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Background: It is unclear whether parathyroidectomy guided by intraoperative parathormone (PTH) monitoring is predictive of operative success in patients with normohormonal hyperparathyroidism (nhHPT), a variant of primary hyperparathyroidism (pHPT) in which patients develop clinical manifestations similar to those of pHPT. This study examined intraoperative PTH monitoring in patients undergoing parathyroidectomy for nhHPT. Methods: We performed a retrospective review of prospectively collected data from adult (age > 18 yr) patients who underwent parathyroidectomy for pHPT at 1 of 2 North American medical centres (in Calgary, Alberta, Canada, or Miami, Florida, United States) between 2007 and 2015. In patients with nhHPT, we used the criterion of an intraoperative decrease of more than 50% in PTH after abnormal gland excision. We defined operative success as continuous eucalcemia more than 6 months after parathyroidectomy. Results: Of 333 patients, 38 (11.4%) had nhHPT, with mean preoperative calcium and PTH levels of 2.7 mmol/L and 53 pg/dL, respectively. An intraoperative decrease of more than 50% in PTH level was seen in 27 patients (71.0%) with nhHPT and 265 patients (89.8%) with classic pHPT at 5 minutes (p < 0.001); the corresponding values at 20 minutes were 35 (92.1%) and 286 (96.9%). Although 5 patients (13.2%) with nhHPT did not reach this criterion until 20 minutes, the rate of operative success was still 97.0% at long-term follow-up (mean 13 mo, range 6-67 mo). Of the 38 patients, 3 (7.9%) did not have an intraoperative decrease of more than 50% in PTH level by 20 minutes. Two of the 3 achieved operative success and remained normocalemic, and 1 developed recurrent disease at 12 months. Conclusion: Parathyroidectomy guided by intraoperative PTH monitoring accurately predicted operative success in patients with nhHPT. Intraoperative PTH monitoring may also help identify multiglandular disease in patients with nhHPT, using criteria similar to those in classic pHPT, with comparable operative success. Contexte : On ne sait pas si la parathyroidectomie guidee par la surveillance peroperatoire de la parathormone (PTH) permet de predire le succes operatoire chez les patients atteints d'hyperparathyroidie normo-hormonale (nhHPT), une variante de l'hyperparathyroidie primaire (pHPT) qui entraine chez les patients des manifestations cliniques similaires a celles de la pHPT. Cette etude a exa mine la surveillance peroperatoire de la PTH chez des patients subissant une parathyroidectomie pour une nhHPT. Methodes : Nous avons effectue une revue retrospective des donnees recueillies prospectivement aupres de patients adultes (> 18 ans) ayant subi une parathyroidectomie pour une pHPT a l'un ou l'autre de 2 centres medicaux nord-americains (a Calgary, en Alberta, au Canada, et a Miami, en Floride, aux Etats-Unis) entre 2007 et 2015. Chez les patients atteints de nhHPT, nous avons utilise le critere d'une diminution peroperatoire de plus de 50 % de la PTH apres l'ablation de la glande anormale. Le critere de succes operatoire consistait en une eucalcemie continue plus de 6 mois apres la parathyroidectomie. Resultats : Sur 333 patients, 38 (11,4 %) avaient une nhHPT, avec des taux moyens de calcium et de PTH preoperatoires de 2,7 mmol/L et 53 pg/dL, respectivement. Une diminution peroperatoire de plus de 50 % du niveau de PTH a ete observee chez 27 patients (71,0 %) avec nhHPT et 265 patients (89.8 %) avec pHPT classique a 5 minutes (p < 0,001); les valeurs correspondantes a 20 minutes etaient 35 (92,1 %) et 286 (96,9 %). Bien que 5 patients (13,2 %) avec nhHPT n'aient pas atteint ce critere avant 20 minutes, le taux de succes operatoire etait encore de 97,0 % lors du suivi a long terme (moyenne 13 mois, intervalle 6-67 mois). Sur les 38 patients, 3 (7,9 %) n'ont pas eu de diminution peroperatoire de plus de 50 % du taux de PTH avant 20 minutes. Pour 2 de ces 3 patients, l'operation a reussi; ils sont demeures normocalcemiques. L'autre patient a developpe une maladie recurrente a 12 mois. Conclusion : La parathyroidectomie guidee par la surveillance peroperatoire de la PTH a permis de predire avec precision le succes operatoire chez les patients atteints de nhHPT. La surveillance peroperatoire de la PTH peut egalement aider a detecter une maladie multiglandulaire chez les patients atteints de nhHPT, par l'utilisation de criteres similaires a ceux de la pHPT classique, avec succes operatoire comparable., Primary hyperparathyroidism (pHPT) affects about 50 per 100 000 people annually, and its clinical manifestations have adverse effects on bone, kidney and cognitive function. (1), (2) With the advent of [...]

Author(s): Priyanka Pavithran (corresponding author) [1] Sir, Charcot Marie Tooth (CMT) disease is the most common neuromuscular disorder.[sup.[1]] CMT is a sensorineural peripheral polyneuropathy. Anaesthetic management of patients with CMT [...]

Byline: Revikrishnan. Sreekumar, Ajay. Hrishi, Manikandan. Sethuraman Patients undergoing complex intracranial neurovascular procedures continue to have a high mortality rate. Individualised goal-directed cerebral resuscitation employing multimodality neuromonitoring may impact these [...]

Dialysis adequacy for pediatric patients has largely followed the trends in adult dialysis by judging the success or adequacy of peritoneal or hemodialysis with urea kinetic modeling. While this provides a starting point to establish a dose of dialysis, it is clear that urea is only part of the picture. Many clinical parameters and interventions now have been identified that are just as impactful on mortality and morbidly as urea clearance. As such, our concept of adequacy is evolving to include non-urea parameters and assessing the impact that following an 'adequate therapy' has on patient lives. As we move to a new era, we consider the impact these therapies have on patients and how it affects the quality of their lives; we must take these factors into consideration to achieve a therapy that is not just adequate, but livable., Author(s): Linda Ding [sup.1] , James Johnston [sup.1] , Maury N. Pinsk [sup.1] Author Affiliations: (1) grid.21613.37, 0000 0004 1936 9609, Department of Pediatrics and Child Health, University of Manitoba, [...]

Background: Acetabular component malposition is a major cause of dislocation following total hip arthroplasty (THA). Intellijoint HIP is an imageless navigation tool that has been shown to provide accurate intraoperative measurement of cup position during primary THA without substantially increasing operative time. However, its accuracy in revision THA has not been evaluated. This study therefore aims to assess the accuracy of Intellijoint HIP in measuring cup inclination and anteversion in comparison with computed tomography (CT) during revision THA. Methods: Intellijoint HIP was used to measure the position of the preexisting cup in 53 consecutive patients undergoing revision THA between December 2018 and February 2020. Two authors blinded to the intraoperative navigation measurements also independently measured cup position using preoperative CT according to Murray's radiographic definitions. Pearson correlation coefficients with 95% confidence intervals (CIs), paired t tests and Bland-Altman plots were used to assess agreement between navigation-and CT-measured cup position. Statistical analysis was performed using GraphPad Prism, with p values less than 0.05 indicating statistical significance. Results: There was excellent agreement between navigation and CT measurements for both cup inclination (r = 0.89, 95% CI 0.81-0.93) and anteversion (r = 0.93, 95% CI 0.88-0.96), with the mean absolute difference being 5.2[degrees] (standard deviation [SD] 4.0[degrees]) for inclination and 4.8[degrees] (SD 5.4[degrees]) for anteversion. The navigation measurement was within 10[degrees] of the radiographic measurement in 47 of 53 (88.7%) cases for inclination and 46 of 53 (86.8%) cases for anteversion. Conclusion: Imageless navigation demonstrated excellent correlation and agreement with CT measurements for both inclination and anteversion over a wide range of acetabular component positions. Contexte: La malposition de la composante acetabulaire est une cause majeure de luxation apres une intervention pour prothese totale de la hanche (PTH). Intellijoint HIPMD est un outil de navigation sans image qui offre une mesure peroperatoire precise de la cupule aceta-bulaire lors d'une PTH primaire, sans prolonger indument le temps operatoire. Par contre, sa precision lors d'une revision de PTH n'a pas ete verifiee. Cette etude vise donc a evaluer la capacite d'Intellijoint HIP a mesurer precisement l'inclinaison et l'anteversion de la cupule acetabulaire en comparaison avec la tomodensitometrie (TDM) lors d'une revision de PTH. Methodes: Intellijoint HIP a ete utilise pour mesurer la position de la cupule preexistante chez 53 patients consecutifs soumis a une revision de leur PTH entre decembre 2018 et fevrier 2020. Deux auteurs non informes des mesures peroperatoires obtenues avec l'outil de navigation ont aussi mesure de facon independante la position de la cupule a l'aide d'une TDM preoperatoire selon les definitions radiographiques de Murray. Nous avons utilise les coefficients de correlation de Pearson avec des intervalles de confiance (IC) a 95 %, des tests t apparies et des graphiques Bland-Altman pour evaluer la concordance entre la position ace-tabulaire mesuree avec l'outil de navigation et par TDM. L'analyse statistique a ete effectuee avec GraphPad Prism et les valeurs p inferieures a 0,05 indiquaient une portee statistique. Resultats: On a observe une excellente concordance entre les mesures obtenues avec l'outil de navigation et par TDM pour l'inclinaison (r = 0,89, IC a 95 % 0,81-0,93) et l'anteversion de la cupule (r = 0,93, IC a 95 % 0,88-0,96),l'ecart absolu moyen etant de 5,2[degrees] (ecart-type [E.-T.] 4,0 [degrees]) pour l'inclinaison et de 4,8 [degrees] (E.-T. 5,4 [degrees]) pour l'anteversion. La mesure au moyen de l'outil de navigation s'est retrouvee a l'interieur d'une limite de 10 [degrees] par rapport a la mesure radiographique dans 47 cas sur 53 (88,7 %) pour l'inclinaison et 46 cas sur 53 (86,8 %) pour l'anteversion. Conclusion: La navigation sans image a donne lieu a une correlation et une concordance excellentes avec les mesures par TDM pour l'inclinaison comme pour l'anteversion et ce, dans un vaste eventail de positions de la composante acetabulaire., Dislocation following total hip arthroplasty (THA) is a common complication associated with substantial morbidity and increased health care expenditures. A 2009 study of more than 50 000 revision THAs found [...]

Background Near-infrared spectroscopy (NIRS) is an emerging tool to identify signs of inadequate tissue oxygenation in preterm neonates with acute kidney injury (AKI). Previous studies have shown a correlation between low renal tissue oxygenation (RrSO.sub.2) in the first 24 hours of age and the later development of AKI. In this prospective clinical trial, NIRS monitoring was used to identify changes in RrSO.sub.2 in comparison to traditional AKI markers, serum creatinine (SCr), and urine output (UOP). Methods We enrolled 35 preterm neonates born less than 32 weeks' gestation and applied neonatal NIRS sensors at less than 48 hours of age. Neonates underwent 7 days of continuous monitoring. Renal and demographic information were collected for the first 7 days of age. AKI was determined by the modified neonatal Kidney Disease: Improving Global Outcomes (KDIGO) definition including UOP. Results Three patients experienced AKI, all based on both SCr and UOP criteria. Each neonate with AKI had decreases in RrSO.sub.2 over 48 hours prior to changes in SCr and UOP. Patients with AKI had lower median RrSO.sub.2 values compared to patients without AKI over the first week of age, (32.4% vs. 60%, p < 0.001). Conclusion RrSO.sub.2 monitoring identified preterm neonates at risk for AKI. NIRS detected a decline in RrSO.sub.2 prior to changes in SCr and UOP and was significantly lower in patients with AKI compared to those without AKI. Further studies are needed to evaluate the ability of RrSO.sub.2 monitoring to detect signs of kidney stress prior to the diagnosis of AKI., Author(s): Matthew W. Harer [sup.1] [sup.2] , Claudette O. Adegboro [sup.1] [sup.2] , Luke J. Richard [sup.1] , Ryan M. McAdams [sup.1] [sup.2] Author Affiliations: (1) grid.14003.36, 0000 0001 2167 [...]

Hepatocellular carcinoma (HCC) can have viral or non-viral causes.sup.1-5. Non-alcoholic steatohepatitis (NASH) is an important driver of HCC. Immunotherapy has been approved for treating HCC, but biomarker-based stratification of patients for optimal response to therapy is an unmet need.sup.6,7. Here we report the progressive accumulation of exhausted, unconventionally activated CD8.sup.+PD1.sup.+ T cells in NASH-affected livers. In preclinical models of NASH-induced HCC, therapeutic immunotherapy targeted at programmed death-1 (PD1) expanded activated CD8.sup.+PD1.sup.+ T cells within tumours but did not lead to tumour regression, which indicates that tumour immune surveillance was impaired. When given prophylactically, anti-PD1 treatment led to an increase in the incidence of NASH-HCC and in the number and size of tumour nodules, which correlated with increased hepatic CD8.sup.+PD1.sup.+CXCR6.sup.+, TOX.sup.+, and TNF.sup.+ T cells. The increase in HCC triggered by anti-PD1 treatment was prevented by depletion of CD8.sup.+ T cells or TNF neutralization, suggesting that CD8.sup.+ T cells help to induce NASH-HCC, rather than invigorating or executing immune surveillance. We found similar phenotypic and functional profiles in hepatic CD8.sup.+PD1.sup.+ T cells from humans with NAFLD or NASH. A meta-analysis of three randomized phase III clinical trials that tested inhibitors of PDL1 (programmed death-ligand 1) or PD1 in more than 1,600 patients with advanced HCC revealed that immune therapy did not improve survival in patients with non-viral HCC. In two additional cohorts, patients with NASH-driven HCC who received anti-PD1 or anti-PDL1 treatment showed reduced overall survival compared to patients with other aetiologies. Collectively, these data show that non-viral HCC, and particularly NASH-HCC, might be less responsive to immunotherapy, probably owing to NASH-related aberrant T cell activation causing tissue damage that leads to impaired immune surveillance. Our data provide a rationale for stratification of patients with HCC according to underlying aetiology in studies of immunotherapy as a primary or adjuvant treatment. In hepatocellular carcinoma driven by non-alcoholic steatohepatitis, aberrant T cell activation and impaired immune surveillance seem to make hepatocellular carcinoma less responsive to anti-PD1 or anti-PDL1 immunotherapy., Author(s): Dominik Pfister [sup.1] [sup.82] , Nicolás Gonzalo Núñez [sup.2] , Roser Pinyol [sup.3] , Olivier Govaere [sup.4] , Matthias Pinter [sup.5] [sup.6] , Marta Szydlowska [sup.1] , Revant Gupta [...]

Context: Approximately 1 in 10 people in the U.S. have diabetes. Meaningful lifestyle changes and coordinated medical interventions can prevent consequences of inadequately managed chronic disease. Today, many patient-facing smartphone apps assist with chronic disease management; however, few tools engage both patients and primary care team members effectively. Objective: We aimed to learn about patient and provider experiences related to usability and acceptability of a program designed to merge intra-visit and episodic EHR information by collecting remote patient monitoring (RPM) data through a patient-facing app (Allie) and organizing the data into a provider-facing website (Foresight). Study design and analysis: Qualitative study using thematic analysis. Themes identified from surveys and focus groups. Setting or dataset: Academic primary care setting from January to March 2022. Population studied: 1 primary care physician, 1 clinical pharmacist, and 5 patients with uncontrolled diabetes, defined as last hemoglobin A1c [greater than or equal to] 8% (40% female, 60% male; age range 41-64 years old). Intervention: Patients received a blood glucose meter and downloaded and used Allie to help manage their diabetes for 2 months. Through the app, patients could access their personalized care plan and track their glucose levels. Providers used Foresight to monitor data that their patients recorded through Allie and adjust their care plan accordingly. Outcome measures: Measures include identifiable themes from patient survey responses to assess intra-visit self-management; provider survey responses to assess intra-visit management of patients; patient survey responses to assess feasibility/usability of Allie; provider survey responses to assess feasibility/usability of Foresight; focus groups to gather pilot feedback. Results: 4 of 5 patients reported they would likely use a program like Allie in the future, and 2 of 2 providers reported they would likely use a program like Foresight in the future. Patients expressed a desire for integration with CGMs, greater control over their care plans, and more positive reinforcement. Providers expressed a desire for integration with the EHR, alerts for acute changes, and prioritization of patient lists. Conclusion: We piloted a program that aims to merge RPM data and episodic EHR data to improve the care of patients with diabetes. Insights gathered will contribute to the limited research on the use of RPM platforms in chronic disease management., Presenters Amelia Sattler, MD, Grace Hong, BA, Judith Fitzpatrick, Steven Lin, MD, Marcie Levine, [...]

Byline: Mayank. Tyagi, Megha. Bir, Akanksha. Sharma, Pankaj. Singh, Ashish. Bindra, P. Chandra We report the strategy of anesthesia and intraoperative neurophysiological monitoring (IONM) in a 29-year-old, 22 weeks pregnant [...]