Initial Management Research Articles

Ileosigmoid knotting: A rare cause of acute intestinal obstruction and peritonitis

Introduction: Ileosigmoid knotting (ISK) is one of the rarer causes of bowel obstruction compared to others. This is also called compound volvulus or double loop obstruction. The presentation symptoms are similar to those of other large bowel or distal intestinal obstructions. But the pathogeny’s or disease’s progression is rapid. So the patient develops ischemia or strangulation of the involved segment of the bowel earlier than the sigmoid or ceal volvulus. One of the challenges of the disease is that, especially in low-income countries like ours, there is no access to contrast computed tomography (CT), which is more sensitive diagnostic imaging. Case Report: A 58-year-old male patient presented to our hospital with abdominal pain for two days. He was referred from the primary hospital. The pain was initially central and later diffused to other parts of the abdomen. Associated with this, he was vomiting of ingested matter for more than two episodes. On physical examinations, he was in acute pain, and his vital signs showed a pulse rate of tachycardia at 127 BPM. On abdominal examination, he had distention and diffused tenderness with gardening. So we diagnosed him with peritonitis secondary to gangrenous sigmoid volvulus obstruction (SVO). So I chose the imaging that is available in our hospital, a plain abdominal X-ray. So the patient was resuscitated with normal saline, an antibiotic was initiated, and he was taken to the operation after giving consent. The ilium and sigmoid colon were gangrened and en bloc resection was done, and the jejunum and remaining 7 cm of ilium from the ileocecal valve were anastomosed. The patient was taken to or for a relook, and the anastomosis was disrupted, then refreshed, and both the proximal and distal segments were taken out as stomas. The output was significant and later developed a controlled entrocutaneous fistula, which was closed after three weeks. Conclusion: The prognosis is poor for ISK compared to other common types of volvulus and worse prognosis challenging management in conditions with both active and passive bowel ischemia which happened to our patients. Diagnosis is also challenging before the surgery. The abdominal X-ray and ultrasound are available and commonly the surgeon commonly will not send for this unless the patient is stable. Blind rectal tube deflation the common intervention in our setup with no access for sigmoidoscopy is not indicated for this non-surgical initial management rather with a highly suspicious diagnosis early resuscitation with early surgical treatment.

Active surveillance is a feasible and safe strategy in selected patients with papillary thyroid cancer and suspicious cervical lymph nodes detected after thyroidectomy.

After initial treatment, up to 30% of patients with papillary thyroid cancer (PTC) have incomplete response, mainly cervical lymph node (LN) disease. Previous studies have suggested that active surveillance (AS) is a possible option for these patients. Our aim was to report the results of AS in patients with PTC and cervical LN disease. In this retrospective observational study, we included adult patients treated and followed for PTC, who presented with cervical LN disease and were managed with AS. Growth was defined as an increase ≥ 3mm in either diameter. We included 32 patients: 27 (84.4%) women, age of 39 ± 14 years, all initially treated with total thyroidectomy, and 22 (69%) with therapeutic neck dissection. Cervical LN disease was diagnosed 1 year (0.3-12.6) after initial management, with a diameter of 9.0 mm (6.0-19.0). After a median AS of 4.3 years (0.6-14.1), 4 (12.5%) patients had LNgrowth: 2 (50%) of whom were surgically removed, 1 (25%) was effectively treated with radiotherapy, and 1 (25%) had a scheduled surgery. Tg increase was the only predictive factor of LN growth evaluated as both the delta Tg (p < 0.0366) and percentage of Tg change (p < 0.0140). None of the included patients died, had local complications due to LN growth or salvage therapy, or developed distant metastases during follow-up. In selected patients with PTC and suspicious cervical LNs diagnosed after initial treatment, AS is a feasible and safe strategy as it allows effective identification and treatment of the minority of patients who progress.

Practice patterns and survival outcomes for Muscle-Invasive Bladder Cancer: real-life experience in a general population setting

Abstract Background: Bladder cancer (BC) is a common malignancy in Europe and in North America. Among BC, muscle-invasive bladder cancers (MIBC) are distinguished, as they require aggressive treatment due to their spreading potential and the poor prognosis. Despite its clinical relevance, little information on MIBC in a general population setting is available. This study aims to report practice patterns and survival outcomes for MIBC patients in a general population setting. Methods: MIBC among BC incident in 2011 and 2012 recorded in a French population-based cancer registry (810,000 inhabitants) were included in the study. Data was extracted from the medical files. Individual, tumour related characteristics and initial management including diagnostic tools, multidisciplinary team meeting (MDT) assessment, treatment delivered were described. Cystectomy, chemoradiation, radiotherapy and chemotherapy were considered as specific treatments. Matching between MDT decision and the treatment provided was detailed. Management practices were discussed according to the guideline’s recommendations. Overall survival (using the Kaplan-Meier method) and net survival (using the Poher-Perme estimator) were calculated. Results: Among 538 incident BC cases, 147 (27.3%) were MIBC. Diagnostic practices displayed a relevant locoregional assessment of BC. Almost all cases (n=136, 92.5%) were assessed during an uro-oncological MDT with a median time from diagnosis of 18 days [First quartile:12-third quartile:32]. Discrepancies appeared between MDT decisions and treatments delivered: 71 out of 86 subjects received the recommended cystectomy or chemoradiation (+/- neoadjuvant chemotherapy); 6 out of 11 had the recommended radio- or chemotherapy; and 9 patients did not undergo any specific treatment despite the MDT decision. Cystectomy was the most common treatment performed; the time to surgery appeared consistent with the guideline’s recommendations. Forty people only received supportive care. Still, five-year overall and net survival were poor, being 19% [13-26] and 22% [14-31] respectively. Five-year net survival was 35% [23-48] for people who underwent curative-intent treatments. Conclusion: MIBC management remains challenging even for cases assessed during an MDT. Many people did not undergo any specific treatment. Prognosis was poor even when curative-intent therapies were delivered. Efforts to reduce exposure to risk factors such as tobacco smoking and occupational exposures must be maintained.

Plasminogen Degradation by Neutrophil Elastase in Pleural Infection, Not High Plasminogen Activator Inhibitor-1 (PAI-1), is the Cause of Intrapleural Lytic Failure.

Complex pleural space infections often require treatment with multiple doses of intrapleural tissue-plasminogen activator(tPA) and deoxyribonuclease(DNase), with treatment failure frequently necessitating surgery. Pleural infections are rich in neutrophils, and neutrophil elastase degrades plasminogen, the target substrate of tPA, that is required to generate fibrinolysis. We hypothesized that pleural fluid from patients with pleural space infection would have high elastase activity, evidence of inflammatory plasminogen degradation, and low fibrinolytic potential in response to tPA that could be rescued with plasminogen supplementation. Does neutrophil elastase degradation of plasminogen contribute to intrapleural fibrinolytic failure? We obtained infected pleural fluid and circulating plasma from hospitalized adults(n=10) with IRB approval from a randomized trial evaluating intrapleural fibrinolytics versus surgery for initial management of pleural space infections. Samples were collected pre-intervention, post-intervention day-1(PID1), PID2, and PID3. Activity assays, enzyme-linked immunosorbent assays, and western blot(WB) analysis were performed, and turbidometric measurements of fibrinolysis were performed on pleural fluid +/- exogenous plasminogen supplementation. Results are reported as median(Q1, Q3) or n(%) as appropriate, with alpha set at 0.05. Pleural fluid elastase activity was >4-fold higher(p=0.02) and plasminogen antigen levels >3-fold lower(p=0.04) than their corresponding plasma. Pleural fluid WB analysis demonstrated abundant plasminogen degradation fragments consistent with elastase degradation patterns. We found that plasminogen-activator inhibitor-1(PAI-1), the native tPA inhibitor, had high antigen levels pre-intervention but the overwhelming majority of this PAI-1(82%) was not active(p=0.003), and all PAI-1 activity was lost by PID2 in patients receiving intrapleural tPA/DNase. Finally, using turbidity clot lysis assays we found that 9 of 10 patients' pleural fluid was unable to generate a significant fibrinolytic response when challenged with tPA and that plasminogen supplementation rescued fibrinolysis in all patients. Inflammatory plasminogen deficiency, not high PAI-1 activity, is a significant contributor to intrapleural fibrinolytic failure.

A Comprehensive Review of the Current State of Robot-assisted Laparoscopic Salvage Prostatectomy.

Salvage robot assisted radical prostatectomy (sRARP) is performed for patients with biochemical or biopsy proven, localized prostate cancer recurrences after radiation or ablative therapies. Traditionally, sRARP has been avoided by lower volume surgeons due to technical demand and high complication rates. Post-radiation sRARP outcomes studies exist but remain few in number. With increasing use of whole gland and focal ablative therapies, updates on sRARP in this setting are needed. The aim of this narrative review is to provide an overview of recently reviewed studies on the oncologic outcomes, functional outcomes, and complications after post-radiation and post-ablative sRARP. Tips and tricks are provided to guide surgeons who may perform sRARP. We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010-2022 without limitation on study design. Only case reports, editorial comments, letters, and manuscripts in non-English languages were excluded. Key Content and Findings: Salvage robotic radical prostatectomy is performed in cases of biochemical recurrence after radiation or ablative therapies. Oncologic outcomes after sRARP are worse compared to primary surgery (pRARP) though improvements have been made with the robotic approach when compared to open salvage prostatectomy. Higher pre-sRARP PSA levels and more advanced pathologic stage portend worse oncologic outcomes. Patients meeting low-risk, EAU-biochemical recurrence criteria have improved oncologic outcomes compared to those with high-risk BCR. While complication rates in sRARP are higher compared to pRARP, Retzius sparing approaches may reduce complication rates, particularly rectal injuries. In comparison to the traditional open approach, sRARP is associated with a lower rate of bladder neck contracture. In terms of functional outcomes, potency rates after sRARP are poor and continence rates are low, though Retzius sparing approaches demonstrate acceptable recovery of urinary continence by 1 year, post-operatively. Advances in the robotic platform and improvement in robotic experience have resulted in acceptable complication rates after sRARP. However, oncologic and functional outcomes after sRARP in both the post-radiation and post-ablation settings are worse compared to pRARP. Thus, when engaging in shared decision making with patients regarding the initial management of localized prostate cancer, patients should be educated regarding oncologic and functional outcomes and complications in the case of biochemically recurrent prostate cancer that may require sRARP.

Abstract PO2-18-01: Assessment of Initial Dosing and Dose Management of Sacituzumab Govitecan-hziy (SG) and How Dosing Practices Impact Duration of Therapy (DOT)

Abstract Background: As the Phase 3 ASCENT trial’s safety analysis found that a 10m/kg dose of SG resulted in better efficacy than treatment with a lower dose, this examination sought to use real-world data to evaluate how patients (pts) were dosed compared to the recommended starting dose for SG as well as how the starting dose impacted pt DOT.1 In addition, this assessment sought to understand the rate of dose reductions for pts treated with SG and how the use of dose reductions impacted DOT. Methods: This assessment utilized the Integra Connect PrecisionQ real-world de-identified database of over 2 million cancer pts across 500 sites of care to evaluate starting dose and rate of dose reduction, as well as whether starting dose and use of dose reductions impacted DOT for pts treated with SG. In analyzing the DOT, pts were required to have had a follow-up of 12 months or greater. The SG pt data utilized reflects treatments through May 31, 2023. Comparisons of proportions were conducted using a two sample two-tailed z-test and compared median DOT using a Wilcoxon Rank Sum test. Descriptive analyses were used to summarize pt demographic statistics. Results: 433 pts treated with SG were identified with an average age at treatment start of 59.6 (median of 61); 17% identified as Black or African American and 62% identified as White or Caucasian. Of the 433 pts treated with SG, 83% received the recommended starting dose of 10mg/kg, 13% initiated treatment at 7.5mg/kg and the remaining 5% received 5mg/kg or less. Among the 433 pts, 37% had a dose reduction. The rate of dose reductions for those who started at 10 mg/kg was 35% compared to 43% for pts who started at 7.5mg or less (p &amp;gt;0.05). The rate of dose reductions for those who started on 7.5mg/kg were 39% (N = 57) compared to 55% (N = 18) for those who started on 5mg/kg or less (p &amp;gt;0.05). The median DOT among the pts regardless of starting dose was 116 days (N = 336). The median DOT for pts who started on 10mg/kg was 136 days (N = 254) compared to 77 (N =61) for pts who started on 7.5 mg/kg or less (p = .012). The median DOT for pts who started on 7.5mg/kg was 91 days (N = 166) compared to 58 (N = 17) for those who started on 5mg/kg or less. The median DOT for pts who had a dose reduction was 172 days (N = 125) compared to 89 days (N = 190) for those who did not have a dose reduction (p &amp;lt; 0.001). Conclusion: The assessment found that SG-treated pts who received the recommended starting dose had a longer DOT than those who received a lower starting dose. In addition, dose reductions on SG contributed to a longer time on therapy for pts. These findings suggest using the recommended starting dose for SG and then dose managing via reductions to help keep pts on therapy and delay disease progression. Further evaluation of the impact of starting dose would be needed to understand pt differences in prior lines of therapy and hormonal status to understand how those factors impact DOT. [1] Rugo, H.S., Tolaney, S.M., Loirat, D. et al. Safety analyses from the phase 3 ASCENT trial of sacituzumab govitecan in metastatic triple-negative breast cancer. npj Breast Cancer 8, 98 (2022). https://doi.org/10.1038/s41523-022-00467-1 Citation Format: Vikram Gorantla, Erin Alwon, Mike Gart, John Li, Simon Blanc, Dawn Brenneman, Prateesh Varughese, Justin Scott, Harvey Katzen. Assessment of Initial Dosing and Dose Management of Sacituzumab Govitecan-hziy (SG) and How Dosing Practices Impact Duration of Therapy (DOT) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-18-01.

Contemporary Diagnosis and Management of Mild TBI (Concussions): What You Need to Know.

Concussion is a common injury in children and adolescents and is a form of mild traumatic brain injury that surgeons will see in their acute care practice. With a rapidly changing evidence base for diagnosis and management, we will focus on the importance of timely identification and diagnosis, as well as the early initiation of active management of pediatric concussion immediately after injury through recovery. This approach involves the application of targeted therapies for specific deficits identified after concussion, addressing the individual pattern of symptoms experienced by patients following concussion. We will review what is known about the underlying pathophysiology that drives the clinical manifestations of concussion, the targeted clinical assessments that can both aid in the diagnosis of concussion, as well as drive the active rehabilitation of deficits seen after concussion. The standardized approach to the return to activities will also be described, including return to learning and sports.

Paradoxical Air Embolism in Spinal Surgery: Case Report and Literature Review

AbstractAir embolism (AE) is a subtype of embolism, caused by the entry of air into the vascular system. It is a predominantly iatrogenic complication, and its symptomatic form is severe, although uncommon. In some cases, a venous thrombi may pass into the arterial system through a venous-arterial shunt, characterizing a paradoxical embolism. Here, we describe the case of a previously healthy 44-year-old female who underwent cauda equina decompression and lumbar epidural abscess drainage. The patient suffered a paradoxical AE intraoperatively and died after 4 days. The occurrence of AE in lumbar spine surgeries in the prone position is rare, but the surgical team must be attentive to its clinical signs and quickly institute initial management when necessary.

Initial surgical management of sporadic medullary thyroid cancer: Guidelines based optimal care - A systematic review.

Medullary thyroid carcinoma (MTC) is a rare neuroendocrine tumor from parafollicular cells that produce calcitonin (Ct). Despite several existing guidelines for the surgical management of sporadic MTC (sMTC), optimal initial surgical management of the thyroid, the central and the lateral neck remains a matter of debate. A systematic review in PubMed and Scopus for current guidelines addressing the surgical management of sMTC and its referenced citations was conducted as per the PRISMA guidelines. Two-hundred and one articles were identified, of which 7 met the inclusion criteria. Overall, guidelines vary significantly in their recommendations for the surgical management of sMTC. Only one guideline recommended partial thyroidectomy for limited disease, but the possibility to avoid completion thyroidectomy in selected cases is acknowledged in 42% (3/7) of the remaining guidelines. The majority of guidelines (71.4%; 5/7) recommended prophylactic central neck dissection (CND) for all patients while the remaining two guidelines recommended CND based on Ct level and tumor size. The role of prophylactic lateral neck dissection based on preoperative Ct levels was recommended by 42% (3/7) of guidelines. Overall, these guidelines are based on low-quality evidence, mostly single-center retrospective series, some of which are over 20 years old. Current surgical management guidelines of sMTC should be revised, and ought to be based on updated data challenging current recommendations, which are based on historic, low-quality evidence. Partial thyroidectomy may become a viable option for small, limited tumors. Prospective, multi-center studies may be useful to conclude whether prophylactic ND is necessary in all sMTC patients.

Unrecognized Focal Nonmotor Seizures in Adolescents Presenting to Emergency Departments.

Many adolescents with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history-taking is essential to prompt diagnosis and treatment. In this study, we investigated ED recognition of motor vs nonmotor seizures and its effect on management and treatment of focal epilepsy in adolescents. This was a retrospective analysis of enrollment data from the Human Epilepsy Project (HEP), an international multi-institutional study that collected data from 34 sites between 2012 and 2017. Participants were 12 years or older, neurotypical, and within 4 months of treatment initiation for focal epilepsy. We used HEP enrollment medical records to review participants' initial diagnosis and management. A total of 83 adolescents were enrolled between 12 and 18 years. Fifty-eight (70%) presented to an ED before diagnosis of epilepsy. Although most ED presentations were for motor seizures (n = 52; 90%), many patients had a history of nonmotor seizures (20/52 or 38%). Adolescents with initial nonmotor seizures were less likely to present to EDs (26/44 or 59% vs 32/39 or 82%, p = 0.02), and nonmotor seizures were less likely to be correctly identified (2/6 or 33% vs 42/52 or 81%, p = 0.008). A history of initial nonmotor seizures was not recognized in any adolescent who presented for a first-lifetime motor seizure. As a result, initiation of treatment and admission from the ED was not more likely for these adolescents who met the definition of epilepsy compared with those with no seizure history. This lack of nonmotor seizure history recognition in the ED was greater than that observed in the adult group (0% vs 23%, p = 0.03) and occurred in both pediatric and nonpediatric ED settings. Our study supports growing evidence that nonmotor seizures are often undiagnosed, with many individuals coming to attention only after conversion to motor seizures. We found this treatment gap is exacerbated in the adolescent population. Our study highlights a critical need for physicians to inquire about the symptoms of nonmotor seizures, even when the presenting seizure is motor. Future interventions should focus on improving nonmotor seizure recognition for this population in EDs.

High Rate of Unplanned Reoperation for Interprosthetic Femur Fractures after Total Hip and Knee Arthroplasty

IntroductionInterprosthetic femur fractures (IPFFs) are a rare, but devastating complication following total joint arthroplasty. There is limited evidence to help guide their management. The purpose of this study was to describe the features, treatment, and outcomes of surgically managed IPFFs. MethodsWe retrospectively identified 75 patients who had 76 IPFFs. The mean age at the time of IPFF was 75 years (range, 29 to 94), and 78% were women. The mean body mass index was 30 (range, 19 to 51), and the mean follow-up was 3 years (range, 0 to 14). There were 16 Vancouver B1 fractures, 28 Vancouver B2 fractures, 2 Vancouver B3 fractures, and 30 Vancouver C fractures. All B1 fractures underwent open reduction internal fixation (ORIF). All Vancouver B2 and B3 fractures underwent revision arthroplasty, including 1 proximal femur replacement (PFR) and 1 total femur replacement (TFR). Vancouver C fractures were treated with ORIF (n = 20), distal femoral replacement (DFR) (n = 9), and in one case, TFR (n = 1). Kaplan-Meier survivorship was used to calculate 2-year survival free from all-cause reoperation and periprosthetic joint infection (PJI). ResultsThe 2-year survivorship-free rate from reoperation was 71%. There were 18 reoperations following initial surgical management of the IPFF, including 9 for infection, 3 for re-fracture, 3 for nonunion, 2 for hardware failure, and 1 for instability. An initial IPFF involving a stemmed femoral TKA component was associated with increased risk for reoperation (P = 0.007) and PJI (P = 0.044). There was no difference in survivorship free of reoperation between IPFFs managed with ORIF or revision arthroplasty (P = 0.72). ConclusionAn IPFF is a devastating complication following total joint arthroplasty with high reoperation rates, most commonly secondary to PJI. Those IPFFs that occurred between two stemmed components were at the highest risk for reoperation.

Management advances for congenital diaphragmatic hernia: integrating prenatal and postnatal perspectives.

In congenital diaphragmatic hernia (CDH), abdominal organs are displaced into the chest, compress the lungs, and cause mediastinal shift. This contributes to development of pulmonary hypoplasia and hypertension, which is the primary determinant of morbidity and mortality for affected newborns. The severity is determined using prenatal imaging as early as the first trimester and is related to the laterality of the defect, extent of lung compression, and degree of liver herniation. Comprehensive evaluation of fetal CDH includes imaging-based severity assessment, severity assessment, and evaluation for structural or genetic abnormalities to differentiate isolated from complex cases. Prenatal management involves multispecialty counseling, consideration for fetal therapy with fetoscopic endoluminal tracheal occlusion (FETO) for severe cases, monitoring and intervention for associated polyhydramnios or signs of preterm labor if indicated, administration of antenatal corticosteroids in the appropriate setting, and planned delivery to optimize the fetal condition at birth. Integrated programs that provide a smooth transition from prenatal to postnatal care produce better outcomes. Neonatal care involves gentle ventilation to avoid hyperinflation and must account for transitional physiology to avoid exacerbating cardiac dysfunction and decompensation. Infants who have undergone and responded to FETO have greater pulmonary capacity than expected, but cardiac dysfunction seems unaffected. In about 25-30% of CDH neonates extracorporeal life support is utilized, and this provides a survival benefit for patients with the highest predicted mortality, including those who underwent FETO. Surgical repair after initial medical management for the first 24-48 hours of life is preferred since later repair is associated with delayed oral feeding, increased need for tube feeds, and increased post-repair ventilation requirement and supplemental oxygen at discharge. With overall survival rates >70%, contemporary care involves management of chronic morbidities in the context of a multidisciplinary clinic setting.

Complex connective tissue convergence: A case report of scleroderma, systemic lupus erythematosus, and Sjögren's Syndrome overlap syndrome in an adolescent female

This case report illustrates the uncommon occurrence of an overlap syndrome involving systemic sclerosis (SSc), systemic lupus erythematosus (SLE), and Sjögren's syndrome in a 16-year-old female patient. Despite their distinct pathophysiological mechanisms and clinical manifestations, these connective tissue diseases converged in this patient, presenting a diagnostic challenge. The clinical presentation included features such as Raynaud's phenomenon, mouth and digit ulcers, alopecia, photosensitivity, and positive autoantibodies. Diagnostic workup revealed positive findings on antinuclear antibodies (ANA) and extractable nuclear antigen (ENA) panel, confirming the presence of autoantibodies associated with all three conditions. The patient was managed with a combination of symptomatic treatment, hydroxychloroquine, and prednisolone. This case underscores the complexity of overlapping autoimmune diseases and emphasizes the importance of a thorough clinical evaluation, appropriate diagnostic testing, and timely initiation of management to optimize patient outcomes.

Premature Ventricular Contraction-Induced Cardiomyopathy: Contemporary Evidence from Risk Stratification, Pathophysiology, and Management.

Premature ventricular complexes (PVCs) are commonly encountered problems in clinical settings. The range of symptoms can be from asymptomatic to palpitations, fatigue, or heart failure symptoms. A higher burden of PVCs is a risk factor for development of PVC-induced cardiomyopathy (PIC). Rhythm evaluation by 12-lead ECG and an ambulatory monitoring device are essential. Currently, several imaging modalities, such as echocardiography and cardiac magnetic resonance imaging, are utilized to evaluate the underlying structure that may be related to PIC. Beta blockers and antiarrhythmic drugs are typically part of the initial management strategy. If these fail, catheter ablation of PVCs is typically the next step. The purpose of this article is to summarize the current evidence/knowledge about PIC.

Hydroponics as an advanced vegetable production technique: an overview

In the recent past, population explosion across the globe has presented many challenges that include the availability of arable land diminishing per capita for traditional soil-based farming. Therefore, the development of advanced agricultural technologies and methods has become important in response to these persistent situations. Amongst these innovations, soilless crop cultivation has emerged as one of the promising solutions, leading from the forefront. This current review offers a comprehensive investigation of hydroponics as an advanced technology for vegetable production. It explains many aspects related to hydroponic systems, viz., methods used in hydroponics, its advantages, challenges as well as application in vegetable production. This paper also explores the hydroponics evolution historically, various hydroponic systems, their essential components, and nutrient solution role in plant growth facilitation. Furthermore, it highlights various advantages of farming under hydroponic culture, viz., increase in yields, efficient usage of water, optimum space utilization, and less environmental impact. Additionally, this review also sheds light on challenges related to hydroponics, like initial setup cost, technical complexity, and management of diseases. Moreover, it also enlightens about vegetables that are suitable to cultivate under hydroponic culture and provides insight into continuing research, and forthcoming projections in the area of vegetable production under hydroponic cultivation.

Modified Delphi Panel Consensus Recommendations for Management of Severe Aplastic Anemia

Severe aplastic anemia (SAA) is a rare hematologic condition for which there is no clear management algorithm. A panel of 11 adult and pediatric experts on aplastic anemia was assembled and, using the RAND/UCLA modified Delphi panel method, evaluated >600 varying patient care scenarios to develop clinical recommendations for the initial and subsequent management of patients of all ages with SAA. Here we present the panel's recommendations to rule out inherited bone marrow failure (IBMF) syndromes, on supportive care prior to and during first-line therapy, and on first-line (initial management) and second-line (subsequent management) therapy of acquired SAA, focusing on when transplant versus medical therapy is most appropriate. These recommendations represent the consensus of 11 experts informed by published literature and experience. They are intended only as general guidance for experienced clinicians who treat patients with SAA and are in no way intended to supersede individual physician and patient decision-making. Current and future research should validate this consensus using clinical data. Once validated, we hope these expert panel recommendations will improve outcomes for patients with SAA.

Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) protocol.

Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication.

Prognostic indicators of corneal ulcer clinical outcomes at a tertiary care center in the Bronx, New York

PurposeCorneal ulcers frequently result in ocular morbidity and may lead to permanent visual impairment if severe or untreated. This study aims to evaluate the association of patient factors and ocular exam findings on clinical outcomes for patients diagnosed with a corneal ulcer at a tertiary care center in the Bronx, New York.MethodsA retrospective chart review was conducted on all ambulatory and admitted patients diagnosed with a corneal ulcer (identified using ICD-10 code H16.0) at Montefiore Medical Center, Bronx, NY between 2016–2022. Patient demographics, presence of known risk factors, characteristics of subsequent clinical course, and microbiological studies were noted. Clinical outcomes following treatment were longitudinally evaluated and categorized based upon the following criteria: 1) ‘No Surgical Intervention’: No severe complications or surgery required after presentation, 2) ‘Surgical Intervention’: Decline in BCVA with surgery required for a severe complication.ResultsThe search criteria identified 205 patients (205 eyes) with the diagnosis of a corneal ulcer. Mean age was 55.3 ± 21.1 years (mean ± SD). Mean ulcer area at presentation was 7 ± 10.5 mm2. Mean LogMAR at presentation was 1.2 ± 1, and following treatment, improved to 1.0 ± 1. ‘Surgical Intervention’ outcome was associated with advanced age (p = 0.005), presence of ocular surface disease (p = 0.008), central location of ulcer (p = 0.014), greater ulcer area at presentation (p = 0.003), worse visual acuity at presentation (p < 0.001), and isolation of fungi (p = 0.004).ConclusionIdentification of risk factors associated with a poor clinical prognosis can guide treatment and inform expectations for patients diagnosed with a corneal ulcer. Our study highlights the importance of timely diagnosis, work-up, and initiation of appropriate management, particularly in vulnerable populations where access to specialty care is logistically challenging.

Long-term outcomes following double kissing crush or mini-culotte stenting for complex coronary bifurcation lesions: the EVOLUTE-CRUSHIV study.

This study aimed to evaluate the long-term outcomes of double kissing crush stenting (DKC) and mini-culotte technique (MCT) in patients with complex bifurcation lesions. This retrospective study enrolled 236 patients who underwent percutaneous coronary intervention (PCI) for complex coronary bifurcation disease between January 2014 and November 2022. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, myocardial infarction (MI), or clinically driven target lesion revascularization (TLR). The secondary endpoint was major cardiovascular and cerebral events (MACCE) including all-cause death, MI, TLR, stroke, or stent thrombosis. The regression models were adjusted by applying the inverse probability weighted (IPW) approach to reduce treatment selection bias. The initial management strategy was DKC in 154 (65.3%) patients and MCT in 82(34.7%) patients (male: 194 [82.2%], mean age: 60.85 ± 10.86years). The SYNTAX scores were similar in both groups. The rates of long-term TLF and MACCE rates were 17.4% and 20%, respectively. The rate of TLF (26.8% vs. 12.3%, p = 0.005) was higher in patients treated with MCT than those treated with the DKC technique, mainly driven by more frequent TLR (15.9% vs. 7.1%, p = 0.035). The long-term TLF and MACCE rates were notably lower in the DKC group compared to the others: adjusted hazard ratio (HR; IPW): 0.407, p = 0.009 for TLF, and adjusted HR(IPW): 0.391 [95% CI: 0.209-0.730], p = 0.003 for MACCE. At long-term follow-up, the rates of TLF and MACCE were 17.4% and 20%, respectively. However, long-term TLF was significantly higher in patients treated with MCT than those treated with the DKC technique, primarily due to amore frequent occurrence of clinically driven TLR.

The State of Oncology Care in Russia: Localization Structure Features, Quality of Recording, and Survival of Cancer Patients in the Major Age Groups of the Population (population study). Part 6

Malignant neoplasms are considered among the most serious and prevalent diseases in many countries worldwide. In the course of our research, we conducted a review where we synthesized findings from five scientific articles providing detailed descriptions of age-related patterns of prevalence, structure, and survival among oncology patients. The final population-based study presents a culmination of all identified characteristics of this process, particularly regarding the role of age in the characteristics of prevalence and survival of cancer patients, which holds significant importance. The study utilized data from the International Agency for Research on Cancer (IARC), handbooks from the P. A. Herzen MNIOI and the N. N. Petrov National Medical Research Center of Oncology, as well as data from population-based cancer registries databases from the Saint Petersburg and Northwestern Federal District of Russia. Data processing was conducted using licensed software MS Excel 2013–2016 and STATISTICA 6.1. Modified Eurocare software, alongside mathematical, bibliographic, and statistical methods, was employed for survival calculations. The population-based study allowed for a detailed examination of the dynamics of age-specific indicators of morbidity, mortality, quality of initial patient management for MN, and survival rates of MN patients, consolidating vast datasets from across Russia and the Northwestern Federal District of Russia. All gathered and analyzed data indicate an enhancement in the quality of initial patient management for MN, a reduction in mortality rates, and an increase in survival rates.