Prospective Series Of Consecutive Patients Research Articles

Lateral-PLIF for spinal arthrodesis: concept, technique, results, complications, and outcomes.

Posterior lumbar interbody fusion (PLIF) surgery represents an effective option to treat degenerative conditions in the lumbar spine. To reduce the drawbacks of the classical technique, we developed a variant, so-called Lateral-PLIF, which we then evaluated through a prospective consecutive series of patients. All adult patients treated at our institute with single or double level Lateral-PLIF for lumbar degenerative disease from January to December 2017 were prospectively collected. Exclusion criteria were patients < 18years of age, traumatic patients, active infection, or malignancy, as well as unavailability of clinical and/or radiological follow-up data. The technique consists of insert the cages bilaterally through the transition zone between the central canal and the intervertebral foramen, just above the lateral recess. Pre- and postoperative (2years) questionnaires and phone interviews (4years) assessed pain and functional outcomes. Data related to the surgical procedure, postoperative complications, and radiological findings (1year) were collected. One hundred four patients were selected for the final analysis. The median age was 58years and primary symptoms were mechanical back pain (100, 96.1%) and/or radicular pain (73, 70.2%). We found a high fusion rate (95%). A statistically significant improvement in functional outcome was also noted (ODI p < 0.001, Roland-Morris score p < 0.001). Walking distance increased from 812m ± 543m to 3443m ± 712m (p < 0.001). Complications included dural tear (6.7%), infection/wound dehiscence (4.8%), and instrument failure (1.9%) but no neurological deterioration. Lateral-PLIF is a safe and effective technique for lumbar interbody fusion and may be considered for further comparative study validation with other techniques before extensive use to treat lumbar degenerative disease.

Patient-Reported Outcomes Improve after Hypothenar Fat Flap for the Treatment of Recurrent Carpal Tunnel Syndrome.

Background: Recalcitrant carpal tunnel syndrome (CTS) can present with persistent or recurrent symptoms after carpal tunnel release (CTR). A common aetiology for recurrent CTS is the development of perineural adhesions due to excess scarring. The hypothenar fat pad flap (HFPF) has been described to decrease the amount of scarring formed after revision CTR. Herein, we present a prospective evaluation of these patients. Methods: A prospective series of consecutive patients by a single surgeon with recurrent CTS was conducted. All patients had at least 3 months follow-up. Patients received a revision open CTR with HFPF. The primary outcome was the Boston Carpal Tunnel Questionnaire (BCTQ). Secondary outcomes included pain and satisfaction on visual analogue scale, range of motion, grip strength, patient-reported outcomes and complications. Clinical outcomes were compared between preoperative and postoperative intervals using paired t-tests, with significance defined as p < 0.05. Results: Fifteen wrists (14 patients) were recruited for the study. Patients were predominantly male (n=9; 66%). Revision open CTR with HFPF was performed a median of 42 months (range: 4-300 months) post primary CTR. Patients demonstrated improved patient-reported outcomes with significantly improved BCTQ pain score (p<0.01), Patient-Rated Wrist and Hand Evaluation (p<0.01) and QuickDASH (p<0.001). Two patients in the series reported postoperative complications; however, there was no incidence of donor site morbidity recorded. Conclusions: Revision open CTR with hypothenar fat pad flap is associated with decreased pain, high patient satisfaction and improved functional measures compared to pre-operative status. Level of Evidence: Level IV (Therapeutic).

Plasma and Urine Free Glycosaminoglycans as Monitoring Biomarkers in Nonmetastatic Renal Cell Carcinoma—A Prospective Cohort Study

BackgroundNo liquid biomarkers are approved in renal cell carcinoma (RCC), making early detection of recurrence in surgically treated nonmetastatic (M0) patients dependent on radiological imaging. Urine- and plasma free glycosaminoglycan profiles—or free GAGomes—are promising biomarkers reflective of RCC metabolism. ObjectiveTo explore whether free GAGomes could detect M0 RCC recurrence noninvasively. Design, setting, and participantsBetween June 2016 and February 2021, we enrolled a prospective consecutive series of patients elected for (1) partial or radical nephrectomy for clinical M0 RCC (cohort 1) or (2) first-line therapy following RCC metachronous metastatic recurrence (cohort 2) at Sahlgrenska University Hospital, Gothenburg, Sweden. The study population included M0 RCC patients with recurrent disease (RD) versus no evidence of disease (NED) in at least one follow-up visit. Plasma and urine free GAGomes—consisting of 40 chondroitin sulfate (CS), heparan sulfate, and hyaluronic acid (HA) features—were measured in a blinded central laboratory preoperatively and at each postoperative follow-up visit until recurrence or end of follow-up in cohort 1, or before treatment start in cohort 2. Outcome measurements and statistical analysisWe used Bayesian logistic regression to correlate GAGome features with RD versus NED and with various histopathological variables. We developed three recurrence scores (plasma, urine, and combined) proportional to the predicted probability of RD. We internally validated the area under the curve (AUC) using bootstrap resampling. We performed a decision curve analysis to select a cutoff and report the corresponding net benefit, sensitivity, and specificity of each score. We used univariable analyses to correlate each preoperative score with recurrence-free survival (RFS). Results and limitationsOf 127 enrolled patients in total, 62 M0 RCC patients were in the study population (median age: 63 year, 35% female, and 82% clear cell). The median follow-up time was 3 months, totaling 72 postoperative visits —17 RD and 55 NED cases. RD was compatible with alterations in 14 (52%) of the detectable GAGome features, mostly free CS. Eleven (79%) of these correlated with at least one histopathological variable. We developed a plasma, a urine, and a combined free CS RCC recurrence score to diagnose RD versus NED with AUCs 0.91, 0.93, and 0.94, respectively. At a cutoff equivalent to ≥30% predicted probability of RD, the sensitivity and specificity were, respectively, 69% and 84% in plasma, 81% and 80% in urine, and 80% and 82% when combined, and the net benefit was equivalent to finding an extra ten, 13, and 12 cases of RD per hundred patients without any unnecessary imaging for plasma, urine, and combined, respectively. The combined score was prognostic of RFS in univariable analysis (hazard ratio = 1.90, p = 0.02). Limitations include a lack of external validation. ConclusionsFree CS scores detected postsurgical recurrence noninvasively in M0 RCC with substantial net benefit. External validity is required before wider clinical implementation. Patient summaryIn this study, we examined a new noninvasive blood and urine test to detect whether renal cell carcinoma recurred after surgery.

Treatment of in-stent restenosis with sirolimus-eluting magnesium bioresorbable scaffolds: optical coherence tomography insights.

To assess the value of sirolimus-eluting magnesium bioresorbable scaffolds (MgS) in the treatment of patients with in-stent restenosis (ISR). The better option for the treatment of patients with ISR remains unsettled. Bioresorbable vascular scaffolds represent an interesting strategy in this setting to avoid another permanent metal layer. The novel MgS is an attractive option to treat these challenging patients. We present the results of the first prospective series of consecutive patients with ISR treated with MgS under optical coherence tomography (OCT) guidance. A total of 14 patients (15 lesions) were prospectively included. The mean age was 67 ± 9 years and six patients (40%) presented with an acute coronary syndrome. In 10 patients (67%), underlying neoatherosclerosis was disclosed by OCT. An excellent MgS expansion was obtained in all but two patients who showed persistent suboptimal expansion in heavily calcified vessels. Minor residual malapposition ( n = 5) and angiographically silent minor edge dissections ( n = 8) were readily recognized by OCT. After a median clinical follow-up of 30 (range, 20-54) months, no patient required repeated revascularization, suffered a myocardial infarction or device thrombosis. These preliminary results suggest a potential role for the MgS in selected patients presenting with ISR.

Intraoperative Computed Tomography–Assisted Spinal Navigation in Dorsal Cervical Instrumentation: A Prospective Study on Accuracy Regarding Different Pathologies and Screw Types

Intraoperative computed tomography (iCT) navigated dorsal instrumentation has been successfully introduced as a new clinical standard. The proximity of vital anatomic structures makes cervical spine instrumentation an especially delicate task. Therefore, navigated approaches might prove to be beneficial. In this study, the accuracy of conventional instrumentation was compared with iCT navigated dorsal cervical spine instrumentation with focus on cervical pedicle screws (CPSs) versus lateral mass screws (LMSs) and pathologies. We analyzed a prospective consecutive series of patients undergoing cervical dorsal instrumentation with iCT and spinal navigation and retrospectively analyzed a cohort that received conventional cervical instrumentation with C-arm fluoroscopy (control group). Accuracy was assessed with a modified Gertzbein-Robbins classification. Underlying pathologies were taken into account regarding accuracy in different entities. Fifty-nine patients were treated using iCT (357 screws: 238 CPSs, 119 LMSs), and 98 patients underwent conventional instrumentation (632 screws: 69 CPSs, 563 LMSs). We achieved an initial accuracy of 93.28% (n= 220 screws) in the iCT group and 80.9% (n= 511 screws) in the control group (P < 0.001). Significant differences were found regarding the accuracy of CPS placement in cases of degenerative disorders (iCT vs. control; 94% vs. 63%; P < 0.001) and trauma (iCT vs. control; 88% vs. 72%; P < 0.05). iCT yielded favorable precision rates in regard to LMS placement (iCT vs. control; 94.2% vs. 82%; P < 0.05). Accuracy of iCT navigated instrumentation was significantly higher than conventional instrumentation. An overall tendency toward the use of CPSs with iCT navigation is evident, increasing the mechanical properties of the construct. iCT appears to be especially beneficial in elective surgery cases of degenerative spinal disorders.

Oesophageal cancer in Area 2 of Kwazulu-Natal: predictors of late presentation

There are limited prospective data sets on clinical characteristics, stage of presentation and treatment of patients with Oesophageal Squamous Cell Carcinoma (OSCC) in South Africa. This study aimed to assess the frequency and severity of clinical characteristics associated with late presentation of patients with OSCC presenting to a cancer referral centre in KwaZulu-Natal, South Africa. A prospective consecutive series of patients presenting with confirmed OSCC treated at Greys Hospital in 2016/2017 were enrolled. Data collected included: age, gender, home language, referral centre, clinical and laboratory characteristics: dysphagia score, Eastern Cooperative Oncology Group (ECOG) performance status, body mass index (BMI), serum albumin, tumour pathology and treatment administered. One hundred patients were analysed. Ninety four percent spoke isiZulu. The mean age was 61 with a male to female ratio of 1.5:1 Ninety percent had palliative treatment as their overall assessment precluded curative treatment. Five patients underwent curative treatment. The age standardised incidence (ASR) was 25.2 per 100 000. The factors associated with late presentation and their frequency were: advanced dysphagia grade ( </=2 in 68%), malnutrition (BMI <18.5kg/m2 in 49%), hypoalbuminaemia (serum albumin < 35 g/l in 70%), poor performance status (ECOG</=2 in 50% ) and moderate to poor tumour differentiation in 95% of patients. OSCC in Kwazulu-Natal has double the ASR of South Africa and places a significant burden on the region's health care system. Factors associated with late presentation occur in the majority and alone or in combination preclude curative therapies. The frequency of these factors serve as a benchmark for comparison, and reduction in their frequency may indicate effectiveness of interventions designed to improve awareness and access to proper care.

Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control

BackgroundThe enhanced recovery program for perioperative care of the surgical patient reduces postoperative metabolic response and organ dysfunction, accelerating functional recovery. The aim of this study was to determine the impact on postoperative recovery and cost-effectiveness of implementing a colorectal enhanced recovery program in an Italian academic centre. Materials and methodsA prospective series of consecutive patients (N = 100) undergoing elective colorectal resection completing a standardized enhanced recovery program in 2013–2015 (ERP group) was compared to patients (N = 100) operated at the same institution in 2010–2011 (Pre-ERP group) before introducing the program. The exclusion criteria were: >80 years old, ASA score of IV, a stage IV TNM, and diagnosis of inflammatory bowel disease. The primary outcome was hospital length of stay which was used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, 30-day readmission and mortality, protocol adherence, nursing workload, cost-effectiveness, and factors predicting prolonged hospital stay. The ERP group patient satisfaction was also evaluated. ResultsHospital stay was significantly reduced in the ERP versus the Pre-ERP group (4 versus 8 days) as well as nursing workload, with no increase in postoperative complications, 30-day readmission or mortality. ERP group protocol adherence (81%) and patient satisfaction were high. Conventional perioperative protocol was the only independent predictor of prolonged hospital stay. Total mean direct costs per patient were significantly higher in the Pre-ERP versus the ERP group (6796.76 versus 5339.05 euros). ConclusionsImplementing a colorectal enhanced recovery program is feasible, efficient for functional recovery and hospital stay reduction, safe, and cost-effective. High patient satisfaction and nursing workload reduction may also be expected, but high protocol adherence is necessary.

Bowel occult microscopic endometriosis in resection margins in deep colorectal endometriosis specimens has no impact on short-term postoperative outcomes

To evaluate the impact of bowel occult microscopic endometriosis (BOME) implants on postoperative outcomes in patients treated with colorectal resection for deep infiltrating digestive endometriosis. Prospective series of consecutive patients with deep colorectal endometriosis managed by colorectal resection in our department from June 2009 to November 2014 and enrolled in the CIRENDO database (NCT02294825). University tertiary referral center. One hundred three patients managed by colorectal resection for deep infiltrating endometriosis. Histologic examination of colorectal resection specimens. Patient characteristics, preoperative and 1-year postoperative symptoms and intraoperative findings were compared between women with and without BOME on specimen resection margins. In 15 cases, BOME was found in one (nine cases) or both resection limits (six cases). No statistical significance was found between BOME and height of colorectal anastomosis, length of the resected bowel specimen or depth of rectal wall infiltration. One patient with BOME underwent a second colorectal resection 5 years later for rectal recurrence. Comparison between the rates of dyschezia, diarrhea, constipation, bloating and overall values of GIQLI and KESS scores 1 and 3 years postoperatively showed no statistical significance between women with and without BOME. BOME was found in 14.6% of specimen resection margins. No impact on either pelvic or digestive symptoms was observed after 1-year follow-up postoperatively. NCT02294825.

Total Anatomical Reconstruction During Robot-assisted Radical Prostatectomy: Implications on Early Recovery of Urinary Continence

BackgroundThe introduction of robotics revolutionized prostate cancer surgery because the magnified three-dimensional vision system and wristed instruments allow microsurgery to be performed. The advantages of robotic surgery could lead to improved continence outcomes in terms of early recovery compared with the traditional surgical methods. ObjectiveTo describe the total anatomical reconstruction (TAR) technique during robot-assisted radical prostatectomy (RARP). Primary endpoint: evaluation of the continence rate at different time points. Secondary endpoint: evaluation of urine leakage and anastomosis stenosis rates related to the technique. Design, setting, and participantsJune, 2013 to November, 2014; prospective consecutive series of patients with localized prostate cancer (cT1-3, cN0, cM0). Surgical procedureRARP with TAR was performed in all cases. Lymph node dissection was performed if the risk of lymph nodal metastasis was over 5%, according to the Briganti updated nomogram. MeasurementsPreoperative, intraoperative, postoperative, and pathological variables were analyzed. Enrolled patients were arbitrarily divided into three groups according to a time criterion. The relationships between the learning curve and the trend of the above-mentioned variables were analyzed using LOESS analysis. Continence was rigorously analyzed preoperatively and at 24h, 1 wk, 4 wk, 12 wk, and 24 wk after catheter removal. Results and limitationsIn total, 252 patients were analyzed. The continence rates immediately after catheter removal and at 1 wk, 4 wk, 12 wk, and 24 wk after RARP were 71.8%, 77.8%, 89.3%, 94.4%, and 98.0%, respectively. Multivariate analysis revealed that the nerve sparing technique, D’Amico risk groups, lymph node dissection, and prostate volume were involved in the early recovery of urinary continence. One ileal perforation requiring reoperation was recorded. The transfusion rate was 0.8%. Thirty-one (12.3%) postoperative complications were recorded up to 6 mo after surgery. Among these, eight acute urinary retentions (3.2%) and three urine leakages (1.2%) were recorded. There was a lack of randomization and comparison with other techniques. Both anatomical dissection of the prostatic apex and TAR were used. The results may not be generalized to low-volume centers. ConclusionsThe TAR technique showed promising results in the early recovery of urinary continence, as well as watertight anastomosis and a low rate of urine leakage. The oncologic results were not affected. Comparative studies are needed to support the quality of reported results. Patient summaryOn the basis of our findings, it seems that the risk of urinary incontinence following radical prostatectomy can be lowered via meticulous anatomical reconstruction using a robotic system. Comparative studies are required to support the reported results.

Colorectal Endometriosis Responsible for Bowel Occlusion or Subocclusion in Women With Pregnancy Intention: Is the Policy of Primary in Vitro Fertilization Always Safe?

To discuss the risk of bowel occlusion or subocclusion in patients with pregnancy wish and deep colorectal endometriosis, when surgery is postponed until after conception. A prospective series of consecutive patients managed for occlusion or subocclusion between January 2012 and January 2015 (Canadian Task Force classification II-2). Deep endometriosis had previously been diagnosed in all patients; however, they were advised to postpone surgery until after conception. University tertiary referral center. Twelve women with bowel occlusion or subocclusion due to deep endometriosis and desiring pregnancy. Surgical management including colorectal resection. Digestive symptoms, including standardized gastrointestinal questionnaires and preoperative imaging assessment of deep endometriosis. The patients enrolled in the series represent 5% of 241 patients with colorectal endometriosis managed over 37 consecutive months. Major digestive complaints were bloating, defecation pain, constipation, liquid stools, and a feeling of incomplete stool evacuation. The median length of digestive tract stenosis was 50 mm (range, 20-100 mm). In 8 patients (67%), computed tomography-based virtual colonoscopy revealed a virtual digestive lumen. The median length of colorectal specimen removed was 120 mm (range, 60-200 mm). Three patients (25%) had Clavien-Dindo IIIb and IVa postoperative complications with favorable outcomes within up to 20 days after surgery. Given the risk of bowel occlusion or subocclusion in young patients with colorectal endometriosis, an exhaustive assessment of deep disease and advice at a tertiary referral center appears to be mandatory before prioritizing primary invitro fertilization instead of primary surgery.

ROL DEL COLGAJO PERFORANTE PEDICULADO EN HÉLICE (PROPELLER FLAP) EN RECONSTRUCCIÓN POST TRAUMÁTICA DE EXTREMIDADES

abstract Propeller flap in post-traumatic lower limb defects aim: To describe indications and results obtained in distal lower leg post traumatic reconstruction using pediculated perforator propeller flap. Patients and methods: Prospective series of consecutive patients treated with propeller flaps between March 2011 and March 2014. Patient’s characteristics, defects and flaps characteristics and post operative complications were recorded. Descriptive statistical methods were used in this study. results: Eight patients were included with a median age of 40 years. The injuries were caused by degloving (one case) and fractures (seven cases), including four calcaneal fractures, two open tibial fractures and one ankle fracture. Three cases were reconstructed with posterior tibial artery pedicled perforator flaps, and five cases with peroneal artery perforator flaps. The median average area of the flaps was 55.8 cm 2 (range 40-117.8 cm 2 ). Coverage was achieved in all cases. no total flap necrosis was reported.

Recurrences and fertility after endometrioma ablation in women with and without colorectal endometriosis: a prospective cohort study.

What are the recurrence and pregnancy rates in women managed for ovarian endometrioma by ablation using plasma energy with and without associated surgery for colorectal endometriosis? Concomitant management of colorectal endometriosis does not impact either risk of recurrences or probability of pregnancy in women managed for endometrioma ablation using plasma energy. No consensus exists on how best to manage patients presenting with ovarian endometriomas and colorectal endometriosis, in terms of impact on fertility preservation and recurrence rates. A prospective series of consecutive patients managed for ovarian endometriomas by ablation using plasma energy, over a period of 48 consecutive months. The study included patients with associated colorectal endometriosis (n = 52) and those who were free of colorectal localizations of the disease (n = 72). No women were lost to follow-up. The 124 women included in this study were managed for either unilateral or bilateral ovarian endometriomas using plasma energy at a university tertiary care center. Recurrences and pregnancy rate were compared in patients with and without colorectal endometriosis. The minimum length of follow-up was 1 year. Cyst recurrences were assessed using pelvic ultrasound and magnetic resonance imaging. Kaplan-Meier and actuarial life-table analysis were used to estimate the recurrence-free survival curve and the probability of pregnancy. The Cox model was used to assess independent predictive factors for recurrences. Pregnancy likelihood and independent predictors were estimated using a regression logistic model. Mean follow-up was 32 ± 18 months. Forty-eight patients (40.3%) were presumed infertile and attended an assisted reproductive techniques (ART) center. Eighteen patients presented with a recurrence (14.5%). Bilateral localization of endometriomas was the only factor independently related to an increased risk of recurrences [hazard ratio 3.3, 95% confidence interval (CI) 1.2-9.4]. Of the 83 women wishing to conceive (66.9%), 51 became pregnant (61.4%) and 33 of these pregnancies were spontaneous (64.7%). The rates of pregnancy were 65.8% for the group of patients with associated colorectal endometriosis and 57.8% for controls (P = 0.50). Age over 35 years was the only independent factor for which association with pregnancy rates approached the significance threshold (adjusted odds ratio 0.35, 95% CI 0.12-1, P = 0.06). The study sample size may be insufficient to reveal statistically significant differences related to risk factors which have low impact on the probability of recurrence and pregnancy. Data on ovarian reserve before and after the procedure was not available in all patients, which would have added to our results and the discussion about treatment of endometrioma in general. Concomitant management of colorectal endometriosis does not impact either risk of recurrences or the probability of pregnancy in women having benefited from ovarian endometrioma ablation using plasma energy. Moreover, surgical management of colorectal and ovarian endometriosis may allow spontaneous conception in one out of three patients, thus reducing expenses related to ART management. No financial support was received for this study. Horace Roman reports personal fees for participating in a symposium and masterclass presenting his experience in the use of PlasmaJet.

Abstract 17544: Reproducibility Between Online and Offline Analysis of Qualitative Optical Coherence Tomography Results After Stenting in non-ST Elevation Acute Coronary Syndromes

Introduction &amp; Hypothesis: We evaluated reproducibility between online and offline analysis of optical coherence tomography (OCT) results of angioplasty with stent implantation in non-ST elevation acute coronary syndromes (NSTEACS). Methods: In a prospective series of consecutive patients undergoing angioplasty of a single lesion responsible for NSTEACS (symptom onset &lt;48 h) with use of OCT to optimise procedural result, we compared presence of thrombus or tissue protrusion, residual dissection, stent malapposition, stent under-expansion, complete coverage of the lesion and side branches by the stent, as assessed online by the operator, versus results of offline analysis by two independent observers. Stent underexpansion was defined as a ratio of in-stent minimal lumen area (MLA) to average reference MLA &lt;80%. Other definitions were based on available consensus documents. Agreement was calculated using the Kappa coefficient with 95% confidence interval (CI). Results: 31 procedures were analyzed. Mean age was 65.7±8 years; 24 (77%) were men. Lesions were situated on the left anterior descending (n=14), right coronary (n=10) or circumflex artery (n=7). Results are shown in the table. Conclusion: There is good agreement between online and offline analysis for stent malapposition, and coverage of the lesion and side branches by the stent. Conversely, presence of thrombus and/or tissue protrusion, and residual dissection is under-estimated during online evaluation.

Alterations in intraocular pressure and ocular axial length after intravitreal Anti-VEGF injection

Objective: To evaluate the effect of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection on intraocular pressure (IOP) and ocular axial length (AL). Methods: A prospective series of consecutive patients undergoing injection of intravitreal bevacizumab or ranibizumab in our clinic was investigated. IOP was measured with Tono-Pen and ocular AL with ultrasound biometry before (IOP0, AL0) and about 1 min (IOP1, AL1) and 24 hours (IOP2, AL2) after intravitreal injection. Logistic regression analysis was used to investigate factors (lens status, presence of glaucoma and previous intravitreal injection) associated with increased IOP and AL. Results: We recruited 96 patients with a mean age of 66.7±12 years, 53 (55%) men and 43 (45%) women. One minute after the injection (IOP1), mean IOP increased from 15.2±3.5 mmHg (IOP0) to 22.2±8.6 mmHg (p<0.001). 24 hours after the injection, IOP decreased a mean level of 14.7±3.6 mmHg (IOP0 vs. IOP2, p˃0.05). Mean AL0, AL1 and AL2 values were 23.1± 0.82 mm, 23.25± 0.81 mm and 23± 0.8 mm, respectively. AL elongation was statistically significant just after injection (AL0 vs. AL1, p˂0.001). 24 hours after AL values were dropped below the baseline values (AL0 vs. AL2 p=0.04). Regression analysis showed a trend towards pseudophakic patients having higher IOP and AL at one minute. It was also observed that having previous intravitreal injections cause higher IOP elevation. Conclusion: Intravitreal anti-VEGF injections may lead a transient IOP elevation and AL elongation. Clinicians should consider checking IOP after intravitreal injections as a precaution. Further investigations are required to understand biometric changes after intravitreal injections.

Cerebral arterial fenestrations: a common phenomenon in unexplained subarachnoid haemorrhage

Fenestrations of intracranial arteries are variants resulting from incomplete fusion of vessels during development with unknown clinical significance. They are best visualised with 3D rotational angiography (3DRA). In a prospective consecutive series of patients with suspected aneurysms, 3DRA was performed to identify not only the potential bleeding source but also to assess the frequency and location of any fenestrations of intracranial arteries. In 287 consecutive patients with possible intracranial aneurysms (accidental discovery or previous history of SAH), 3DRAs were prospectively performed, and the location of subarachnoid haemorrhage was assessed by CT. Of 174 patients presenting with SAH, 153 had saccular aneurysms, and in 21 cases (12.1%), no source of bleeding was found. In 20 of these 21 patients with "unexplained SAH" (95.2%) an arterial fenestration was detected in the neighbourhood of the clot. The incidence of fenestration in the 153 aneurysmal SAH patients was 22.9%, and it was 23.3% in 266 patients with intracranial aneurysms (113 accidental and 153 ruptured). Arterial fenestration was detected in 22.9% of ruptured cerebral aneurysms, in contrast with 95.2% in patients with unexplained SAH, the difference being statisctically significant (p < 0.01). Fenestration is a developmental defect, a structural wall weakness possibly making the vessel prone to rupture. Its incidence of nearly 100% may suggest a connection with idiopathic SAH. The presented data indicate that arterial fenestrations are generally overlooked, and they can be considered as one of the candidates for the source of idiopathic SAH.

Spontaneous Coronary Artery Dissection: Long-Term Follow-Up of a Large Series of Patients Prospectively Managed With a “Conservative” Therapeutic Strategy

This study sought to assess the long-term clinical outcome of patients with spontaneous coronary artery dissection (SCD) managed with a conservative strategy. SCD is a rare, but challenging, clinical entity. A prospective protocol, including a conservative management strategy, was followed. Revascularization was only considered in cases with ongoing/recurrent ischemia. Inflammatory/immunologic markers were systematically obtained. Forty-five consecutive patients (incidence 0.27%) were studied during a 6-year period. Of these, 27 patients (60%) had "isolated" SCD (I-SCD), and 18 had SCD associated with coronary artery disease (A-SCD). Age was 53 ± 11 years, and 26 patients were female. Most patients presented with an acute myocardial infarction. SCD had a diffuse angiographic pattern (length: 31 ± 23 mm). In 11 patients, the diagnosis was confirmed by intracoronary imaging techniques. Sixteen patients (35%) required revascularization during initial admission. One patient died after surgery, but no additional patient experienced recurrent myocardial infarction. No significant inflammatory/immunologic abnormalities were detected. At follow-up (median 730 days), only 3 patients presented with adverse events (1 died of congestive heart failure, and 2 required revascularization). No patient experienced a myocardial infarction or died suddenly. Event-free survival was similar (94% and 88%, respectively) in patients with I-SCD and A-SCD. Notably, at angiographic follow-up, spontaneous "disappearance" of the SCD image was found in 7 of 13 (54%) patients. In this large prospective series of consecutive patients with SCD, a "conservative" therapeutic strategy provided excellent long-term prognosis. Clinical outcome was similar in patients with I-SCD and A-SCD. The natural history of SCD includes spontaneous healing with complete resolution.

Bacterial wound contamination during simple and complex spinal procedures. A prospective clinical study

Spinal procedures have a potential of intraoperative contamination. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been used to diagnose postoperative infections after spinal surgery. However, it has not been demonstrated if there is an association between surgical site contamination and clinical manifestation of postoperative infection based on inflammatory markers and patients' clinical course. The purpose of this prospective study was to evaluate the association between surgical site contamination and the development of a postoperative infection in simple and complex surgical procedures. C-reactive protein and ESR levels were observed. The correlation between their values, surgical time, type of surgical procedures, and contaminated surgical sites was investigated. Prospective clinical study. The study consisted of 40 patients divided into two groups. Group A included 20 patients (mean age, 46.2 years; 12 women and 8 men) who underwent an open discectomy for a lumbar herniated disc. Group B consisted of 20 patients (mean age, 67.9 years; 11women and 9 men) who underwent a decompression and instrumented fusion for lumbar spinal stenosis. They were followed up for an average of 26.7 months (range, 11-40 months). Samples were obtained for cultures in standard time intervals during surgery. The types of bacteria cultured were evaluated, and CRP and ESR levels were measured. Simple lumbar discectomy (Group A, 20 patients) and instrumented lumbar decompression for degenerative lumbar stenosis (Group B, 20 patients) were performed in a prospective consecutive series of patients. All patients were operated by the same surgeon in the same operating room. Surgical site preparation in each patient was done by a standard manner. Samples were obtained for cultures in standard time intervals during surgery. C-reactive protein and ESR levels were measured preoperatively on the 3rd, 7th, and 21st postoperative days, and the clinical course of each patient was recorded. From 40 patients, three patients in Group A and five patients in Group B, a total of eight patients (20%) had positive cultures for bacteria. There was no statistical significance between contamination and duration of surgery in both groups. None of the patients with positive intraoperative cultures developed any clinical signs of superficial or deep postoperative spinal infection, and no additional antibiotic treatment was administered. Three patients with negative cultures developed a postoperative infection. There were no differences in CRP and ESR values between patients with contamination and noncontamination in both groups. C-reactive protein and ESR levels were significantly elevated in complex procedures (Group B) than in simple procedures (Group A). Statistical analysis of CRP and ESR values in both groups and types of bacteria cultured intraoperatively are presented. The results of this study demonstrate that intraoperative contamination can occur during simple and complex spinal procedures. In the absence of postoperative signs of infection in patients with intraoperative contamination, there is no need of continuing antibiotic treatment. Postoperative kinetics of CRP and ESR showed to be the same in patients with and without intraoperative contamination. Higher levels of inflammatory markers were noted in complex spinal procedures where instrumentation was applied.

Prone Thoracoscopic Release Does Not Adversely Affect Pulmonary Function When Added to a Posterior Spinal Fusion for Severe Spine Deformity

Prospective clinical study. To analyze the effect of adding a thoracoscopic release and fusion performed in the prone position with double lung ventilation to a posterior spinal fusion and instrumentation (PSFI) for severe idiopathic scoliosis. A prone thoracoscopic anterior release (TAR) offers the advantages of a minimally invasive approach, without requiring repositioning for the PSFI, and has significantly less acute pulmonary complications since single lung ventilation is avoided. It is unclear whether prone thoracoscopy adversely affects pulmonary function tests (PFT) when added to a PSFI for severe deformity. A prospective consecutive series of patients from a single institution undergoing spinal deformity surgery were reviewed. Those patients who underwent prone TAR followed by PSFI were compared to patients who had PSFI alone. In addition, those patients who had a thoracoplasty and PSF (PSFI-T) were compared to those who had a TAR and PSFI with T. (PFTs were measured before surgery and 1, 3, 6 weeks, 3 and 6 months, and 1 year after surgery. Forced vital capacity (FVC) and FE-1 parameters were compared to baseline levels for each patient. RESULTS.: There were 13 patients in the TAR + PSFI groups and 83 in the PSFI groups. The patients in the TAR + PSFI group had larger thoracic curves (83.2 degrees vs. 59.7 degrees ), greater correction (59.4% vs. 50.1%) (P = 0.07), and greater increase in thoracic height (16.4% vs. 6.8%) following surgery. (P < 0.05) PFTs declined more rapidly for the TAR + PSFI patients in the first 3 weeks, however, improved rapidly until 1 year when they were significantly better than the PSFI group for predicted FVC % (29.7% vs. 7.5% above baseline) and forced expiratory volume (FEV) 1% (28.5% and 8.9% above baseline). (P < 0.05) When a thoracoplasty was added to the procedure, the differences in PFTs between those who had a TAR and those who did not was not significant. The TAR + PSFI-T group had FVC % predicted of 5.3% above baseline compared to 4.3% above baseline for the PSFI-T group. The percent predicted FEV 1% was 10.4% above baseline for the TAR + PSFI-T group compared to 4.5% for the PSF-T group (P > 0.05). When performing a prone thoracoscopic release for severe thoracic deformity, excellent coronal plane correction is achieved. There does not appear to be any detrimental effect on pulmonary function when a prone thoracoscopic release using double lung ventilation is added to a PSFI. This technique can be efficacious in achieving excellent deformity correction without adversely affecting pulmonary function and is recommended when treating severe spinal deformity. Adding a thoracoplasty provided a negative effect on pulmonary function and limited the benefits of performing a thoracoscopic release to the PSFI patients.

Short-term intraocular pressure changes after intravitreal injection of bevacizumab

Background: This study examines the changes in short-term intraocular pressure (IOP) in patients receiving intravitreally administered bevacizumab. A prospective series of consecutive patients undergoing injection of intravitreal bevacizumab was investigated. Methods: All patients received bevacizumab (0.05 cc) injected intravitreally in a standard fashion. IOP was measured at baseline, 2, 5, and 30 minutes after injection by 1 of 2 observers using Goldman applanation tonometry. An intraobserver study was done to assess agreement in IOP measurements. Results: We accrued 104 patients with a mean age of 76 years: 58% were female, and 42% were male. Most patients (85%) were being treated for neovascular age-related macular degeneration. The mean IOP values at baseline, 2, 5, and 30 minutes after injection were 14.0 (95% confidence interval [C1] 13.4–14.7) mm Hg, 36.1 (95% C1 33.5–38.6) mm Hg, 25.7 (95% C1 23.8–27.5) mm Hg, and 15.5 (95% C1 12.4–16.51) mm Hg, respectively. Three patients (2.9%) had an IOP of 25 mm Hg or higher at 30 minutes. IOP normalized within 2 hours without medical therapy in 2 of these patients, and 1 patient required a 1-week course of glaucoma medication. Regression analysis showed a trend towards phakic patients having higher IOP at 30 minutes (odds ratio = 3.2; p = 0.089). Interpretation: Intravitreal injection of bevacizumab is safe with respect to short-term IOP changes, as almost all patients’ IOP returned to a safe range (<25 mm Hg) within 30 minutes. Elevated IOP at 30 minutes after injection does occur, rarely, thus clinicians should consider checking IOP after injection as a precaution.Transient extreme IOP elevations occur in a significant percentage of patients, but the consequences of these events are unknown.

Expression of p63 Differs in Peritoneal Endometriosis, Endometriomas, Adenomyosis, Rectovaginal Septum Endometriosis, and Abdominal Wall Endometriosis

Although there is evidence that endometriosis results from basal endometrium dislocation, the underlying biology is not fully understood. One protein that plays an important role in regulating epithelial proliferation and differentiation is the 63-kDa membrane protein (p63), which is also a marker of basal and reserve cells in the female genital tract. To determine whether p63 is expressed differently in peritoneal endometriosis, endometriomas, and adenomyosis, as well as in deep endometriotic nodules of the rectovaginal septum and abdominal wall. This study includes a prospective series of consecutive patients (Canadian Task Force classification II-2) from a tertiary care university hospital. Specimens collected from 83 patients (15 peritoneal endometriosis specimens, 22 endometrioma specimens, 36 adenomyosis specimens, and 10 rectovaginal septum/abdominal wall specimens) were evaluated. Diagnostic and operative laparoscopies or laparotomies were performed, and tissue samples were obtained. Immunohistochemistry was used to evaluate p63 expression. Positivity for p63 was detected in 93.3% of the peritoneal endometriosis specimens, 81.8% of the endometrioma specimens, 36.1% of the adenomyosis specimens, and none of the rectovaginal/abdominal wall endometriosis specimens (P < .001). Distribution of p63 immunostaining in the positive specimens was homogeneous. Endometriotic lesions express p63 differently, and some retain the basal/reserve cell immunophenotype. Nevertheless, it remains unclear whether the lack of p63 expression in some lesions is related to the extent of the disease, to its clinical behavior, or to exacerbation of the accompanying symptoms.