Follow-up Protocol Research Articles

Autotransplanation of immature premolars to replace a severely traumatized maxillary central incisor in young patients: Orthodontic and surgical cooperation

Young patients with a severely traumatized maxillary central incisor have limited possibilities to restore its loss. Autotransplantation of immature premolars has been documented as a predictable long-term outcome with the potential for preservation and regeneration of alveolar bone. They can also be successfully reshaped to the central incisor's morphology using direct composite build-ups. However, tooth transplantation is a technique sensitive procedure and requires good case selection, an understanding of relevant tooth transplantation biological principles and careful execution of the optimal surgical and follow-up protocols. Orthodontists play an important role in cooperation with the surgeon before and after surgery. This includes selection of suitable candidates based on orthodontic evaluation of occlusion and indications for premolar extraction, opening adequate space before transplantation and post-surgical alignment of the transplant for an optimal reshaping and establishing a stable occlusion. The aim of the paper is to present clinical application of autotransplanation of immature premolars to replace a traumatized central incisor in growing patients and to discuss the role of an orthodontist in the interdisciplinary team.

PO-01-050 STRUCTURAL CARDIAC CHANGES DETECTED BY MRI AFTER STEREOTACTIC BODY RADIOTHERAPY FOR TARGETS IN CLOSE PROXIMITY TO THE HEART

Stereotactic body radiation therapy (SBRT) has become a standard of care for inoperable early-stage non-small cell lung cancer and in case of pulmonary oligometastases. Recent studies indicate that incidental irradiation of the heart may be associated with an increased risk of non-cancer-related deaths. This study aims to assess and examine structural cardiac changes following peri- and myocardial SBRT using a systematic cardiac follow-up protocol including cardiac magnetic resonance (CMR) imaging. For 1485 patients treated with local-ablative SBRT from January 2014 to February 2022 at our institution, the distance between the planning target volume (PTV) and the heart was measured. Forty-eight out of 134 patients treated in close proximity (<2cm) to the heart were alive at follow-up. Of those, 20 were randomly invited to undergo a structured cardiac follow-up protocol including CMR. Ten patients consented to participate and underwent a structural follow-up protocol. Registration of CMR image data and the SBRT treatment plan was performed to examine a possible correlation between the dose delivered to the myocardium and structural cardiac changes assessed by CMR. Among the 10 participating patients, the most common primary tumors were non-small cell lung cancer (n=3) and small-cell lung cancer (n=2) (Table 1). Five patients presented with pre-SBRT cardiovascular comorbidities. Seven patients received SBRT for pulmonary or vertebral metastases and three patients for primary lung cancer with a median dose of 42.5 Gy (30.0-48.0 Gy) in 3-10 fractions. The mean heart dose (Dmean) and maximum heart dose (Dmax) were 4.9 Gy (0.7-8.4 Gy) and 36.2 Gy (8.3 – 64.1 Gy), respectively. On CMR, five patients showed myocardial alterations, such as late gadolinium enhancement and edema after a median follow-up time of 5.6 years (0.1-6.3 years) as shown in Figure 1. In patients with structural changes of the myocardium the median distance between the treated lesion and myocardium with 0.0 (0.0-1.08) cm vs. 1.4 (0.41-2.0) cm was significantly lower (p=0.015). Additionally, patients with structural changes on CMR showed significantly higher Dmax (135.4 Gy vs. 25.4 Gy, p=0.009), Dmean (4.4 Gy vs. 3.4 Gy, p=0.05). In this pilot study, patients treated with SBRT for pulmonary targets with PTV overlapping the heart showed structural changes of the myocardium in CMR. The presence of structural changes correlates with higher heart doses.

Stent Angioplasty in Coronary Artery Anomalies With Intramural Course: When, Why, How, With What Results?

Although coronary artery anomalies include multiple disorders, few are likely to require intervention, given that the risk for critical sequelae (ie, sudden cardiac arrest and sudden cardiac death) is generally low. This article addresses which coronary artery anomaly carriers may need intervention and which interventions may be required. The recent introduction of stent angioplasty is discussed in particular, along with general reviews of nomenclature, various anatomical and functional presentations, quantitative diagnosis methods, and indications for surgical versus percutaneous intervention. Novel criteria for defining severe stenosis also are proposed. Optimal risk quantification depends on precise imaging that only intravascular ultrasonography or optical coherence tomography can reliably obtain. Accordingly, the technique of intravascular ultrasonography-monitored stent angioplasty is described in detail. Initial results from our group's study of 100 patients with right or left anomalous origin of a coronary artery from an opposite sinus of Valsalva with intramural course are reported. Future efforts should prospectively evaluate stent angioplasty in multicenter studies based on precise, consistent techniques and follow-up protocols, such as those initiated by our group. Comparisons with surgical results should be part of the program, with the understanding that detailed and complete results from those techniques will require long-term (5- to 10-year) studies.

Identification of rapid progression of right ventricular functional measures using three-dimensional cardiac computed tomography after total surgical correction of tetralogy of Fallot

ObjectiveTo identify subsets of patients with tetralogy of Fallot (TOF) after total surgical correction demonstrating the rapid progression of right ventricle (RV) functional measures using cardiac computed tomography (CT) ventricular volumetry. MethodsRapid or slow progression of RV functional measures was determined in 109 patients with TOF who underwent cardiac CT ventricular volumetry more than twice after total surgical correction. Patient age, body surface area, postoperative days, the time interval between the first and last cardiac CT examinations, and CT-based functional measures were evaluated using binary logistic regression to determine the predictors of the rapid progression. Receiver operating characteristic curve analysis was performed to evaluate diagnostic performance of the potential predictors. ResultsThe rapid progression of indexed RV end-systolic volume (ESV) (≥2.7 mL/m2/year) and indexed RV end-diastolic volume (≥0.9 mL/m2/year) could be predicted by RV ejection fraction (EF) at the last cardiac CT with an odds ratio of 1.340 (95 % confidence interval [CI], 1.122–1.600; p = 0.001) and age at the last cardiac CT with an odds ratio of 8.255 (95 % CI, 1.531–44.513; p = 0.014), respectively. RV EF at the last cardiac CT showed the highest diagnostic performance (area under the curve = 0.799; p < 0.002) for the rapid progression of indexed RV ESV. ConclusionCardiac CT ventricular volumetry can be used to identify patients demonstrating the rapid progression of RV functional measures after total surgical correction of TOF and follow-up imaging protocols can be individually optimized based on initial progression rate.

Barriers and Facilitators to Pre-Exposure Prophylaxis by Men Who Have Sex with Men and Community Stakeholders in Malaysia.

Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy; yet, uptake remains low among Malaysian MSM, who have a limited understanding of barriers to PrEP. We employed the nominal group technique (NGT), a structured mixed-methods strategy to understand the barriers and facilitators to PrEP use among Malaysian MSM, combined with a qualitative focus group. Six virtual focus group sessions, three among MSM (n = 20) and three among stakeholders (n = 16), were conducted using a video-conferencing platform. Rank-ordering of barriers from NGT was recorded, and thematic analysis was conducted for content. Similar barriers were reported by MSM and community stakeholders, with aggregated costs associated with PrEP care (e.g., consultation with a clinician, medication, laboratory testing) being the greatest barrier, followed by limited knowledge and awareness of PrEP. Additionally, the lack of access to PrEP providers, the complex clinical protocol for PrEP initiation and follow-up, and social stigma undermined PrEP delivery. Qualitative discussions identified potential new strategies to overcome these barriers, including expanded outreach efforts to reach hard-to-reach MSM, a 'one-stop' delivery model for PrEP services, a patient-centered decision aid to guide PrEP uptake, and easy access to LGBT-friendly PrEP providers. Current barriers may be overcome through governmental subsidy for PrEP and evidence-informed shared decision aids to support both MSM and PrEP providers.

Predictors of Relapse and Survival in Testicular Germ cell Tumors in Children

Background: Testicular germ cell tumors are common solid organ malignancies in children with a survival rate of more than 90 %. This study aims to assess the predictors of relapse and survival in testicular germ cell tumors in children.&#x0D; Methodology: A retrospective review was conducted on children up to the age of 18-years from January 2010 to December 2020 with a diagnosis of primary testicular germ cell tumors. Factors related to relapse and survival like age, baseline levels of tumor markers in serum and on relapse, stage at diagnosis, histological type, tumor laterality &amp; size of the tumor in testicular germ cell tumors were analyzed. The data was entered into SPSS version 20. Statistical significance was set at a p-value ≤0.05.&#x0D; Results: A total of 115 patients with a mean age of 5.42+ 1.54 years having testicular germ cell tumor were treated. Seventeen patients (14.7 %) had relapse of disease. Relapse was highest in patients with stage I disease (64.7 %). Yolk sac tumor was the most common pathology that was noted in twelve (70 %) patients. The most common site of relapse was the retroperitoneum (70 %). Age of patient, stage of disease, and lymphovascular invasion were significant predictors of relapse and survival in testicular germ cell tumors.&#x0D; Conclusion: Management of patients with testicular germ cell tumors requires standardized follow-up protocol for early detection and treatment of disease relapse. Complete surgical excision with meticulous control of the residual disease is critical to prevent disease relapse.&#x0D; Keywords: Chemotherapy, Children, Outcome, Relapse, Testicular Tumor&#x0D; &#x0D;

Hypercalcemia–leukocytosis syndrome from non-schistosomiasis-associated squamous cell carcinoma of the urinary bladder: a case report and review of the literature

BackgroundNon-schistosomiasis-associated squamous cell carcinoma of the urinary bladder is less common in the Western world. Limited information on its possible paraneoplastic syndromes exists. Leukocytosis tends to commonly be regarded by clinicians as an indication of sepsis, rather than a feature of paraneoplasia, potential surrogate marker for recurrence, and prognostic marker. Accompanying hypercalcemia may be missed entirely.Case presentationA 66-year-old Caucasian man presented with visible painless hematuria and symptomatic hypercalcemia. Investigations revealed a squamous cell carcinoma of the urinary bladder with marked leukocytosis. Hypercalcemia and leukocytosis resolved following radical cystectomy, recurred with nodal recurrence and regressed with radiotherapeutic control. Subsequently, serum leukocyte and calcium assays were included in his follow-up protocol. His survival was 20 months by the time of the report.ConclusionThis report highlights hypercalcemia–leukocytosis syndrome as a paraneoplastic manifestation of non-schistosomiasis-associated squamous cell carcinoma to reemphasize the need for clinicians to assay for calcium in the presence of leukocytosis in such patients. Prompt identification and control of the paraneoplastic derangements, with treatment of the cancer recurrence it may connote, is advocated to provide a chance for better long-term outcomes in these patients.

A prospective long-term evaluation of the ocular findings of children followed with the diagnosis of multisystem inflammatory syndrome (long-term evaluation of ocular findings following MIS-C).

The most frequently reported ocular finding in the acute phase of the multisystem inflammatory syndrome in children (MIS-C), is conjunctivitis. More rarely, punctuate epitheliopathy, anterior uveitis and optic disc oedema can be seen. We aimed to investigate the acute and long-term ocular effects of MIS-C. Cases aged 1 month to 18 years who were diagnosed with MIS-C between January 2022 and June 2022 in the Department of Pediatric Infectious Diseases in our hospital were included in the study. Ophthalmological examinations were performed immediately after diagnosis, at one month, three months, and six months. Males consisted of 64.7% of the 34 cases included in the study and the mean age was 8.68 ± 4.32 years (min-max:2-17). In the first examination, conjunctivitis was observed in 6 (17.6%), punctuate epitheliopathy in 4 (11.7%), and subconjunctival haemorrhage in 3 (8.8%) patients. Two patients (5.8%) had optic disc oedema. No pathological anterior or posterior segment findings were observed in the sixth-month examination. The relationship between subconjunctival haemorrhage and intensive care hospitalisation was statistically significant (p = 0.014). Also, all patients with subconjunctival haemorrhage were clinically classified as severe MIS-C (p = 0.002). Although pathological ocular findings were observed in the acute phase of the disease, all of them were found to be improved at the sixth-month follow-up. The most striking finding of our study is that cases with subconjunctival haemorrhage were clinically more severe, and all patients needed intensive care. This study may be informative in establishing ocular follow-up protocols that are expected to be carried out in the acute period and in the follow-up of these patients.

New Biomarkers (Endocan, Interleukin-17, and Thrombospondin-4) for the Diagnosis, Assessment of Severity, and Follow-Up of Peripheral Arterial Disease.

The present study evaluated the use of endocan, interleukin-17 (IL-17), and thrombospondin-4 (TSP-4) blood levels as potential biomarkers for the diagnosis and follow-up of peripheral arterial disease (PAD). Patients with PAD (Rutherford categories I, II, and III) who were admitted between March 2020 and March 2022 for cardiovascular surgery or outpatient clinic follow-up were included. The patients (n = 60) were divided into 2 groups: medical treatment (n = 30) and surgical treatment (n = 30). In addition, a control group (n = 30) was created for comparison. Endocan, IL-17, and TSP-4 blood levels were measured at the time of diagnosis and at the first month after treatment. Endocan and IL-17 values were found to be significantly higher in both groups that underwent medical (259.7 ± 46pg/mL, 63.7 ± 16.6pg/mL) and surgical (290.3 ± 84.5pg/mL, 66.4 ± 19.6pg/mL) treatment than the control group (187.4 ± 34.5pg/mL, 56.5 ± 7.2pg/mL P < .001). Tsp-4 value was found to be significantly higher only in the surgical treatment group (15 ± 4.3ng/mL) than the control group (12.9 ± 1.4ng/mL P < .05). The decreases in endocan, IL-17, and TSP-4 levels at the first month of treatment in both groups were also significant (P < .001). A combination of classical and these new biomarkers could be included in PAD screening, early diagnosis, severity determination, and follow-up protocols in order to provide effective assessment in clinical practice.

The patients’ experience of neuroimaging of primary brain tumors: a cross-sectional survey study

PurposeTo gain insight into how patients with primary brain tumors experience MRI, follow-up protocols, and gadolinium-based contrast agent (GBCA) use.MethodsPrimary brain tumor patients answered a survey after their MRI exam. Questions were analyzed to determine trends in patients’ experience regarding the scan itself, follow-up frequency, and the use of GBCAs. Subgroup analysis was performed on sex, lesion grade, age, and the number of scans. Subgroup comparison was made using the Pearson chi-square test and the Mann–Whitney U-test for categorical and ordinal questions, respectively.ResultsOf the 100 patients, 93 had a histopathologically confirmed diagnosis, and seven were considered to have a slow-growing low-grade tumor after multidisciplinary assessment and follow-up. 61/100 patients were male, with a mean age ± standard deviation of 44 ± 14 years and 46 ± 13 years for the females. Fifty-nine patients had low-grade tumors. Patients consistently underestimated the number of their previous scans. 92% of primary brain tumor patients did not experience the MRI as bothering and 78% would not change the number of follow-up MRIs. 63% of the patients would prefer GBCA-free MRI scans if diagnostically equally accurate. Women found the MRI and receiving intravenous cannulas significantly more uncomfortable than men (p = 0.003). Age, diagnosis, and the number of previous scans had no relevant impact on the patient experience.ConclusionPatients with primary brain tumors experienced current neuro-oncological MRI practice as positive. Especially women would, however, prefer GBCA-free imaging if diagnostically equally accurate. Patient knowledge of GBCAs was limited, indicating improvable patient information.

Biomonitoring California Protocol for Following up on Elevated Levels of Urinary Arsenic

to develop and implement a follow-up protocol for Biomonitoring California study participants with elevated levels of urinary arsenic, particularly inorganic forms. We selected 20 μg/L as the level of concern for urinary inorganic arsenic; samples with total arsenic ≥20 μg/L were speciated. Participants with elevated inorganic arsenic were notified of their level and invited to participate in a telephone survey to help determine possible exposure sources. We illustrate the protocol in four Biomonitoring California studies, which collected samples from 2010-2013 in locations across the state. 48 participants in the four studies had elevated urinary inorganic arsenic levels. Consumption of rice and rice-based products was the most commonly identified potential source of inorganic arsenic exposure. Of 48 participants with elevated inorganic arsenic, 27 would have been missed if we had used the previously published threshold of 50 µg/L total arsenic to identify urine samples for speciation. This protocol fills a gap in the clinical literature by providing a more health-protective approach to identify individuals with elevated urinary inorganic arsenic and help determine potentially significant exposure sources.

Assessing suicidality during the SARS-CoV-2 pandemic: Lessons learned from adaptation and implementation of a telephone-based suicide risk assessment and response protocol in Malawi.

The SARS-CoV-2 pandemic led to the rapid transition of many research studies from in-person to telephone follow-up globally. For mental health research in low-income settings, tele-follow-up raises unique safety concerns due to the potential of identifying suicide risk in participants who cannot be immediately referred to in-person care. We developed and iteratively adapted a telephone-delivered protocol designed to follow a positive suicide risk assessment (SRA) screening. We describe the development and implementation of this SRA protocol during follow-up of a cohort of adults with depression in Malawi enrolled in the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP) randomized control trial during the COVID-19 era. We assess protocol feasibility and performance, describe challenges and lessons learned during protocol development, and discuss how this protocol may function as a model for use in other settings. Transition from in-person to telephone SRAs was feasible and identified participants with suicidal ideation (SI). Follow-up protocol monitoring indicated a 100% resolution rate of SI in cases following the SRA during this period, indicating that this was an effective strategy for monitoring SI virtually. Over 2% of participants monitored by phone screened positive for SI in the first six months of protocol implementation. Most were passive risk (73%). There were no suicides or suicide attempts during the study period. Barriers to implementation included use of a contact person for participants without personal phones, intermittent network problems, and pre-paid phone plans delaying follow-up. Delays in follow-up due to challenges with reaching contact persons, intermittent network problems, and pre-paid phone plans should be considered in future adaptations. Future directions include validation studies for use of this protocol in its existing context. This protocol was successful at identifying suicide risk levels and providing research assistants and participants with structured follow-up and referral plans. The protocol can serve as a model for virtual SRA development and is currently being adapted for use in other contexts.

Impact of Post-EVAR Aneurysm Sac Behavior on Clinical Outcomes and Follow-up Protocols: Shrinkage as the Only Reliable Predictor of Healing, but Influenced by Comorbidities and Graft Model

Impact of Post-EVAR Aneurysm Sac Behavior on Clinical Outcomes and Follow-up Protocols: Shrinkage as the Only Reliable Predictor of Healing, but Influenced by Comorbidities and Graft Model

Chemoresistive Nanosensors Employed to Detect Blood Tumor Markers in Patients Affected by Colorectal Cancer in a One-Year Follow Up

Colorectal cancer (CRC) represents 10% of the annual tumor diagnosis and deaths occurring worldwide. Given the lack of specific symptoms, which could determine a late diagnosis, the research for specific CRC biomarkers and for innovative low-invasive methods to detect them is crucial. Therefore, on the basis of previously published results, some volatile organic compounds (VOCs), detectable through gas sensors, resulted in particularly promising CRC biomarkers, making these sensors suitable candidates to be employed in CRC screening devices. A new device was employed here to analyze the exhalations of blood samples collected from CRC-affected patients at different stages of their pre- and post-surgery therapeutic path, in order to assess the sensor's capability for discriminating among these samples. The stages considered were: the same day of the surgical treatment (T1); before the hospital discharge (T2); after one month and after 10-12 months from surgery (T3 and T4, respectively). This device, equipped with four different sensors based on different metal-oxide mixtures, enabled a distinction between T1 and T4 with a sensitivity and specificity of 93% and 82%, respectively, making it suitable for clinical follow-up protocols, patient health status monitoring and to detect possible post-treatment relapses.

Optimization of postoperative surveillance protocols in upper tract urothelial cancer: A retrospective cohort study.

Upper tract urothelial carcinoma (UTUC) is an aggressive disease that is managed by radical or organ-sparing surgery. High recurrence rates require early detection and strict follow-up (FU) protocols. Recommendations are assigned to a low level of evidence. Our aim was to identify time-to-tumor recurrence, analyze the temporal relation to recommended FU regimens, and provide a critical proposal for further surveillance. This retrospective study included 54 patients receiving radical nephroureterectomy (RNU) in high-risk UTUC and 14 patients assigned to kidney-sparing surgery (KSS) with low-risk disease. FU surveillance protocols consisted of close intervals irrespective of the received type of surgery. In total, 68 patients were included with a median FU of 23 months. Mean overall survival (OS) was significantly shorter in RNU compared to KSS (P = .027). Recurrence in the bladder and/or upper urinary tract (UUT) was 57.1% in KSS and 38.9% after RNU (P = .241). Mean recurrence-free survival (RFS) was significantly shorter in RNU patients compared to KSS (22.4 vs. 47.9 months, P = .013), and 76.2% of the recurrences in the RNU group occurred in the first postoperative year. UUT recurrence was diagnosed after a median of 3.0 (RNU) and 25.0 (KSS) months. There was a frequent onset of metastases in the RNU group, with 85.7% in the first year compared to the KSS group with 50%. Multivariable regression analysis showed that the tumor stage was the parameter independently related to OS (P = .002), RFS (P = .008), and metastasis-free survival (MFS, P = .002). In conclusion, surveillance of UTUC should be adapted to real-time occurrence patterns. Strict imaging protocols are recommended in the first two years irrespective of the method of surgery. As recurrence is equally distributed over the years after KSS, cystoscopy should be offered regularly for five years and diagnostic URS for three years. After RNU, cystoscopies should be decreased to yearly intervals after year three. Contralateral UUT should also be examined after RNU.

Characterization of hemodialysis fistulas experienced abrupt thrombosis and determination of a proper follow-up protocol: A retrospective cohort study and an interventionist's perspective.

Abrupt thrombosis is a form of thrombosis that occurs unexpectedly and without being preceded by hemodialysis fistula (AVF) dysfunction during dialysis. We found that AVFs with a history of abrupt thrombosis (abtAVF) appeared to have more episodes of thrombosis and required more frequent interventions than those without such history. Therefore, we sought to characterize the abtAVFs and examined our follow-up protocols to determine which one is optimal. We performed a retrospective cohort study using routinely collected data. The thrombosis rate, AVF loss rate, thrombosis-free primary patency, and secondary patency were calculated. Additionally, the restenosis rates of the AVFs under the follow-up protocol/sub-protocols and the abtAVFs were determined. The thrombosis rate, procedure rate, AVF loss rate, thrombosis-free primary patency, and secondary patency of the abtAVFs were 0.237/pt-yr, 2.702/pt-yr, 0.027/pt-yr, 78.3%, and 96.0%, respectively. The restenosis rate for AVFs in the abtAVF group and the angiographic follow-up sub-protocol were similar. However, the abtAVF group had a significantly higher thrombosis rate and AVF loss rate than AVFs without a history of abrupt thrombosis (n-abtAVF). The lowest thrombosis rate was observed for n-abtAVFs, followed up periodically under the outpatient or angiographic sub-protocols. AVFs with a history of abrupt thrombosis had a high restenosis rate, and periodic angiographic follow-up with a mean interval of 3 months was presumed appropriate. For selected populations, such as salvage-challenging AVFs, periodic outpatient or angiographic follow-up was mandatory to extend their usable lives for hemodialysis.

Benefits of Using Smartphones and Other Digital Methods in Achieving Better Cardiac Rehabilitation Goals: A Systematic Review and Meta-Analysis.

BACKGROUND The importance of introducing digital technology as an alternative to classical cardiac rehabilitation has been discussed in several reviews. The purpose of this systematic review and meta-analysis was to analyze the effectiveness of digital technology use in cardiac rehabilitation to determine whether digital methods like use of smartphones, compared to traditional rehabilitation methods, can improve the overall quality of life and exercise capacity of cardiac patients. MATERIAL AND METHODS PubMed, EMBASE, and ScienceDirect were systematically searched in a randomized manner, resulting in 11 randomized controlled trials (RCTs) that met all the inclusion criteria. The inclusion criteria were patients with coronary heart disease, valvular surgery, or post- myocardial revascularization that were in a technology-assisted cardiac rehabilitation program vs traditional standard physical follow-up protocol. RESULTS Seven eligible trials including a total of 802 participants examined the effect of interventions on VO2 peak. One of the studies comprised 2-stage analysis for this parameter. We found that VO₂ peak was significantly higher in the intervention group. Three studies analyzed the 6-minute walk test (6MWT) results; significant differences were reported, with better results in the interventional group. CONCLUSIONS The results of our meta-analysis support conducting further randomized trials, considering that the development of technology is on the rise. In the past decade there has been an immense increase in the use of smartphones, which can widely be used in healthcare, with promising benefits in having efficient home-based monitoring of the patients and in reducing financial burden.

Isolated anterior pituitary dysfunction in adulthood.

Hypopituitarism is defined as a complete or partial deficiency in one or more pituitary hormones. Anterior hypopituitarism includes secondary adrenal insufficiency, central hypothyroidism, hypogonadotropic hypogonadism, growth hormone deficiency and prolactin deficiency. Patients with hypopituitarism suffer from an increased disability and sick days, resulting in lower health status, higher cost of care and an increased mortality. In particular during adulthood, isolated pituitary deficits are not an uncommon finding; their clinical picture is represented by vague symptoms and unclear signs, which can be difficult to properly diagnose. This often becomes a challenge for the physician. Aim of this narrative review is to analyse, for each anterior pituitary deficit, the main related etiologies, the characteristic signs and symptoms, how to properly diagnose them (suggesting an easy and reproducible step-based approach), and eventually the treatment. In adulthood, the vast majority of isolated pituitary deficits are due to pituitary tumours, head trauma, pituitary surgery and brain radiotherapy. Immune-related dysfunctions represent a growing cause of isolated pituitary deficiencies, above all secondary to use of oncological drugs such as immune checkpoint inhibitors. The diagnosis of isolated pituitary deficiencies should be based on baseline hormonal assessments and/or dynamic tests. Establishing a proper diagnosis can be quite challenging: in fact, even if the diagnostic methods are becoming increasingly refined, a considerable proportion of isolated pituitary deficits still remains without a certain cause. While isolated ACTH and TSH deficiencies always require a prompt replacement treatment, gonadal replacement therapy requires a benefit-risk evaluation based on the presence of comorbidities, age and gender of the patient; finally, the need of growth hormone replacement therapies is still a matter of debate. On the other side, prolactin replacement therapy is still not available. In conclusion, our purpose is to offer a broad evaluation from causes to therapies of isolated anterior pituitary deficits in adulthood. This review will also include the evaluation of uncommon symptoms and main etiologies, the elements of suspicion of a genetic cause and protocols for diagnosis, follow-up and treatment.

Relationship between large and small for gestational age and hospital readmission after postpartum discharge: a population-based, data-linkage study.

In contrast to SGA, LGA was associated with hospital readmission during the first month of life. Follow-up protocols that include LGA should be evaluated. •Newborns are at high risk of hospital readmission during the postpartum period. •However, the influence of appropriateness for gestational age at birth, i.e. being born small for gestational age(SGA) or large for gestational age (LGA), has been little evaluated. •In contrast to SGA born infants, we found that infants born LGA were at high risk of hospital admission and the maincause was infectious diseases. •This population should be considered at risk of early adverse outcomes and should require attentive medical follow-up after postpartum discharge.

Outcomes of Bosniak Classification Version 2019 Class IIF Cystic Renal Masses at Imaging Surveillance.

BACKGROUND. Bosniak classification system version 2019 (v2019) recommends that class IIF masses undergo follow-up imaging at 6 months, 12 months, and then annually for 5 years. The frequency and timing of upgrade on follow-up imaging are incompletely understood. OBJECTIVE. The purpose of this article is to describe the temporal evolution of Bosniak v2019 class IIF cystic renal masses, with attention to outcomes at 6-month follow-up, the time to class upgrade, and malignant histologic diagnoses. METHODS. This retrospective study included 219 patients (91 women, 128 men; median age, 72 years) with 246 localized class IIF masses from January 2005 to June 2022. Patients underwent both a baseline and at least one follow-up renal-mass protocol contrast-enhanced CT or MRI examination. Two radiologists evaluated masses at all follow-up time points to categorize masses as downgraded (class I or II), stable (localized class IIF), or upgraded (class III or IV, solid, or category T3a, N1, or M1 or higher disease); a third radiologist resolved discrepancies. Incidence rate of upgrade was determined. Histopathologic outcomes were assessed for resected masses. RESULTS. Median follow-up was 28.4 months (IQR, 13.7-59.4 months). At 6-month follow-up, five (2%) masses were downgraded, 241 (98%) were stable, and none were upgraded. On the basis of final follow-up, 14 (6%) masses were downgraded, 223 (91%) were stable, and nine (4%) were upgraded. All upgrade events entailed a class increase to III (n = 7) or IV (n = 2); no mass became solid or developed T3, N1, or M1 disease. Among the nine upgraded masses, median time to upgrade was 53.5 months (IQR, 23.2-63.7 months). Incidence rate of upgrade was 3.006 per 100,000 person-days (95% CI, 1.466-5.516). Ten masses were resected; histopathology was benign in six and malignant in four. Of the four malignant masses, one was upgraded to class III after 15 months of preoperative follow-up imaging, and three remained class IIF on preoperative follow-up imaging. No resected malignant mass developed postoperative recurrence. CONCLUSION. Bosniak v2019 class IIF masses are unlikely to represent aggressive malignancy; only 4% were upgraded over time and never on initial 6-month follow-up. CLINICAL IMPACT. The currently recommended initial 6-month follow-up imaging examination for class IIF masses is of questionable clinical utility.