Maximal Medical Therapy Research Articles

Incremental eligibility criteria for the BMT CTN 1507 haploidentical trial for children with sickle cell disease

AbstractThe Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 1507 leadership and the data safety monitoring board (DSMB) established incremental entry criteria for children aged 5 to 14.99 years with sickle cell disease (SCD) enrolling in a phase 2 trial of HLA-haploidentical hematopoietic stem cell transplantation. First, the enrollment was limited to overt stroke in the first 10 participants (stage 4). Subsequently, the DSMB reviewed the interim results and expanded the eligibility to include children with silent cerebral infarcts or abnormal transcranial Doppler velocities with magnetic resonance angiography–defined cerebral vasculopathy (stage 3). A third cohort was enrolled after the DSMB reviewed the clinical outcomes in these cumulative initial enrollments (n = 18). Additions to the entry criteria included nonneurologic morbidities (stage 2). Eligibility criteria included the following: (1) life-threatening acute chest syndrome requiring exchange transfusion; (2) right heart catheterization confirmed pulmonary hypertension; (3) persistent systemic hypertension despite maximum medical therapy; (4) acute pain despite maximum medical therapy in the absence of psychosocial factors and unmanaged asthma after adjudication; or (5) 2 major priapism episodes in 12 months or 3 in 24 months. Children with SCD who did not meet the criteria for stages 4, 3, and 2 were not eligible. To our knowledge, for the first time, we introduce a staged strategy for eligibility in a curative therapy trial for children with SCD concordant with 45 Code of Federal Regulations § 46.405(b). The research governance–mandated eligibility strategy used within the BMT CTN 1507 phase 2 study may apply to future pediatric SCD curative therapy trials. This trial was registered at www.ClinicalTrials.gov as #NCT032635590.

8537 Refractory Hypoglycemia Secondary To Metastatic Insulinoma Treated With Novel Insulin Receptor Antibody - A Case Report

Abstract Disclosure: J. Lloyd: None. S. Abu Omar: None. L. Lester: None. L. Wilson: None. Introduction: Insulinoma is the most common functional pancreatic neuroendocrine tumor, characterized by hypersecretion of insulin, causing hypoglycemia. Insulinomas are mostly benign, however malignant neoplasms account for 5-10 % of cases. Surgical resection is the preferred treatment for solitary tumor, however metastatic insulinoma requires a more aggressive approach with medications to prevent hypoglycemia, resection of primary tumor, resection of metastasis, and chemoembolization. We describe a case of metastatic insulinoma with refractory hypoglycemia despite treatment with multiple medications, surgical resection of tumor, embolization of liver metastasis and successfully treated with a novel monoclonal antibody that blocks insulin receptor. Clinical Case: 43-year-old female was initially diagnosed with metastatic insulinoma in 2021. The primary tumor was pancreatic with metastasis to the liver. She was treated with surgical resection of the primary tumor and three hepatic embolizations for liver metastasis. She required a progressive number of medications to treat frequent, debilitating hypoglycemia. These medications included diazoxide, verapamil, lanreotide then changed to pasireotide, everolimus, and dexamethasone. Despite these treatments, she experienced refractory hypoglycemia and was admitted to the hospital. She required continuous dextrose infusion up to 100ml/hr of D50. Due to the large volume of fluid from dextrose infusion and other medications, she developed severe edema and AKI and required aggressive diuretic regimens and briefly intermittent CRRT. As there were no additional medications to add and prospects for future liver embolization were limited, we requested use of RZ358 through the manufacturer’s Expanded Patient Access program. This medication is a monoclonal antibody that blocks the insulin receptor to counteract the effects of insulin and thereby reduce hypoglycemia. This mechanism of action is unique from medications used to manage insulinoma induced hypoglycemia. She received her first infusion of RZ358 which she tolerated well. She had baseline elevation of ALP due to liver metastasis with further rise after liver embolizations, most recently 4 weeks prior. There was a rise in ALP levels which stabilized after 3 days. She experienced no significant side effects. For the first time in two months, five days after her first infusion of RZ358, the dextrose infusion could be stopped. She received her second infusion of RZ358 one week after first infusion. She was discharged home in a stable condition shortly after the second infusion. Conclusion: The Insulin receptor blocking monoclonal antibody, RZ358, offers a promising approach to patients with metastatic insulinoma who have refractory hypoglycemia despite maximal medical and surgical therapy. Presentation: 6/1/2024

A Prospective Comparative Study of Impedance Audiometry Findings Preoperatively and Postoperatively in Cases of Conventional Adenoidectomy versus Microdebrider Assisted Adenoidectomy.

The aim of the study was to evaluate and compare the efficacy of Endoscopic Adenoidectomy with Microdebrider over Conventional technique by Curettage using Impedance Audiometry findings. In this prospective, randomised, comparative study patients were divided into two groups to undergo one of the above adenoidectomy surgeries. Patients with symptoms of Adenoid hypertrophy after failed maximal medical therapy (12 weeks) were selected after due consideration of the inclusion and exclusion criteria. Baseline Impedance Audiometric assessment was done one week prior to surgery which was compared to Impedance Audiometric values 12 weeks post operatively in each group. This study enrolled 50 patients with adenoid hypertrophy, 25 patients of group A underwent Conventional adenoidectomy and the other 25 patients of group B underwent Endoscopic Adenoidectomy with Microdebrider. Significant difference in type of tympanogram before and after adenoidectomy was found in both the groups (p = 0.0008 in group A & p < 0.0001 in group B). In Group A Percentage of abnormal tympanograms becoming normal (Type A), 12 weeks after adenoidectomy was 80%. In Group B Percentage of abnormal tympanograms becoming normal (Type A), 12 weeks after adenoidectomy was 88%. A statistically significant improvement (p < 0.0001 in both the groups) in the percentage of ears with absent stapedial reflex was observed in both groups postoperatively, with no difference between the two groups suggestive of improvement in eustachian tube function. Association of Preoperatively & Postoperatively Eustachian tube function in each group undergoing adenoidectomy was statistically significant (p < 0.0001). Both forms of adenoidectomy are effective in managing adenoid hypertrophy with tubal dysfunction causing mild conductive hearing loss and prone for OME. However, the audiological and endoscopic evaluation seems to favor Endoscopic Adenoidectomy with microdebrider over conventional adenoidectomy, and it should be therefore considered in the therapeutic management of young patients with adenoidal disease.

Indian Consensus on the Role and Position of Angiotensin Receptor-neprilysin Inhibitors in the Management of Heart Failure.

The incidence of heart failure (HF) in India is estimated to be 0.5-1.7 cases per 1,000 people per year, and approximately 4,92,000-1.8 million new cases are detected every year. Despite the high rate of mortality associated with HF, most patients do not receive maximal guideline-directed medical therapy (GDMT). Current guidelines advocate early multidrug combination therapy with four classes of drugs, namely, beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), angiotensin receptor-neprilysin inhibitors (ARNIs), and sodium-glucose transport protein 2 inhibitors (SGLT-2is), particularly in patients with heart failure with reduced ejection fraction (HFrEF). ARNIs reduce cardiac morbidity and mortality in patients with HFrEF. However, recent data indicated that only 4.8% of patients with HFrEF receive ARNI in India. Hence, at a national consensus on HF meeting, cardiology experts from India formulated a national consensus on the use of ARNI in HF based on current evidence and guidelines. The consensus states that ARNI should be used early in HF, particularly in de novo patients with HFrEF, and those with acute decompensated heart failure (ADHF), irrespective of the presence of low systolic blood pressure (SBP) or diabetes. Moreover, those with HFrEF on renin-angiotensin-aldosterone system (RAAS) inhibitors should be switched to ARNI to reduce the risk of repeated hospitalization for HF, worsening HF, and cardiac death, and to improve the quality of life (QoL). Starting ARNI during the first hospitalization is preferable, and it is safe and effective across all doses. ARNIs can also be used for secondary benefits in patients with preserved ejection fraction [heart failure with preserved ejection fraction (HFpEF)] and HF with mildly reduced EF [heart failure with mildly reduced ejection fraction (HFmrEF)].

279. NOVEL REFLUX MICROASPIRATION SCINTIGRAPHY ALLOWS EFFECTIVE PATIENT SELECTION FOR ANTIREFLUX SURGERY IN PROXIMAL REFLUX EVENTS

Abstract Background and Aims There is currently no reference standard test for the detection of the extra-esophageal manifestations of gastroesophageal reflux disease (GORD). The current suite of diagnostic tests principally assess reflux events in the oesophagus have problematic accuracy issues in the pharynx. A new scintigraphic technique has been developed and validated against 24-hour oesophageal monitoring with pH, impedance. It allows direct visualization of refluxate in the laryngopharynx and lungs. This was utilised to evaluate patients having laparoscopic fundoplication for severe proximal reflux resistant to maximal medical therapy. Scanning may allow succesful patient selection for antireflux surgery. Methodology Following Institutional Ethics approval, 50 patients were assessed by scintigraphy before and after laparoscopic fundoplication (LF) at a single nuclear medicine facility. Standardised Reflux Symptom Indices (RSI) were obtained from each patient before and after surgery. Patients were scanned after oral 99m technetium Fyton administration with early dynamic images and delayed SPECT/CT images of the head, neck and lungs. Background corrected time-activity curves were generated for the pharynx and upper oesophagus from which frequency of reflux was estimated by counting events with activities greater than 2 standard deviations above fitted values. Frequencies, Spearman correlation and the student’s t test were utilised for analysis. Results The study population (35F, 15M) had a mean age of 63.9 years (Range 21-86). All patients underwent LF. Mean BMI was 26.8 with 67% being over-weight or obese. All patients had proximal reflux events in the early dynamic study. SPECT/ CT showed LPR events in 45/50 and pulmonary micro-aspiration (PMA) in 45/50 pre-operatively and in 36/50 and 20/50 post-operatively. The RSI, cough and throat clearing indices showed a significant fall post-operatively (p&amp;lt; 0.001). The frequency of scintigraphic pharyngeal reflux events was reduced from a mean of 4.5 in 30 minutes to 2.9 (t=9.1, p=0.004). Conclusion The novel scintigraphic test detects oesophageal and extra-oesophageal reflux events and permits direct visualization of refluxate in the head and neck structures and lungs. Scintigraphy correlates well with symptoms of reflux in the oesophagus and extra-esophageal structures such as the laryngopharynx (chronic cough and throat clearing) and the response to LF albeit partial. PMA was significantly reduced.

Treatment algorithm for pulmonary arterial hypertension.

Pulmonary arterial hypertension leads to significant impairment in haemodynamics, right heart function, exercise capacity, quality of life and survival. Current therapies have mechanisms of action involving signalling via one of four pathways: endothelin-1, nitric oxide, prostacyclin and bone morphogenetic protein/activin signalling. Efficacy has generally been greater with therapeutic combinations and with parenteral therapy compared with monotherapy or nonparenteral therapies, and maximal medical therapy is now four-drug therapy. Lung transplantation remains an option for selected patients with an inadequate response to therapies.

Failed airway in the emergency department; what’s next?

A failed airway is defined as an unsuccessful intubation. It is a rare occurrence in the emergency department (ED) and always poses a challenge to emergency physicians. The ‘can’t intubate, can ventilate’ situation is one of the two ways a failed airway can occur in ED. Here, we present a case of failed emergency endotracheal intubation due to unanticipated subglottic stenosis. An elderly presented to a district hospital (without specialist) with acute bronchospasm, in which he was treated as severe exacerbation of chronic obstructive pulmonary disease (COPD). Despite maximal medical therapy, symptoms worsen, requiring intubation for airway protection. Standard rapid sequence intubation (RSI) was performed, with a good view of glottic opening; however endotracheal tube (ETT) size 7.5 could not be passed beyond the larynx. Several attempts using smaller-size ETTs still failed. A laryngeal mask airway (LMA) was inserted as a rescue device for ventilation. The patient was then sent to our centre for further evaluation and treatment. Initial examination in our ED revealed an elderly that was sedated and ventilated through LMA. Ventilation and oxygenation via the LMA were adequate. Diagnostic endoscopy was performed through LMA using flexible intubating scope which showed subglottic stenosis around 2cm below the vocal cord. The patient was referred to the Ear, Nose and Throat (ENT) team, where emergency tracheostomy was then performed in operating theatre. He was discharged well after 14 days of admission and given follow-up for his COPD and tracheostomy care.

Assessing the information needs of patients implanted with a left ventricular assist device via analysis of social media forums

Abstract Background Left Ventricular Assist Devices (LVADs) serve as a feasible treatment alternative for patients with end-stage heart failure who do not respond sufficiently to maximal medical therapy. An increasing number of individuals with end-stage heart failure, both pre- and post-LVAD implantation, are utilizing social media to find medical information and peer support. Purpose The objective of this study was to identify unmet education and information needs of patients with LVAD through social media interactions. Methods In this research, information was gathered from the forum section of the website MyLVAD.com through an automated extraction technique. We conducted an anonymous collection and analysis of a dataset from MyLVAD.com, which comprised 459 forum threads and 3886 messages across the entire forum, contributed by 945 unique users. To establish a matrix addressing existing information and educational needs, we examined 867 posts and conversations that contained questions and inquiries, ultimately identifying a total of 435 concrete questions. A series of categorization matrices were developed and updated to facilitate the discovery of new categories. Results Numerous information gaps and unanswered questions were discovered in relation to the following areas: clothing, complications/adverse events, LVAD pros and cons, self-care, therapy, and recent LVAD implantation. Among the 435 questions, 216 (49.7%) questions had a primary focus on self-care for patients with LVAD, including subjects such managing the driveline site, understanding equipment functionality, and adapting lifestyle habits to ensure safety and health while living with an LVAD. Two other major question categories emerged: those regarding complications/adverse effects, comprising 80 questions (18.4%), and those discussing the pros and cons of LVAD, with 67 questions, accounting for 15.4%. Conclusion The social media data retrieved from MyLVAD.com is the first to be used to assess the unmet needs and knowledge gaps among patients implanted with LVAD and develop categories to describe LVAD patient knowledge and information needs. Unlike investigator-generated data, social media data reflect the natural and organic conversation between patients, untainted by investigator agendas or biases. Social media data can enhance our understanding of patient information deficiencies. This can lead to the creation of materials specifically aimed at fulfilling unaddressed educational requirements.Unmet LVAD patients information needs

Disseminated Histoplasmosis with Secondary Hemophagocytic Lymphohistiocytosis in a Renal Transplant Recipient on Belatacept-based Immunosuppression

Effective post-transplant immunosuppression is essential to induce tolerance to allogeneic tissues and promote long-term graft survival. However, suppression of the immune system significantly increases the risk of opportunistic infections. In addition to the ongoing challenge of balancing graft survival and preventing infections, previous gold-standard calcineurin inhibitor-based immunosuppression also posed an increased risk of nephrotoxicity, cardiac disease, and diabetes. Belatacept is approved as an alternative to calcineurin inhibitor-based regimens. Although belatacept has improved cardiovascular and metabolic adverse events in renal transplant patients’ but it carries a notably higher risk of long-term graft survival and renal toxicity, similar to calcineurin inhibitor-based regimens. However, there may be an increased risk of infections with its mechanism of action. We present a case of a 62-year-old female who developed disseminated histoplasmosis 18 months after being on belatacept-based immunosuppression after a deceased donor renal transplant for end-stage renal disease secondary to focal segmental glomerulosclerosis. Grocott Methenamine Stain (GMS) of peripheral blood smear showed intracellular yeast in neutrophils, consistent with histoplasmosis. Disseminated histoplasmosis was confirmed with positive bronchoalveolar lavage (BAL) and urine culture. The patient later developed hemophagocytic lymphohistiocytosis (HLH) secondary to immunosuppression and disseminated histoplasmosis. The patient succumbed to the disease despite maximal medical therapy. To our knowledge, there is one other published report of disseminated histoplasmosis in a patient with belatacept-based immunosuppression. The unique feature of this case is the development of HLH secondary to disseminated histoplasmosis while on belatacept. Further research is needed to evaluate the need for antifungal prophylaxis in patients on belatacept therapy.

Internal Hernia Post-Single Anastomosis Gastric Bypass: Case Series with Review of Literature.

Obesity is an emerging worldwide health care issue. It has a direct and indirect bearing on health-related outcomes. Rates of overweight and obesity have grown manifold in the past few decades globally. Once considered a problem of the affluent societies only, obesity is now dramatically on the rise in low- and middle-income countries also. Single anastomosis gastric bypass (SAGB) is one of the combined bariatric procedures adopted for weight loss in patients failing maximal medical therapy. Internal hernia (IH) after SAGB is a less recognized clinical entity. We hereby report our experience with four such cases under light of current available literature. Bariatric procedures are associated with some short- and long-term limitations. IHs are among one of the dreaded complications associated with some bariatric procedures with rates reaching up to 16% after classic Roux-en-Y gastric bypass. The incidence of IH post-SAGB is comparatively rare and is very less frequently reported. Symptoms of IH post-SAGB are quite nonspecific and depend on the time and extent of herniation. The symptoms can vary from benign intermittent colicky pain to severe intra-abdominal pain presenting as a surgical emergency. Routine physical examination and biochemical investigations are nonspecific and unreliable in evaluating those patients. Computed tomography (CT) with intravenous and oral contrast is the most common imaging modality used for preoperative evaluation of those symptoms. The CT findings can be unremarkable in patients having intermittent symptoms/herniation. Diagnostic laparoscopy is the cornerstone for diagnosis and management of patients having high suspicion of IH.

Short Cilia, Immunodeficiency, and Cystic Fibrosis in a Mother-Daughter Pair

Patients with chronic rhinosinusitis (CRS) that is refractory to maximal medical and surgical therapy should be evaluated for other primary conditions. Cystic fibrosis (CF), primary immunodeficiency (PID), and primary ciliary dyskinesia (PCD) are potential risk factors for refractory CRS. These conditions present with variable disease severity and diagnosis may be delayed into adulthood. We report a case of a mother-daughter pair with CRS refractory to maximal medical management. The patients were further evaluated and found to have features consistent with CF, PID, and PCD. All 3 are rare disorders and thought to cause CRS in isolation. Patients with refractory CRS should be further evaluated to identify alternative diagnoses and ensure proper management. Refractory CRS may be multifactorial, with different risk factors simultaneously contributing to its persistence.

Safety and Efficacy of Surgical Implantation of Intrathecal Drug Delivery Pumps in Patients With Cancer With Refractory Pain.

Pain management in patients with cancer is a critical issue in oncology palliative care as clinicians aim to enhance quality of life and mitigate suffering. Most patients with cancer experience cancer-related pain, and 30%-40% of patients experience intractable pain despite maximal medical therapy. Intrathecal pain pumps (ITPs) have emerged as an option for achieving pain control in patients with cancer. Owing to the potential benefits of ITPs, we sought to study the long-term outcomes of this form of pain management at a cancer center. We retrospectively reviewed medical records of all adult patients with cancer who underwent ITP placement at a tertiary comprehensive cancer center between 2013 and 2021. Baseline characteristics, preoperative and postoperative pain control, and postoperative complication rate data were collected. A total of 193 patients were included. We found that the average Numerical Rating Scale (NRS) score decreased significantly by 4.08 points (SD = 2.13, P < .01), from an average NRS of 7.38 (SD = 1.64) to an average NRS of 3.27 (SD = 1.66). Of 185 patients with preoperative and follow-up NRS pain scores, all but 9 experienced a decrease in NRS (95.1%). The median overall survival from time of pump placement was 3.62 months (95% CI: 2.73-4.54). A total of 42 adverse events in 33 patients were reported during the study period. The 1-year cumulative incidence of any complication was 15.6% (95% CI: 10.9%-21.1%) and for severe complication was 5.7% (95% CI: 3.0%-9.7%). Eleven patients required reoperation during the study period, with a 1-year cumulative incidence of 4.2% (95% CI: 2.0%-7.7%). Our study demonstrates that ITP implantation for the treatment of cancer-related pain is a safe and effective method of pain palliation with a low complication rate. Future prospective studies are required to determine the optimal timing of ITP implantation.

A contemporary systematic review of penile lengthening procedures with penile prosthesis.

Penile prosthetic devices are the standard treatment for erectile dysfunction (ED) after failure of maximum medical therapy and conservative options. Several penile lengthening procedures (PLPs) can be performed concurrently with penile prosthesis (PP) insertion in patients with severe ED, penile shortening, and/or Peyronie's disease to help combat negative emotional and psychological concerns from penile length loss with penile prosthetic device placement. An extensive, systematic literature review of the various pre-, intra-, and post-operative techniques that can be applied to preserve, restore or enhance penile length at the time of penile prosthetic implantation. Numerous pre-operative and post-operative inflation protocols exists with vacuum erection devices and penile traction therapy. Intraoperative surgical techniques include cavernosal sparing and channeling without dilatation, subcoronal incision with circumferential penile degloving and grafting, the sliding technique, the modified sliding technique, the multiple-slit technique, the tunical expansion procedure (TEP), modified TEP, and the auxetic expansion procedure. These approaches can be meaningful to restore and/or preserve length for patients undergoing PP insertion. PLPs can be performed by surgeons who have extensive penile reconstruction experience and have been trained to do these procedures, as there is significant risk to the patient and limitations to what can be expected. Each patient must be counseled in detail about the risks and benefits of these procedures and have their expectations managed as the average postoperative penile length recovery is around 3 cm and can range from 0-4.0 cm. Future research is needed to identify the appropriate candidate for each approach, and how much length gain the patient can expect.

The resolute Onyx in TIA management (ROTIA).

First-line treatment for symptomatic intracranial atherosclerotic disease (ICAD) is medical management; however, interventional approaches are increasingly considered for refractory disease. The Resolute Onyx in TIA management (ROTIA) study is a post-market evaluation of the Resolute Onyx (R-Onyx) drug-eluting stent in the treatment of recurrent transient ischemic attacks (TIAs) due to refractory ICAD (off-label use). This is a single-center, retrospective case series of consecutive patients who underwent angioplasty and stenting with R-Onyx for treatment of recurrent TIAs due to refractory ICAD from October 2019 to November 2022. Included patients were ages 22-80, had a baseline modified Rankin Scale of ≤2, and had recurrent TIAs attributed to intracranial artery stenosis >70% despite maximal medical therapy. Primary outcomes of interest were peri-procedural complications (TIA, stroke, intracranial hemorrhage, mortality) up to 72 h post-stenting and ischemic stroke up to 18 months post-stenting. Twenty patients (mean age 66.84 ± 14; 25% female; 80% Hispanic) were included. A total of 21 stents were successfully deployed with no peri-procedural complications. There were no recurrent ischemic events at 30 days post-stenting. At 18 months post-stenting, there were no ischemic events and no patient exhibited in-stent restenosis. ROTIA demonstrates the feasibility of using the Resolute Onyx drug-eluting stent for the management of TIAs due to refractory ICAD, with high technical success and low peri-procedural complications. Limitations include the retrospective and single-center nature of this study. Future prospective, multi-center, randomized trials with extended observation periods are needed.

The association of serum immunoglobulin E levels on outcomes of maximal medical therapy among patients of chronic rhinosinusitis

The association of serum immunoglobulin E levels on outcomes of maximal medical therapy among patients of chronic rhinosinusitis

Glaucoma secondary to cosmetic iris implants in congenital iris coloboma

Introduction: To report a case of angle closure and corneal decompensation requiring surgical intervention secondary to BrightOcular cosmetic iris implantation in a patient with a history of congenital bilateral iris coloboma. Patient and Clinical Findings: A 40-year-old male patient with a history of bilateral congenital coloboma presented to the emergency department with reduced visual acuity to count fingers and moderate pain in the left eye 4 months after bilateral BrightOcular iris implant surgery in Mexico. Intraocular pressure (IOP) was 70 mm Hg with little response to maximal medical therapy. Gonioscopy revealed dense pigment obstructing angle inferiorly. Diagnosis, Interventions, and Outcomes: The patient was diagnosed with angle closure, pigment dispersion syndrome, and corneal decompensation secondary to bilateral cosmetic iris implants. IOP stabilized after emergency Ahmed valve and Baerveldt shunt placement. Corneal decompensation addressed first with endothelial keratoplasty, however ultimately failed leading to penetrating keratoplasty in the left eye. Fellow eye required glaucoma shunt placement 4 years after initial presentation due to persistent glaucoma not controlled with laser and medical therapy. Conclusions: The use of iris implants for cosmetic reasons can have serious ocular morbidity in patients with iris coloboma. Close monitoring and explantation should be strongly recommended at the earliest sign of complication.

Case Report: Temporary management of delayed postoperative hypotony with Baerveldt tube: Ab Interno stenting using 3-0 nylon suture

Background To describe the management of delayed postoperative hypotony and choroidal detachment in a 79-year-old female patient with advanced pseudoexfoliative open-angle glaucoma. Case The patient, refractory to maximal medical therapy, underwent Baerveldt tube implantation with a ripcord using a 4-0 nylon suture. Ripcord removal and the reintroduction of antiglaucoma medication were initiated in response to a hypertensive phase. Delayed postoperative hypotony and choroidal effusions were managed through ab interno stenting of the tube, employing a 3-0 nylon suture. Ab interno stenting of the tube, employing a short segment of 3-0 nylon suture, initially addressed delayed postoperative hypotony and choroidal effusions. However, recurrence of hypotony and choroidal detachment occurred as the short stent descended into the anterior chamber. To manage the recurrent hypotony, Baerveldt tube truncation was performed, along with re-stenting of the tube using a longer 3-0 Nylon ripcord. Conclusions While ab interno occlusion with a short segment of 3-0 nylon suture may offer temporary hypotony control, the risk of segment descent warranted the use of a longer ripcord to enhance efficacy and stability.

The Role of Coronary Physiology Assessment in the Diagnosis and Treatment of Stable Angina. Dive Inside Recent Findings of Diffuse Coronary Disease Treatment.

Coronary physiology is widely used to assess epicardial coronary lesions in patients with stable angina. Based on the available evidence, physiology plays a crucial role in diagnosing and treating patients. There have been invasive methods for determining cardiac physiology, such as fractional flow reserve and instantaneous wave-free ratio. Still, new non-invasive approaches provide extra anatomical information, such as fractional flow reserve computed tomography (FFR-CT) based on computed tomography and physiology based on angiography. Even though FFR-guided percutaneous coronary intervention (PCI) is clinically beneficial, one-third of patients retain suboptimal FFR after the procedure, associated with severe adverse events, rendering PCI in diffuse coronary artery disease questionable. Using the pullback pressure gradient (PPG), we can analyze the magnitude and extent of pressure losses; a lower value may indicate diffuse disease, while a high value with an abrupt curve may indicate focal disease. Since PCI is not the best option for treating diffuse coronary disease, current strategies focus on conservatively using medical therapy or bypass surgery. It has been demonstrated that patients with diffuse disease of the left anterior descending (LAD) are at a greater risk of developing occlusion of the left internal mammary artery graft than those with focal disease and that maximal medical therapy may be the most effective treatment for these patients.

Gonioscopy-Assisted Transluminal Trabeculotomy in Uveitis-Related Ocular Hypertension and Glaucoma.

Gonioscopy-assisted transluminal trabeculotomy (GATT) may be an effective first-line surgery for decreasing intraocular pressure (IOP) and medication burden in patients with uveitis-related ocular hypertension (OHT) or glaucoma. The purpose of the study is to determine the efficacy of GATT in lowering IOP in uveitis-related OHT or glaucoma. Retrospective case series that included patients with uveitis-related OHT or glaucoma who underwent GATT with or without concomitant cataract extraction and intraocular lens implantation at 2 Canadian academic centres from July 2018 to May 2022. Primary outcomes were: complete (no medications) and qualified success (with medication), and failure defined as (1) IOP >21 mm Hg with maximal medical therapy, (2) the need for additional glaucoma procedure, (3) loss of light perception secondary to glaucoma, and (4) IOP <6 mm Hg for 3 months. Twenty-one eyes from 18 patients were included with a mean preoperative IOP of 26.2 ± 7.3 mm Hg on 4.3 ± 0.7 classes of glaucoma drops. The average follow-up was 29.2 ± 17.6 months and 76% of eyes (n = 16) had reached at least 12 months of follow-up. At the 12-month follow-up visit, there was a significant decrease in average IOP by 9.9 ± 7.9 mm Hg (38%, P = 0.005) and a decrease of 1.9 in glaucoma medication classes ( P = 0.002). Of eyes, 14% achieved complete success, whereas 80% of eyes achieved qualified success. Six eyes failed (29%) and 5 patients (24%) required additional glaucoma surgery. The most common postoperative complication was hyphema (n = 9; 43%). This small case series suggests that GATT may be an effective first-line surgery for decreasing IOP and medication burden in patients with uveitis-related OHT or glaucoma. Further studies with longer follow-ups should be conducted to assess its long-term outcomes.

Predictors of Success of Adenoidectomy in the Treatment of Pediatric Chronic Rhinosinusitis.

Objectives: There is consensus for adenoidectomy as treatment of chronic rhinosinusitis (CRS) in children younger than 6 years but less consensus for those aged 6 years and older. The present clinical research study investigated predictors of adenoidectomy success for pediatric CRS. Methods: A retrospective chart review was conducted for 107 children who presented to an otolaryngology clinic and had an adenoidectomy for CRS after failure of maximal medical therapy. Results: The majority of sample was male (N = 63; 58.9%) with mean age of 4.88 (SD = 2.54) and mean Lund-Mackay score of 7.76 (SD = 3.87). Patients who had success with adenoidectomy were older on average [mean (M) = 5.46; SD = 2.83] than patients who failed the procedure (M = 4.36; SD = 2.40; F = 4.06, P = .047). This equated to 67.9% of children aged 6 years and older and 39.2% of children younger than 6 years succeeding with the surgery. Conclusions: Adenoidectomy is a good first-line surgery for children aged 12 years and younger, especially in the 6 to 12 years group which had a high rate of success with 68% experiencing remission of symptoms after surgery.