Initial Management Research Articles

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.

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.

Prehospital Surgical Cricothyrotomy in a Ground-Based 9-1-1 EMS System: A Retrospective Review.

Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system. This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated. A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt. Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.

Investigating the Influence of Project Initiation Management on Performance of Mega-dam Projects: Empirical Evidence from Kenya

Performance of large projects including mega-dams could be associated with strict adherence to project life cycle (PLC) phases while considering the risks such as displacement of people and natural ecosystem disturbance. Understanding these risks helps project managers and stakeholders make informed decisions thus creating a positive legacy for the project in the long run. The main objective of the research was to determine how project initiation management influences the performance of mega-dam projects in Kenya. This study was guided by positivist research philosophy. A descriptive cross-sectional survey research design was adopted. In this study, the unit of analysis was 18 mega-dam projects launched and completed across Kenya as listed under the Ministry of Water, Sanitation, and Irrigation (MoWSI) while the unit of observation was the respective three officials (project manager, project engineer, geospatial engineer) in the MoWSI. A Census of all mega-dams completed in Kenya was conducted. In addition, the study purposively interviewed 5 key stakeholders including the cabinet secretary, permanent secretary from the MWSI, donor, contractor, and one randomly selected beneficiary from the community with the target mega-dam. This formed a total sample size of 180 respondents. Primary data was collected using the semi-structured questionnaires as well as the Key Informant Interview (KII) guide. Quantitative and qualitative data from multiple sources and perspectives provided a more comprehensive and robust understanding. Pretesting was done by way of pilot testing to ascertain the validity and reliability of the tools. Descriptive and inferential statistics were used to summarize and describe the key characteristics of the data, as well as draw conclusions and make inferences. Correlation findings showed that project initiation management and performance of selected mega-dam projects in Kenya have a strong positive and significant relationship (r= 0.874, p&lt;0.05). In addition, regression findings showed that one-unit rise in project initiation management corresponds to a 0.433 improvement in the performance of these mega-dam projects. Based on the findings, the study concluded that project initiation management positively and significantly influences the performance of selected mega-dam projects in Kenya. This study therefore recommends that project managers should give priority to project initiation management

Outcomes in orthopedic device infections due to Streptococcus agalactiae: a retrospective cohort study

BackgroundGroup B streptococci (Streptococcus agalactiae) (GBS) is a rare cause of prosthetic joint infection (PJI) occurring in patients with comorbidities and seems to be associated with a poor outcome. Depiction of GBS PJI is scarce in the literature.MethodsA retrospective survey in 2 referral centers for bone joint infections was done Patients with a history of PJI associated with GBS between 2014 and 2019 were included. A descriptive analysis of treatment failure was done. Risk factors of treatment failure were assessed.ResultsWe included 61 patients. Among them, 41 had monomicrobial (67%) infections. The median duration of follow-up was 2 years (interquartile range 2.35) Hypertension, obesity, and diabetes mellitus were the most reported comorbidities (49%, 50%, and 36% respectively). Death was observed in 6 individuals (10%) during the initial management. The rate of success was 63% (26/41). Removal of the material was not associated with remission (p = 0.5). We did not find a specific antibiotic regimen associated with a better outcome.ConclusionThe results show that S. agalactiae PJIs are associated with high rates of comorbidities and a high treatment failure rate with no optimal treatment so far.

A Novel Model for Xenograft Right Ventricle to Pulmonary Artery Conduit.

The last 40 years have shown dramatic improvement in outcomes for neonatal cardiac surgery for a spectrum of congenital heart disease diagnoses. With more patients surviving into adulthood, the long-term impact of initial management strategies of these patients has come into focus. This is particularly true for patients with pediatric heart valve disease. Many patients born with right ventricular to pulmonary artery (RVPA) discontinuity require placement of a valved conduit in the neonatal period. Valved conduit options are limited in this patient population due to patient size and inability to respond to somatic growth. Genetically engineered porcine (GEP) donors may offer a xenograft conduit alternative that can grow with the patient. We have developed a model utilizing GEP donor RVPA conduits placed in infantile nonhuman primate (NHP) recipients. Our recipient is maintained on single-drug immunosuppression and demonstrates no evidence of pulmonary valve insufficiency or stenosis during short-term follow-up. Further studies and long-term outcomes are necessary to determine the utility of this technology in human application.

Factors Associated With Coronary Angiography Performed Within 6 Months of Randomization to the Conservative Strategy in the ISCHEMIA Trial.

ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) did not find an overall reduction in cardiovascular events with an initial invasive versus conservative management strategy in chronic coronary disease; however, there were conservative strategy participants who underwent invasive coronary angiography early postrandomization (within 6 months). Identifying factors associated with angiography in conservative strategy participants will inform clinical decision-making in patients with chronic coronary disease. Factors independently associated with angiography performed within 6 months of randomization were identified using Fine and Gray proportional subdistribution hazard models, including demographics, region of randomization, medical history, risk factor control, symptoms, ischemia severity, coronary anatomy based on protocol-mandated coronary computed tomography angiography, and medication use. Among 2591 conservative strategy participants, angiography within 6 months of randomization occurred in 8.7% (4.7% for a suspected primary end point event, 1.6% for persistent symptoms, and 2.6% due to protocol nonadherence) and was associated with the following baseline characteristics: enrollment in Europe versus Asia (hazard ratio [HR], 1.81 [95% CI, 1.14-2.86]), daily and weekly versus no angina (HR, 5.97 [95% CI, 2.78-12.86] and 2.63 [95% CI, 1.51-4.58], respectively), poor to fair versus good to excellent health status (HR, 2.02 [95% CI, 1.23-3.32]) assessed with Seattle Angina Questionnaire, and new/more frequent angina prerandomization (HR, 1.80 [95% CI, 1.34-2.40]). Baseline low-density lipoprotein cholesterol <70 mg/dL was associated with a lower risk of angiography (HR, 0.65 [95% CI, 0.46-0.91) but not baseline ischemia severity nor the presence of multivessel or proximal left anterior descending artery stenosis >70% on coronary computed tomography angiography. Among ISCHEMIA participants randomized to the conservative strategy, angiography within 6 months of randomization was performed in <10% of patients. It was associated with frequent or increasing baseline angina and poor quality of life but not with objective markers of disease severity. Well-controlled baseline low-density lipoprotein cholesterol was associated with a reduced likelihood of angiography. These findings point to the importance of a comprehensive assessment of symptoms and a review of guideline-directed medical therapy goals when deciding the initial treatment strategy for chronic coronary disease. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

Stepwise algorithm using computed tomography and magnetic resonance imaging for differential diagnosis of fat-poor angiomyolipoma in small renal masses: A prospective validation study.

To validate the diagnostic accuracy of a stepwise algorithm to differentiate fat-poor angiomyolipoma (fp-AML) from renal cancer in small renal masses (SRMs). We prospectively enrolled 223 patients with solid renal masses <4 cm and no visible fat on unenhanced computed tomography (CT). Patients were assessed using an algorithm that utilized the dynamic CT and MRI findings in a stepwise manner. The diagnostic accuracy of the algorithm was evaluated in patients whose histology was confirmed through surgery or biopsy. The clinical course of the patients was further analyzed. The algorithm classified 151 (68%)/42 (19%)/30 (13%) patients into low/intermediate/high AML probability groups, respectively. Pathological diagnosis was made for 183 patients, including 10 (5.5%) with fp-AML. Of these, 135 (74%)/36 (20%)/12 (6.6%) were classified into the low/intermediate/high AML probability groups, and each group included 1 (0.7%)/3 (8.3%)/6 (50%) fp-AMLs, respectively, leading to the area under the curve for predicting AML of 0.889. Surgery was commonly opted in the low and intermediate AML probability groups (84% and 64%, respectively) for initial management, while surveillance was selected in the high AML probability group (63%). During the 56-month follow-up, 36 (82%) of 44 patients initially surveyed, including 13 of 18 (72%), 6 of 7 (86%), and 17 of 19 (89%) in the low/intermediate/high AML probability groups, respectively, continued surveillance without any progression. This study confirmed the high diagnostic accuracy for differentiating fp-AMLs. These findings may help in the management of patients with SRMs.

Neurologic Emergencies in Pregnancy

Neurologic emergencies in pregnancy require prompt evaluation and early, focused intervention to improve neurologic outcomes for the affected person and to avoid further injury. Neurologic events in pregnancy, although rare, present a time of extreme risk of permanent injury for the person who is pregnant. Therefore, obstetric clinicians should be well versed in the risk factors for potential neurologic events and understand the symptoms and events that should prompt evaluation for a neurologic event. In addition, they should support other specialties in aggressive and early neurologic care for the patient to improve outcomes while assessing fetal well-being and care optimization for the dyad. Obstetric clinicians can uniquely provide knowledge of changes in pregnancy physiology that can increase the risk of neurologic events, as well as change the treatment of these events. For all patients with neurologic events, “time is brain.” Therefore, it is important to be aware of changes in common presenting pregnancy concerns that should prompt evaluation for other pathogeneses. Finally, pregnancy care teams should be prepared to begin the initial stabilization and management of acute neurologic emergencies, including seizure, stroke, and meningitis, while seeking aid from other medical and neurologic specialists who can support their care and interventions. Early and aggressive interventions for individuals with neurologic events during pregnancy and postpartum are critical to the overall well-being of the dyad.

Infected pancreatic necrosis-Current trends in management.

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, amajority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Recommendations for the Management of Initial and Refractory Pediatric Status Dystonicus.

Status dystonicus is the most severe form of dystonia with life-threatening complications if not treated promptly. We present consensus recommendations for the initial management of acutely worsening dystonia (including pre-status dystonicus and status dystonicus), as well as refractory status dystonicus in children. This guideline provides a stepwise approach to assessment, triage, interdisciplinary treatment, and monitoring of status dystonicus. The clinical pathways aim to: (1) facilitate timely recognition/triage of worsening dystonia, (2) standardize supportive and dystonia-directed therapies, (3) provide structure for interdisciplinary cooperation, (4) integrate advances in genomics and neuromodulation, (5) enable multicenter quality improvement and research, and (6) improve outcomes. © 2024 International Parkinson and Movement Disorder Society.

Management of surgical diseases of Primary Hyperparathyroidism: indications of the United Italian Society of Endocrine Surgery (SIUEC).

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in parathyroid surgery published in 2014, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 12 members of the SIUEC highly trained and experienced in thyroid and parathyroid surgery. The main topics concern diagnostic test and localization studies, mode of admission and waiting time, therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications), hospital discharge and patient information, outpatient care and follow-up, outpatient initial management of patients with pHPT.

Potentially fatal complications of new systemic anticancer therapies: pearls and pitfalls in their initial management.

Various types of immunotherapy (i.e. immune checkpoint inhibitors [ICIs], chimeric antigen receptor [CAR] T-cells and bispecific T-cell engagers [BiTEs]) and antibody drug conjugates (ADCs) have been used increasingly to treat solid cancers, lymphomas and leukaemias. Patients with serious complications of these therapies can be presented to physicians of different specialties. In this narrative review we discuss potentially fatal complications of new systemic anticancer therapies and some practical considerations for their diagnosis and initial treatment. Clinical presentation of toxicities of new anticancer therapies may be unpredictable and nonspecific. They can mimic other more common medical conditions such as infection or stroke. If not recognized and properly treated these toxicities can progress rapidly into life-threatening conditions. ICIs can cause immune-related inflammatory disorders of various organ systems (e.g. pneumonitis or colitis), and a cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) may develop after treatment with CAR T-cells or BiTEs. The cornerstones of management of these hyper-inflammatory disorders are supportive care and systemic immunosuppressive therapy. The latter should start as soon as symptoms are mild-moderate. Similarly, some severe toxicities of ADCs also require immunosuppressive therapy. A multidisciplinary team including an oncologist/haematologist and a corresponding organ-site specialist (e.g. gastroenterologist in the case of colitis) should be involved in the diagnosis and treatment of these toxicities. Health professionals should be aware of potential serious complications of new systemic anticancer therapies. Early diagnosis and treatment with adequate supportive care and immunosuppressive therapy are crucial for the optimal outcome of patients with these complications.

The Effect of Ketogenic Metabolic Therapy on Recurrent High-Grade Gliomas: Case Series

High-grade gliomas represent the most prevalent primary malignant brain tumors in the adult population. Despite extensive efforts dedicated to advance in therapeutic modalities, treatment options remain very limited in this field, leading to a worse prognosis for affected patients. Moreover, a considerable number of cases exhibit refractory disease following the initial management. Ketogenic Metabolic Therapy (KMT) has emerged as a promising adjunctive approach for recurrent high-grade gliomas, offering them a synergistic effect enhancement of the effectiveness of conventional therapies against this type of cancer. The underlying hypothesis relies on the use of high-fat, low-carbohydrate diet, with adequate protein content can potentially induce metabolic reprogramming in cancer cells. Currently, the use of KMT is on the rise and has shown positive effects on the control of selected neurological symptoms and improvements in patient’s quality of life. This is a descriptive observational multicenter study (case series) that includes patients with recurrent high-grade gliomas who underwent Ketogenic Metabolic Therapy (KMT) and were supplemented with a liquid ketogenic formula (in a 3:1 ratio) as a complementary treatment to the ongoing medical regimen for recurrence. The results show a positive impact on seizure control, as well as significant improvements in cognition, memory and functionality, as reported by patients and/or their families (caregivers). Regarding the disease status, assessed by the RANO criteria, the 12-month follow-up evaluation indicated stable disease in 55% and a partial response in 20% of cases. Although the results of this work are promising, more conclusive clinical data are still needed to support the use of KMT in the treatment of high-grade gliomas.