Absolute Indication Research Articles

Cervical disc herniation : Symptomatology, diagnostics, therapy

Although herniated discs in the cervical spine are rare overall, patients with this clinical picture regularly present themselves in orthopedic and neurosurgical practice. Initially, those affected often have severe local and predominantly radicular pain and, optionally, dermatome-related neurological deficits in the upper extremities, with medullary signs occasionally being found. The prognosis for complete remission is usually favorable, so that primary therapy is almost always conservative. Based on guidelines, the relative and absolute indications for surgery can be derived depending on pain symptoms and neurological deficits. There are various surgical procedures to choose from. The ventral approach to the cervical spine with either insertion of acage and the goal of fusion or implantation of an intervertebral disc prosthesis as arthroplasty is most often chosen. For lateral disc prolapse, dorsal foraminotomy with sequestrectomy is recommended. The postoperative outcome is predominantly positive with arelatively low complication rate.

Alpha-fetoprotein-producing intramucosal gastric cancer found during examination of metastatic lymph nodes.

Endoscopic resection has been applied as an absolute indication for early gastric cancer showing intramucosal cancer ≤ 2cm in diameter, differentiated-type adenocarcinoma without ulcerative findings. We describe the case of a 76-year-old man who underwent radical gastrectomy for alpha-fetoprotein-producing gastric cancer, in which the depth of invasion was clinically diagnosed as T1a after lymph node metastases were detected. Upper gastrointestinal endoscopy revealed a type 0-IIc tumor nearly 10mm in diameter at the antrum. Computed tomography showed a 47-mm nodule along the common hepatic artery and a 22-mm nodule in the infrapyloric area. Both were pathologically confirmed as adenocarcinoma by endoscopic ultrasound-guided aspiration. No evidence of malignancy elsewhere was seen on 18F-fluorodeoxyglucose positron emission tomography. Serum alpha-fetoprotein level was elevated. Postoperatively, microscopic examination revealed moderately differentiated adenocarcinoma confined to the mucosal layer without lymphovascular involvement. Immunohistochemical examination for alpha-fetoprotein revealed that the metastatic nodes were positive despite the primary tumor being negative. The patient died of exacerbation of myelodysplastic syndrome 5years 8months postoperatively with no recurrence. Our experience suggests the need for further studies to validate whether the indications for endoscopic resection can apply to alpha-fetoprotein-producing gastric cancer in the same manner as to conventional gastric cancer.

Critical care unit bed availability and postoperative outcomes: a multinational cohort study.

Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes. This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis. A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01-1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57-1.45), p = 0.710). Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission.

Emergency management of orbital compartment syndrome: Lateral canthotomy and cantholysis case series

BackgroundOrbital compartment syndrome (OCS) is considered a time critical condition that requires urgent surgical decompression to preserve vision. This study aims to evaluate the current clinical criteria for performing a lateral canthotomy and cantholysis (LCC) in the emergency management of suspected traumatic OCS. MethodsA retrospective audit of patients with suspected traumatic OCS presenting to an adult major trauma centre between January 1, 2017, and August 1, 2022, was performed. Results20 patients with traumatic OCS treated with a LCC were identified. Five patients satisfied the definitive clinical criteria for LCC. The remaining 15 patients received LCC based on secondary clinical findings, or computed tomography (CT) findings suggestive of OCS. 17 patients received non-contrast CT scanning prior to LCC. Of the nine patients noted to regain baseline or close to baseline vision, only one was decompressed within two hours of injury. ConclusionDespite OCS being a clinical diagnosis, the signs and symptoms associated with OCS are difficult to elicit on presentation. Seeking imaging should not delay time to decompression when clinical diagnostic criteria are present. However, imaging may have a role in determining the need for orbital decompression where the absolute indications for LCC cannot be adequately assessed.

Latest guideline of endoscopic submucosal dissection of early gastric cancer may not be suitable for Chinese patients: retrospective study findings from two centers

BackgroundTo analyze the diagnostic efficiency of the four absolute endoscopic submucosal dissection (ESD) indications for lymph node metastasis (LNM) of Chinese patients with early gastric cancer (EGC).MethodsWe retrospectively analyzed EGC patients who underwent radical D2 gastrectomy from January 2019 to December 2022. We evaluated the rate of LNM, false-negative rate, and negative predictive value of the four ESD indications.ResultsOf enrolled 2722 EGC patients, 388 (14.3%) patients presented LNM. Tumor size > 2 cm, ulceration, submucosal invasion, undifferentiated type, and lymphovascular invasion were independent risk factors of LNM in patients with EGC. 1062 (39%) cases of EGC conformed to the four EDS indications; however, 4% of them had LNM. 451 cases were fully in accord with the fourth ESD indication (undifferentiated intramucosal carcinoma without ulceration and a maximum lesion diameter of ≤ 2 cm), and 35 of them had LNM, with a false-negative rate (FNR) of 9.02% and a negative predictive value (NPV) of 92.24%. There was significant difference among the four indications in terms of the rate of LNM (1.0% vs 1.5% vs 1.3% vs 7.8%, P < 0.001), FNR (1.03% vs 0.52% vs 0.26% vs 9.02%, P < 0.001), and NPV (98.99% vs 98.53% vs 98.75% vs 92.24%, P < 0.001).ConclusionOverall, the fourth ESD indication was associated with a high rate of LNM compared to the other three indications. Thus, it might not be safe to classify it as an absolute indication in Chinese patients with EGC.

Assessing Severity and Need for Delivery in Early Onset Preeclampsia Before 32 Weeks of Gestation: a Delphi Consensus Procedure.

Preeclampsia is a potentially life-threatening hypertensive pregnancy disorder that carries an acute risk of an unfavorable outcome of the pregnancy but also has consequences for the long-term health of the mother. Women who develop the early form of pre-eclampsia before the 32nd week of pregnancy have the highest risk and are also the most difficult to treat. The severity of pre-eclampsia is not characterized uniformly in Germany, so that the indication for delivery is rather individualized. The aim of this study was to reach a consensus on parameters that could serve as criteria for describing the severity of pre-eclampsia based on the urgency of delivery. To this end, a Delphi procedure was used to present a scenario in which a woman was admitted for preeclampsia before 32 gestational weeks and after completion of antenatal steroid therapy. Clinicians specialized in maternal-fetal medicine from German-speaking countries completed five rounds of a modified Delphi questionnaire. Presented parameters were selected by the section "Hypertensive Pregnancy Diseases and Fetal Growth Restriction" of the German Society of Gynecology and Obstetrics after reviewing the literature. These included objectifiable laboratory or clinical parameters as well as subjective symptoms of the patient. In addition, nine fetal parameters were taken into account. The clinicians were asked to rate presented parameters as an indication for delivery on a Likert scale from 0 to 4 (no indication to absolute indication without delay). For each item, the predefined cut-off for group consensus was ≥70% agreement. A total of 126 experts were approached. Sixty-nine experts (54.8%) took part in the first round; of those 50 completed the entire Delphi procedure. A consensus was reached on 14 parameters to be considered rapid preparation for delivery without delay (4 points on the Likert scale). These were among others hepatic hematoma or liver capsule rupture, acute liver failure with fulminant coagulation disorder or disseminated intravascular coagulation, eclampsia, pathologic findings in imaging (e.g. cMRI) or electrocardiogram arranged for new onset of headache or retrosternal pain, respectively. Twenty-six parameters were rated as factors that should be considered in the decision without being absolute (1 to 3 points), and 13 parameters should have no influence on the decision to deliver (0 points). No consensus on severe hypertension as an indication for delivery could be reached for blood pressure values below 220/140mmHg. A consensus was reached on whether to deliver in preeclampsia typic clinical findings and symptoms. The results can serve as guidance for current clinical practice and for the definition of clinical endpoints in intervention studies. Nevertheless, the isolated criteria are a theoretical construction since the combined deterioration or summation of several factors rather than a single factor most likely influences the decision to deliver and reflect the severity of preeclampsia. Moreover, the degree of hypertension as an indication for delivery remains controversial, unless the patient suffers additionally from complaints. Future research should be enforced to incorporate long-term risks for the mother into a decision aid.

Missile Injuries to The Spine Local Experience and Review of The Literature

Introduction: Missile injuries of the spine particularly the high velocity projectiles are very destructive, leading to real disaster and even death. The incidence has increased recently on both civilian and military troops. The ideas behind writing this article is to shed the light on the seriousness of this type of injury and on the consensus for the ideal treatment depending on our local experience and others experience. Materials and Methods: We review our patient’s files whom had missile injuries related to orthopaedic practice since the last 40 years in public and private hospitals and we also search the web looking for articles discussing missile injuries in orthopaedic practice. We collect complications that observed in our patients and reported in literatures to be mentioned in the results of this review. Results: Missile injuries is the cause of 13-44% of all spinal injury. The cervical lesion is behind complete neurological deficit in 70% of cases. Almost all injuries are stable particularly in the cervical lesion provided that both facet and both pedicles remain intact. Probably pain is one of the commonest complications recorded. Bullets removed did not relieve the pain due to depression. Infection is very much expected after the dirty missile wounds. Neurogenic bladder and urinary tract infection are also possible, meningitis, bone infection, Charcot arthropathy and deformity are all possible. Lead intoxication is a late and very rare complication. The last rare but possible complication is the migration of the missile. Conclusions: Gunshot injury to the spine is becoming more and more prevalent in both military and civilian practice. Probably the absolute indication for surgery is the progressive neurological deficit. A cover of antibiotic is mandatory. A careful search for the instability is mandatory and lastly, Steroids use in spinal missile injuries is controversial.

Optimal Management of Traumatic Abdominal Wall Hernias Remains Unclear.

High-energy, blunt force trauma to the abdomen results in an abdominal wall injury (AWI) in up to 9% of patients. In 1% of blunt abdominal trauma, they result in a traumatic abdominal wall hernia (TAWH). Optimal management of these injuries remains unclear. Because they are the result of a high-energy mechanism, concomitant serious abdominal organ injuries are common. This has prompted some to advocate that the presence of a TAWH on physical exam mandates exploratory laparotomy. However, delayed repairs have better outcomes and nontherapeutic celiotomy should be avoided. Similarly debated is the expanding use of minimally invasive techniques and the use of mesh for hernia repairs. Overall, the presence of a TAWH is likely not an absolute indication for emergency surgery. Rather, it is an indicator of high-energy impact and associated with a high rate of visceral injury. These patients require a close observation for clinical decline and development of typical indicators for laparotomy.

Management of alcohol withdrawal syndrome (AWS)

Alcohol withdrawal syndrome (AWS) is a complex set of symptoms that occur in alcohol-dependent individuals after sudden withdrawal or a significant reduction in alcohol consumption. AWS symptoms occur in about 50% of alcohol abusers. These symptoms may include restlessness, tremor, nausea, nervousness, tachycardia, elevated blood pressure, hyperhidrosis, insomnia, hyperactivity, and hallucinations. In some cases, seizures may occur and delirium tremens may develop, which is life-threatening and an absolute indication for hospitalization of the patient. Effective treatment of AWS is the key to prevent complications and to reduce the risk of death. Treatment of alcohol withdrawal syndrome requires a complex approach that combines properly performed diagnosis, careful monitoring of the patient's condition, pharmacotherapy, equalization of electrolyte disorders, adequate hydration of the patient, supplementation of thiamine deficiencies and, in the case of symptoms of alcoholic delirium, intensive medical care. Pharmacological treatment plays a key role, with the first line of treatment being benzodiazepines, which reduce the risk of epileptic seizures and delirium tremens, and reduce mortality in the course of AWS. Individualized therapy adjustment and patient monitoring are crucial to ensure effective and safe treatment.

Race-modified estimated glomerular filtration rate underestimates chronic kidney disease prevalence in Black patients undergoing partial and radical nephrectomy: Implications for surgical planning.

In estimated glomerular filtration rate equations (eGFR), the race multiplier (RM) yields greater eGFR values and may assign less severe chronic kidney disease (CKD) stages to black individuals. When deciding on appropriateness for partial nephrectomy (PN), patients with CKD are often considered a relative or absolute indication. We hypothesize that the eGFR RM may have ramifications for patients being counseled for radical nephrectomy (RN) versus PN to manage their renal tumor. We utilized prospective and retrospective, IRB-approved single-center databases to select patients who underwent PN or RN between 2016 and 2022. Demographics, preoperative risk factors, preoperative eGFR, and surgical management were collected. Descriptive statistics and two-tailed difference of proportion tests compared the percentage of patients with CKD who underwent nephrectomy. This cohort included 1137 patients who underwent RN or PN, including 74 (6.5%) Black patients and 93.5% (n = 1063) non-Black patients. There was no statistically significant difference between the eGFR of Black and non-Black individuals using the Modification of Diet in Renal Disease equation (P = 0.24) or Chronic Kidney Disease Epidemiology Collaboration 2009 (CKD-EPI 2009) (P = 0.45); however, there was statistically significant difference in eGFR between sample populations when using CKD-EPI 2021 (P = 0.0055). Of the Black patient cohort, 16.2% of patients reclassified to a worse CKD class using CKD-EPI 2021, including 9.5% of Black patients reclassified to CKD3a or worse, and 14.6% of all patients (Black and non-Black) reclassified to a different CKD class under the CKD-EPI 2021 equation. There are quantitative differences in the evaluation of eGFR when utilizing different equations that may impact clinical considerations and health equity outcomes for nephrectomy across racial groups.

Construction of a predictive model of respiratory endoscopic intervention in children with lobar pneumonia caused by Mycoplasma pneumoniae infection.

This study aimed to analyze the clinical features of children with lobar pneumonia caused by Mycoplasma pneumoniae (MP) infection, to explore the independent risk factors for bronchoscopic intervention in children with lobar pneumonia caused by MP infection. There is a lack of objective assessment tools to guide the use of bronchoscopy in clinical practice. For children with lobar pneumonia caused by MP infection, whether line shall be actively bronchoscope intervention therapy remains to be further defined. We also aimed to construct an early warning model of bronchoscopic intervention to provide an objective evaluation tool for clinicians. We collected the clinical data of 533 children with lobar pneumonia caused by MP infection. The patients were divided into three groups according to the interventional indications for bronchoscopy and whether they were treated with bronchoscopic intervention, and the clinical features and prognosis of the three groups were compared. A binary logistic regression analysis was performed on the indicators with a significance value of P<0.05, which we retrieved from the comparative analysis between the first two groups to uncover the independent risk factors and regression equations concerning bronchoscopic intervention. The regression coefficient (β) of our regression model was then used to score related values in the model to construct a predictive scoring model of bronchoscopic intervention for the treatment of children with lobar pneumonia caused by MP infection. Children with lobar pneumonia caused by MP infection who demonstrated absolute indications for bronchoscopy exhibited more severe clinical manifestations, and children without absolute indications for bronchoscopy had a better prognosis even without bronchoscopic intervention. To establish our early warning model of bronchoscopic intervention for children with lobar pneumonia caused by MP infection, we used the following indices: C-reactive protein ≥20.94 mg/L (β1=2.253) received 3 points, while a fever duration before bronchoscopy ≥6.5 d (β2=1.424), lactate dehydrogenase ≥461.5 U/L (β3=1.246), or fever (β4=1.223) each received 2 points, and the complication of pleural effusion (β5=0.841) received 1 point, for a total possible score of 10 points. When the score for the children with lobar pneumonia caused by MP infection was ≥6, the possibility of bronchoscopic intervention for treatment was >80%. The higher the score, the greater the possibility of bronchoscopic intervention.

Pengaruh Blanket Warmer Terhadap Suhu Tubuh Pasien Intra Sectio Caesarea Sebagai Upaya Pencegahan Terjadinya Hipotermi

Sectio caesarean is a surgical process involving an incision that is very risky and causes many complications for the human body. One of the complications caused by an intra-cesarean section is hypothermia. Hypothermia is a medical emergency that occurs when the body loses heat faster than it produces warmth. When the body temperature drops, the nervous system and other organs typically cannot function properly, which in turn affects the functioning of many other organs (Dafiani, 2021). This study aimed to determine the effect of a blanket warmer on the body temperature of intra-cesarean section patients to prevent hypothermia. This quantitative study used a quasi-experimental design (pre-test–post-test with a control group design). Data were collected on intra-section cesarean patients. As many as 35 respondents had been given non-pharmacotherapy therapy in the form of a blanket warmer. The results of the analysis showed that most pregnant women were aged 20–35 years in the no-risk group (91.4%), cesarean section with absolute indication (68.6%), and cesarean section duration &lt; 60 minutes (57.1%). The minimum body temperature of 35.7°C before receiving a blanket warmer, and a maximum body temperature of 36.6°C after receiving one. After carrying out statistical tests using the Wilcoxon test, a P-value of 0.000, or ≤ 0.05, was obtained. In conclusion, blanket warmers influence the incidence of intra-cesarean hypothermia at SMC Telogorejo Hospital. Suggestions for further research include developing variables that can disrupt the thermoregulation system, as well as comparing the use of tools other than blanket warmers to prevent hypothermia before surgery.

Modelling and comparing the use of IVF and ICSI in Australia

PurposeThis study estimates the need of IVF/ICSI in Australia as compared to its actual uptake.MethodsWe created a model estimating for the annual demand for IVF/ICSI in a hypothetical infertile population, using demographic data from medical literature and Australian government databases. For each category of infertility (tubal, severe male, endometriosis, anovulation and unexplained), our estimated need for IVF/ICSI was compared to the actual IVF/ICSI uptake (ANZARD 2019). The model consisted of three categories depending on couples’ cause of infertility, i.e. couples with absolute indications for IVF/ICSI (couples with severe male factor infertility and tubal obstruction); couples with anovulatory infertility (couples with ovulation disorders) and couples with ovulatory infertility (couples suffering from unexplained infertility and endometriosis). The model was applied to each of these categories to determine the number of couples that would require IVF/ICSI treatment after failing to conceive naturally or after following alternative treatment plans. The main outcomes of this study were the estimate of IVF/ICSI cycles and the difference between the estimate and the reported number of IVF/ICSI cycles (2019 ANZARD report).ResultsWe estimated that approximately 35,300 couples required IVF/ICSI treatment in Australia in 2019, while in 2019 according to ANZARD, 46,000 couples underwent IVF/ICSI. A higher uptake of IVF/ICSI cycles than expected was specifically reported in couples with unexplained infertility, ovulation disorders and endometriosis, while for tubal and severe male infertility uptake seemed adequate.ConclusionIn Australia, there seems to be overservicing of IVF/ICSI, specifically for unexplained, ovulatory and endometriosis-related infertility.

Graves-Basedow ophthalmopathy surgical approaches: Open vs Endoscopic

Graves-Basedow's disease (GBD) is an autoimmune pathology that affects the thyroid and is characterized by the presence of goiter, hyperthyroidism, ophthalmopathy, and dermopathy. Graves-Basedow ophthalmopathy (GBO) is a set of inflammatory and infiltrative alterations of the orbital tissue that affects 40–90% of subjects suffering from GBD. Our study aims to investigate the differences in the clinical outcomes of patients treated with two different techniques: the classic open and the more modern endoscopic. A retrospective clinical study was carried out from the year 2011 until the year 2020 to evaluate the clinical outcomes of two different surgical techniques for the treatment of GBO. Eighteen patients were given surgical indications, 12 males and 6 females aged between 37 and 69 years (average age 48.5 years), for a total of 36 orbits. From the year 2011 to the year 2014, all patients were treated with the open orbital decompression technique; from 2015 onwards, patients were subjected to orbital decompression with the endoscopic transnasal approach. Pre- and postoperative ophthalmometry, reduction of proptosis, and reduction of oculo-orbital index were compared for the two techniques. As evidenced by the statistical analysis carried out on the sample before and after surgical treatment, there is a statistically significant difference between ophthalmometry and the Oculo-Orbital Index (IOO) values; this indicates that surgical orbital decompression with two walls (floor and medial wall) is effective in reducing exophthalmos. The positive result is also confirmed by the reduction of proptosis, measured in millimeters, averaging 1.7 mm. In the analysis of data relating to the two different patient groups, treated respectively with endoscopic orbital decompression (Technique 1) and classical open orbital decompression (Technique 2), the results obtained show that there is no statistically significant difference between the results of the two techniques. Therefore, the choice of surgical approach is at the discretion of the surgeon. It is our opinion that orbital decompression with the endoscopic transnasal technique should be an absolute indication in all patients who have clinical and radiographic signs of involvement of the optic nerve at the orbital apex (crowded apex syndrome) thanks to the ability of this technique to add and decompress the optical channel at the apex. For all other patients with GBO, the endoscopic technique of orbital decompression can be indicated as a first-line surgical approach considering the absence of skin scars and the best aesthetic results.

PRAME expression in genital melanocytic lesions – Potential diagnostic pitfall of intermediate expression in atypical genital nevi

IntroductionThe Preferentially Expressed Antigen in Melanoma (PRAME) immunostain has seen significant diagnostic use in confirming malignancy for melanocytic lesions. However, the expression of PRAME in genital melanocytic lesions have not been reported. In this study, PRAME staining was performed on a cohort of genital melanocytic lesions, aiming to investigate the diagnostic role of PRAME in genital melanocytic lesions and its expression in atypical genital nevi. MethodologyA cohort including genital invasive melanoma, melanoma-in-situ, atypical genital nevus (AGN), compound nevus, intradermal nevus, blue nevus, lentigo and melanosis was retrieved with histology reviewed and PRAME immunostaining performed. ResultsA total of 66 cases were reviewed. The average proportion expression of PRAME were 56.75 % and 57.43 % for invasive melanoma and melanoma-in-situ, with average H-scores of 153.5/300 and 163.14/300 respectively, which were greater than AGN (3.25 %, 7.75/300, p<0.001), compound/intradermal nevi, lentigo/melanosis, and background junctional melanocytes (<1 %, <1/300, p<0.001). The different cutoffs of PRAME expression, the sensitivity and specificity were 65.22 % and 100 % (>100/300); 69.57 % and 95.83 % (>10/300); and 82.61 % and 93.75 % (≥1/300) respectively. Low level PRAME expression was seen in half of the cases of AGN (n=2/4, 50 %), and at low cutoffs (>10/300 and ≥1/300) unable to differentiate invasive melanoma from AGN (p>0.05). ConclusionsFor genital melanocytic lesions, PRAME immunostain shows high specificity at strong and diffuse staining. AGN not uncommonly display low level expression. Focal and/or weak PRAME expression should not be considered as an absolute indication of malignancy, and comprehensive histological assessment remains the key to accurate diagnosis of melanocytic lesions.

#2576 Effect of dialysis versus conservative care on all-cause mortality in older patients with advanced CKD: nationwide Swedish cohort study

Abstract Background and Aims Conservative care is emerging as an alternative to dialysis in older patients with advanced chronic kidney disease (CKD). However, high-quality evidence comparing the effect of dialysis versus conservative care on patient survival is lacking. Previous observational studies suffered from avoidable biases, such as immortal time bias and lead time bias, and adjusted for limited confounders. This study aimed to assess the effects of dialysis versus conservative care on mortality in older patients with advanced CKD. Method The target trial emulation framework was used to design and analyze this observational study. We conducted a nationwide observational cohort study using data from the Swedish Renal Registry between 2007-2021. We included all nephrologist-referred patients with eGFR &amp;lt; 20 ml/min/1.73 m2 who had a registered decision for dialysis or conservative care. Eligible patients were required to be ≥ 65 years with a Davies Comorbidity Score ≥ 2 or ≥ 80 years. The primary endpoint was 5-year all-cause mortality. Inverse probability of treatment weighting was used to adjust for 50 baseline confounders, including demographics, comorbidities, medication use, blood pressure, laboratory measurements, hospitalizations, and calendar year. Patients in the non-overlapping region of the propensity score distribution were excluded since they had an absolute indication for dialysis or conservative care. Cox proportional hazards regression was used to estimate intention-to-treat hazard ratios (HRs) with 95% confidence intervals (CIs), and the Kaplan-Meier estimator was used to estimate absolute risks. Additionally, we calculated the 5-year restricted mean survival times (RMST) and the 5-year RMST difference between dialysis and conservative care arms. To test the robustness and consistency of our main results, we performed a subgroup analysis in patients aged ≥80. Results Of 2834 eligible patients, 1903 had a registered choice for dialysis and 931 for conservative care. The median age was 81 years, 36.1% were female and median eGFR was 13.1 ml/min/1.73 m2. During the 5-year follow-up period, 29 conservative care patients started dialysis and 430 patients died before starting dialysis. After weighting, all confounders were balanced (standardized mean difference &amp;lt; 0.10). Compared to dialysis, conservative care was associated with a higher absolute 5-year risk of death (91.8% vs. 74.1%), corresponding with an absolute risk difference of 17.6% (95% CI 13.3%-21.9%) (Fig. 1). The adjusted hazard ratio for conservative care vs. dialysis was 2.3 (95% CI 2.0-2.6). The 5-year restricted mean survival times were 34.8 (95% CI 33.2-37.3) months for dialysis and 21.5 (95% CI 19.4-23.6) months for conservative care groups. The 5-year RMST difference was 13.3 months (95% CI 10.8-16.6), meaning that dialysis patients would live on average 13.3 months longer over a 5-year follow-up period than conservative care patients (Table 1). The results were consistent among people ≥ 80 years (adjusted HR 2.2, 95% CI 1.9-2.5; 5-year RMST difference 9.4 months, 95% CI 7.2-13.9). Conclusion In older patients with advanced CKD under nephrologist care, conservative care was associated with a higher risk of mortality than dialysis. These findings could improve the shared decision-making process with patients on the choice of kidney failure treatment.

New Diagnostic-Based Systematic Classification for Skier's Thumb Injuries: A Revision That is Needed

Abstract Background Acute injuries to the ulnar collateral ligament (UCL) of the first metacarpophalangeal joint (MCPj), commonly referred to as Skier’s thumb injuries, can be further categorized into different types based on bone lesions and joint instability. However, none of the existing classifications encompasses all types and combinations of injuries. A unified classification system that provides direct treatment recommendations for each type is required, particularly for cases with no clear indications. Aims To develop a new classification system for acute UCL injuries of the first MCPj that comprehensively defines all possible combinations and types of injuries and facilitates treatment decision-making for each specific type in daily clinical practice. Methods The retrospective study included patients with acute UCL lesions who underwent conservative or operative treatment at our clinic between 2018 and 2023. This classification addresses ligamentous or osseous lesions, fracture fragment size and dislocation, ligament configuration (e.g. Stener lesions), and joint stability. Correlated radiography, ultrasonography, MRI, and intraoperative findings were used to define all combinations and variants of skier`s thumb injuries. Pre-therapeutic joint stability was characterized according to the criteria established in the literature. Dislocation criteria for bone lesions were defined in a preliminary observer trial. The classification was applied by three hand surgeons with different training levels. Treatment applied and a 3-months follow-up was documented. Results In 213 patients with acute UCL tears, the new classification was consistently applied, and the treatment derived was largely aligned with the recommendations in the literature for both absolute and relative indications for splint or operative therapy. The vast majority of the patients were stable after 3 months. Conclusion This new classification is the first to combine the clinical and radiological aspects of skier`s thumb injuries into one classification and encompasses all variants. It is comprehensive, can be easily applied retrospectively, and provides clear treatment recommendations in most cases.

PREVALENCE OF URINARY TRACT STONES IN PATIENTS WITH BENIGN PROSTATIC HYPERPLASIA (BPH) UNDERGOING TRANS URETHRAL RESECTION OF THE PROSTATE (TURP) OPERATION

Objective: This study aims to determine the prevalence of urinary tract stones in BPH patients undergoing TURP surgery. Material &amp; Methods: This research is a descriptive study using secondary data with medical records of BPH patients who underwent TURP at Saiful Anwar General Hospital (RSSA) for the period of 2018 – 2022. Results: From the results of the 169 patient samples BPH undergoing TURP, there were 35 samples, who experienced urinary tract stones. The most frequent incidence of urinary tract stones in patients with BPH at the age of 60 – 70 years of 15 samples (42.90 %), with the highest prostate volume being &gt;50 mL, there are 15 samples (42.90 %), and the location of the most urinary tract stone were in the lower urinary tract with the bladder stone type being 30 samples (85.7%). Conclusion: From the results, it can be concluded that the prevalence of urinary tract stones in BPH patients undergoing TURP surgery is 20.7%, which is an absolute indication for TURP. Keywords: Benign prostatic hyperplasia, urinary tract stone, age, prostate volume.

Descemet’s membrane endothelial keratoplasty is the predominant keratoplasty procedure in Germany since 2016: a report of the DOG-section cornea and its keratoplasty registry

Background/aimsThis retrospective multicentric panel study provides absolute numbers, types of and indications for corneal transplantation in Germany from 2011 to 2021 and sets them into the international context.MethodsA questionnaire was...

Preliminary study on diagnosis of gallbladder neoplastic polyps based on contrast-enhanced ultrasound and grey scale ultrasound radiomics.

Neoplastic gallbladder polyps (GPs), including adenomas and adenocarcinomas, are considered absolute indications for surgery; however, the distinction of neoplastic from non-neoplastic GPs on imaging is often challenging. This study thereby aimed to develop a CEUS radiomics nomogram, and evaluate the role of a combined grey-scale ultrasound and CEUS model for the prediction and diagnosis of neoplastic GPs. Patients with GPs of ≥ 1cm who underwent CEUS between January 2017 and May 2022 were retrospectively enrolled. Grey-scale ultrasound and arterial phase CEUS images of the largest section of the GPs were used for radiomics feature extraction. Features with good reproducibility in terms of intraclass correlation coefficient were selected. Grey-scale ultrasound and CEUS Rad-score models were first constructed using the Mann-Whitney U and LASSO regression test, and were subsequently included in the multivariable logistic regression analysis as independent factors for construction of the combined model. A total of 229 patients were included in our study. Among them, 118 cholesterol polyps, 68 adenomas, 33 adenocarcinomas, 6 adenomyomatoses, and 4 inflammatory polyps were recorded. A total of 851 features were extracted from each patient. Following screening, 21 and 15 features were retained in the grey-scale and CEUS models, respectively. The combined model demonstrated AUCs of 0.88 (95% CI: 0.83 - 0.93) and 0.84 (95% CI: 0.74 - 0.93) in the training and testing set, respectively. When applied to the whole dataset, the combined model detected 111 of the 128 non-neoplastic GPs, decreasing the resection rate of non-neoplastic GPs to 13.3%. Our proposed combined model based on grey-scale ultrasound and CEUS radiomics features carries the potential as a non-invasive, radiation-free, and reproducible tool for the prediction and identification of neoplastic GPs. Our model may not only guide the treatment selection for GPs, but may also reduce the surgical burden of such patients.