Patient Selection Research Articles

554. SHORT TERM OUTCOMES OF ESOPHAGECTOMY FROM LOW VOLUME CANCER CENTRE IN INDIA

Abstract This study evaluates short term outcomes of esophagectomy at a low volume cancer hospital in Visakhapatnam, India. Fifteen patients who underwent esophagectomy from 2020 to 2023 were analysed. The most common histology was squamous cell carcinoma. The mean age was 55 years and the majority were male. The common approaches used were open trans hiatal and transthoracic esophagectomy. The mean operative time was 9.5 hours and the mean hospital stay was 15.92 days. There were no perioperative deaths but complications included pulmonary issues, vocal cord paralysis, anastomotic leaks, chyle leaks and wound infections. Higher volume centres tend to have better outcomes after esophagectomy. However, factors other than volume like patient selection, ERAS (Enhanced Recovery After Surgery) protocols, specialized critical care and trained multidisciplinary teams also impact outcomes. At our centre, though a low volume hospital, proper patient selection, prehabilitation and a collaborative team approach helped achieve acceptable results. We recommend developing consensus on defining low and high-volume centres for esophagectomy in the Indian context, based on disease burden, resources and constraints. Overall, there is a lack of Indian data comparing outcomes between low and high-volume centres for esophagectomy.

Temporary mechanical circulatory support in infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials with 6-month follow-up

Percutaneous active mechanical circulatory support (MCS) devices are being increasingly used in the treatment of acute myocardial infarction-related cardiogenic shock (AMICS) despite conflicting evidence regarding their effect on mortality. We aimed to ascertain the effect of early routine active percutaneous MCS versus control treatment on 6-month all-cause mortality in patients with AMICS. In this individual patient data meta-analysis, randomised controlled trials of potential interest were identified, without language restriction, by querying the electronic databases MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, and Embase, as well as ClinicalTrials.gov, up to Jan 26, 2024. All randomised trials with 6-month mortality data comparing early routine active MCS (directly in the catheterisation laboratory after randomisation) versus control in patients with AMICS were included. The primary outcome was 6-month all-cause mortality in patients with AMICS treated with early routine active percutaneous MCS versus control, with a focus on device type (loading, such as venoarterial extracorporeal membrane oxygenation [VA-ECMO] vs unloading) and patient selection. Hazard ratios (HRs) of the primary outcome measure were calculated using Cox regression models. This study is registered with PROSPERO, CRD42024504295. Nine reports of randomised controlled trials (n=1114 patients) were evaluated in detail. Overall, four randomised controlled trials (n=611 patients) compared VA-ECMO with a control treatment and five randomised controlled trials (n=503 patients) compared left ventricular unloading devices with a control treatment. Two randomised controlled trials also included patients who did not have AMICS, who were excluded (55 patients [44 who were treated with VA-ECMO and 11 who were treated with a left ventricular unloading device]). The median patient age was 65 years (IQR 57-73); 845 (79·9%) of 1058 patients with data were male and 213 (20·1%) were female. No significant benefit of early unselected MCS use on 6-month mortality was noted (HR 0·87 [95% CI 0·74-1·03]; p=0·10). No significant differences were observed for left ventricular unloading devices versus control (0·80 [0·62-1·02]; p=0·075), and loading devices also had no effect on mortality (0·93 [0·75-1·17]; p=0·55). Patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality with MCS use (0·77 [0·61-0·97]; p=0·024). Major bleeding (odds ratio 2·64 [95% CI 1·91-3·65]) and vascular complications (4·43 [2·37-8·26]) were more frequent with MCS use than with control. The use of active MCS devices in patients with AMICS did not reduce 6-month mortality (regardless of the device used) and increased major bleeding and vascular complications. However, patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality after MCS use. Therefore, the use of MCS should be restricted to certain patients only. The Heart Center Leipzig at Leipzig University and the Foundation Institut für Herzinfarktforschung.

Factors Influencing Long-term Outcomes After Matrix-Induced Autologous Chondrocyte Implantation: Long-term Results at 10 Years.

Matrix-induced autologous chondrocyte implantation (MACI), the third-generation of the technique, is an established procedure for the treatment of focal cartilage defects in the knee. However, the literature lacks long-term results of MACI with good statistical power. To determine long-term survival and patient-reported outcomes (PROs) in a representative cohort and to identify patient- and surgery-related parameters that may influence long-term clinical outcomes. Case series; Level of evidence, 4. A total of 103 patients were clinically evaluated at the current follow-up of 8.1 years (range, 5-11.9 years). PRO measures (PROMs) included the Knee injury and Osteoarthritis Outcome Score (KOOS), EQ-5D, visual analog scale for pain, and Tegner Activity Scale. Magnetic resonance imaging results were evaluated by using the AMADEUS (area measurement and depth and underlying structures) and MOCART (magnetic resonance observation of cartilage repair tissue) 2.0 knee score classification systems. Potential factors influencing PROs were first identified univariately and investigated in a multivariate regression model. The defects had a mean size of 4.8 cm2 (range, 1.2-12 cm2) and were predominantly femorotibial (66%). The mean Kaplan-Meier survival rate of revision for any reason was 97.2% 6 1.6% at 10 years. In comparison to preoperative values, all PROMs were significantly improved at the current follow-up (P < .05). The MOCART 2.0 score peaked at 12 months (mean, 80.2 6 15.3 months) and showed no significant change at 96 months (mean, 76.1 ± 19.5 months; P = .142). The linear multivariate regression model identified an association of body mass index (BMI), MOCART 2.0 score, and number of previous knee surgeries with KOOS (R2 = 0.41; f2 = 0.69). Further analysis of the individual determinants revealed an optimal BMI range of 20 to 29 for favorable PROs at 96 months. Significant correlations of MOCART subscores with the overall KOOS were found for graft surface and structure, bony reaction, and subchondral detectable changes. Only 30% of patients with 2 previous surgeries and 20% of patients with 3 previous surgeries achieved a Patient Acceptable Symptom State (χ2 = 10.93; P = .012). The present study shows consistently good long-term clinical outcomes after MACI with a low revision rate and high patient satisfaction. BMI and number of previous knee surgeries may influence clinical outcomes and should be considered in patient selection and education. There is a correlation between graft structure, subchondral bone changes on magnetic resonance imaging, and long-term PROMs.

Efficacy and safety of endoscopic ultrasound-guided hepaticogastrostomy: a meta-regression analysis.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is a valid option for EUS-guided biliary drainage that has been increasingly used in the last decade. The aims of this study were to provide a systematic review with meta-analysis and meta-regression of the features and outcomes of this procedure. The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for literature pertinent to EUS-HGS. Meta-analysis of the proportions and meta-regression of potential modifiers of the main outcome measures were applied. The main outcome was technical success; secondary outcomes were clinical success and procedure-related adverse events (AEs). 33 studies, including 1644 patients, were included in the meta-analysis. Malignant biliary obstruction (MBO) was the underlying cause in almost all cases (99.6%); the main indications for EUS-HGS were duodenal/papillary invasion (34.8%), surgically altered anatomy (18.4%), and hilar stenosis (16.0%). The pooled technical success of EUS-HGS was 97.7% (95%CI 96.1%-99.0%; I 2 = 0%), the intention-to-treat clinical success rate was 88.1% (95%CI 84.7%-91.2%; I 2 = 33.9%), and procedure-related AEs occurred in 12.0% (95%CI 9.8%-14.5%; I 2 = 20.4%), with cholangitis/sepsis (2.8%) and bleeding (2.3%) the most frequent. The rate of procedure-related AEs was lower with the use of dedicated stents on univariable meta-regression analysis. Meta-regression showed that technical success and clinical success rates were modified by the centers' experience (>4/year). EUS-HGS represents an effective and safe procedure for EUS-guided biliary drainage in patients with MBO. Future studies should address the impact of center experience, patient selection, and the use of dedicated stents to improve performance of this technique.

Practical Recommendations on Laboratory Monitoring in Patients with Atopic Dermatitis on Oral JAK Inhibitors.

Oral Janus kinase inhibitors (JAKi), a class of advanced targeted systemic therapy, have demonstrated efficacy and safety in the treatment of moderate-to-severe atopic dermatitis (AD). Like other small molecules, oral JAKi have the potential for off-target effects including laboratory-related adverse events (AEs). Product labels for oral JAKi recommend an initial laboratory assessment and follow-up 4-12weeks later to monitor for potential changes, based on evidence from clinical trials across therapeutic indications for oral JAKi, which may not reflect a population of moderate-to-severe AD patients typically seen in routine clinical practice. To address this gap, a panel of eight dermatologists with clinical and research experience with oral JAKi for the management of AD conducted a targeted review of the literature focused on key laboratory-related AEs associated with oral JAKi in the moderate-to-severe AD population. Based on the synthesis of evidence and informed opinion, a set of best practice statements related to fundamental standards of care and consensus recommendations on laboratory monitoring were suggested, and level of agreement was ascertained using a Likert scale from 0 to 100. There was a high level of agreement on three of the four suggested recommendations related to assessment and monitoring of key laboratory parameters and to dose reduction or switching in response to laboratory changes; there was a lower level of agreement related to the frequency of ongoing laboratory monitoring. Appropriate patient selection and laboratory assessment is an important strategy to mitigate the potential risks associated with oral JAKi when treating AD.

“A stratified pathway to stent-free reperfusion: Selecting suitable patients in ST-elevation myocardial infarction”

BackgroundThe DANAMI-3 DEFER study demonstrated that deferring stent implantation in ST-elevation myocardial infarction (STEMI) is safe, although not superior to immediate stenting. It is possible that an individualized revascularization strategy in STEMI, achieved through appropriate patient selection, could be feasible and effective. MethodsThis prospective, non-randomized study included 198 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) between October 2019 and November 2021. Patients were assigned to either the deferred stenting (DS) group (n = 19) or the control group (C) undergoing immediate stenting (n = 179) based on a multimodal approach integrating coronary angiography, intravascular imaging, physiological assessments, and clinical judgment. The primary endpoints included all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). ResultsThe DS group showed a significantly lower rate of stent implantation (10.5 % vs. 97.7 %, p < 0.001) and a higher use of thrombus aspiration (89.5 % vs. 30.7 %, p < 0.001) and glycoprotein IIb/IIIa inhibitors (31.6 % vs. 6.7 %, p < 0.001) compared to the C group. No significant differences were observed between the groups in terms of all-cause mortality (5.3 % vs. 8.9 %, p = 0.59) or MACCE (10.5 % vs. 8.4 %, p = 0.71). ConclusionsThis study demonstrates the feasibility of implementing individualized reperfusion strategies in STEMI within a real-world clinical setting. The findings, while limited by the study design, generate valuable hypotheses that warrant further investigation to refine patient selection criteria and optimize outcomes.

Efectividad de la resonancia magnética cerebral en el diagnóstico precoz y caracterización de las demencias: revisión sistemática

IntroductionMagnetic resonance imaging (MRI) is a frequently used test in the diagnosis of dementia. The objective was to evaluate its effectiveness for the early diagnosis of dementia in patients with mild cognitive impairment (MCI). Material and methodsOriginal studies were selected from systematic reviews between 2011 and 2021, according to PRISMA 2020 criteria. QUADAS-2 and GRADE tools were used, and a meta-analysis was performed. ResultsFinal selection of 23 articles. Patient selection and index test had a high probability of bias. The certainty of the evidence was very low. In the hippocampus, sensitivity was 0.62 (95%CI 0.48-0.79) and specificity 0.70 (95%CI 0.55-0.80). In the temporal lobe, sensitivity was 0.65 (range 0.45) and specificity 0.69 (range 0.32). ConclusionsThere is insufficient evidence to recommend routine brain MRI for the early diagnosis of dementia in patients with MCI.

Omalizumab Implementation in Practice: Lessons Learned from the OUtMATCH Study

In February 2024, omalizumab was approved by the Food and Drug Administration for the treatment of food allergy, based on data from the landmark Phase 3 clinical trial “Omalizumab as Monotherapy and as Adjunct Therapy in Children and Adults (OUtMATCH).” In this Rostrum, OUtMATCH investigators share their perspectives on the trial results, the implications for translation into daily practice, and on remaining gaps in the field. The study met its primary and key secondary endpoints, demonstrating a large effect size in multi-allergen desensitization compared to placebo; yet there were some participants who did not respond, and the percentage of responders tolerating all 3 food allergens was lower than that for single foods. . Clinicians are likely to have many questions about appropriate patient selection, monitoring for treatment responsiveness, and how to manage off-label considerations such as dietary incorporation or co-treatment with oral immunotherapy. Additional research is needed to answer these remaining questions and ensure that the translation of omalizumab in real-world practice leads to high-quality outcomes.

744. LEFT THORACOABDOMINAL ESOPHAGECTOMY: ITS VALIDITY IN MODERN ESOPHAGEAL SURGERY

Abstract Background The optimal surgical approach for the treatment of esophageal and gastroesophageal junction tumors remains elusive. An open left thoracoabdominal approach may prove particularly useful in certain clinical scenarios, mainly because of its versatility and excellent exposure provided. The aim of this study is to present our experience and evaluate the early outcomes related to an open left thoracoabdominal esophagectomy (LTE). Methods A retrospective cohort study of prospectively collected data was conducted from two institutions performing esophageal surgery. Patients with distal esophageal or junctional tumors who underwent an open LTE between November 2018 and December 2023 were included. Primary outcomes were 30-day and in-hospital mortality, postoperative complications, and surrogates of oncological efficacy, including resection margin status and lymph node yield. Complications were recorded using the definitions provided by the Esophagectomy Complications Consensus Group and scored according to the Clavien-Dindo classification. Circumferential resection margin status was based on the definition used by the College of American Pathologists. Results During the study period 22 patients underwent an open LTE with a standard two-field lymphadenectomy. Eight patients (36%) suffered from postoperative complications, with pulmonary complications being the most common (7 patients; 32%). Severe complications (Clavien-Dindo ≥3) occurred in 3 patients. One patient experienced a clinical anastomotic leak. None of the patients required a reoperation or a step-up to a higher level of care. The 30-day and in-hospital mortality were zero. On histological examination, 6 patients (27%) had tumor cells at the surgical margin, most commonly the circumferential resection margin. A mean number of 27 lymph nodes were retrieved. Conclusion This small series demonstrates the applicability of an open left thoracoabdominal approach in everyday surgical practice for the treatment of distal esophageal and gastroesophageal junction tumors. Our results imply that open LTE can be implemented in select patients with acceptable morbidity and oncological efficacy.

Isotype deficiencies (IgG subclass and selective IgA, IgM, IgE deficiencies).

Background: Immunoglobulin G (IgG) subclass deficiencies and isolated IgA, IgM, IgE deficiencies have all been described in the literature with variable prevalence. Methods: These isotype deficiencies have a variable presentation from asymptomatic to recurrent infections resistant to prophylactic antibiotics. Results: Atopic disorders and autoimmune diseases are common comorbidities. IgE deficiency has been associated with impaired vaccine response and an increased risk of malignancy, particularly in patients with no allergic comorbidities and those with non-common variable immunodeficiency (CVID) humoral immunodeficiency, IgM deficiency, IgG2 deficiency, and CD4 lymphopenia. Conclusion: Close monitoring for malignancy should be strongly considered for these patients who are at risk. Treatment is variable and may include antimicrobial therapies for illnesses and prophylactic antibiotics in select patients, and immunoglobulin replacement can be considered for patients with refractory, recurrent infections.

Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients.

Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms andquality of life. As this procedure has only been performed in the United States for the past 4years, safety and efficacy have not been well established. This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data,operative intervention, 90-day complications, andresponse to treatment. Quality of life and patient satisfaction data were collected by phone survey. Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. POPE is an endoscopicprocedure that is efficacious in relieving emptying difficulties for the end-stage esophagus andgastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.

Combined Endoscopy-Laparoscopy Surgery: When and How to Utilize This Tool.

Combined endoscopic and laparoscopic surgery (CELS) has been used to resect colon polyps since the 1990s. These colon-sparing techniques, however, have not yet been widely adopted. With the evolution of technology in both diagnosing and treating colon cancer, colorectal surgeons should strive for a diverse and complete armamentarium through which they can best serve their patients. In this article, we hope to provide clarity on CELS by discussing three topics: (1) the history and fruition of CELS; (2) the techniques involved in CELS; and (3) the utility of CELS within different clinical scenarios. Our goal is to educate readers and stimulate consideration of CELS in select patients who might benefit greatly from these techniques.

Protocolo diagnóstico y terapéutico de la obesidad en el adulto

Obesity should be understood as a chronic disease that involves multiple organs. As a disease that is largely multifactorial, its causes must be studied and all complications arising from it must also be taken into account. First, a diagnosis should be made based on the medical record, body mass index (BMI), and waist circumference. This should then be followed by more precise diagnostics by specialists. New classifications, such as ABCD, should be considered and different scales should be used to predict associated risks. Objectives for control should be realistic and agreed upon with patients and therapies must be individualized. The pillars of treatment should be diet and exercise. Drug treatment or invasive techniques may be used in select patients, always taking into account the contraindications and associated side effects.

Nonoperative Management of Glenoid Baseplate Failure in Reverse Shoulder Arthroplasty

BackgroundGlenoid baseplate failure in reverse shoulder arthroplasty (RSA) remains a challenging problem. Nonoperative management may be an option in certain patients. The purpose of this study was to evaluate outcomes following nonoperative management of glenoid baseplate failure after RSA. MethodsUtilizing a single institution database, a retrospective review was performed to identify patients from 2010-2019 who sustained glenoid baseplate failures after RSA and were treated nonoperatively. Exclusion criteria included revision surgery and presence of active infection. Included patients had minimum 2 year clinical and radiographic follow-up. Chart review captured patient demographics, surgical indications and technique. Radiographs were reviewed to determine etiology of baseplate failure and other implant complications. Glenosphere inclination angle was measured on true AP radiographs immediately postoperatively and after baseplate failure. ResultsEighteen patients had glenoid baseplate failures treated nonoperatively during the study period. Five patients were deceased, leaving 13 patients who were available for clinical follow-up. Twelve (92%) patients were successfully contacted. Mean age was 77 years, BMI was 28, and 8/12 were female. Mean Charlson Comorbidity Index score was 4.1. Mean preoperative ASES score was 43.0 and VAS pain was 6.3. At mean 5.7-year follow-up, patients had an ASES score of 49.2, VAS pain of 4.3, SANE of 49% and 50% of patients were satisfied with their outcome. Preoperative and final follow-up ASES and VAS scores were similar. Average time from index surgery to baseplate failure was 19 months. Of the eighteen identified patients, 16 (89%) failures resulted in increased baseplate superior tilt (7 with concomitant broken baseplate screws). For these 16 patients, mean glenosphere inclination angle after failure (131°) was significantly greater than initial inclination angle (100°), p=0.03. The other 2 failures resulted in increased baseplate anteversion. 8/18 (44%) patients had bone grafting at the time of surgery. When comparing dissatisfied and satisfied patients, there were no specific patient characteristics or radiographic parameters that were associated with satisfaction. ConclusionNonoperative management of glenoid baseplate failure yields modest patient reported outcomes, with 50% patient satisfaction at mid-term follow-up. The mortality rate in this cohort of patients was almost 30%. Therefore, in select patients, nonoperative treatment of RSA baseplate failure may be a reasonable option.

Optimal patient and mechanical circulatory support device selection in acute myocardial infarction cardiogenic shock

Optimal patient and mechanical circulatory support device selection in acute myocardial infarction cardiogenic shock

Implementation of modified enhanced recovery after surgery (ERAS) following surgery for abdominal trauma; Assessment of feasibility and outcomes: A Randomized controlled trial (RCT)

BackgroundEnhanced recovery after surgery(ERAS) is an established protocol with improved outcomes for elective surgeries. This study aimed to assess the feasibility and outcomes in trauma patients undergoing laparotomy. Study designProspective single-centre randomized controlled trial(RCT). Patients undergoing emergency laparotomy following trauma were randomized into ERAS(early removal of catheters, early mobilization and initiation of diet, use of opioid-sparing multimodal analgesia) and conventional care groups 24 hours post-surgery. Outcome measures included length of hospitalization(LOH), recovery of bowel function, duration of removal of catheters and 30-day complications(Clavien-Dindo). ResultsFifty patients were randomized into ERAS(n=25) and conventional care(n=25) groups. Ninety-two percent of patients were young males, 58% had blunt trauma to the abdomen and the most common indication of surgery was hollow viscus injury(88%). ERAS group had a reduced median LOH(days) (6 versus 8, p=0.007), early recovery of bowel function(p=0.010) and shorter times for nasogastric tube(p=0.001), urinary catheter(p=0.007) and drain(p=0.006) removal. The complications were comparable in both groups except for deep surgical site infection[significantly lower in ERAS group(p=0.009)]. ConclusionERAS is safe and significantly reduces LOH in select trauma patients undergoing laparotomy.

Long-Term Results of Valve Sparing Aortic Root Replacement in Acute Type A Aortic Dissection

Valve preservation in acute type A aortic dissection (ATAAD) can be accomplished with root repair or replacement. Long-term valve durability with root repair has been established, but limited data exists regarding long-term durability of valve sparing root replacement (VSRR). This study compared long-term results of VSRR to root repair in ATAAD. From 2005-2023, 866 patients underwent ATAAD repair, of which 675 underwent root repair and 191 underwent root replacement (VSRR = 65, Bentall = 126). VSRR patients were compared to 123 patients who underwent valve resuspension and root repair (Root Repair) with postoperative echocardiograms ≥ 1 year. VSRR patients were younger (VSRR 44±11 vs. Root Repair 55±13 years, p<0.001). Preoperatively, 57% of VSRR and 35% of Root Repair patients had ≥ moderate aortic insufficiency. Cardiopulmonary bypass and, myocardial ischemia times were significantly longer in VSRR (p<0.001). Postoperative echocardiograms with ≥ 1 year follow-up were analyzed in 58 VSRR patients with median follow-up of 4.8 [IQR 3,12] years and in 123 Root Repair patients with median follow-up of 3.6 [IQR 3, 8] years. At 10 years, VSRR patients had superior freedom from > mild aortic insufficiency (VSRR 91% vs. Root Repair 49%, p <0.001). At 10 years, freedom from aortic valve replacement was equivalent (VSRR 98% vs. Root Repair 92%, p=0.269). VSRR provides equivalent long-term valve durability as root repair in ATAAD, even in patients with moderate or severe aortic insufficiency. In select young patients who require root replacement during ATAAD repair, VSRR represents an ideal therapy.

The roles of genetic mutation and cytokines/chemokines in immune response and their association with uveal melanoma patient outcome

The impact of tumor mutations and the interplay of cytokines and chemokines on the immune response and clinical outcomes in uveal melanoma (UM) warrants further exploration. In our study, we delved into the correlation between genetic alterations and survival rates in a cohort of 188 UM patients, utilizing data from cBioPortal. We assessed the composition of immune cell populations within 80 UM tumors by examining RNA sequence-based gene expression data from The Cancer Genome Atlas (TCGA). Furthermore, we scrutinized the relationship between genetic mutations and the expression of cytokines and chemokines, as well as their influence on various immune cell subsets. Our investigation revealed a significant association between the presence of mutated GNAQ or SF3B1 genes and improved progression-free survival (PFS), disease-specific survival (DSS), and overall survival (OS) when compared to patients with non-mutated counterparts. In contrast, the presence of immune response gene mutations was associated with a detrimental effect on PFS, DSS, and OS. We also observed that the expression levels of cytokines and chemokines were positively linked to the infiltration of immune killer cells and inversely related to the populations of B cells and dendritic cells. Elevated expression levels of PDCD1, TNF, IL6, CXCL9, and CXCL10 were found to be correlated with reduced OS. Intriguingly, an increase in CD8+ T cell populations was associated with a poorer OS, a finding that warrants further investigation. These findings underscore the potential utility of cytokines/chemokines expression levels, immune cell subsets, and mutation status as critical biomarkers for the selection of patients who are most likely to benefit from immunotherapeutic interventions. Our research provides valuable insights that could guide the development of more targeted and effective treatment strategies for UM patients.

Cleft lip and palate surgery in the Otolaryngology and Head-neck surgery department of a Medical College Hospital in Bangladesh

Background: Cleft lip and palate (CLP) are one of the most common developmental anomalies in orofacial region. CLP surgery lies in the anatomical domain of Ear Nose Throat and Head - Neck Surgery. In Bangladesh specialty of plastic surgery is still in developing stage and plastic surgeons are not easily available everywhere. ENT and Head-Neck surgeon had to take up the responsibility of some of cleft patients. This article is a retrospective analysis of a series of 200 cases of cheiloplasty and palatoplasty done in ENT and Head-Neck Surgery department of Khulna City Medical College Hospital, Bangladesh. Results were satisfactory in our, patient and parent's consideration. Objective: Our aim is to discuss the demographic profile, presentations, degree &amp; type of cleft and outcome of CLP surgery in Otolaryngology and Head-Neck Surgery department of a Medical College Hospital of Bangladesh. We will also discuss the embryology of face &amp; historical background of the cleft surgery. Materials and Methods: This is a retrospective analysis of CLP surgery for 200 cleft patients. We based on inclusion and exclusion criteria for selection of patients. Majority of cleft lip patients were operated following the Millard modified rotation advancement technique and isolated cleft palate patients were operated following Von Langenbeck bipedicle flap and Veau-Wardil-Kilner V-Y pushback technique in the ENT and Head-Neck Surgery Department of a Medical College Hospital. Patients were advised for periodic follow up. Results: Total of 200 patients of CLP were operated in our department out of which male was 92 (46%) and female was108 (54%)), male and female ratio being 1:1.08. The age range was 3 months to 40 years with a mean of 8.38 years. Pre alveolar group both male and female comprised of 134 (67%) and alveolar group 66 (33%) patients and that of isolated cleft palate 7 (10.60%) patients. Pre alveolar unilateral CLP was high. The results of surgery were satisfactory in our postoperative evaluation. Patients and parents were also satisfied with the outcome. Conclusion: Majority of CLP patients don’t suffer functional problem apart from facial disfigurement. Restoration of normal anatomy, facial appearance and function can be achieved by surgery in appropriate time and age. Few cases may be associated with feeding difficulties, dental and hearing problems. Some cases are associated with other congenital anomalies and syndromes. Those cases demand team approach of different specialty.

Direct Anterior Approach in Total Hip Arthroplasty: A Single Center Experience.

The direct anterior approach (DAA) for conducting total hip arthroplasty (THA) is gaining popularity worldwide. However, careful selection of patients and surgeon experience are important. Although promising outcomes have been reported in international studies, research on DAA in Southern and Southeast Asia has been limited. This prospective study included 157 patients who underwent THA using the DAA between January 2019 and June 2022. The patients were divided into three groups for the comparison. Data on preoperative, intraoperative, and postoperative variables were acquired. Improvement of the surgeon's performance to use of a DAA approach was examined using the CUSUM (cumulative summation method). The mean age of the patients was 43.9 years. Differences in intraoperative variables and complications were observed among the three groups, and improved outcomes were reported in later cases. Functional outcomes showed significant improvement, and no differences were observed between groups. The results of learning curve analysis indicated a shift towards consistent success after the 82nd case, reaching an acceptable rate of failure by the 118th case. The findings of this study suggest that DAA can offer benefits but there is a learning curve. Complications were initially high but began decreasing after approximately 80 cases. Careful selection of patients is critical, particularly in the effort to minimize being presented with a challenging case. This study provides insights that may be helpful to surgeons when considering DAA; however, further study is warranted.