Challenging Group Of Patients Research Articles

Mid-term to Long-term Outcomes and Complications of Total Hip Arthroplasty in Patients Who Have Crowe IV Developmental Dysplasia of the Hip: A Systematic Review and Meta-Analysis

BackgroundSevere forms of developmental dysplasia of the hip (DDH) in adulthood often lead to total hip arthroplasty (THA). This study aimed to evaluate the mid-term to long-term outcomes of THA in Crowe type IV DDH cases, which represent a technically challenging and complex patient group. MethodsPubMed, EMBASE, Web of Science, and Scopus were searched for observational studies and case series with over 100 months of mean follow-up on adult patients who had Crowe type IV DDH treated with THA. A total of 3,710 records were initially identified, leading to the inclusion of 24 studies in the final analysis. These studies were subjected to quality assessment using the National Institutes of Health (NIH) Quality Assessment tool. Various outcomes including revision rates, leg length discrepancy (LLD), Harris Hip Score (HHS), and complications like periprosthetic joint infections (PJI), dislocations, and nerve injuries were analyzed. A random effects model was employed for statistical analysis, with sensitivity analysis and meta-regression applied in cases of high heterogeneity. ResultsThe included studies assessed 1,024 hips with a mean follow-up of 11 years, revealing improvements in HHS and reductions in LLD post-THA. However, notable challenges were noted, including a 10.7% rate of intraoperative fractures, a 1.8% PJI rate, and a 5.8% dislocation rate. Osteolysis and aseptic loosening revisions were observed in 9.1 and 8% of cases, respectively. Heterotopic ossification (HO) occurred in 11.1% of patients. Nerve injury was reported in 4.2% of cases. With the use of meta-regression, some factors for observed heterogeneity were identified. ConclusionTotal hip arthroplasty in Crowe type IV DDH patients presents notable challenges, but can lead to substantial long-term improvements in patient-reported outcomes.

Neoadjuvant radiotherapy followed by hysterectomy in locally advanced endometrial cancer: Outcomes from a tertiary government hospital in the Philippines

ObjectiveManaging endometrial cancer with suspected or gross cervical involvement lacks a standard approach. This study evaluated outcomes in patients with cervical and/or parametrial involvement treated with neoadjuvant radiation followed by hysterectomy. MethodsFourteen patients from 2007 to 2022 with locally advanced endometrial cancer and cervical and/or parametrial involvement were retrospectively analyzed. They received neoadjuvant external beam radiotherapy (45–50.4 Gy in 25–30 fractions) and high-dose rate brachytherapy (5.5–7.0 Gy per fraction in 3–4 fractions), followed by extrafascial hysterectomy. Clinical data, pathologic response, and survival outcomes were assessed, along with factors associated with pathologic response. ResultsMost patients (86%) had stage III disease with cervical extension, 93% had parametrial involvement, and 14% had nodal involvement. Chemotherapy was given to 86% either concurrently or adjuvantly. Post-surgery, 86% had no pathologic cervical involvement, and 93% had negative surgical margins. Pathologic complete response was seen in 43%. Locoregional recurrence occurred in 14%. Median follow-up was 30 months, with recurrence-free survival and overall survival rates of 86% and 100%, respectively. Lower grade tumors significantly correlated with pathologic complete response (Φ = 0.72, p = 0.026). No significant correlation was found between pathologic complete response and other factors. No late grade 3–4 toxicities were reported. ConclusionNeoadjuvant radiation followed by hysterectomy, with or without chemotherapy, is a viable strategy for managing endometrial cancer with cervical and/or parametrial involvement. This approach enhances resectability, yielding high rates of pathologic complete response and negative resection margins, showing promise for this challenging patient group.

A decade's summary of transcatheter tricuspid valve repair.

Tricuspid regurgitation (TR) is the most common pathology for the tricuspid valve. Moderate to severe TR is associated with morbidity and adverse outcomes. The concept that TR resolves on its own if the underlying disease is successfully treated has proven to be false. Only a few patients with significant TR are deemed suitable for surgery. Given the late presentation of patients with high perioperative risks and substantial perioperative mortality, the development of transcatheter therapies and the experience gained with transcatheter aortic valve implantation operations have turned attention towards treating this challenging group of patients. In this article, we review the treatment options and highlight the role of transcatheter valve therapies in patients with severe TR.

Intermediate uveitis in common variable immunodeficiency (CVID) associated with a heterozygous variant in the TNFRSF13B gene.

To report on a rare case of intermediate uveitis occurring in a patient with common variable immunodeficiency (CVID) and a heterozygous TNFRSF13B variant. Observational case report. A 23-year-old male presented with a 3-month history of increasing floaters and blurred vision to both eyes. He had been treated with topical and intravitreal corticosteroids by his local ophthalmologist nine months before. Ocular examination demonstrated bilateral intermediate uveitis with retinal vasculitis. He had been treated with intravenous immunoglobulins during childhood, due to primary humoral immunodeficiency. Systemic work-up for other causes of intermediate uveitis was unremarkable, notably no features of systemic sarcoid-like disease were detected. Initial treatment with mycophenolate mofetil showed insufficient response, and upon switching to adalimumab, clinical remission was achieved. Immunocytometry and genetic work-up revealed a smB+CD21norm subtype of CVID and a heterozygous TNFRSF13B variant. This report of CVID-associated intermediate uveitis in a patient with a heterozygous TNFRSF13B variant highlights the potential involvement of the eye within CVID-associated autoimmunity and the role for anti-TNF blockade in this challenging group of patients.

Prognostic Scores for Mortality in Invasive Mechanically Ventilated Burn Patients.

Managing burn patients is a challenge requiring a multidisciplinary team with the ability to predict complications and act early to avoid them. There are few studies characterizing the population of critically ill burn patients in need of ventilatory support. This study aimed to describe the population of burn patients in need of invasive mechanical ventilation supportand assess in-hospital mortality and the factors associated with it. A longitudinal retrospective study was conducted, including burn patients admitted to a tertiary hospital burn unit over five consecutive years, who required invasive mechanical ventilation support during their hospitalization. Demographic data, comorbidities, characteristics of the injury scene, etiology, and characteristics of the burn were collected.Length of mechanical ventilation and hospitalization as well as mortality rate were evaluated.The determination of mortality predictors and the prognostic performance of mortality prediction scores were analyzed. A one-year follow-up was performed to evaluate the survival of discharged patients. A total of 141 patients were included in this study; 68.1% patients were malewith a median age of 58 years. The mean percentage of total body surface area (TBSA) burned was 24.5%. Home incidents were the most frequent, and fire was the most common cause of burns (80.9% of patients). The mean Abbreviated Burn Severity Index Score (ABSI) was 7.83, with an area under the curve in receiver operating characteristic curve (ROC) analysis (AUC_ROC) of 0.725; the mean Belgium Outcome of Burn Injury (BOBI) score was 3.45, with AUC_ROC of 0.740 and mean R-Baux of 89.1 and AUC_ROC of 0.834. The mean duration of invasive mechanical ventilation was 16.9±19.3 days. Age (p<0.001), length of mechanical ventilation (p<0.001), length of hospitalization (p<0.001), higher degree of burn (p=0.001), TBSA (p=0.040), and the presence of buttock burn (0.006) were associated with mortality in this sample. In-hospital mortality was 29.8%. The survival group had a 12% death rate at one-year follow-up, mostly in the first three months after discharge. Age, duration of mechanical ventilation, length of hospitalization, higher degree of burn, TBSA, and the presence of buttock burn were associated with mortality in this sample. R-Baux score was the most accurate test score to predict mortality in this challenging group of patients.

Oral discomfort and health behavior of patients with typical vs. atypical antipsychotic drugs.

Psychiatric patients suffer from oral diseases and side effects of antipsychotic medication. In particular, the typical antipsychotic drugs may cause severe hyposalivation with subsequent oral symptoms. We therefore aimed to compare oral health behavior and oral side effects of in-hospital patients taking typical vs. atypical antipsychotic drugs with the hypothesis that the former drugs cause more oral pain than the newer drugs. This cross-sectional questionnaire and interview study investigated subjective oral symptoms and their health behavior in 170 hospitalized psychiatric patients, comparing those taking typical vs. atypical antipsychotic drugs. Cross-tabulations and chi-square tests were used for analyses. Persistent oral pain lasting throughout the day was reported by 46% in the typical, and 5% in the atypical antipsychotic group patients, respectively. In both groups, the pain was mainly in the tongue and buccal mucosa and was described as a burning sensation. A significantly higher prevalence of xerostomia was reported in the typical antipsychotic medication group (66%) compared with the atypical antipsychotic medication group (53%, p<0.01). Self-assessed dental health was assessed as poor by two-thirds of the patients of whom 69% reported toothbrushing once daily. Approximately half of them reported having had a visit to a dentist within the previous year. Of the women 28%, and of the men 17%, respectively, had received professional consultations for oral symptoms. The current results on psychiatrically hospitalized patients emphasize the need for awareness of oral discomfort and its subsequent effects on the quality of life in this challenging patient group. Focus should also be placed on a wide range of support encouraging the patients to maintain good daily oral hygiene and seek professional dental help when needed.

#364 Patient characteristics, treatment history and prognosis of adult survivors of childhood kidney replacement therapy—an ERA Registry study

Abstract Background and Aims Young adults who initiated kidney replacement therapy (KRT) during childhood and reached their 18th birthday (i.e. adult survivors of childhood KRT) are a particularly challenging patient group. Besides the changes associated with adolescence, they go through a transition from paediatric to adult nephrology centres, in which patients are expected to take responsibility of their own care. This increases the risk of non-compliance to treatment and graft failure. Nevertheless, not many epidemiological studies have focused on adult survivors of childhood KRT. This type of study would support healthcare providers in obtaining knowledge about the prognosis of this patient group and, perhaps, recognizing possibilities of treatment improvements. We aimed to provide up-to-date information on patient characteristics, treatment history, (graft) survival, 5-year prognosis and expected remaining lifetime of adult survivors of childhood KRT. Method KRT data was used from 21 European countries/regions that contributed with individual patient data to the European Renal Association (ERA) Registry. Adult survivors of childhood KRT, reaching the age of 18 years between 2008 and 2019, were included in the analysis, and their patient characteristics and treatment trajectories were examined. Kaplan-Meier and Cox proportional hazards regression were used in patient and graft survival analyses. The expected remaining lifetime of all KRT patients from the age of 18 years onwards was calculated overall and stratified by sex and treatment modality at the 18th birthday. Results We included 2 944 patients in the analysis, most of them were 10-14 (32.9%) or 15-17 (30.6%) years at start of KRT, and congenital anomalies of the kidney and urinary tract (CAKUT) were the most frequent cause of kidney failure (38.8%). Peritoneal dialysis was the most common treatment at start of KRT (37.8%), yet the percentage of adult survivors who received a pre-emptive kidney transplant increased from 25.6% in 2008-2011 to 32.4% in 2016-2019. By their 18th birthday, 81.4% of patients had a functioning kidney transplant. The overall unadjusted 5-year patient survival after their 18th birthday was 96.9% (95% CI 96.2-97.5), yet adult survivors on dialysis had an almost 4 times higher risk of death than their peers with a functioning kidney graft (adjusted HR 3.76 (95% CI: 2.55-5.53)). Besides, about 21% of the grafts failed during the 5 years after the 18th birthday (unadjusted 5-year graft survival: 78.9% (95% CI: 77.1-80.7)). Eighteen-year-old kidney transplant recipients reached 74% of the expected remaining lifetime of the general population, whereas dialysis patients only reached 37%. Conclusion Even at the young age of 18 years the remaining life expectancy of kidney transplant recipients was lower compared with the general population, and about one fifth of the grafts failed within 5 years after the patients’ 18th birthday. Still, as expected, adult survivors with a functioning kidney transplant at 18 years showed better outcomes than the ones on dialysis, with a greater 5-year survival and longer life expectancy. This epidemiological study reports on one of the biggest cohorts of adult survivors of childhood KRT studied to date. It provides unique knowledge on the prognosis of these patients, establishing the first step towards the optimization of care in this challenging patient group.

APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer.

Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer. A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded. A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months. This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.

Real-world effectiveness and safety of pembrolizumab in mismatch repair-deficient (dMMR) gastrointestinal non-colorectal tumors.

733 Background: The KEYNOTE-158 trial demonstrated durable clinical efficacy with pembrolizumab in long-term follow-up of previously treated unresectable or metastatic MSI-H/dMMR non-colorectal cancer. Our study, the GAIN study, aims to evaluate effectiveness and safety of pembrolizumab in dMMR Gastrointestinal Non-Colorectal Tumors in real-world clinical practice. Methods: We conducted a multicenter, retrospective, observational study on patients with Mismatch Repair-Deficient (dMMR) Gastrointestinal Non-Colorectal Tumors treated with pembrolizumab in real-world practice at six university hospitals affiliated with the Galician Research Group on Digestive Tumors (GiTUD) in Northwest Spain. Results: Between January 2018 and April 2023, 35 patients were enrolled. The median age was 66 years (range 33-88), with 54.3% being male. Tumor locations included 23 (65.7%) gastroesophageal adenocarcinomas, 3 (8.6%) pancreatic adenocarcinomas, 2 (5.7%) duodenal adenocarcinomas, 2 (5.7%) intrahepatic cholangiocarcinoma, 2 (5.7%) jejune adenocarcinomas, 2 (5.7%) esophageal squamous cell carcinomas, and 1 (2.8%) tumor of unknown origin. 54.3% of tumors were poorly differentiated. The most frequent alteration was the loss of MLH1-PMS2 expression (71.4%). By tumor location, 100% of gastroesophageal, jejune, and unknown origin tumors showed MLH1-PMS2 loss; while 100% of duodenal, pancreatic, and biliary tumors exhibited MSH2-MSH6 loss. All patients received pembrolizumab, with 57.1% having no prior metastatic disease treatment, 80% having ECOG PS0-1, and 31.4% having hepatic metastases. Among 33 evaluable patients, the overall response rate (ORR) was 81.8% (including 30.3% complete response) and the disease control rate (DCR) was 90.9%. Specifically, in gastroesophageal adenocarcinomas, the ORR was 81%, and the DCR was 90.5%. In the overall population, the median progression-free survival (PFS) was 34.76 months (95% CI 5.33 – 64.19 months), and the median overall survival (OS) was 39.75 months (95% CI 4.33-75.18 months). Treatment was well-tolerated; only 3 patients discontinued treatment due to nephritis, sarcoidosis-like symptoms, or diarrhea. No treatment-related deaths occurred. Conclusions: Our study underscores the real-world effectiveness of pembrolizumab in patients with dMMR Gastrointestinal Non-Colorectal Tumors. The high ORR, DCR, and favorable safety profile support its use in this challenging patient group, providing valuable real-world evidence for clinical decision-making.

Tibiotalocalcaneal arthrodesis with an intramedullary nail: The functional and clinical outcome of a challenging patient group and its comparison to a below knee amputation

BackgroundTibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to fuse the ankle and subtalar joints to treat severe ankle and hindfoot disease. Patients often have multiple operations before a TTCA. A below knee amputation (BKA) has major physical and psychological impacts. Our aim is to investigate the outcomes of these treatments in salvage situations, with a focus on objective functional measurements and patient reported outcome measures (PROMs). Methods52 patients underwent TTCA with a retrograde intramedullary nail and contacted for clinical and functional assessments and compared to patients who underwent traumatic BKA. PROMS such as AOFAS score, SF-36 and foot function index (FFI), and objective functional outcome measures were used. ResultsOf the 52 TTCA patients, 28 patients were recruited for follow-up. 35.7% of patients had postoperative complications. Mean postoperative AOFAS score was 63.9 ± 8.4 (range, 47–81), FFI 48.8 ± 15.8 (range, 22.2–75.2). 11 BKA patients (mean age 46.4 years) were included as control group. BKA patients scored higher than the TTCA patients on SF-36 physical functioning (p < 0.01) and SF-36 mental health (p < 0.05) subscales. The flat-surface functional tests (timed up and go test, 2-minute walk test, 10-meter walk test) showed significantly (p < 0.05) better outcomes for the BKA compared to TTCA. ConclusionsA TTCA is a salvage procedure with high complication rates. Functional and psychometric results are reduced compared to the normal population. Patients after a BKA had significantly better scores on SF-36 functional and mental health subscales and better functional outcomes for flat ground activities compared to TTCA. Heterogeneity of the TTCA and BKA patient cohorts is a limitation of this study. With these results in mind, the outlook of a BKA is not necessarily a grim one. They may be used by surgeons to counsel patients preoperatively when managing complex ankle and hindfoot disease. Level of evidenceLevel III, retrospective cohort study

Treatment tactics for gastric erosive-ulcerative bleeding on the background of liver cirrhosis

Analysing the polymorphism of etiological factors that contribute to the development of erosive‑ulcerative gastric lesions in patients with liver cirrhosis (acid‑peptic factors, transformation of venous blood flow, immune complexes, etc.), it should be noted that portal hypertension is the most important cause of these lesions. Bleeding from erosive‑ulcerative gastric lesions is a direct cause of death, occupying the first place in the structure of mortality and far exceeding ulcer perforations in this regard. Mortality in the first massive acute gastric bleeding reaches 50%, after the second — 70%, in hepatic coma — 80% or more. Objective — to improve the treatment outcomes for patients with erosive and ulcerative bleeding in the stomach due to liver cirrhosis. Materials and methods. The treatment outcomes of 192 patients with the hepatic form of portal hypertension (liver cirrhosis) who were hospitalised in the therapeutic and surgical departments, which are the clinical bases of the Department of Surgery No. 2 at Bogomolets National Medical University, were studied for the period from 2005 to 2023. During upper endoscopy, degenerative changes in the gastric mucosa were detected in 94 (48.9%) patients. Specifically, gastric erosions were observed in 31 (33.0%) patients, gastric ulcers in 34 (36.2%), and portal gastropathy in 29 (30.8%) patients. A total of 88 (46.6%) patients with liver cirrhosis and acute gastric bleeding were admitted to the surgical department as an emergency. According to the Child‑Pugh scale, the vast majority of patients were at the stage of sub‑ and decompensation (71 patients, or 89.1%). In 41 (45.2%) patients, gastric cancer was attributed to gastric erosive and ulcerative lesions: erosive gastritis — in 20 (48.8%) patients and gastric ulcer — in 21 (51.2%) patients. Results. Enhancing the protective properties of the mucous‑bicarbonate barrier of the gastric mucosa as part of pathogenetic conservative treatment schemes can reduce the influence of this mechanism on the development of hemorrhagic complications in 89.4% of patients. The risk of bleeding in this group of patients with liver cirrhosis is 15.1%, which requires the search for new methods of conservative treatment. In 79.6% of cases, primary endoscopic hemostasis of bleeding erosive‑ulcerative gastric lesions was effective when combined with drug therapy. For 53.1% of patients, it proved to be the final treatment. This enabled a reduction in overall mortality to 22.4% from 50% (p &lt;0.05) and, if necessary, a delay in surgical intervention. Out of the total number of patients, 19 (38.8%) patients required surgical intervention, with 73.7% of them undergoing urgent surgery and 26.3% undergoing delayed surgery. When considering operative methods for peptic ulcers complicated by hemorrhage, preference should be given to organ‑ and function‑preserving interventions. They yield more favourable immediate outcomes for this extremely challenging group of patients (postoperative mortality was reduced to 26.3% vs. 50.0% (p &lt;0.05). Conclusions. Acute gastric bleeding resulting from erosive‑ulcerative gastric lesions, which are complications of liver cirrhosis, can significantly impair the health of patients. However, by implementing modern treatment technologies, such as surgical procedures, it is feasible to achieve a 50% reduction in both overall and postoperative mortality.

Converting the Fontan Circulation: Challenges and Evolution.

The Fontan operation, the final palliative step after a series of complex operations in patients with univentricular hearts, has undergone multiple modifications throughout the last decades, with the goal of finding the method which combines the optimal hemodynamic effects of the Fontan circulation with minimal long term side effects. An understanding of the operative evolution and subsequent side effects, as well as the management thereof seems imperative. Since its inception by Francis Fontan the, now obsolete, initial atriopulmonary connection has passed through several milestones into having now reached the era of total cavopulmonary connection. However, recently published results bring to light the new option of biventricular conversion which comes to challenge the management of Fontan patients as we know it. Currently, there is no consensus as to whether to continue with palliation in this challenging group of patients or proceed with heart transplantation. In this collective review, we provide a historic overview of the Fontan evolution as well as future insights, discussing the perspectives of options for patients with failing Fontan, including the latest addition of biventricular correction.

Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications

BackgroundDistal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). MethodsAll patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). ResultsRevision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1–57.8). ConclusionThe use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.

Recurrent Atrial Fibrillation Ablation after Initial Successful Pulmonary Vein Isolation.

Pulmonary vein isolation (PVI) is an effective treatment option for patients with symptomatic atrial fibrillation (AF). However, the electrical recovery of pulmonary veins (PVs) is the main trigger for AF recurrences. This study investigates the characteristics of patients admitted for redo AF ablation, the PV reconnection rates depending on previous ablation modalities and the impact of different ablation strategies for redo procedures. Consecutive patients undergoing first redo AF ablation were included. Patients were grouped according to the electrical recovery of at least one PV. The impacts of the technique for first AF ablation on PV reconnection rates and patients with and without PV reconnection were compared. Different ablation strategies for redo procedures were compared and its recurrence rates after a mean follow-up of 25 ± 20 months were investigated. A total of 389 patients (68 ± 10 years; 57% male; 39% paroxysmal AF) underwent a first redo. The median time between the first and redo procedure was 40 ± 39 months. Radiofrequency was used in 278 patients, cryoballoon was used in 85 patients and surgical AF ablation was performed on 26 patients. In total, 325 patients (84%) had at least one PV reconnected, and the mean number of reconnected PVs was 2.0 ± 1.3, with significant differences between ablation approaches (p for all = 0.002); this was mainly due to differences in the left inferior PV and right superior PV reconnections. The presence of PV reconnection during redo was not associated with better long-term success compared to completely isolated PVs (67% vs. 67%; log-rank p = 0.997). Overall, the different ablation strategies for redos were comparable regarding AF recurrences during follow-up (p = 0.079), with the ablation approach having no impact in the case of left atrial low voltage or without. PV reconnections after initial successful PVI are common among all techniques of AF ablation. Long-term rhythm control off antiarrhythmic drugs was possible in 2/3 of all patients after the redo procedure; however, different ablation strategies with extra-PV trigger ablation did not improve long-term success. Patients with recurrent AF after PVI constitute a challenging group of patients.

Crouzon Syndrome Spanning Three Generations: Advances in the Treatment of Syndromic Midface Deficiency.

Crouzon syndrome is an autosomal dominant genetic disorder characterized by craniosynostosis, midface retrusion, and exophthalmos. Over the past century, the treatment of craniofacial disorders like Crouzon syndrome has evolved significantly. An institutional review board-approved retrospective study was conducted to ascertain the treatment of three individuals with Crouzon syndrome from one family, complemented with a series of literature searches to examine the evolution of craniofacial surgical history. Dr. David Williams Cheever developed the Le Fort I level to correct malocclusion, maxillomandibular malformations, and midface hypoplasia. Later, Dr. Paul Tessier introduced the Le Fort II and III osteotomies to treat syndromic midface hypoplasia. In 1978, Dr. Fernando Ortiz-Monasterio and Dr. Antonio Fuente del Campo published the first series of monobloc osteotomies, allowing for simultaneous correction of supraorbital and midface malformations, although complicated by blood loss and high infection rates. In 1992, McCarthy et al introduced the concept of gradual distraction to the craniofacial skeleton. In 1995, Polley et al performed the first monobloc advancement using external distraction. Subsequently, in 1997, Polley and Figueroa introduced a rigid external distraction device with multiple vector control to manage severe cleft maxillary hypoplasia. The technique was further refined and applied to treat syndromic midface hypoplasia, reducing complication rates. Currently, either external or internal distraction approaches are used to safely treat this challenging group of patients. The treatment of syndromic midface deficiency has significantly evolved over the past 50 years, as evidenced by this report of three generations of Crouzon syndrome.

Management of Patients After Treatment of Severe Alcohol-associated Hepatitis.

Alcohol-associated liver disease is the leading indication for hospitalization among patients with chronic liver disease. Rates of hospitalization for alcohol-associated hepatitis have been rising over the last 2 decades. Patients with alcohol-associated hepatitis carry significant morbidity and mortality, but there is a lack of standardized postdischarge management strategies to care for this challenging group of patients. Patients warrant management of not only their liver disease but also their alcohol use disorder. In this review, we will discuss outpatient management strategies for patients who were recently hospitalized and discharged for alcohol-associated hepatitis. We will discuss short management of their liver disease, long-term follow-up, and review-available treatment options for alcohol use disorder and challenges associated with pursuing treatment for alcohol use disorder.

Education's impact on primary care dentists' confidence in treating patients with special health care needs.

Special care dentistry (SCD) is still developing in XX. This study aimed to clarify whether primary care dentists are treating patients with special health care needs (SHCN), to know if they have had previous education on SCD (on an undergraduate or postgraduate level), whether their training level impacts their confidence when treating patients with SHCN, and to assess their opinion on SCD as a relevant topic in undergraduate education. A survey was answered by 149 primary care dentists working for the National Health Service of the XX region in XX, including information on their daily clinical practice, undergraduate, and postgraduate training in SCD, and their opinions on them. Most interviewees would like to complement their training and believed that SCD should be formally incorporated into undergraduate programs. There was a significant association between confidence in treating patients with SHCN and the rating of their undergraduate training, and between confidence and the number of hours of continuous development courses. Most primary care dentists treat patients with SHCN regularly. Therefore, including training in the undergraduate curriculum and afterward becomes necessary to increase their confidence when facing this challenging group of patients.

Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance.

Developing good interpersonal relationships is one of the main impediments for people with an antisocial personality disorder (ASPD). However, in treatment of psychiatric disorders, establishing a strong therapeutic alliance (TA) is important for effective treatment. Nevertheless, there is little knowledge on how to establish this TA with this challenging patient group. This study investigates which factors are important in TA development. For this study, a qualitative research methodology is applied. In-depth interviews with therapists experienced in treating ASPD were conducted and analysed through thematic analysis. The analysis revealed six themes important in alliance formation: the patient's needs, regulating interpersonal dynamics, connective attitude, connective skills, treatment process and treatment goals. Each theme is defined including aspects of the recommended therapeutic attitude and required skills for therapists working with patients with ASPD. This study determined that, for therapists working with patients with ASPD, several key factors are essential in establishing a strong TA. These factors include the ability to be firm, authentic, non-judgmental and genuinely involved. An attentive presence is crucial, in which the therapist takes initiative in establishing contact and makes the patient feel that he is truly seen as an autonomous and equal person. In doing so, the therapist needs to provide clarity and structure while remaining perceptive to boundary violations. The therapist must be able to set limits using a clear yet kind tone of voice. Furthermore, it was notable that an intensive appeal is made to the therapist's reflective capacity in these treatments.

Late Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention in the Workup Pre-TAVR

BackgroundIn patients undergoing percutaneous coronary intervention (PCI) in the work-up pre–transcatheter aortic valve replacement (TAVR), the incidence and clinical impact of late bleeding events (LBEs) remain largely unknown. ObjectivesThis study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of LBEs in patients undergoing PCI in the work-up pre-TAVR. MethodsThis was a multicenter study including 1,457 consecutive patients (mean age 81 ± 7 years; 41.5% women) who underwent TAVR and survived beyond 30 days. LBEs (>30 days post-TAVR) were defined according to the Valve Academic Research Consortium-2 criteria. ResultsLBEs occurred in 116 (7.9%) patients after a median follow-up of 23 (IQR: 12-40) months. Late bleeding was minor, major, and life-threatening or disabling in 21 (18.1%), 63 (54.3%), and 32 (27.6%) patients, respectively. Periprocedural (<30 days post-TAVR) major bleeding and the combination of antiplatelet and anticoagulation therapy at discharge were independent factors associated with LBEs (P ≤ 0.02 for all). LBEs conveyed an increased mortality risk at 4-year follow-up compared with no bleeding (43.9% vs 36.0; P = 0.034). Also, LBE was identified as an independent predictor of all-cause mortality after TAVR (HR: 1.39; 95% CI: 1.05-1.83; P = 0.020). ConclusionsIn TAVR candidates with concomitant significant coronary artery disease requiring percutaneous treatment, LBEs after TAVR were frequent and associated with increased mortality. Combining antiplatelet and anticoagulation regimens and the occurrence of periprocedural bleeding determined an increased risk of LBEs. Preventive strategies should be pursued for preventing late bleeding after TAVR, and further studies are needed to provide more solid evidence on the most safe and effective antithrombotic regimen post-TAVR in this challenging group of patients.