Single Center Research Articles

Fluorescence detection of pituitary neuroendocrine tumour during endoscopic transsphenoidal surgery using bevacizumab-800CW: a non-randomised, non-blinded, single centre feasibility and dose finding trial [DEPARTURE trial

Achieving endocrine remission by gross total resection is challenging in pituitary neuroendocrine tumours (PitNETs) with cavernous sinus invasion. This study aims to assess the safety, feasibility, and optimal dose for intraoperative fluorescence imaging as an added instrument to discriminate PitNET from surrounding tissue using bevacizumab-800CW, targeting vascular endothelial growth factor A (VEGF-A). In part I, dose-escalation (0-4∙5-10-25mg) was performed in 4 groups of 3 patients with PitNETs Knosp grade 3-4. In part II, after interim analysis, the 10mg and 25mg groups were expanded to a total of 6 patients. Quantitative fluoroscence molecular endoscopy consisted of wide field fluorescence molecular endoscopy and multi-diameter single fiber reflectance / single fiber fluorescence spectroscopy. Mean fluorescence intensity (MFI) of the fresh surgical specimen was calculated and VEGF-staining was performed. Eighteen patients were included. All doses were well tolerated. Three serious adverse events were registered, but none were tracer-related. Part I showed an adequate in-vivo tumour-to-background ratio for both 10mg (TBR 2∙00 [1∙86, 2∙19]) and 25mg (TBR 2∙10, [1∙86, 2∙58]). Part II revealed a substantially higher MFI in the 25mg group. With both 10mg and 25mg a statistically significant difference between tumour and surrounding tissue was detected (p < 0∙0001). All surgical specimens had VEGF-A expression. This study demonstrates the safety and feasibility of quantitative fluorescence molecular endoscopy during PitNET surgery. Both 10mg and 25mg bevacizumab-800CW result in clear differentiation in-vivo, with improved contrast ex-vivo (MFI) in the 25mg group. NCT04212793 / Study Details| Detection of PitNET Tissue During TSS Using Bevacizumab800CW| ClinicalTrials.gov.

Antibody responses to re-immunization in recipients of allogeneic hematopoietic cell transplantation

Abstract Background Immunologic memory against vaccine-preventable diseases is often lost after an allogeneic hematopoietic cell transplant (allo-HCT), therefore recipients are required to be re-immunized after allo-HCT to regain immunity against these infections. But the response to vaccination after an allo-HCT can be highly variable and is not well understood. We performed a single center retrospective study to examine immunization practices and determine the rate of vaccine protection and seroconversion following vaccination after allo-HCT. Methods Electronic medical records (EMR) from patients ≤18 years of age who underwent allo-HCT at St. Jude Childrens’ Research Hospital between 2005 - 2021 were reviewed. Clinical information and serology results before and after completion of the immunizations series were extracted from the EMR. The vaccines included in this analysis were diphtheria, measles, mumps, rubella (MMR), varicella, and polio. Protection was evaluated only for infections with established immune correlates. Seroconversion was defined as 4-fold increase in titers for vaccines with quantitative antibody assays, or as a change from negative to positive IgG for vaccines with qualitative antibody tests. Results 760 patients were included in this cohort. Demographic and clinical data are summarized in Table 1. The mean age at allo-HCT was 10.4 years, most were male (56.8%) and white (74.6%). Acute leukemia accounted for 66.4% of allo-HCT recipients. Conditioning was myeloablative for 53.45%, and reduced intensity for 37.9%. Most received transplants from mismatched-related donors, (44.9%), followed by matched unrelated donors (35.4%) and matched related donors (19.5%). The number of patients who received the full vaccination series at our institution differed by vaccine and ranged from 41-150, and the respective subsets with available pre-vaccination and post-vaccination titers ranged from 24-93. The median time from transplant to initiation of immunizations was 12 months (range: 6-58) for non-live vaccines, 25 months (range: 23, 63) for MMR vaccine, and 28 months (range: 16, 117)) for varicella vaccine. Protection post immunization varied, with less patients demonstrating protections for mumps (79%) and measles (82%) (Figure 1). Seroconversion also varied among the different vaccine components and types of vaccines. Conclusion Current strategies to re-immunize patients after allo-HCT do not provide protection to all patients. Understanding the factors associated with suboptimal immune responses is critical for advancing our knowledge in this area. Whether time-based approaches combined with immune reconstitution data are required to further optimize protection remains unclear. Additionally, different vaccine schedules (i.e., higher doses) may be required in these patients. Figure 1. Protection and seroconversion rate by vaccine target.

Use of T2Bacteria Panel in Pediatric Hematopoietic Stem Cell Transplant Patients: A Single Center Experience

Abstract Background Bloodstream infection is a common complication following hematopoietic cell transplant (HCT), occurring in 10-40% of patients (1,2). Rapid identification of causative bacteria is imperative to provide proper empiric therapy and ensure optimal patient outcomes. The T2Bacteria Panel detects five bacterial pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli) using T2 magnetic resonance (T2MR, T2Biosystems, Lexington MA, USA) directly from blood specimens. Previous studies have reported per-patient sensitivity, specificity, and negative predictive value (NPV) of 84-90%, 85.9-90%, and 99.7%, respectively, as well as 100% positive agreement and 98.4% negative agreement when compared to blood culture (3-5). To date, there have been no studies on the use of this test in pediatric HCT recipients. Methods We reviewed all pediatric HCT patients at St. Jude Children’s Research Hospital who had a T2Bacteria Panel performed for fever and suspected infection between January 2019 and September 2022. A total of 706 T2Bacteria Panel results and concurrent blood culture results from 251 unique patients were analyzed to determine assay performance for detection of the 5 targeted pathogens. Results T2Bacteria PCR and blood culture showed concordant results in 97% of cases. Overall, our study revealed 65% positive percent agreement with blood culture and 95% negative percent agreement for bacteremia caused by any of the target pathogens. PPV, NPV, sensitivity and specificity for each organism detected by the panel, and the panel overall, are presented in Table 1. Positive predictive value ranged from 28-73%. Negative predictive value was high for all organisms (98-100%). Sensitivity was highest for Pseudomonas aeruginosa (88%), and lowest for Escherichia coli (44%). Specificity was high for all organisms (97-99%). Conclusion In pediatric HSCT patients, the T2Bacteria Panel was most useful for rapidly ruling out the presence of target pathogens, with high negative percent agreement, NPV, and specificity. Positive percent agreement was lower than noted in previous studies. Positive predictive value and sensitivity varied per pathogen.

Antibiotic Overuse in Pediatric Patients Hospitalized with RSV, COVID-19, and Influenza

Abstract Background Children hospitalized with viral respiratory tract infections (RTIs) are often treated with antibiotics due to concern for bacterial co-infection, although most do not have concurrent bacterial infections. This practice leads to unnecessary antibiotic treatment, which can lead to development of resistant bacteria and adverse events. The extent of antibiotic overuse in hospitalized children with community-onset viral RTI has not been well-quantified in recent years and may have worsened during the COVID-19 pandemic. The objectives of this study were to quantify and compare the extent of antibiotic overtreatment and to determine predictors of antibiotic use post-COVID-19 pandemic in children hospitalized with RSV, COVID-19, and influenza. Methods We performed a single center retrospective study evaluating percentages of antibiotic use and bacterial co-infection among children and adolescents aged &amp;lt;19 years old, hospitalized with respiratory syncytial virus (RSV), influenza, or SARS-CoV-2 between April 2020 and May 2023. Bacterial infection was defined as growth of bacteria from any specimen source, including blood, urine, pleural fluid, cerebrospinal fluid, and respiratory secretions, excluding common contaminants like coagulase-negative Staphylococci. Predictors of antibiotic treatment were determined using multivariable logistic regression. Results During the study period 1,718 patients were included (1022 with RSV, 188 with influenza, 535 with COVID-19). RSV patients were younger and more likely to be in the ICU than influenza or COVID-19 patients. The overall proportion of patients with culture-confirmed bacterial co-infection was low at 8% and did not differ greatly by virus type (8% for influenza, 6.9% for RSV, 10.3% for COVID-19, p=0.03). The proportion of children receiving antibiotics was higher for influenza than for other viruses (60.6% for influenza, 41.2% for RSV, and 48.6% for COVID-19, p &amp;lt; 0.001). Among patients with the lowest severity of illness (with normal inflammatory markers [PCT &amp;lt;0.5 ug/mL or CRP &amp;lt;50 mg/L] and not admitted to the ICU), 7.3% had a culture-confirmed bacterial infection while 48.1% received antibiotics. Independent predictors for receiving antibiotics were elevated inflammatory markers (C-reactive protein or procalcitonin), having &amp;gt;3 comorbidities, mechanical ventilation, and influenza diagnosis. Conclusion In children hospitalized with community-onset viral RTIs, antibiotic treatment is substantially higher than the burden of culture-confirmed bacterial infection, suggesting antibiotic overuse. Antibiotic use was greater for patients with influenza than for those with RSV or COVID-19. Antibiotic overuse was estimated to occur in over 40% of patients with low severity of illness. Stewardship programs can use this data to design interventions to promote more judicious antibiotic use. Figure 1. Rates of bacterial co-infection and antibiotic utilization among patients hospitalized with influenza, RSV, and COVID. Blue, percentage of patients who had a culture-confirmed bacterial infection; orange, percentage of patients who received any antibiotics; green, percentage of patients who received &amp;gt;3 days of antibiotics.

Analysis of selective neurocritical care admission costs following elective endovascular treatment of unruptured intracranial aneurysms.

No consensus exists on the necessity of neurocritical care unit (NCU)-level care following unruptured intracranial aneurysm (UIA) treatment. We aim to identify patients requiring NCU-level care post-treatment and determine potential cost savings utilizing a selective NCU admission protocol. A retrospective analysis of all UIA patients who underwent endovascular treatment at a single center from 2017-2022 was conducted. Data on demographics, preprocedural variables, radiographic features, procedural techniques, intra/postoperative events, and length of stay (LOS) were collected. Multivariable analysis was performed to identify patients requiring NCU-level care post-treatment. Cost analysis using hospital cost data (not charges/reimbursement) was performed using simulated step-down and floor protocols for patients without NCU indications following a hypothetical six-hour post-anesthesia care unit observation period. Of 209 patients, 179 were discharged within 24 h and 30 had prolonged LOS. In our analysis, intra- and postoperative events independently predicted prolonged LOS. In our subanalysis, 47 patients demonstrated NCU needs: 24 with intraoperative indications, 18 with postoperative indications, and five with both. Of the 23 with postoperative indications, 20 were identified within six hours, while three were identified within six to 24 h. The median variable cost per patient for the current NCU protocol was $31,505 (IQR, $26,331-$37,053) vs. stepdown protocol $29,514 (IQR, $24,746-$35,011;p = 0.061) vs. floor protocol $26,768 (IQR, $22,214-$34,107;p < 0.001). Total variable costs were $6,211,497 for the current NCU protocol vs. $5,921,912 for the step-down protocol (4.89% savings) and $5,509,052 for the floor protocol (12.75% savings). Most patients requiring NCU-level care following UIA treatment were identified within a six-hour postoperative window. Thus, selective NCU admission for this cohort following a six-hour observation period may be a logical avenue for cost reduction. Our analysis demonstrated 5% and 13% savings for uncomplicated patients using step-down and floor admission protocols, respectively.

Antibiotic spectrum coverage scoring as a potential metric for evaluating the antimicrobial stewardship team activity: a single-center study.

Days of antibiotic spectrum coverage (days of ASC: DASC) is a metric for antibiotic usage calculated by ASC scores for spectrum and addresses limitations of days of therapy (DOT), which does not include spectrum. This study aims to investigate whether ASC-related metrics offer different aspects compared to aggregated DOT for all antibiotics (DOTtotal) and to assess their correlation in evaluating the impact of antimicrobial stewardship team (AST) programs. Retrospective. A single center within an 845-bed hospital. Trends in DOTtotal, DASC, and the DASC/DOT ratio, representing the average spectrum coverage per therapy day, were analyzed pre- and post-AST programs (April 2018) from January 2015 to December 2023, using interrupted time series analysis. Independent of the DASC/DOT, we also advocated ASC-stratified DOT (ASDOT), which facilitates comprehensive evaluation of DOT across ASC scores of <6, 6-10, and >10, representing narrow-, intermediate-, and broad-spectrum antibiotics. Among inpatients, AST programs significantly moderated the increasing trends of these metrics. Specifically, although the rates of increase in DOTtotal and DASC were slowed or plateaued, the DASC/DOT ratio decreased (P < 0.001). ASDOT metrics revealed a decrease and subsequent plateau in DOTtotal for the broad- and intermediate-spectrum antibiotics, with an increase observed for the narrow-spectrum antibiotics (P < 0.001 for each). DASC did not provide additional insights in the outpatient's population. The study demonstrates that ASC-related metrics may yield different and useful conclusions about the effectiveness of AST programs for inpatients.

"Voiceless Pain"-Assessment of Pain in Patients with Obstetric Brachial Plexus Injuries: A Retrospective, Single Center Analysis.

Obstetric brachial plexus injuries (OBPIs) not only lead to severe and life changing sequelae regarding motor impairment but can also be responsible for multi-characteristic pain. In everyday routine, questions regarding pain of the developing child with an OBPI are often overseen and neglected. We aimed to elucidate this specific question and analyzed all patients with OBPI treated in our center to unmask initially non-observed pain and ultimately put pain in correlation to the surgical reconstructive treatment performed. This single center retrospective study analyzes patients with OBPI treated in our center over the past 20 years. Patients were surveyed by the adolescent pediatric pain tool assessment to evaluate pain over their entire life span by excluding potential postoperative pain episodes. A total of 95 patients were initially contacted of which 78 returned the questionnaire (53.8% female, 46.2% male). In our patient cohort, the vast majority constituting 84.6 percent did not experience pain in the affected upper extremity over the years up to the date of their examination. Most of the patients describing pain had not been microsurgically treated for brachial plexus reconstruction in their neonate period. Merely, 33.3 percent of all OBPI experiencing pain had been microsurgically reconstructed at a median age of 7 months. Pain interrogation in patients with OBPI is often overseen during daily clinical routine. Adequate age-appropriate analgesic therapy regimens adapted to the individual are highly recommended. Timely microsurgical brachial plexus reconstruction may result in reduced lifetime pain experiences.

Correlation of the treatment sensitivity of patient-derived organoids with treatment outcomes in patients with head and neck cancer (SOTO): protocol for a prospective observational study

IntroductionOrganoids have been successfully used in several areas of cancer research and large living biobanks of patient-derived organoids (PDOs) have been developed from various malignancies. The characteristics of the original...

Apraxia phenotypes and frontotemporal lobar degeneration.

Apraxia has been identified in all clinical forms of frontotemporal lobar degeneration (FTLD). The characteristics of apraxia symptoms and their underlying cognitive/motor basis are not fully understood. This study investigated apraxia in pathological subtypes of FTLD. The study constituted a retrospective review of 115 pathologically confirmed cases of FTLD from a single cognitive neurology centre. Patients in whom apraxia had been documented as a notable clinical characteristic were identified. Apraxia features, demographic, cognitive, neurological, and imaging findings were recorded. Eighteen patients were identified: 12 with FTLD-tau pathology (7 corticobasal degeneration (CBD), four Pick type and one progressive supranuclear palsy (PSP)) and six with FTLD-TDP pathology, all type A and four linked to progranulin gene mutations. Apraxia as a dominant presenting feature was typically associated with tau pathologies, whereas it emerged in the context of aphasia in TDP pathology. Apraxia typically predominated in one body part (face or limb) in tau but not TDP pathology. Relatively preserved activities in daily life were associated with TDP. Apraxia of speech was associated with tau pathology. Pick-type pathology was linked to symmetrical atrophy and late development of limb rigidity. Apraxia in FTLD subtypes has variable characteristics. Apraxia associated with CBD pathology conformed to criteria for probable corticobasal syndrome (CBS), whereas apraxia with Pick-type pathology did not. Apraxia in patients with TDP-A pathology was interpreted as one manifestation of their generalised communication disorder. Apraxia in FTLD may have distinct cognitive and motor substrates that require prospective investigation.

Sterile Intraocular Inflammation Associated With Faricimab

Randomized clinical trials are conducted to establish both drug safety and efficacy. However, evidence of adverse events associated with these drugs in the clinical practice setting can be of value at generating hypotheses regarding less common safety issues, even if causality cannot be determined. To present and analyze cases of intraocular inflammation associated with faricimab therapy in patients referred to a single European institution. This was a review starting in April of 2024 of an observational case series. Patients were from a single academic-based tertiary referral center in Switzerland. Included in the analysis were patients referred for intraocular inflammation soon after receiving a faricimab intravitreal injection between June 1, 2022, and March 5, 2024. Faricimab, 6 mg (0.05 mL of a 120-mg/mL solution), administrated for neovascular age-related macular degeneration or diabetic macular edema. The systemic and ocular histories and imaging data available were reviewed. The following were evaluated: visual acuity measured with habitual correction using the Early Treatment of Diabetic Retinopathy Study charts before and after the event; intraocular pressure; patient symptoms; anterior, intermediate, or posterior location of the intraocular inflammation; and the presence of retinal vasculitis. Multimodal imaging including color fundus photographs, fluorescein angiograms, indocyanine green angiograms, and optical coherence tomography were reviewed. A total of 12 eyes from 7 patients (mean [SD] age, 73.3 [16.7] years; 4 female [57.1%]) over 22 months were identified as having noninfectious intraocular inflammation after intravitreal faricimab injections. Among these cases, in 2 eyes, retinal vasculitis was present together with anterior and posterior inflammation. One of the 2 eyes had an occlusive form of vasculitis of the arteries and veins, leading to subsequent macular capillary nonperfusion and clinically relevant irreversible vision deterioration from 20/80 to 20/2000. The remaining eyes were characterized by moderate anterior segment inflammation without substantial vision changes. The intraocular inflammation event occurred after a median (IQR) of 3.5 (2.0-4.3) faricimab injections. The median (IQR) interval between the last faricimab injection and the diagnosis of inflammation was 28 (24-38) days. Increased intraocular pressure of 30 mm Hg or higher was found in 3 eyes. This case series highlights the occurrence of rare, but potentially severe, intraocular inflammation associated with faricimab therapy. Although these findings do not prove causality and can only generate hypotheses for future investigations, these results suggest the importance of continuous surveillance and monitoring for patients undergoing faricimab therapy to promptly identify and manage potential adverse events.

Creating a Learning Health System in a Cancer Center: Generalizability of an Electronic Health Record Phenotype for Advanced Solid Cancer.

To test the generalizability of an electronic health record (EHR) phenotype for patients with advanced solid cancer, which was previously developed in a single cancer center. We compared an algorithm to identify patients with advanced solid cancer from a random sample of patients with active cancer in the Veterans Health Administration (VA) and an academic cancer center with a human-coded reference standard between January 1, 2016, and December 31, 2019. Compared with the human-coded reference standard, the algorithm had high specificity (93%; 95% CI, 87 to 99 and 97%; 95% CI, 93 to 100) and reasonable sensitivity (85%; 95% CI, 76 to 94 and 87%; 95% CI, 77 to 97) in the VA and academic cancer center populations, respectively. Patients with advanced cancer (compared with those with active nonadvanced cancer) had higher mortality at the VA and academic cancer center (29.2% and 17.0% 6-month mortality v 6.8% and 3.5%), respectively. This EHR phenotype can be used to measure and improve the quality of palliative care for patients with advanced cancer within and across health care settings.

Characteristics and prognosis of hepatocellular carcinoma patients after direct-acting antiviral hepatitis C virus therapy in a single medical center in Egypt

Objective: Hepatocellular carcinoma (HCC) incidence has increased dramatically over the previous two decades and is anticipated to rise further in some countries, notably the United States, by 2030. HCC is most widespread in Asia and Africa, where hepatitis B and C are ubiquitous and lead to the development of chronic liver disease and, finally, HCC. In this study, we examined changes in the characteristics and prognosis of HCC patients, as well as the risk of developing HCC after direct-acting antiviral (DAA) medication.Methods: The study enrolled all individuals who attended the Clinical Oncology and Nuclear Medicine Department, Suez Canal University Hospital, Ismailia, Egypt, with a proven diagnosis of HCC in the period between January 2020 and December 2021. HCC is diagnosed based on radiographic appearance (arterial enhancement phase and delayed washout phase) or compatible histology.Results: This retrospective cohort included 254 HCC patients, separated into three groups. Kaplan-Meier curves with log-rank analysis revealed that hepatitis C virus (HCV) treatment therapy considerably reduced the time to HCC development following hepatitis diagnosis (p &lt; .001). HCV therapy had a substantial impact on progression-free survival and overall survival in HCC patients (p &lt; .001).Conclusions: The emergence of DAA medication has greatly altered the management of HCV patients in the context of HCC. DAAs have been shown to be both safe and beneficial in these individuals, particularly in terms of lowering the risk of hepatic decompensation. DAAs have been reported to enhance overall survival in patients with cirrhotic HCV-related HCC, most likely due to decreased hepatic decompensation.

Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis

Background and aimsRelief of cholestasis in hilar cholangiocarcinoma is commonly undertaken in both curative and palliative treatment plans. There are numerous open questions with regard to the ideal biliary drainage strategy – including what constitutes clinical success (CS). In the existing data, curative patients and patients from the Western world are underrepresented.Patients and methodsWe performed a retrospective analysis of patients with complex malignant hilar obstruction (Bismuth-Corlette II and higher) due to cholangiocarcinoma who underwent biliary drainage at a German referral center between 2010 and 2020. We aimed to define CS and complication rates and directly compare outcomes in curative and palliative patients.Results56 curative and 72 palliative patients underwent biliary drainage. In patients with curative intent, CS was achieved significantly more often regardless of what definition of CS was applied (e.g., total serum bilirubin (TSB) < 2 mg/dl: 66.1% vs. 27.8%, p = < 0.001, > 75% reduction of TSB: 57.1% vs. 29.2%, p = 0.003). This observation held true only when subgroups with the same Bismuth-Corlette stage were compared. Moreover, palliative patients experienced a significantly greater percentage of adverse events (33.3% vs. 12.5%, p = 0.01). Curative intent treatment and TSB at presentation were predictive factors of CS regardless of what definition of CS was applied. The observed CS rates are comparable to published studies involving curative patients, but inferior to reported CS rates in palliative series mostly from Asia.ConclusionsBiliary drainage in complex malignant hilar obstruction due to cholangiocarcinoma is more likely to be successful and less likely to cause adverse events in curative patients compared to palliative patients.

Long-term outcome of variety of techniques used to stabilize left ventricular lead in difficult coronary sinus anatomy- A single centre experience

IntroductionDifficult coronary sinus (CS) anatomy may lead to difficulty in optimal left ventricular (LV) lead placement and lead displacements leading to nonresponse to cardiac resynchronization therapy (CRT). MethodsIn this retrospective study, we studied the CRT parameters of devices implanted by single operator during the time period from January 2014 till December 2021, where different off-label techniques were used to place/stabilize LV lead. The technique used to stabilize LV lead, CRT parameters at baseline and follow up were noted for each patient. ResultsOut of 133 CRTs implanted during the study period, 23 patients (17.29 %) required off-label techniques. Stylet and guidewire retaining techniques were used in 11/23 (47.82 %) and 7/23 (30.43 %) patients respectively. In two patients, LV lead was jailed using coronary stent to prevent displacement. Two patients had CS stenosis and required balloon dilation while one patient had tortuous posterolateral vein which was straightened using a coronary stent. There was technical failure of 6/23 LV leads (26.08 %) with loss of capture, at a median follow up of 44 months (Range: 06–114 months). Out of these 6 patients, stylet and guidewire retaining techniques were used in 4 and 2 patients respectively. ConclusionDespite having acceptable parameters at implantation, these techniques particularly stylet and guidewire retention, may lead to non-capture of LV lead on long term follow ups. Better LV leads like active fixation leads and conduction system pacing (His Bundle/left bundle branch pacing) should be preferred in difficult CS anatomy.

Outcomes of robotic surgery for inflammatory bowel disease using the Medtronic Hugo™ Robotic-Assisted Surgical platform: a single center experience

PurposeThe aim of the study was to compare the perioperative outcomes of patients affected by inflammatory bowel disease (IBD) who underwent surgery performed through laparoscopy or using the Medtronic Hugo™ RAS.MethodsThis is a retrospective study from a prospectively maintained database comparing laparoscopic vs. robotic-assisted surgery for IBD from 01/11/2017 to 15/04/2024. All procedures were performed by a single surgeon robotic-naïve with a large experience in laparoscopic surgery for IBD. The robotic procedures were performed using the Medtronic Hugo™ RAS platform. Outcomes were 30-day postoperative complications, operative time, conversion rate, intraoperative complications, length of hospital stay, and readmission rate.ResultsAmong 121 consecutive patients, 80 underwent laparoscopic (LG) and 41 robotic-assisted surgery (RG). Baseline, preoperative and disease-specific characteristics were comparable except for older age (50 [38–56] vs. 38 [28–54] years; p = 0.05) and higher albumin level (42 [40–44] vs. 40 [38–42] g/L, p = 0.006) in the RG. The intracorporeal anastomosis was more frequent in the RG (80% vs. 6%; p < 0.001) with longer operative time (240 vs. 205 min; p = 0.006), while the conversion rate was not different (5% vs. 10%, p = 0.49). Surgical procedure types were equally distributed between the two groups, and the rate of intra-abdominal septic complication (IASC) was comparable across the different procedures. Postoperative complications were similar, including the rate of IASC (5% vs. 5%, p = 1), postoperative ileus (5% vs. 7.5%, p = 0.71), bleeding (2% vs. 5%, p = 0.66), and Clavien-Dindo > 2 complications (7% vs. 6%; p = 1).ConclusionIBD surgery performed using the Medtronic Hugo™ RAS is safe and feasible, with similar postoperative outcomes when compared to the laparoscopic approach.

Recurrent acute kidney injury is associated with delayed language development in infants with Congenital Heart Disease.

Neurodevelopmental delay is common in children who undergo surgery for Congenital Heart Disease (CHD) in infancy. Cardiac surgery associated acute kidney injury (CS-AKI) occurs frequently in the paediatric cardiac Intensive care unit (ICU). Cardiac surgery associated acute kidney injury (CS-AKI) is associated with worse neurodevelopmental scores and delay in cognitive, language, and motor domains in children with CHD. No known data exist regarding the association of CS-AKI and motor and language subscales. In this study, we explored the relationship between CS-AKI and receptive and expressive language, as well as gross and fine motor delay. This was a single centre retrospective observational cohort study. Children who underwent surgery for CHD and developed recurrent CS-AKI in the first year of life who had follow-up neurodevelopmental testing using the Bayley Scale of Infant Development Version III were included. Neurodevelopmental delay subscales assessed included: receptive and expressive language, fine and motor skills. The study cohort included 203 children. Recurrent CS-AKI was significantly associated with lower scores in receptive and expressive language, as well as fine and gross motor on unadjusted analyses. On adjusted analyses, recurrent CS-AKI was significantly associated with severe receptive language delay. The independent association of recurrent CS-AKI with severe language delay in children who undergo surgery for CHD in infancy is novel. Our findings may contribute to the understanding of language impairment in this population. Further studies are required to better understand this relationship and any potentially modifiable factors.

Inpatient zoledronic acid in older hip fracture patients is well tolerated and safe.

According to the 2022 Dutch 'Osteoporosis and fracture prevention' guideline, zoledronic acid (ZA) is the preferred osteoporosis treatment for hip fracture patients. Less than 25% of hip fracture patients visit the outpatient fracture liaison service, therefore inpatient administration of ZA during the hip fracture hospitalization is now recommended in patients > 75years. In the OLVG Hospital, inpatient administration of ZA during hospitalization for hip fracture in older patients has been standard of care since 2020. This single center retrospective observational follow-up study included hip fracture patients > 75years admitted to the orthogeriatric ward of the OLVG Hospital, and treated with 5mg of ZA intravenously on the day of hospital discharge between June 2020 and December 2022. Life expectancy estimated < 12months, creatinine clearance < 35ml/min, hypocalcemia, and high risk of osteonecrosis of the jaw were contra-indications. During three months of follow-up (FU) adverse events, emergency room visits, hospital readmissions, and death were recorded. In 161 consecutive hospitalized hip fracture patients (mean age 86 ± 6years, 65% female, 18% nursing home) ZA was administered and no adverse events were recorded. During 3months of FU, 8 patients (5%) visited the emergency room, 19 patients (12%) were re-admitted to the hospital, 3 with a new fracture (2 contralateral hip, 1 radius), and 17 patients (11%) died of reasons unrelated to ZA. This study shows that inpatient administration of zoledronic acid during hip fracture hospitalization is safe and feasible to prevent future fragility fractures in older hip fracture patients.

Surgical management and outcomes of renal tumors with inferior vena cava extension among children: a single center retrospective study from Pakistan

ObjectiveThe aim of this study was to assess management and determine outcomes of renal tumors with inferior vena cava (IVC) and intracardiac (IC) extension in a tertiary care center in Pakistan.MethodsA retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, Pakistan. All patients from 1 to 18 years of age with renal tumors with intravascular extensions, surgically managed from January 1988 till June 2016, were included. Data was extracted by reviewing medical records, and the tumor details, treatment and outcomes were analyzed.ResultsA total of 18 patients out of the total 61 patients with renal tumors, presented with IVC and/or IC extension, with the majority involving the right kidney. Mean age was 5.9 (SD:4.9) and a female preponderance (56%) was seen. Wilms tumor (77%) was the most common tumor type, with the level of tumor extension into IVC predominantly being below the diaphragm (55.5%). Fourteen patients received preoperative chemotherapy, with tumor regression, seen in 10. Most patients underwent thrombectomy through the renal vein (56%). Regarding outcomes, frequency of mortality and morbidity was 1 and 2, respectively, with 7 patients having no recurrent 5 years post-surgery.ConclusionA greater incidence (29.5%) of IVC and or IC Tumor extension was found compared to existing literature, which could likely be due to a higher referral rate to the center. Moreover, this is a single-center study and so a multi-center study is crucial to form an assessment of surgical management in resource-limited settings. Our study is the first from Pakistan on this particular renal tumor presentation. Considering the varying case presentations and surgical techniques used, further studies are needed to standardize surgical management and optimize patient outcomes.

Postdissection Abdominal Aorto-Iliac Aneurysm Open Repair: A Surgical Technique Description and Systematic Review of the Literature

BackgroundPost-dissection abdominal aortic aneurysms (pDAAA) may develop in up to 7% of patients affected by aortic dissection. However, there is no consensus on the optimal management. Different endovascular and open surgical techniques have been reported. This case-series describes the open surgical technique employed at a tertiary vascular surgery center to manage this complex pathology to allow future treatment of the visceral aorta if needed. A systematic review of the relevant literature on surgical and endovascular management of pDAAA was conducted. MethodConsecutive patients surgically treated at a single center for pDAAA metachronous to a Stanford type A or type B aortic dissection from January 2018 to March 2023 were retrospectively retrieved. The surgical technique we employed entails the use of large-diameter bifurcated grafts (≥ 9 mm branches) with longer main body, fenestration of the septum at renal arteries ostia and landing on a common femoral artery in case of small caliber iliac arteries (< 8 mm) to provide a suitable landing zone and access route for future endovascular thoracoabdominal repair in case of subsequent aneurysmal degeneration. The primary outcome was 30-day mortality. Secondary outcomes were major complications, late mortality, aortic-related mortality, and aortic-related reinterventions. Then, a systematic review of the literature until March 2023 was conducted. ResultsFive patients were included, all males with a mean age of 61 years. 30-day mortality was 0. One patient suffered from post-operative acute kidney injury and acute distress respiratory syndrome, and another one underwent repeat laparotomy for abdominal seroma. The mean follow-up was 44 months with no aortic-related reinterventions to date. One patient died from non-aortic-related causes 9 months after surgery. ConclusionsOpen repair of pDAAA appears to be an effective treatment in selected patients, with low mortality rates, and technical choices should consider future endovascular treatment of the thoracoabdominal aorta.

Totally 3D endoscopic aortic valve replacement: initial results and experience from a single center.

This study aimed to evaluate the feasibility and initial outcomes of totally endoscopic aortic valve replacement (TEAVR) performed via a single working port at the fourth intercostal space (ICS) utilizing a 3D endoscopic system. A retrospective observational study was conducted on 35 consecutive patients who underwent TEAVR over a six-month period from December 2023 to June 2024. Patient selection was based on the presence of isolated aortic valve disease without the need for ascending aorta replacement or aortic root enlargement. A 4 cm single working port was created at the 4th ICS, extending from the right mid-axillary to the anterior axillary line. A 10-mm trocar for a 3D endoscope was placed at the right anterior-axillary line. Peripheral cardiopulmonary bypass (CPB) was established. The primary outcomes investigated included the success rate of the procedure, in-hospital mortality, and perioperative complications. The mean age of the patients was 58.7 ± 12.8 years, with 22.9% being female. The majority of patients (77.1%) presented with aortic stenosis, often accompanied by severe calcification. The medianCPB time was 210 ± 43 min, and the median aortic cross-clamp time was 132 ± 41 min. The procedure was successfully completed in all patients using the endoscopic approach, with no conversions to full sternotomy. Two mortalities were recorded, attributed to postoperative complications including bleeding and cerebral infarctions. The early (30-day) mortality rate was 5.7%. Prolonged mechanical ventilation (>48 h) was required in 17.1% of patients, and reoperation for bleeding was necessary in 2.9% of patients. TEAVR is a feasible procedure with the potential to replace the traditional sternotomy approach for aortic valve replacement.