Less-invasive Treatment Research Articles

Effectiveness of low to moderate potency topical corticosteroids for phimosis resolution in children: results of a network meta-analysis.

The use of topical corticosteroids (TCSs) has become an efficient, less-invasive treatment for phimosis. Whether any significant difference in efficacy exists between TCSs based on their potency is unclear. Electronic databases were searched up to March 2024 for randomised controlled trials (RCTs) comparing the use of any type or concentration of TCSs with placebo or no treatment in boys with any degree of physician diagnosed phimosis. A random-effects network meta-analysis (NMA) using a consistency model within a frequentist approach was employed. The primary outcome was partial or complete resolution of phimosis reported as a pooled risk ratio (RR) with 95% CI. Relative ranking was assessed with surface under the cumulative ranking curve (SUCRA) probabilities. Seventeen RCTs, containing 2057 participants were identified. NMA suggested that, compared with control, the high (RR 3.19 (95% CI 1.42 to 7.16), moderate (RR 2.68 (95% CI 1.87 to 3.83) and low (RR 3.05 (95% CI 1.63 to 5.71) potency TCSs statistically significantly increased complete or partial clinical resolution of phimosis. The SUCRA plot revealed that high potency (SUCRA = 0.76) was ranked first followed by low and moderate TCSs. When we assessed comparative efficacy among TCSs based on potency, none of the classes were superior to others. The certainty of the evidence for an effect of moderate potent TCSs was that of moderate GRADE quality. Moderate to low potency TCSs are of comparable therapeutic effect in the treatment of phimosis to that of highly potent formulations. More high-quality RCTs are warranted.

Modern Management of Gastric Neuroendocrine Neoplasms.

Gastric neuroendocrine neoplasms (G-NENs) are a heterogeneous group of tumors that broadly fall into two groups. The first group, driven by oversecretion of gastrin, are generally multifocal, small, and behave indolently with a low (but non-zero) risk of progression and metastatic spread. They are conventionally categorized into type 1, with endogenous gastric-based overproduction of gastrin, and type 2 G-NEN, with overproduction of gastrin from an extra-gastric gastrin-secreting tumor. The second group, termed type 3 G-NEN, occur spontaneously and are potentially more aggressive, having a clinical course analogous to other neuroendocrine tumors of the gastrointestinal tract. Type 1 G-NEN can be managed with endoscopic surveillance and resection of visible lesions with great success, reserving surgery for the rare high-risk lesion, whereas surgical resection of the causative gastrin-secreting tumor in type 2 G-NEN is usually curative. Type 3 G-NEN is usually managed with formal surgical resection but there is growing evidence that limited surgery or even endoscopic resection in appropriately selected patients with low risk is both safe and effective. A novel subtype of G-NEN, associated with long-term proton pump inhibitor usage, is increasing in incidence. The pathophysiology seems to parallel type 1 G-NEN. In the setting of metastatic disease, which can occur in any subtype but is most common by far in type 3 G-NEN, the lack of trial data unique to G-NEN results in extrapolation of strategies and agents for treatment of non-gastric neuroendocrine disease. The rapid pace of development in this area is likely to benefit the metastatic G-NEN patient as well. As treatment is predicate on type of G-NEN, establishing the etiology of the lesion is crucial but growing knowledge of G-NEN pathophysiology and close collaboration between pathologists, gastroenterologists, radiologists, surgeons, and oncologists have enabled a growing trend towards de-escalation and less-invasive treatment paradigms.

Gastric peroral endoscopic myo-neurotomy as less-invasive bariatric surgery in porcine models: an experimental study with video

Background and AimsObesity is a global health problem, and less-invasive treatments are warranted. We developed a novel endoscopic intervention named peroral endoscopic myo-neurotomy (POEM-N) that is performed at the greater curvature of the gastric antrum as a bariatric/metabolic procedure and assessed its feasibility using porcine models. MethodsSix live pigs were divided into three groups of two: POEM-N with high-fat diet (HFD) (POEM-N group); sham procedure with HFD (HF-control group); and sham procedure with normal diet (N-control group). All pigs were fed the diets for 2 weeks, underwent POEM-N or sham procedure, and were followed up for 2 weeks after the procedure. The primary outcome was the safety and feasibility of POEM-N. Adverse events and the histology of the area after POEM-N were evaluated to assess the procedure’s safety and feasibility. The secondary outcomes were the changes in body weight and glycolipid levels. ResultsThere was no severe worsening of vital signs during or after the POEM-N procedure. All pigs were well and food intake was good, with no delayed adverse events. Excessive storage of dietary residue, deformity of the gastric antrum and fold concentration were observed after POEM-N, as expected. Histological examination showed hypertrophic regeneration of Auerbach’s plexus, which regulates gastric peristalsis, in both POEM-N pigs. After the procedure, HFD-induced weight gain in POEM-N pigs slowed down, and the increase in serum and liver cholesterol level was suppressed. ConclusionsWe applied POEM-N as a bariatric/metabolic procedure and showed its safety and feasibility using porcine models.

Endoscopic vacuum therapy: pitfalls, tips and tricks, insights, and perspectives.

This article provides a comprehensive review of the use of endoscopic vacuum therapy (EVT) in the management of transmural gastrointestinal (GI) defects (TGIDs) and its future perspectives, such as pre-emptive EVT and novel indications, including GI bleeding and large gastroduodenal ulcers management. This review is based on the available literature data and personal experience to demystify the mentioned limitations of EVT as technical difficulties related to the procedure, possible patients' complaints, and institutions' concerns, by sharing several tips and tricks to overcome EVT-related challenges that may discourage endoscopists from using this live-saving technique, and consequently, restricting patients to receive this therapy, which may lead to undesired outcomes. Several factors, such as placement techniques, EVT type selection, management during its use, EVT system exchanges, device removal, type of anesthesia, and how to avoid EVT-related adverse events are described in detail. Additionally, this review discusses good ways to promote effective communication with patients and relatives, surgeons, and multidisciplinary team. EVT possesses a unique mechanism of action including macro/micro deformation, changes in perfusion (stimulating angioneogenesis), exudate control, and bacterial clearance, promoting healing. EVT has an adequate safety profile and higher clinical success rate compared to any other endoscopic therapy for TGID. Additionally, pre-emptive EVT and its novel indications are promising due to its satisfactory effectiveness in initial studies. Therefore, detailing some practical solutions obtained by years of experience may collaborate to widespread EVT adoption, providing less-invasive treatment for several critical conditions to more patients worldwide.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Implementation and Nursing Care

Uncontrolled hemorrhagic shock is the main cause of death in patients with traumatic injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapidly performed and less-invasive treatment to stop bleeding. The REBOA balloon may be placed at the location of bleeding to achieve hemostasis. Prior to balloon placement, the indications for placement must be evaluated, including non-thoracic aortic trauma and non-traumatic patients with postpartum hemorrhage, and the appropriate sheath size (from 5 to 8 French) must be selected based on the bleeding site. As vascular injury of aortic dissection, rupture, or perforation may occur during the procedure, changes in hemodynamic parameters should be monitored. After balloon placement, ischemic complications due to blood flow occlusion such as lower extremity ischemia and acute renal failure should be tracked. After balloon removal, reperfusion injuries may occur, which can result in multiple organ failure, and should be observed closely. When caring for patients receiving REBOA, physicians should explain the procedure to their families to obtain informed consent. Also, nurses should prepare supplies and closely monitor changes in critical life signs to minimize the risks of hypotension, arrhythmia, and changes in consciousness during the procedure. After placement, the neurovascular and peripheral limbs "5P" (pain, pallor, paresthesia, pulselessness and paralysis) condition should be evaluated and recorded in detail. This treatment approach requires further study and research to assess the long-term impacts of placement and improve quality of care in these patients.

Transvaginal Urethrolysis As A Treatment Option For Women With Recurrent Cystitis

Objectives: To demonstrate the outcome of transvaginal urethrolysis as a treatment option for women with recurrent cystitis, which could be caused from voiding problems. In the case of a failure of non-invasive treatment, the surgical procedure to decrease outlet resistance may have a role. Materials and Methods: Between January 2016 and December 2020, women with recurrent cystitis who underwent urethrolysis at Siriraj Hospital were retrospectively reviewed. Only women who were followed-up for more than 6 months were analyzed. Cure was defined by no clinical symptoms of cystitis, no pyuria on urine analysis, and/or negative urine culture during the follow-up period. Results: In total, 52 women underwent transvaginal urethrolysis. The overall cure rate was observed 53.9% (28 cases) at a median follow-up time of 11.9 (6–59) months. Eighteen of the 44 cases (40.9%) who underwent a video urodynamics study showed bladder outlet obstruction, defined as a Solomon–Greenwell bladder outlet obstruction index of more than 5. None of the characteristics or urodynamics parameters showed statistically significant differences between the cure and failure groups. Postoperative urinary incontinence was reported in 14 cases (26.9%) but showed no statistical difference between the cure and failure group (p = 0.748). Conclusion: Bladder outlet obstruction is a common cause of recurrent cystitis. Transvaginal urethrolysis may have a role as treatment for women with recurrent cystitis from voiding dysfunction who have failed non- and less-invasive treatments. Here, the overall cure rate was 53.8%. A factor associated with the cure rate could not be demonstrated in this study.

Analysis of prognostic factors in patients with self-expandable metallic stents for treatment of malignant gastric outlet obstruction

Background and aim Self-expandable metallic stents (SEMSs) are widely accepted as a less-invasive treatment for malignant gastric outlet obstruction (GOO). However, the factors related to prognosis and stent dysfunction after SEMS placement are not well known, and we aimed to investigate them. Methods This was a single-center retrospective cohort study of 212 malignant strictures in 207 patients. Factors related to prolonged overall survival (OS) and time to recurrent GOO (TRGOO) after SEMS placement were evaluated. Results Improvement of oral intake was confirmed in 179 patients (86%). The median OS was 65 days. A Cox proportional hazards model revealed that lower cancer stage, lower performance status score at the time of SEMS placement, and administration of chemotherapy after SEMS placement were significant predictive factors for prolonged OS. The median OS was 182 days in the group of SEMS followed by chemotherapy (group A) and 43 days in the group of SEMS alone (group B) (p< .0001). Chemotherapy after SEMS implantation contributed to the prolongation of survival in gastric cancer (hazard ratio (HR), 0.12) and pancreatic cancer (HR, 0.41). Furthermore, the cumulative incidence rates of stent dysfunction on day 120 after SEMS placement were 30% in group A and 61% in group B (p=.03). Notably, the preventive effect of chemotherapy on stent dysfunction was significant in pancreatic cancer. Conclusions SEMS is a treatment with high technical and clinical success rate for malignant GOO. Furthermore, subsequent chemotherapy prolongs OS especially in gastric cancer, and TRGOO in pancreatic cancer.

Bipolar Radiofrequency Ablation of the Adrenal Gland: In Vivo and Ex Vivo Experiments.

Laparoscopic adrenalectomy is currently the standard treatment modality for unilateral aldosterone-producing adenoma (APA); however, a less-invasive treatment is needed for its treatment. A new bipolar ablation system that poses a lower risk of complications has been recently developed. This study aimed to evaluate the safety and performance of a novel bipolar radiofrequency ablation (RFA) system for the treatment of APAs. Ablations were performed in an ex vivo study using bovine adrenal glands [group A: n = 6, single-probe; group B: n = 6, two probes, interprobe distance (ID) = 12 mm; group C: n = 6, two probes, ID = 20 mm]. The in vivo study was conducted in groups A and B (n = 2 each) using porcine adrenal glands. For the ex vivo study, the mean vertical diameter (Dv) of the coagulative necrosis area and the mean transverse diameter (Dt) values were 11.99 mm and 10.96 mm for group A, 12.66 mm and 10.0 mm for group B, and 23.37 mm and 22.10 mm for group C, respectively. For the in vivo study, the mean Dv and Dt values were 12.23 mm and 9.03 mm for group A, and 16.38 mm and 9.52 mm for group B, respectively. No heat-induced damage to the adjacent organs was observed. To our best knowledge, this is the first study to evaluate the performance of the bipolar system in RFA of the adrenal gland. RFA using the new bipolar ablation system is safe and produces a sufficient coagulation area to treat APAs.

The Effectiveness and Safety of the Duodenal-Jejunal Bypass Liner (DJBL) for the Management of Obesity and Glycaemic Control: a Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The duodenal-jejunal bypass liner (DJBL) is a less-invasive treatment of obesity and type 2 diabetes mellitus (T2DM). This is a systematic review and meta-analysis including randomized clinical trials (RCTs) comparing DJBL versus sham or pharmacotherapies aiming to evaluate the effectiveness and safety of DJBL. Ten RCTs (681 patients) were included. The DJBL group showed superior excess weight loss (+ 11.4% [+ 7.75 to + 15.03%], p < 0.00001) and higher decrease in HbA1c compared to the control group (- 2.73 ± 0.5 vs. - 1.73 ± 0.4, p = 0.0001). Severe adverse events (SAEs) occurred in 19.7%. The DJBL did not reach the ASGE/ASMBS thresholds for the treatment of obesity. However, it is important to state that many SAEs were not really severe. Therefore, we believe this therapy plays an important role in the management obesity and T2DM.

SURG-22. STAGED LASER INTERSTITIAL THERAPY (LITT) FOR THE SURGICAL TREATMENT OF INSULAR GLIOMA: A CASE SERIES WITH A NOVEL TREATMENT PARADIGM

Abstract BACKGROUND Insular gliomas pose a significant surgical challenge due to the insula’s delicate surrounding functional and vascular anatomy. Insular gliomas are conventionally treated with open surgical resection augmented by several surgical adjuvants. Despite advancements in technology and surgical techniques, surgical resection of insular gliomas has been associated with frequent and potentially severe morbidity. Laser interstitial thermal therapy (LITT) is a novel, cytoreductive, and less-invasive treatment option for glioma. OBJECTIVE We describe the first-ever series of patients with insular glioma treated with staged LITT with or without subsequent craniotomy. METHODS A retrospective institutional database identified patients with insular glioma who underwent staged LITT treatments. Clinical, histopathological, and volumetric lesional characteristics were obtained. Procedural characteristics, morbidity, overall survival (OS), and progression-free survival (PFS) were determined. RESULTS Between 2019-2022, 11 patients with insular glioma were treated in stages with a total of 21 LITT procedures with or without subsequent craniotomy. Four patients had Diffuse Astrocytoma (IDHmt/TP53+), one Gemistocytic Astrocytoma (IDHmt/TP53+), three Anaplastic Astrocytoma (IDHmt/TP53+), one Anaplastic Oligodendroglioma (IDHmt/1p19q codel), one secondary GBM (IDHmt/TP53+), and one GBM (IDHwt/TP53-). Six patients were treated with LITT alone, while five patients were treated with LITT followed by a craniotomy for complete resection. Patients had a median tumor volume of 31.5 cm3 (9.58, 97) and a mean extent of ablation±resection of 97.68% (S.D. 5.4). At a median follow-up of 12.59 months, patients had a median PFS of 12.88 months and an OS of 14.46 months. No patients had a change in KPS following LITT. Two patients had a decrease in KPS following surgery. CONCLUSION We present the first-ever reported series of insular glioma treated with staged LITT with/without subsequent resection. We found that staged treatment of insular gliomas with LITT is safe, effective, and a minimally invasive option that avoids the potentially significant morbidity associated with conventional surgery.

Abstract 15248: Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention - An Updated Meta-Analysis and Systematic Review

Hypothesis: Transcatheter aortic valve replacement (TAVR) serves as a less-invasive treatment option for high-risk patients with severe aortic stenosis. Given the coexistence of obstructive coronary artery disease in patients with high-grade aortic stenosis (estimated to be 40-75%), there is inconsistent clinical data regarding potential mortality benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. Methods: We performed a literature search using PubMed, Embase, and Cochrane Library from inception through April 2022 to assess the mortality impact of preceding/concomitant PCI in patients undergoing transcatheter aortic valve replacement. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding/vascular complications, and acute kidney injury. Results: 11 studies (10 retrospective cohort studies, 1 randomized control trial) involving 2791 patients were included in the meta-analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, p =0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, p =0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, p =0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group compared to the TAVR group (RR 3.09, CI 1.26, 7.57, p =0.01), while no significant differences were found in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, p =0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, p =0.55), and acute kidney injury (RR 1.07, CI 0.75, 1.54, p =0.71). Conclusion: Concomitant/preceding percutaneous coronary intervention does not confer any additional mortality benefit, and may increase the risk of 30-day myocardial infarction, in patients with high-grade aortic stenosis undergoing transcatheter aortic valve replacement. Further trials with large sample sizes are needed to confirm our findings.

Lateral T-Capsulotomy with Hip Arthroscopy for Access and Excision of Posterior Intra-Articular Mass

There is a lack of literature regarding arthroscopic access to the posterior peripheral compartment of the hip. Compared with open surgery, arthroscopy offers less-invasive treatment for intra-articular mass excision. Arthroscopic hip mass excision has focused on selective resection of lesions in the central compartment and anterior peripheral compartment due to difficult and previously undescribed posterior access. We introduce a technique for arthroscopic excision of a posterior intra-articular hip mass consistent with pigmented villonodular synovitis, also known as tenosynovial giant cell tumor, using a modified T-capsulotomy based on the lateral aspect of the hip capsule. This modified capsulotomy allows for more posterior and lateral access to the central and peripheral compartments while minimizing violation of the iliofemoral ligament.

Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study From Spain.

Several randomized clinical trials on the treatment of meniscal tears have shown that surgery is not superior to nonoperative treatment in middle-aged and older adults. However, clinical practice has not changed consistently worldwide in response to this evidence, and arthroscopic meniscectomy remains one of the most frequently performed operations. (1) How has the use of arthroscopic meniscectomy changed in Spain between 2003 and 2018, particularly in middle-aged (35 to 59 years) and older patients (over 60 years) relative to younger patients? (2) How have surgical volumes changed across different healthcare areas in the same health system? (3) How has the proportion of outpatient versus inpatient arthroscopic procedures changed over time? Data on all 420,228 arthroscopic meniscectomies performed in Spain between 2003 and 2018 were obtained through the Atlas of Variations in Medical Practice project (these years were chosen because data in that atlas for 2002 and 2019 were incomplete). This database has been promoted by the Spanish Health Ministry since 2002, and it collects basic information on all admissions to public and public-private partnership hospitals. The Spanish population of 2003 was used to calculate age- and sex-standardized rates of interventions per 10,000 inhabitants and year. To assess the change in standardized rates among the age groups over the study period, a linear regression analysis was used. Standard small-area variation statistics were used to analyze variation among healthcare areas. Data on outpatient surgery and length of stay for inpatient procedures were also included. The standardized rate of arthroscopic meniscectomy in Spain in 2003 was 4.8 procedures per 10,000 population (95% CI 3.9 to 5.6), while in 2018, there were 6.3 procedures per 10,000 population (95% CI 5.4 to 7.3), which represents an increase of 33%. Standardized rates increased slightly in the age group < 35 years (0.06 interventions per 10,000 inhabitants per year [95% CI 0.05 to 0.08]), whereas they increased more markedly in the age groups of 35 to 59 years (0.14 interventions per 10,000 inhabitants per year [95% CI 0.11 to 0.17]) and in those 60 years and older (0.13 interventions per 10,000 inhabitants per year [95% CI 0.09 to 0.17]). The variability among healthcare areas in the meniscectomy rate progressively decreased from 2003 to 2018. In 2003, 32% (6544 of 20,384) of knee arthroscopies were performed on an outpatient basis, while in 2018, these accounted for 67% (19,573 of 29,430). We observed a progressive increase in arthroscopic meniscectomies in Spain; this procedure was more prevalent in older patients presumed to have degenerative pathologic findings. This increase occurred despite increasing high-level evidence of a lack of the additional benefit of meniscectomy over other less-invasive treatments in middle-aged and older people. Our study highlights the need for action in health systems with the use of financial, regulatory, or incentive strategies to reduce the use of low-value procedures, as well as interventions to disseminate the available evidence to clinicians and patients. Research is needed to identify the barriers that are preventing the reversal of interventions that high-quality evidence shows are ineffective. Level III, therapeutic study.

Design of a flexible robot toward transbronchial lung biopsy

AbstractTransbronchial lung biopsy is an effective and less-invasive treatment for the early diagnosis of lung cancer. However, the limited dexterity of existing endoscopic instruments and the complexity of bronchial access prevent the application of such procedures mainly for biopsy and diagnosis. This paper proposes a flexible robot for transbronchial lung biopsy with a cable-driven mechanism-based flexible manipulator. The robotic system of transbronchial lung biopsy is presented in detail, including the snake-bone end effector, the flexible catheters and the actuation unit. The kinematic analysis of the snake-bone end effector is conducted for the master-slave control. The experimental results show that the end effector reaches the target nodule through a narrow and tortuous pathway in a bronchial model. In conclusion, the proposed robotic system contributes to the field of advanced endoscopic surgery with high flexibility and controllability.

Platelet function changes in patients undergoing endovascular aortic aneurysm repair: Review of the literature.

Patients with abdominal aortic aneurysm (AAA) have a higher risk of cardiovascular (CV) events, which seems to be associated with disturbed platelet (PLT) function. Endovascular aneurysm repair (EVAR) is an emerging, less-invasive treatment alternative to surgical AAA repair. Both platelet function abnormalities in patients with AAA and the effect of EVAR on platelet function are poorly understood. In this review, we aim to fill the gap regarding the effect of EVAR on PLT function in AAA patients by discussing PLT function disturbances in patients with AAA, PLT function changes after EVAR, evidence from clinical studies regarding PLT function before and after EVAR, and antiplatelet or and antithrombotic treatment in patients undergoing EVAR. The goal of our review is to summarize the contemporary knowledge and initiate further studies to better understand PLT function changes in patients undergoing EVAR, optimize the pharmacotherapy before and after EVAR and further improve outcomes in this group of patients.

Male urethral stricture disease: why management guidelines are challenging in low-income countries.

Urethral stricture disease (USD) is one of the commonest urological pathologies in adult men in low- or low-middle-income countries, providing a significant work burden for the small number of specialist surgeons who are able to provide appropriate treatment. The underlying causes of anterior urethral stricture relate to urethral fibrosis from sexually transmitted infection, with posterior urethral disruption secondary to pelvic trauma being an equally common cause of USD in many countries in sub-Saharan Africa. Anterior urethral strictures are often long, and multifocal, and bulbo-prostatic disruptions are usually due to relatively low-velocity pelvic trauma. The management options available in resource-poor settings are often severely limited by the individual's ability to pay for care, the availability of a specialist surgeon and, importantly, a shortage of functioning endoscopic equipment for less-invasive treatments. Consequently, reconstructive surgery is often regarded by the patient, and surgeon, as the most cost-effective and, therefore, primary means of treating a urethral stricture once urethral dilatation has failed. Regional anaesthetic techniques have limited the adoption of free-graft augmentation as an alternative to pedicled flaps of locally available skin for reconstruction, whilst an inability to provide tension-free bulbo-prostatic anastomoses has negatively impacted the outcome from the treatment of pelvic fracture disruption injuries in much of sub-Saharan Africa. However, Urolink has found that local surgeons can be taught sustainable skills required for successful complex urethroplasty when supported by longitudinal mentorship in the management of difficult clinical issues. Evidence-based practice is known to improve the standard of care in specific conditions in high-income countries, including the management of male USD. However, guidelines developed in high-income countries are not necessarily appropriate for stricture management in less well-resourced healthcare environments but could be adapted to help improve the delivery of stricture care for men in low- or low-middle income countries.

Combining conventional ultrasound and sonoelastography to predict axillary status after neoadjuvant chemotherapy for breast cancer.

To determine the ability of conventional ultrasound (US) combined with shear wave elastography (SWE) to reveal axillary status after neoadjuvant chemotherapy (NAC) in breast cancer patients. From September 2016 to December 2021, 201 patients with node-positive breast cancer who underwent NAC were enrolled in this prospective study. Conventional US features of axillary lymph nodes and SWE characteristics of breast lesions after NAC were analyzed. The diagnostic performances of US, SWE, and their combination were assessed using multivariate logistic regression and receiver operator characteristic curve (ROC) analyses. The area under the ROC curve (AUC) for the ability of conventional US features to determine axillary status after NAC was 0.82, with a sensitivity of 85.23%, a specificity of 67.39%, and an accuracy of 76.11%. Shear wave velocity (SWV) displayed moderate performance for predicting axilla status after NAC with SWVmean demonstrating an AUC of 0.85. Cortical thickness and shape of axillary nodes and SWVmean of breast tumors were independently associated with axillary nodal metastasis after NAC. Compared to conventional US, the combination of conventional US of axillary lymph nodes with SWE of breast lesions achieved a significantly higher AUC (0.90 vs 0.82, p < 0.01, Delong's test) with a sensitivity of 87.50%, improved specificity of 82.61% and accuracy of 85.00%. BreastSWE was independently associated with residual metastasis of axillary node after NAC in patients with initially diagnosed positive axilla. Combining SWE with conventional US showed good diagnostic performance for axillary node disease after NAC. • Breast SWE can serve as a supplement to axilla US for the evaluation of the axilla after NAC. • The combination of axilla US with breast SWE may be a promising method to facilitate less-invasive treatment in patients receiving NAC.

Endoscopic endonasal transpetroclival approach for recurrent bilateral petroclival meningioma.

The authors performed an endoscopic endonasal transpetroclival approach for recurrent bilateral petroclival meningioma, with the aim of sufficient tumor resection with cranial nerve functional preservation. The tumor was sufficiently removed with excellent postoperative course. Petroclival meningioma, especially located in the medial region with dural attachment of the clivus, is considered a good indication for this approach. Recurrent tumors after radiotherapy often have strong adhesion to the brainstem and basilar artery; therefore, careful assessment of whether or not tumor detachment is possible is essential. The endoscopic endonasal transpetroclival approach is an acceptable, less-invasive treatment for petroclival tumors.The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21229

Irreversible Electroporation of Carcinoma of the Prostate Gland with a Focus on Localized Carcinoma of the Prostate Gland: A Review and Update

Irreversible Electroporation of Carcinoma of the Prostate Gland with a Focus on Localized Carcinoma of the Prostate Gland: A Review and Update

Perspectives on Dental Caries: A Cross-Sectional Study among Parents of Primary School Children in Saudi Arabia

Background: Dental caries is one of the most prevalent chronic childhood diseases affecting many people worldwide. Many people do not recognize the early signs of dental caries or its causes, which is crucial for the prevention and early intervention of the disease and consequently less-invasive and cheaper treatment options. Objective: This study aimed to evaluate the perspectives of parents about the meaning, causes, and early signs of dental caries, the association of tooth discoloration with decay, and the effect of different socio-demographic variables on the knowledge of patients regarding caries. Methods: Questionnaires were distributed to parents of primary school children in the region of Madinah, Saudi Arabia. Meaning of dental caries, early signs, causes of tooth discoloration related to decay, and the effect of different socio-demographic variables were calculated. Multiple linear regression analysis was carried out to identify significant predictor variables associated with caries knowledge scores. Results: There was a total of 2690 respondents. The majority had average caries knowledge scores. Lighter shades of tooth discoloration were reported to be associated with stains and warranted home care only, while darker shades were associated with caries and yielded a necessity for a visit to the dentist. Different socio-demographic variables had an effect on the caries knowledge of the parents. Conclusion: There is a need for increased knowledge about the early signs of dental caries among parents. Delayed recognition of signs of dental caries has a detrimental effect on the teeth of children and leads to seeking dental care at the later stages of the disease process. Community-oriented programs are fundamental for improving caries knowledge, its clinical presentations starting from its early signs, causes, and prevention.