably among participants and was dependent on timing of anticoagulation reinitiation. Conclusions There is considerable variation in current practice patterns and perceived risks of embolic and hemorrhagic complications with anticoagulation reinitiation after cSDH evacuation. These results demonstrate clinical equipoise that warrant further targeted investigation in large-scale randomized controlled trials.

Urethral stones are a very rare form of urolithiasis, they most often originate from the upper urinary tract or bladder, and are rarely formed primarily in the urethra, it is formed on a urethral anatomical pathology in the majority of cases. The clinical symptomatology is very variable ranging from simple dysuria with penile pain to acute retention of urine. Smaller stones can be expelled spontaneously without intervention, but larger stones or complicated stones or those developed on an underlying urethral anatomical pathology require surgical treatment. The minimally invasive treatment should be the preferred route for the surgical treatment of this disease when feasible. We report the case of a young man with no particular pathological history who presented to the emergency department for acute retention of urine secondary to a primary fossa navicularis calculus, through this case, we discuss the different clinical aspects, etiology, pathogenesis, diagnosis and therapy of urethral stone in men.

BACKGROUND Respiratory viral infections can increase the risk of chronic lung allograft dysfunction after lung transplantation, but the mechanisms are unknown. In this study, we determined whether symptomatic respiratory viral infections after lung transplantation induce circulating exosomes that contain lung-associated self-antigens and assessed whether these exosomes activate immune responses to self-antigens. METHODS Serum samples were collected from lung transplant recipients with symptomatic lower- and upper-tract respiratory viral infections and from non-symptomatic stable recipients. Exosomes were isolated via ultracentrifugation; purity was determined using sucrose cushion; and presence of lung self-antigens, 20S proteasome, and viral antigens for rhinovirus, coronavirus, and respiratory syncytial virus were determined using immunoblot. Mice were immunized with circulating exosomes from each group and resulting differential immune responses and lung histology were analyzed. RESULTS Exosomes containing self-antigens, 20S proteasome, and viral antigens were detected at significantly higher levels (p < 0.05) in serum of recipients with symptomatic respiratory viral infections (n = 35) as compared with stable controls (n = 32). Mice immunized with exosomes from recipients with respiratory viral infections developed immune responses to self-antigens, fibrosis, small airway occlusion, and significant cellular infiltration; mice immunized with exosomes from controls did not (p < 0.05). CONCLUSIONS Circulating exosomes isolated from lung transplant recipients diagnosed with respiratory viral infections contained lung self-antigens, viral antigens, and 20S proteasome and elicited immune responses to lung self-antigens that resulted in development of chronic lung allograft dysfunction in immunized mice.