Frequent Indication Research Articles

Safety and Efficacy of Oral Mifepristone for Cervical Ripening and Induction of Labor.

Background Labor induction, a common practice to prevent maternal and fetal complications from prolonged labor, involves stimulating contractions before they begin naturally. This can be achieved through medications, mechanical methods, or surgical interventions. Cervical ripening is crucial for successful delivery. When the cervix is not sufficiently ripe, drugs are often used to augment this process chemically. Objective To evaluate the safety and efficacy of mifepristone for cervical ripening and induction of labor. Method A sample size of 200 was used in this single-blind randomized control trial. Primarily, pregnant women with term pregnancies, Bishop scores <6, and cephalic fetal presentation were included in the study. The study population was randomly divided into test and control groups. The test group (n=100) was administered 200 mg of mifepristone orally, while the control group (n=100) received a placebo. The Bishop score was reassessed 24 hours after mifepristone administration. Patients were taken for labor induction if their Bishop score was >6. For individuals with a Bishop score of <6, 1 mg of dinoprostone gel was administered intracervically once every six hours. Safety and efficacy were assessed by analyzing several parameters associated with labor progression, maternal outcomes, and fetal outcomes. Results The mean age of patients in the test group was 26±4.5 years, while in the control group, it was 26±5 years. The induction-to-delivery interval was notably shorter in the test group (18.8±2.3 hours) than in the control group (19.24±1.8 hours, p<0.0001). After the administration of 200 mg mifepristone, the mean Bishop score in the test group was 5.74±0.8, compared to 5.13±0.76 in the control group. The increase in the Bishop score after mifepristone treatment was significantly higher in the test group than in the control group (p-value=0.013). In the study, 73 (73%) patients in the test group had a normal vaginal delivery (NVD), whereas NVD accounted for 64 (64%) patients in the control group. Instrumental deliveries were less frequent in the test group, accounting for 14 (14%) patients, compared to 16 (16%) patients in the control group. The frequency of lower segment cesarean section (LSCS) was also lower in the mifepristone-treated group at 13 (13%) compared to the control group at 20 (20%). Fetal distress in five (38%) patients and non-progression of labor in 11 (55%) patients were the most frequent indications for LSCS in the test and control groups, respectively. There was no significant difference in neonatal outcomes between the test and control groups. Meconium-stained liquor was the most frequent complication in both the test group(10, 10%) and the control group (5, or 5%). Conclusion Administration of mifepristone effectively increased the Bishopscores and reduced the induction-to-delivery interval compared to controls, highlighting its potential as a cervical ripening agent.

Reoperative aortic root surgery: single-center long-term outcomes and literature review.

Reoperative aortic root surgery has become more and more common over the years and is considered high-risk, with significantly worse outcomes compared to first-procedure root surgery. At our institution, this kind of surgery is frequently performed. The aim of the present review is to describe currently available literature on reoperative surgery on the aortic root in terms of patients' population, indications for surgery and outcomes and to present our center's experience on the matter. A literature review was performed in order to identify pertinent studies. They were then compared and described. We also described preoperative characteristics, operative strategies and outcomes of all the patients who underwent redo aortic root surgery from January 1986 to December 2022 at our center. Our literature review identified 12 pertinent studies, with a total of 16,627 considered patients. The most frequent indications for redo surgery were endocarditis (35.5%), aneurysm, dissection and pseudoaneurysm. Mean cardiopulmonary bypass (CPB) and cross-clamp times were 218 and 152 minutes, respectively. In-hospital mortality was 12%. When analyzing our center's data, 344 procedures were identified. Aortic root dilation was the most frequent indication (36.9%). Mean CPB and cross-clamp times were 218.0±78.8 and 158.2±49.7 minutes, respectively. In-hospital mortality was 9.6%. Survival at 5 and 15 years was 76.1% and 51.4% respectively. Freedom from further aortic reintervention was 88.1% after 5 years and 64.9% after 15 years. Reoperative aortic root surgery is a difficult cardiac procedure which is linked to significantly higher mortality than first-time root replacement. If it is performed by experienced surgeons with a careful preoperative planning its result can still be satisfactory. Our results showed acceptable rates of mortality and reinterventions at follow-up. Endocarditis, however, was linked to worse outcomes.

Evaluation of Various Indications of Total Abdominal Hysterectomy in Holy Family Red Crescent Medical College Hospital for Last 20 Months

Background: Total Abdominal Hysterectomy (TAH) is a common surgical procedure for treating various gynecological conditions. This study aims to evaluate the demographic characteristics, comorbidities, and clinical indications for TAH at Holy Family Red Crescent Medical College Hospital, Dhaka, Bangladesh. Methods: This retrospective study included all TAH cases performed from January 2018 to August 2019. Data on patient age, comorbidities (hypertension and diabetes), and indications for TAH were collected from hospital records. Descriptive statistics were used to analyze the data. Results: A total of 320 TAH cases were reviewed. The most common age group was 41-50 years (43.13%), followed by patients aged ≤40 years (31.56%). Hypertension was present in 36.25% of the patients, and diabetes was observed in 30.94%. The most frequent indication for TAH was fibroid uterus (55.63%), followed by adenomyosis (18.75%) and post-menopausal bleeding (14.38%). Other indications included ovarian cysts (5.63%), endometrial hyperplasia (5.00%), and pelvic mass (6.25%). Conclusion: The findings highlight uterine fibroids, adenomyosis, and post-menopausal bleeding as the primary indications for TAH, with a significant prevalence of hypertension and diabetes among the patients. Effective management strategies for these conditions and considerations of comorbidities are crucial in optimizing surgical outcomes. Further research into minimally invasive techniques may enhance patient care in gynecological surgery.

Prospective antimicrobial stewardship interventions by multidisciplinary teams to reduce neonatal antibiotic use in South Africa: The Neonatal Antimicrobial Stewardship (NeoAMS) study

BackgroundHospitalized neonates are vulnerable to infection and have high rates of antibiotic utilization. MethodsFourteen South African neonatal units (seven public, seven private sector) assembled multidisciplinary teams involving neonatologists, microbiologists, pharmacists, and nurses to implement prospective audit and feedback neonatal antimicrobial stewardship (NeoAMS) interventions. The teams attended seven online training sessions. Pharmacists conducted weekday antibiotic prescription reviews in the neonatal intensive care unit and/or neonatal wards providing feedback to the clinical teams. Anonymized demographic and NeoAMS interventions data were aggregated for descriptive purposes and statistical analysis. FindingsDuring the 20-week NeoAMS intervention in 2022, 565 neonates were enrolled. Pharmacists evaluated seven hundred antibiotic prescription episodes; rule-out sepsis (180; 26%) and culture-negative sepsis (138; 20%) were the most frequent indications for antibiotic prescription. For infection episodes with an identified pathogen, only 51% (116/229) of empiric treatments provided adequate antimicrobial coverage. Pharmacists recommended 437 NeoAMS interventions (0·6 per antibiotic prescription episode), with antibiotic discontinuation (42%), therapeutic drug monitoring (17%), and dosing (15%) recommendations most frequent. Neonatal clinicians’ acceptance rates for AMS recommendations were high (338; 77%). Mean antibiotic length of therapy decreased by 24% from 9·1 to 6·9 days (0·1 day decrease per intervention week; P = 0·001), with the greatest decline in length of therapy for culture-negative sepsis (8·2 days (95% CI 5·7-11·7) to 5·9 days (95% CI 4·6-7·5); P = 0·032). InterpretationThis neonatal AMS programme was successfully implemented in heterogenous and resource-limited settings. Pharmacist-recommended AMS interventions had high rates of clinician acceptance. The NeoAMS intervention significantly reduced neonatal antibiotic use, particularly for culture-negative sepsis. FundingA grant from Merck provided partial support.

Preferences for albumin use in adult intensive care unit patients with shock: An international survey.

Use of albumin is suggested for some patients with shock, but preferences for its use may vary among intensive care unit (ICU) physicians. We conducted an international online survey of ICU physicians with 20 questions about their use of albumin and their opinion towards a randomised trial among adults with shock comparing the use versus no use of albumin. A total of 1248 respondents participated, with a mean response rate of 37%, ranging from 18% to 75% across 21 countries. Respondents mainly worked in mixed ICUs and 92% were specialists in intensive care medicine. The reported use of albumin in general shock varied as 18% reported 'almost never', 22% 'rarely', 34% 'occasionally', 22% 'frequently' and 4% 'almost always' using albumin. In septic shock, 19% reported 'almost never', 22% 'rarely', 29% 'occasionally', 22% 'frequently' and 7% 'almost always' using albumin. Physicians' preferences were more consistent for haemorrhagic- and cardiogenic shock, with more than 45% reporting 'almost never' using albumin. While the reported use of albumin for other purposes than resuscitation was infrequent (40%-85% reported 'almost never' for five other indications), the most frequent other indications were low serum albumin levels and improvement of the efficacy of diuretics. Most respondents (93%) would randomise adult ICU patients with shock to a trial of albumin versus no albumin. In this international survey, the reported preferences for the use of albumin in adult ICU patients with shock varied considerably among surveyed ICU physicians. The support for a future randomised trial was high.

Real-World Experience with Isavuconazole in Allogeneic Stem Cell Transplantation in Spain

Invasive fungal infections (IFI) pose a significant complication after hematopoietic stem cell transplantation (HSCT). Isavuconazole (ISV) is a new generation azole with a favourable adverse effect and interaction profile approved for the treatment of invasive aspergillosis and mucormycosis. We analyzed the indications, effectiveness, adverse event profile and drug interaction management of ISV in the real-world setting in adults who received allogeneic-HSCT (allo-HSCT) within the Spanish Group of HSCT and Cell Therapy (GETH-TC). We conducted a multicenter retrospective study of all consecutive adult allo-HSCT recipients (≥18 years) who received ISV either for IFI treatment or prophylaxis, from December 2017 to August 2021, in 20 centers within the Spanish Group of Hematopoietic Stem Cell Transplantation and Cell Therapy (GETH-TC). A total of 166 adult allografted patients who received ISV from 2017 to 2021 were included. Median age was 48 years with 43% females. In 81 (49%) patients, ISV was used for treatment of IFI, and in 85 (51%) for prophylaxis. Median duration of ISV administration for IFI treatment was 57 days (range 31-126) and 86 days (range 33-196) for prophylaxis. Most frequent indication for treatment was invasive aspergillosis (78%), followed by mucormycosis (6%). Therapeutic success (45%) was the most frequent reason for ISV withdrawal. In the prophylaxis group, the resolution of IFI risk factors was the most frequent reason for withdrawal (62%). Six (7%) breakthrough IFI were reported. The majority of patients (80%) presented pharmacologic interactions. Twenty-one patients (13%) reported adverse events related to ISV, mainly liver biochemistry abnormalities, which led to ISV withdrawal in 7 patients (4%). ISV was effective and well tolerated for IFI treatment and prophylaxis, with a manageable interaction profile.

Admission indications, initial diagnoses, Interventions, and patient outcomes within the sole obstetric high-dependency unit in Ethiopia

BackgroundObstetric high-dependency care offers holistic care to critically ill obstetric patients while maintaining the potential for early mother-child bonding. Little is known about the obstetric high-dependency unit (HDU) in Ethiopia. Therefore, the objective of the study was to review the admission indications, initial diagnoses, interventions, and patient outcomes in the obstetric high-dependency unit at St.Paul’s Hospital.MethodsA retrospective observational study was carried out at St. Paul’s Hospital in Addis Ababa, Ethiopia, between September 2021 and September 2022, targeting patients in the obstetric high-dependency unit during pregnancy or with in 42 days of termination or delivery. A checklist was used to compile sociodemographic and clinical data. Epidata-4.2 for data entry and SPSS-26 for data analysis were employed. Chi-square tests yielded significant results at p < 0.05.ResultRecords of 370 obstetric patients were reviewed and analyzed. The study enlisted participants aged 18 to 40, with a mean age of 27.6 ± 5.9. The obstetric high-dependency unit received 3.5% (95% CI, 3.01-4.30) of all obstetric admissions. With the HDU in place, only 0.42% of obstetric patients necessitated adult intensive care unit (ICU) admission. The predominant motive behind HDU admissions (63.2%) was purely for observation. Hypertensive disorders of pregnancy (48.6%) and obstetric hemorrhage (18.9%) were the two top admission diagnoses. Ten pregnant mothers (2.7%) were admitted to HDU: 2 with antepartum hemorrhages, and 8 with cardiac diseases. Maternal mortality and transfer to the ICU were both 1.4 per 100 HDU patients.ConclusionOur study found that the most frequent indication for admission to the HDU was just for observational monitoring. Hypertensive disorders of pregnancy and obstetric hemorrhage were the two leading admission diagnoses. Expanding HDUs nationwide is key for mitigating the ICU burden from obstetric admissions. Strategies for early prenatal screening, predicting preeclampsia, and addressing postpartum hemorrhage should be reinforced. Future studies should focus on a broader array of factors affecting fetomaternal outcomes in such a unit.

Surgical access to the mediastinum-all roads lead to Rome: a literature review.

The mediastinum is a complex, heterogeneous area, which leads vertically across the thoracic cavity between the bilateral mediastinal pleurae, connecting the head and neck region with the thoracic cavity. Different classifications have been published to differentiate between the so-called mediastinal compartments while the most used classification surely is the 4-compartments Gray`s classification, dividing it into the superior, anterior, middle and posterior mediastinum. Mediastinal abnormalities include infections (mediastinitis) and solid or cystic mediastinal masses. These masses can be divided into benign and malignant lesions originating from mediastinal structures/organs or represent manifestations of metastatic disease, often metastatic non-small cell lung cancer (NSCLC). This review aims to explore the different mediastinal pathologies along with indications and surgical approaches. We performed literature research in PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases. Only papers written in English were included. Depending on the indication for surgical intervention and the localization of the pathology, surgical approach may differ immensely. Mediastinal staging of lung cancer, primary lesions of the mediastinum, mediastinitis and traumatic mediastinal injuries display the most frequent indications for mediastinal surgery. Surgical approaches trend towards minimally invasive, video- or robotic-assisted techniques and are becoming increasingly refined to adapt to the special characteristics of the mediastinum. However, certain indications still require open access for best possible mediastinal exposure or oncological reasons. To guide optimal surgical approach selection to the mediastinum, the following overview will present all published surgical approaches to the mediastinum and discuss their practical relevance and indications aiming to help surgeons in the management of patients with mediastinal pathologies who should undergo surgery.

Results of sleeve gastrectomy conversion to Roux-en-Y gastric bypass on gastroesophageal reflux disease symptoms and proton pump inhibitors use evolution over time

BackgroundAlthough sleeve gastrectomy (SG) is associated with excellent results in the short term, it has been shown that it is plagued by weight regain and new onset or worsening of gastroesophageal reflux disease (GERD). These 2 clinical conditions are currently the 2 most frequent indications for revisional surgery. To date, only a few studies have focused exclusively on GERD. In a selected series of patients complaining of GERD symptoms after SG as a main complaint, we analyzed the efficacy of conversion to Roux-en-Y gastric bypass (RYGB), with a standardized surgical technique. MethodsThis is a retrospective study including all consecutive cases of SG to RYGB conversion for GERD not controlled by medical treatment. We excluded all patients undergoing conversion for weight regain without GERD. Quality of life and GERD symptoms were evaluated at outpatient’s clinic visits before and after surgery with 2 standardized questionnaires (Gastroesophageal Reflux Disease Questionnaire and Simplified Form 6). ResultsThis study showed that 70% of patients had complete resolution of GERD symptoms and 60% had completely discontinued proton pump inhibitors (PPIs). The conversion to RYGB resulted in a significant decrease in the rate of patients presenting daily symptoms of GERD and use of PPIs (10% and 16.6%, respectively; P < .019) and a dramatic increase in those without symptoms and no need for PPIs (70% and 60%, respectively; P < .001). ConclusionConversion to RYGB is a good option for GERD complications after SG providing a high rate of symptom remission and PPI discontinuation. Conversion to RYGB in the setting of GERD complications after SG improves postoperative outcomes decreasing GERD symptoms and improving quality of life.

Clinical and endoscopic characteristics of patients undergoing gastrointestinal endoscopic procedures in Egypt: a nationwide multicenter study

BackgroundEgypt faces a significant public health burden due to chronic liver diseases (CLD) and peptic ulcer disease. CLD, primarily caused by Hepatitis C virus (HCV) infection, affects over 2.9% of the population nationwide, with regional variations. Steatotic liver disease is rapidly emerging as a significant contributor to CLD, especially in urban areas. Acid-related disorders are another widespread condition that can significantly impact the quality of life. These factors and others significantly influence the indications and findings of gastrointestinal endoscopic procedures performed in Egypt.AimWe aimed to evaluate the clinico-demographic data, indications, and endoscopic findings in Egyptian patients undergoing gastrointestinal endoscopic procedures in various regions of Egypt.MethodsThis study employed a retrospective multicenter cross-sectional design. Data was collected from patients referred for gastrointestinal endoscopy across 15 tertiary gastrointestinal endoscopy units in various governorates throughout Egypt.Results5910 patients aged 38–63 were enrolled in the study; 75% underwent esophagogastroduodenoscopy (EGD), while 25% underwent a colonoscopy. In all studied patients, the most frequent indications for EGD were dyspepsia (19.5%), followed by hematemesis (19.06%), and melena (17.07%). The final EGD diagnoses for the recruited patients were portal hypertension-related sequelae (60.3%), followed by acid-related diseases (55%), while 10.44% of patients had a normally apparent endoscopy. Male gender, old age, and the presence of chronic liver diseases were more common in patients from upper than lower Egypt governorates. Hematochezia (38.11%) was the most reported indication for colonoscopy, followed by anemia of unknown origin (25.11%). IBD and hemorrhoids (22.34% and 21.86%, respectively) were the most prevalent diagnoses among studied patients, while normal colonoscopy findings were encountered in 18.21% of them.ConclusionThis is the largest study describing the situation of endoscopic procedures in Egypt. our study highlights the significant impact of regional variations in disease burden on the utilization and outcomes of GI endoscopy in Egypt. The high prevalence of chronic liver disease is reflected in the EGD findings, while the colonoscopy results suggest a potential need for increased awareness of colorectal diseases.

Real-world evaluation of the treatment yield of implantable loop recorders (ILR) in the Netherlands

Abstract Background Implantable loop recorders (ILRs) are invasive and expensive diagnostic tools used to determine the underlying arrhythmias associated with syncope and palpitations as well as capture atrial fibrillation (AF). The diagnostic and treatment yield from ILRs is uncertain. Prior studies indicated that 26-52% ILR patients were diagnosed with arrhythmias and 11-30% received subsequent treatment. Purpose Our primary aim was to determine the incidence of pacemaker and ICD implants within 1- and 3- years of ILR implantation. The secondary aims include 1) an evaluation of the incidence of AF ablation, 2) the identification of predictors for treatment, and 3) safety. Methods Adult patients who underwent an ILR implant in the Netherlands Heart Registration (NHR) Pacemaker and ICD registry (2018-2021) were included. The NHR device registry was linked to the ablation registry to determine the incidence of AF ablation after ILR. Incidence rates for pacemaker implants, ICD implants, AF ablations, and complications among ILR patients were reported as a proportion of ILR patients over 1- and 3- years. Predictors for treatment following an ILR were determined from multivariable logistic regression models. Results From 2018 to 2021, 11,961 patients underwent an ILR implant in the Netherlands. Patients who underwent ILR implantation were a median age 69 (IQR 56-77) years, 46.9% female, and 24.9% had AF. The most frequent indication for ILR implantation was syncope (76.2%), followed by palpitations (15.2%). At 1- and 3-years post-ILR implantation, 12.0% and 14.6% of ILR patients underwent a pacemaker implant, respectively (Figure 1). Fewer patients underwent ICD implants (0.9% and 1.3%) and AF ablation (1.3% and 1.8%) at 1- and 3-years post-ILR implantation, respectively (Figure 1). Compared to males, females were 28% and 70% less likely to undergo a pacemaker and ICD implant following ILR, respectively (Figure 2). Additional predictors for pacemaker implantation included older age, AF, and syncope (p&amp;lt;0.05 for all, Figure 2a). In addition to female sex, AF was a predictor of ICD implantation (Figure 2b). The incidence of complications was relatively low (0.3%). Infection was the most frequent complication (0.2%), followed by device dislocation (0.06%), bleeding (0.02%), and device defect (0.01%). Conclusion Despite the benefits of ILRs for long-term remote monitoring, the therapeutic yield of ILRs is relatively low with 14.6%, 1.3%, and 1.8% of ILR patients undergoing implantation for pacemakers, ICDs, and AF ablation at 3-years follow-up. As an expensive and invasive diagnostic tool, a more targeted approach for referrals is warranted to increase the therapeutic yield of the ILRs. Further investigations are warranted to determine the diagnostic yield of ILRs, regardless of subsequent invasive therapy.

Preliminary implantation experience in Europe with a novel insertable cardiac monitor

Abstract Background The LUX-Dx is a new insertable cardiac monitor (ICM) available in the European market since October 2022. Purpose To describe the initial experience of LUX-Dx implantation in Europe and report feedbacks from operators and patients. Methods The system includes an incision tool and a single-piece insertion tool that is pre-loaded with the small (1.2 cm3) ICM. The implantation procedure is straightforward and comprises the incision, the creation of the device pocket, the insertion of the ICM, the verification of sensing and the incision closure. Following implantation, patients are provided with a mobile device preloaded with the App which connects to their ICM and transmits data daily, or as needed, to the management system. We analyzed data and feedbacks collected at 20 European centers at the time of implantation and before patient discharge. Results A total of 175 implantation procedures were performed in 20 European centers. The most frequent indications for ICM implantation were syncope (n = 119, 68%) and cryptogenic stroke (n=15, 9%). Most procedures (157, 90%) were performed in electrophysiology laboratories by expert operators. The procedure was performed under local anesthesia in 169 (97%) patients, and systemic or local antibiotics were used before the procedure in 96 (55%) cases. A surface ECG mapping was performed before 65 (37%) insertions. All ICMs were implanted in the left parasternal region, with an orientation of 45° in 159 (91%) patients. Device repositioning was required after verification of sensing in 6 (3%) patients. The ICM was successfully implanted in all patients and no procedural complications were reported; the median time from skin incision to suture was 4 min (25th-75th percentiles 2-7). The mean R-wave amplitude was 0.38±0.34 mV at implantation and 0.42±0.38 mV before patient discharge (on average after 1 day). The P-wave visibility, i.e., the ratio between the number of clearly identifiable P-waves and the number of heart cycles during 10 sec ECG with a regular 1:1 conduction, was 92±21% at implantation and 93±18% before discharge. Survey questions on the overall operator experience with the implantation procedure are reported in Figure 1 and those on the patient experience are reported in Figure 2. Conclusions Implantation of the LUX-Dx seems fast and uncomplicated; operator and patient feedbacks are positive. Post-implantation sensing values, i.e. R-wave sensing and P-wave visibility, are good.Figure 1Figure 2

#2557 Clinical and histological findings in cancer patients—a single center study

Abstract Background and Aims During the last years, there has been an outstanding improvement in cancer treatment. As patients’ survival has been elongated, the prevalence of kidney injury is increasing. However, clinicopathological data are limited in these patients. We aimed to assess the spectrum of kidney biopsy findings in cancer patients and their relation to treatment. Method Single center retrospective study of all patients with solid and hematologic malignancies, who underwent kidney biopsy due to renal impairment, from September 2015 to July 2023. Clinical, laboratory, histopathological and therapeutic data were evaluated Results Fifty-four patients were biopsied, 35 men and 21 women, of median age 66 (42-84) years and follow up 15 (3-84) months. Median serum creatinine was 3 (0.5-22) mg/dl and proteinuria 3 (0.1-23) gr per day at the time of biopsy. Among the solid malignancies (38/54), lung cancer was the commonest (11), followed by gastrointestinal (5), breast (4), sarcoma (5) and melanoma (3); the rest 10 included other solid malignant tumors. Hematologic malignancies (16/54) were mainly multiple myeloma (6) and lymphomas (5), followed by lymphoblastic leukemia (3) and AL amyloidosis (2). The most frequent indication of biopsy was acute kidney injury (AKI) (29/54), followed by both AKI and proteinuria (15/54) and proteinuria with preserved kidney function (9/54); out of 24 patients with proteinuria, 12 exhibited nephrotic range proteinuria (median 10, 3.5-23 gr/day). At the time of biopsy, more than half of patients (30/54) were on cancer treatment; 5 on immunotherapy, 11 on immunotherapy combined to chemotherapy, 10 on chemotherapy solely and four of them received other kind of treatment. Glomerulonephritis (GN) was shown on 24/54 patients. Among GN, focal segmental glomerulosclerosis (FSGS) was the most common lesion (7), followed by light chain deposit disease (LCDD, 3) and membranous nephropathy (MN, 2); among the last, a rare case of MN with a full-house immunoflorescence pattern was reported. Notably, four patients showed amyloidosis (three AL-amyloidosis linked to multiple myeloma and one AA-amyloidosis possibly related to immunotherapy). A rare case of bevacizumab-induced hyaline occlusive glomerular microangiopathy is also reported. The rest 7/24 cases included glomerulosclerosis (1), minimal change disease (MCD, 1), IgA nephropathy (1), diabetic nephropathy (2) and membranoproliferative glomerulonephritis (2). Tubulointerstitial lesions were found on 30 patients. Acute interstitial nephritis (AIN), acute tubular necrosis (ATN) and combination of two (AIN+ATN) were found on 7, 4 and 12 patients respectively (23 in total). Of note, four out of five patients receiving ifosfamide for sarcomas, presented karyomegalic tubulointerstitial nephritis. Four patients, (three with B-cell lymphoma and one with urothelial carcinoma) exhibited renal infiltration by tumor cells. In addition, two patients were shown with oxalate nephropathy and one with nephrocalcinosis. Kidney disease was secondary to treatment in 23 patients, predominantly attributed to immunotherapy (13). Based on histological findings, cancer treatment was withheld in all patients (23/23).Sixteen of all patients received specific treatment for kidney injury, including corticosteroids, cyclosporine or colchicine. In most of them (14), kidney injury was evaluated as secondary to treatment; Two patients, who presented FSGS and MCD, exhibited renal damage attributed to cancer itself. All treated patients (16/16) recovered renal injury. A small proportion of patients (6/54) underwent dialysis—two due to oxalate nephropathy, two with ifosfamide toxicity, one with LCDD and the last due to sepsis. Half of patients (27/54), including 5/6 who were on dialysis, died during observation period. Conclusion Diagnosing and managing kidney injury in cancer patients may be a challenging task. In our single center study, kidney biopsy revealed diverse and rare histological findings, which necessitated tailored therapeutic interventions.

Macular hole: Differential diagnosis, treatment options and new guideline recommendations

Full-thickness macular holes (FTMH) usually result in apronounced reduction of visual acuity and represent one of the most frequent indications for retinal surgery. If diagnosed and treatment is initiated at an early stage, surgery has ahigh success rate with respect to both hole closure and improvement of visual acuity. Optical coherence tomography (OCT)-based staging and sizing enables an estimation of the surgical outcome. The differential diagnostic distinction from clinically similar disorders, such as lamellar macular holes, macular pseudoholes, and foveoschisis is clinically relevant as the pathogenesis, prognosis and treatment are significantly different. While vitrectomy with peeling of the inner limiting membrane (ILM) and gas tamponade is established as the standard treatment for FTMH, some aspects of treatment are handled differently between surgeons, such as the timing of surgery, the choice of endotamponade and the type and duration of postoperative positioning. For FTMH associated with vitreomacular traction, alternative treatment options in addition to vitrectomy include intravitreal ocriplasmin injection and pneumatic vitreolysis. The current clinical guidelines of the German ophthalmological societies summarize the evidence-based recommendations for diagnosis and treatment of FTMH.

Implantation of a novel insertable cardiac monitor: preliminary multicenter experience in Europe.

The LUX-Dx™ is a novel insertable cardiac monitor (ICM) introduced into the European market since October 2022. The aim of this investigation was to provide a comprehensive description of the ICM implantation experience in Europe during its initial year of commercial use. The system comprises an incision tool and a single-piece insertion tool pre-loaded with the small ICM. The implantation procedure involves incision, creation of a device pocket, insertion of the ICM, verification of sensing, and incision closure. Patients receive a mobile device with a preloaded App, connecting to their ICM and transmitting data to the management system. Data collected at European centers were analyzed at the time of implantation and before patient discharge. A total of 368 implantation procedures were conducted across 23 centers. Syncope (235, 64%) and cryptogenic stroke (34, 9%) were the most frequent indications for ICM. Most procedures (338, 92%) were performed in electrophysiology laboratories. All ICMs were successfully implanted in the left parasternal region, oriented at 45° in 323 (88%) patients. Repositioning was necessary after sensing verification in 9 (2%) patients. No procedural complications were reported, with a median time from skin incision to suture of 4min (25th-75th percentiles 2-7). At implantation, the mean R-wave amplitude was 0.39 ± 0.30mV and the P-wave visibility was 91 ± 20%. Sensing parameters remained stable until pre-discharge and were not influenced by patient characteristics or indications. Procedural times were fast, exhibited consistency across patient groups, and improved after an initial experience with the system. Operator Operator feedback on the system was positive. Patients reported very good ease of use of the App and low levels of discomfort after implantation. LUX-Dx™ implantation appears efficient and straightforward, with favorable post-implantation sensing values and associated with positive feedback from operators and patients.

Preoperative MRCP is not Associated with Lower Complication Rates but Shorter Hospital Stay in Laparoscopic Cholecystectomy

Abstract Background Laparoscopic cholecystectomy is a very common procedure and while preoperative magnetic resonance cholangiopancreatography (pMRCP) is widely used for detection of choledocholithiasis and preoperative planning, the benefits in patients with normal preoperative cholestatic parameters remain unclear. Aims We aimed to investigate a large cohort of patients after laparoscopic cholecystectomy to analyse the impact of pMRCP on complication rates. Methods This retrospective cohort study consecutively includes all patients receiving elective or acute laparoscopic cholecystectomy between 2010 and 2020. Exclusion criteria were conversion to open cholecystectomy and preoperatively elevated cholestatic parameters. Complication rates were recorded and patients stratified depending on the use of pMRCP for preoperative planning. Results 3163 patients underwent laparoscopic cholecystectomy between 2010 and 2020, 2568 of which showed normal cholestatic parameters preoperatively. Of these patients, 684/2568 (27%) were male and 1884/2568 (73%) female. The most frequent indications for laparoscopic cholecystectomy were cholecystolithiasis in 72% (1845/2568) of cases, followed by cholecystitis in 18% (465/2568). The majority of patients (2267/2568, 88%) indeed received pMRCP, while the remaining 301/2568 patients did not. Postoperative complication rates did not significantly differ between the two groups (396/2267 (17%) in the pMRCP group and 58/301 (19%) without pMRCP, p=0.469). One case of pancreatitis occurred in the pMRCP group, versus two reported cases in the other group. Interestingly, the length of hospital stay after cholecystectomy was significantly shorter in the group with pMRCP versus without (4 days (range 1-61 days) versus 7 days (range 1 – 66 days), respectively, p = 0.023). Conclusion Preoperative MRCP seems to not prevent complications in laparoscopic cholecystectomy, since postoperative complication rates were comparable between the two patient groups with and without pMRCP. However, postoperative hospital stay was significantly shorter in patients undergoing pMRCP compared to patients without pMRCP.

Human leukocyte antigen class II (DRB1 and DQB1) alleles frequencies in patients with various forms of pemphigus among the Russian population

BACKGROUND: Autoimmune bullous dermatoses are known to be the most severe blistering conditions of skin. HLA-DRB1 and DQB1 alleles might play a crucial role in their onset. In pemphigus HLA class II molecules stimulate the division of T helper cells, which in turn stimulate B cells to produce antibodies to epidermal keratinocytes causing acantholysis. The HLA-DRB1 and DQB1 alleles’ frequencies studied in pemphigus in a vast variety of populations worldwide. However, as of yet, this mechanism was not investigated in Russian population. AIM: To estimate the prevalence of the HLA-DRB1 and DQB1 alleles at a low- and high-resolution levels in patients with various forms of pemphigus. We observed 86 patients with pemphigus vulgaris, 13 ― with pemphigus foliaceus, 6 patients with paraneoplastic pemphigus and 92 healthy volunteers. MATERIALS AND METHODS: HLA typing for DRB1 and DQB1 was performed with 50 nanogram DNA extraction and polymerase chain reaction. RESULTS: At a low-resolution level HLA-DRB1*4 and DRB1*14 alleles were statistically significant more frequent in pemphigus vulgaris and pemphigus foliaceus patients compared to those in control subjects, whereas HLA-DRB1*11, DRB*16, and DRB1*3 alleles were more frequent in healthy volunteers. At a high-resolution level, DRB1*04:02 allele was observed to show its statistically significant higher frequency in all variants of pemphigus, including paraneoplastic pemphigus. However, DRB1*14:05 HLA allele was more frequent in pemphigus vulgaris and pemphigus foliaceus patients, whereas DRB1*11:04 one was found to be 3.7 times more frequent in healthy controls. Additionally, at a low-resolution level for HLA-DQB1 alleles no statistically significant results were observed. However, at a high-resolution level the chances for more frequent indication of DQB1*03:02 allele were 7.09 times higher in pemphigus foliaceus group and 2.49 higher in pemphigus vulgaris patients compared to healthy volunteers. Moreover, DQB1*05:03 was identified more frequently in pemphigus vulgaris and paraneoplastic pemphigus groups of patients, whereas DQB1*03:01 allele was shown to be increased in the group of healthy donors. CONCLUSION: HLA-DRB1*4, DRB1*14, DRB1*04:02, DRB1*14:05, DQB1*03:02 and DQB1*05:03 alleles might be considered as the genetic markers for pemphigus vulgaris susceptibility, while HLA-DRB1*11, DRB*16, DRB1*3, DRB1*11:04 and DQB1*03:01 allelic groups appear to be protective for Russian population.

Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes.

Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population. Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated. Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months. Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.

UNRAVELING THE OUTCOMES: A RETROSPECTIVE ANALYSIS OF ABERRANTLY POSITIONED IMPACTED THIRD MOLAR EXTRACTIONS

In the realm of dentistry, the extraction of third molars occupying abnormal positions poses a formidable challenge. These enigmatic teeth, deviating from their anticipated anatomical location, demand meticulous evaluation and specialized approaches to ensure their successful removal. Intriguingly, the evaluation of such cases has remained unexplored in the context of Kazakhstan until now. Aim: The objective of this study is to examine the occurrence of mandibular third molar impaction and its correlation with factors such as impaction type, impaction side, age, and gender among patients. Methods: A retrospective review was conducted on the medical records of 2351 patients who underwent surgical extraction of impacted mandibular third molars. Results: The findings revealed a remarkable prevalence of mesioangular impaction (56.15%) in the lower third molars. The highest number of patients were observed in the age group of 18–30 years (25.05%), and a majority of cases involved the left side (75.75%). A notable female predominance (66.35%) was also observed. The most frequent indication for surgical removal was recurrent pericoronitis (24.25%). Conclusion: This pioneering study in Kazakhstan provides insights into extraction success for impacted third molars. It reveals a remarkable prevalence of mesioangular impaction in the lower molars, predominantly on the left side with a notable female predominance. Recurrent pericoronitis is the primary reason for surgical removal. Early removal of symptomatic impacted molars prevents future complications, but careful patient selection is crucial. Further research is needed to understand these findings in the Kazakhstani population.

Psychopharmacological treatment in patients planned for hip or knee replacement.

Psychopharmacological treatment may be an independent risk factor for increased length of stay and readmission after hip and knee replacement. Thus, temporary perioperative discontinuation may be beneficial. However, little is known regarding the treatments, and not all are feasible to discontinue. Therefore, the aim of this study was to describe the treatments in terms of type, dose, duration, indication and initiating physician to assess the feasibility of temporary perioperative discontinuation. We included 482 patients planned for hip or knee replacement in psychopharmacological treatment for psychiatric disorders from 2021 to 2023 at five orthopaedic departments in Denmark. Most patients were treated with antidepressants (89%); most frequently, either selective serotonin reuptake inhibitors (SSRIs; 48%) or serotonin-norepinephrine reuptake inhibitors (SNRIs; 21%). The majority received monotherapy (70%); most frequently, an SSRI (36%) or an SNRI (12%). Most antidepressants were initiated by general practitioners (71%), and the treatments had lasted for more than a year (87%). The doses of SSRIs/SNRIs were moderate, and the most frequent indication for antidepressants was depression (77%). These results imply that temporary perioperative SSRI/SNRI discontinuation may be feasible in hip and knee replacement patients and support a future randomized controlled trial investigating the potential benefits of temporary discontinuation.