Societal Guidelines Research Articles

The use of protection measures in dento-maxillofacial radiology in Europe: a survey among experts

Patient contact shielding to reduce radiation exposure to radiosensitive organs of patients is known to be used inconsistently in the field of dento-maxillofacial radiology (DMFR). There is an ongoing discussion if its use is still justified with regard to recent technical enhancements in the field. Thus, the aim of this study was to investigate the recommended and applied safety standards regarding dose protection measures in dental radiology within European countries. With an online questionnaire the use of safety measures, especially lead protection and collimation, in different patient groups (adults, children, pregnant women) was interrogated including leading experts in the field of DMFR. Among the 24 participants from 13 different countries, there was a tendency towards lead protection for intraoral radiography and towards collimation for extraoral radiography. Participants based their decision mainly on law and societal guidelines. Overall, the application of radiation protection measures varies within Europe. It seems safe to say that lead protection as a measure of radiation dose limitation is still recommendable even though collimation and technical advancements have led to great dose reductions. Collimation should be used more broadly and a standardization of protection measures and an update of radiation protection guidelines in Europe is desirable. Accepted for publication: September 12, 2022 Published online: September 13, 2022

The use of protection measures in dento-maxillofacial radiology in Europe: a survey among experts.

Patient contact shielding to reduce radiation exposure to radiosensitive organs of patients is known to be used inconsistently in the field of dento-maxillofacial radiology (DMFR). There is an ongoing discussion if its use is still justified with regard to recent technical enhancements in the field. Thus, the aim of this study was to investigate the recommended and applied safety standards regarding dose protection measures in dental radiology within European countries. With an online questionnaire the use of safety measures, especially lead protection and collimation, in different patient groups (adults, children, pregnant women) was interrogated including leading experts in the field of DMFR. Among the 24 participants from 13 different countries, there was a tendency towards lead protection for intraoral radiography and towards collimation for extraoral radiography. Participants based their decision mainly on law and societal guidelines. Overall, the application of radiation protection measures varies within Europe. It seems safe to say that lead protection as a measure of radiation dose limitation is still recommendable even though collimation and technical advancements have led to great dose reductions. Collimation should be used more broadly and a standardization of protection measures and an update of radiation protection guidelines in Europe is desirable.

Effects of SGLT2 inhibitors and GLP1-receptor agonists on cardiovascular and limb events in peripheral artery disease: A review.

Peripheral artery disease (PAD) and diabetes mellitus are two overwhelming health problems associated with major cardiovascular (CV) and limb events, in addition to increased mortality, despite advances in medical therapies including statins and renin-angiotensin system inhibitors. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1-receptor agonists (GLP1-RA) are two new antihyperglycemic drug classes that have been associated with a significant reduction of major adverse cardiovascular events (MACE) in patients with type 2 diabetes (T2D) and CV risk. Whereas most studies had enrolled patients with T2D and concurrent CV disease (CVD), patients with PAD were obviously underrepresented. Furthermore, there was a signal of increased risk of amputation in one of the main trials with canagliflozin. We aim to provide a general review of the current literature and summarize societal guideline recommendations addressing the role of SGLT2i and GLP1-RA drugs in patients with CVD focusing on the PAD population when data are available. Endpoints of interest were MACE and, when available, major adverse limb events (MALE).

The needle in the haystack: deciphering diagnostic data in a case of acute on chronic liver failure

The needle in the haystack: deciphering diagnostic data in a case of acute on chronic liver failure

Surveillance Duplex Ultrasound Prompted Interventions After Carotid Endarterectomy

Current societal guidelines recommend duplex ultrasound surveillance beyond 30 days after carotid endarterectomy for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate length for this surveillance has not yet been identified, and the rate at which surveillance prompts intervention is unknown. Multiple calls for decreasing health care spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance duplex ultrasound on the ipsilateral or contralateral carotid artery after carotid endarterectomy.

Gastroparesis and Functional Dyspepsia: Spectrum of Gastroduodenal Neuromuscular Disorders or Unique Entities?

Gastroparesis is defined by delayed gastric emptying in the absence of mechanical obstruction of the stomach. Patients experience symptoms of nausea, vomiting, abdominal pain, fullness, and early satiety. The recognition of the disorder has progressed due to availability of gastric emptying scintigraphy and advancements made in understanding its pathophysiology and treatment options. The clinical presentation and treatment of gastroparesis overlap with a more commonly recognized disorder of gut-brain interaction, functional dyspepsia. Recent studies have reenergized the discussion whether these two are separate entities or perhaps reflect a spectrum of gastroduodenal neuromuscular disorders. The societal guidelines conflict on the utility of gastric emptying scintigraphy in assessment of patients with upper gastrointestinal symptoms. A better appraisal of similarities and differences between gastroparesis and functional dyspepsia will allow targeted treatment for these disorders. This is particularly important as specific pharmacological and endoscopic treatment options are being developed for gastroparesis which are unlikely to be helpful for functional dyspepsia. This review makes the case for considering these disorders in a spectrum where identification of both would most ideally position us toward providing the optimal clinical care.

Morel-Lavallée Lesion Diagnosed by Point-of-Care Ultrasound: A Case Report and Review of Treatment Strategies

BackgroundMorel-Lavallée lesions, also known as an internal degloving injuries, occur hours to months after high-speed shearing trauma, usually in the peri-trochanteric region. These are uncommon injuries, and are often missed as part of the trauma examination. Failure to diagnose or treat these lesions may result in complications, such as infected seromas, chronic cosmetic deformities, capsule formation, or skin necrosis. There are no formalized societal guidelines for management, but smaller studies have recommended compression alone for asymptomatic lesions, aspiration for small symptomatic lesions, and open debridement for large lesions. Case ReportA young woman presented with swelling, fluctuance, and paresthesia to her right hip after falling off her bicycle 1 week earlier. Physical examination showed a fluctuant and hypoesthetic area over the greater trochanter and point-of-care ultrasound showed a hypoechoic and compressible fluid collection between a fascial layer and a subcutaneous layer, confirming the diagnosis of a Morel-Lavallée lesion (internal degloving injury). Symptoms did not improve with compression alone, but did improve after fluid aspiration. Why Should an Emergency Physician Be Aware of This?Morel-Lavallée lesions are frequently missed traumatic injuries. Morel-Lavallée lesions can be diagnosed quickly and cost-effectively in the emergency department through the combination of a thorough history, physical examination, and bedside ultrasound. Although there are no formal societal guidelines, limited studies suggest management strategies, including compression, aspiration, and open debridement, with treatments varying by symptom severity and lesion size.

New avenue of diagnostic stewardship: procedural stewardship for recurrent urinary tract infections in female patients.

Societal guidelines offer a weak recommendation to perform cystoscopy for female patients with recurrent urinary tract infections (rUTI) of advanced age and/or with high-risk features. These guidelines lack the support of robust data and are instead based on expert opinion. In this retrospective cohort study, we aim to determine the utility of cystoscopy in patients with and without high-risk features for rUTI. We identified 476 women who underwent cystoscopy for the evaluation of rUTI at a single tertiary academic medical center from May 1, 2015 and March 15, 2021. Patients were excluded if they had a competing indication for cystoscopy. Risk factors, demographic information, cystoscopic findings, and patient outcomes were analyzed. 192 (41.1%) were classified as having complicated UTI. We identified six patients (1.3%) with findings that prompted management to significantly impact patient outcomes. All six patients had high-risk features. 14 patients (3.0%) were found to have mucosal abnormalities prompting biopsy, three of which required general anesthesia. All 14 biopsies were ultimately benign. Our findings demonstrate a low diagnostic yield and increased risk exposure for women undergoing cystoscopy for the evaluation of complicated rUTI. Additionally, our observations support prior studies indicating that cystoscopy has limited utility in the evaluation of rUTI without high-risk features.

Clinical variation in surveillance and management of Barrett’s esophagus: A cross-sectional study of gastroenterologists and gastrointestinal surgeons

Appropriate surveillance and treatment of Barrett's esophagus (BE) is vital to prevent disease progression and decrease esophageal adenocarcinoma (EAC)-related mortality. We sought to determine the variation in BE care and identify improvement opportunities. 275 physicians (113 general gastroenterologists, 128 interventional gastroenterologists, 34 gastrointestinal surgeons) cared for 3 simulated patients, one each from 3 BE clinical scenarios: non-dysplastic BE (NDBE), BE indefinite for dysplasia (IND), and BE with low grade dysplasia (LGD), and care scores were measured against societal guidelines. Overall quality-of-care scores ranged from 17% to 85% with mean of 47.9% ± 11.8% for NDBE, 50.8% ± 11.7% for IND, and 52.7% ± 12.2% for LGD. Participants appropriately determined risk of progression 20.3% of the time: 14.4% for NDBE cases, 19.9% for LGD cases, and 26.8% for IND cases (P = .001). Treatment and follow-up care scores averaged 12.9% ± 17.5% overall. For the LGD cases, guideline-recommended twice-daily PPI treatment was ordered only 24.7% of the time. Guideline-based follow-up endoscopic surveillance was done in only 27.7% of NDBE cases and 32.7% of IND cases. For the LGD cases, 45.4% ordered endoscopic eradication therapy while 25.1% chose annual endoscopic surveillance. Finally, participants provided counseling on lifestyle modifications in just 20% of cases. Overall care of patients diagnosed with BE varied widely and showed room for improvement. Specific opportunities for improvement were adherence to guideline recommended surveillance intervals, patient counseling, and treatment selection for LGD. Physicians would potentially benefit from additional BE education, endoscopic advances, and better methods for risk stratification.

Investigational Role of Convalescent Plasma in the Management of COVID-19 Disease in Inpatient & Outpatient Settings

Introduction:Historically, both convalescent plasma & hyperimmune globulin have been tried & tested in multiple viral outbreaks in order to confer passive immunity. These products are obtained from previously infected subjects who have fully recovered and are opined to have generated optimal immune response (polyclonal antibodies to the causative pathogen at sufficient titre and biologic activity) to confer passive immunity in the recipient. Neutralizing antibodies are the main active component of such products. In this article practical aspects of obtaining and administering convalescent plasma and evidence-base for its use in the management of COVID-19 disease in inpatient & outpatient settings is presented. Method:A comprehensive search of PubMed & EMBASE from March 2020 to July 2022 was made using 3 search items: COVID-19, convalescent plasma, and hyperimmune globulin. The search items were combined using the Boolean operator. Societal guidelines reviewed at the time of writing this article include: US Food and Drug Administration (FDA), Association for the Advancement of Blood & Biotherapies (AABB), American Society of Hematology (ASH), International Society on Thrombosis and Haemostasis (ISTH), and National Institute for Health and Care Excellence (NICE) in the United Kingdom. Results: Administering COVID-19 convalescent plasma can confer immediate passive immunity that may help shorten the duration of the COVID-19 disease &/or diminish its severity thus preventing life-threatening complications. Besides FDA issued EUA of considering convalescent plasma therapy in immunocompromised individuals with severe COVID disease, other investigational indications for convalescent plasma therapy include a) individuals exposed to SARS-CoV-2 who have not yet become ill (i.e. post-exposure prophylaxis), and b) individuals who are at high-risk of exposure or high-risk of severe disease if exposed (i.e. pre-exposure prophylaxis). Convalescent plasma has recently been successfully tried in the outpatient setting to help reduce disease severity and the incidence of hospitalizations. Conclusion: Convalescent plasma therapy remains an investigational approach to treating severe COVID disease both in inpatient and outpatient settings. Whereas more data is needed to establish its indications, safety, and relative efficacy in novel COVID-19 variant infection cases, its use in immunocompromised individuals with severe COVID disease remains a valid therapeutic consideration.

Natural history of renal artery aneurysms

ObjectiveThe existing renal artery aneurysm (RAA) literature is largely composed of reports of patients who underwent intervention. The objective of this study was to review the natural history of RAA. MethodsThis single-institution retrospective analysis studied all patients with RAA diagnosed by computed tomography imaging between 2015 and 2019, identified by our institutional radiology database. Imaging, demographic, and clinical data were obtained via the electronic medical record. He growth rate was calculated for all patients with radiological follow-up. ResultsThe cohort consists of 331 patients with 338 RAAs. Most patients were female (61.3%), with 11 (3.3%) of childbearing age. The mean age at diagnosis was 71.5 years (range, 24-99 years). Medical comorbidities included hypertension (73.7%), prior smoking (34.4%), and connective tissue disease (3.9%). Imaging indications included abdominal pain (33.5%), unrelated follow-up (29.6%), and follow-up of an RAA initially diagnosed before the study period (10.7%). Right RAA (61.9%) was more common than left (35.1%); 3% of patients had bilateral RAA. The mean diameter at diagnosis was 12.9 ± 5.9 mm. Size distribution included lesions measuring less than <15 mm (69.9%), 15 to 25 mm (27.1%), and more than 25 mm (3.0%). Anatomic locations included the distal RA (26.7%), renal hilum (42.4%), and mid-RA (13.1%). The majority were true aneurysms (98%); of these, 72.3% were fusiform and 27.7% were saccular. Additional characteristics included calcification (82.2%), thrombus (15.9%), and dissection (0.9%). Associated findings included aortic atherosclerosis (65.6%), additional visceral aneurysms (7.3%), and abdominal aortic aneurysm (5.7%). The mean clinical follow-up among 281 patients was 41.0 ± 24.0 months. The mean radiological follow-up among 137 patients was 26.0 ± 21.4 months. Of these, 43 patients (31.4%) experienced growth, with mean growth rate of 0.23 ± 4.7 mm/year; the remainder remained stable in size. Eight patients eventually underwent intervention (5 endovascular), with the most common indications including size criteria (4/8) and symptom development (3/8). No patient developed rupture. On multivariate analysis, obesity (P = .04) was significantly associated with growth. An initial diameter of more than 25 mm was significantly associated with subsequent intervention (P = .006), but was not significantly associated with growth. Four of five RAAs with an initial diameter 30 mm or greater did not undergo intervention. The mean clinical follow-up for these patients was 24 months; none developed rupture and two remained stable in size. ConclusionsThis large institutional cohort found that the majority of RAAs remained stable in size, with few patients meeting indications for repair based on societal guidelines. Current guidelines recommending intervention for asymptomatic aneurysms more than 30 mm seem to be appropriate given their slow progression.

2022 Peggi Guenter Excellence in Clinical Practice Lectureship: Expanding the clinical practice of nutrition-Challenging the known, exposing inconvenient truths, and engaging the young.

To expand the clinical practice of nutrition, the influence of the American Society for Parenteral and Enteral Nutrition (ASPEN) must reach an audience outside the nutrition community, must be relevant and meaningful to clinicians, and must meet the needs of specific patient populations throughout medical and surgical specialties. Individual members of our society need to share their enthusiasm and expertise with youth through conscious, intentional mentorship. Efforts should be made to promote advanced practice, increasing the skill set of the individual nutritionist. Nutrition research should be of the highest quality, matching that of any current medical or surgical discipline. Members of a nutrition consult service should speak the same language as the physicians they work with, through discussions on rounds and in communication through their charting and consult notes. Our societal guidelines should define clinical practice. Relationships with other societies should be cultivated through these guidelines, position papers, and public health initiatives to increase the relevance and impact of our society. To position itself for future generations, the role of ASPEN should be expanded to be more comprehensive and involve all nutrition aspects of patient care.

Abstract 12126: Trends in Lipoprotein(a) Testing in Individuals With Cardiovascular Disease

Introduction: There is consensus amongst major international societal guidelines including the AHA/ACC that elevated lipoprotein(a) [Lp(a)] &gt; 50 mg/dL, present in 20% of the population, is a likely causal, independent, and hereditary risk factor for several cardiovascular (CVD) conditions. Despite its high prevalence, clinical measurement of Lp(a) has anecdotally been considered rare but has not been systematically quantified. Methods: We assessed the prevalence of Lp(a) testing for various CVD conditions across six academic medical centers associated with the University of California (UC), in total and by year from 2012-2021. Data from the UC data warehouse on unique CVD diagnoses using ICD codes, and unique Lp(a) testing for individuals with each diagnosis were collected. The proportion of individuals with a given CVD diagnosis and Lp(a) testing at any time during the study period or in the same year of their diagnosis was quantified. Finally, we evaluated the prevalence of elevated Lp(a) (&gt;30 mg/dL and &gt;50 mg/dL) for each diagnosis. Results: From 2012-2021, there were 18,830 unique Lp(a) tests. Lp(a) testing was performed in 6,855 individuals with ischemic heart disease (3.1%), 2,454 (3.4%) with MI, 1,157 (2.1%) with PVD, 1,261 (3.4%) with carotid stenosis, 1,250 (1.8%) with stroke, 908 (3.4%) with aortic stenosis, and 5,136 (3.6%) with a family history of CVD. For most conditions, the prevalence of testing in the same year as the diagnosis of CVD was relatively consistent over the study period, except for a progressive increase among those with MI ( Figure ). Across CVD diagnoses, the prevalence of Lp(a) &gt;30mg/dL was 47.9 to 55.3% and for Lp(a) &gt;50 mg/dL was 36.7 to 44.9%. The highest prevalence of elevated Lp(a) was among those with carotid stenosis, and the lowest was among those with family history of CVD. Conclusions: Lp(a) testing persists at low rates, even among those with diagnosed CVD, and remained stable over the study period except for MI.

ODP431 Adiposity in menstrual dysfunction and the role of laboratory testing in diagnosis

Abstract Adiposity significantly contributes to reproductive function. Whereas lower body weight is strongly associated with increased risk of functional hypothalamic amenorrhea (FHA), the relationship between BMI and the timing of menopause is poorly understood. Recent studies of self-reported data suggest women with BMI&amp;lt;18.5kg/mg 2 have a significantly higher risk of menopause before age 45 years. However, without confirmatory testing, there is the possibility of misdiagnosis of menopause given the prevalence of FHA in low-weight women. Although FHA and menopause are clinically identical, laboratory evaluation could potentially aid in differentiating the two entities, as menopause is characterized by high gonadotropin levels, whereas FHA is characterized by low-normal gonadotropin levels. Given the increased morbidity and mortality associated with early age of menopause, this distinction is clinically important. We sought to identify age of menopause in low-weight women using clinically available data at a large, academic health system. We hypothesized that women with a BMI&amp;lt;18.5kg/m 2 would have a lower age of menopause but that confirmatory diagnostic testing to differentiate menopause from FHA would be infrequently performed. The study was conducted by retrospective chart review of the electronic medical records of 3,000 women &amp;gt;50 years of age and BMI&amp;lt;18.5kg/m 2 . After exclusion of individuals with no date of menopause, BMI&amp;gt;18.5 kg/m 2 at the menopausal transition and history of known cause of early menopause, 239 charts were included in the analysis. Participants had a median BMI of 17.7kg/m 2 at the final menstrual period (FMP). Median age at the FMP in all low weight women with BMI&amp;lt;18.5kg/m 2 was 51 years. There was a positive correlation between age of the FMP and BMI (rho=0.13, p=0. 04). When stratified by BMI, age of the FMP decreased with decreasing BMI. For women with a BMI of 18-18.49kg/m 2, FMP occurred at a median age of 51 years; for women with a BMI of 16-17.99 kg/m 2, FMP occurred at a median age of 50 years; and for women with BMI&amp;lt;16kg/m 2, FMP occurred at a median age of 48 years. Only 30 women (12.6%) included in the study had an FSH level measured after diagnosis of menopause and eight of these women (26.67%) had an FSH&amp;lt;18 (range: 0.7-14.7 IU/mL), which is lower than expected for menopause. Therefore, these data, obtained from clinical data rather than self-report, provide further evidence that low-BMI is associated with lower age of menopause. Although current societal guidelines do not recommend diagnostic evaluation of menopause in women older than 45 years, our data suggest that there is a risk of misclassifying FHA as menopause in low-weight women if diagnostic evaluation is not performed. Further studies are necessary to determine the role and clinical benefit of diagnostic confirmation of menopause in low-weight women with amenorrhea. Presentation: No date and time listed

Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia

ObjectiveDespite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. MethodsWe evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. ResultsA total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). ConclusionsEarly PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.

Current and investigational drugs in early clinical development for portal hypertension.

IntroductionThe development of portal hypertension leads to a majority of complications associated with chronic liver disease. Therefore, adequate treatment of portal hypertension is crucial in the management of such patients. Current treatment options are limited and consist mainly of medications that decrease the hyperdynamic circulation, such as non-selective beta blockers, and treatment of hypervolemia with diuretics. Despite these options, mortality rates have not improved over the last two decades. Newer, more effective treatment options are necessary to help improve survival and quality of life in these patients.Areas coveredMultiple preclinical models and clinical studies have demonstrated potential efficacy of a variety of new treatment modalities. We introduce treatment options including the use of vasodilation promotors, vasoconstriction inhibitors, anticoagulants, antiangiogenics, and anti-inflammatory drugs. We examine the most recent studies for treatment options within these drug classes and offer insights as to which show the most promise in this field.MethodologyPublished studies that identified novel medical treatment options of portal hypertension were searched using PubMed (https://pubmed.ncbi.nlm.nih.gov/). Clinical trials listed in Clinicaltrials.gov were also searched with a focus on more recent and ongoing studies, including those with completed recruitment. Searching with key terms including “portal hypertension” as well as individually searching specific treatment medications that were listed in other publications was carried out. Finally, current societal guidelines and recent review articles relevant to the management of portal hypertension were evaluated, and listed references of interest were included.ConclusionMany ongoing early phase studies demonstrate promising results and may shape the field of portal hypertension management in future. As concrete results become available, larger RCTs will be required before making definitive conclusions regarding safety and efficacy and whether or not they can be incorporated into routine clinical practice. Statins, anticoagulants, and PDE inhibitors have been among the most studied and appear to be most promising.

Ileoanal pouch cancers in ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis.

Restorative proctocolectomy results in the formation of a pouch that adapts to a more colonic phenotype. The incidence of cancer of the pouch is thought to be low with most societal guidelines differing on their recommendations for surveillance. We conducted a systematic review with meta-analysis to report the incidence of cancer in all pouch patients. The Embase, Embase classic and PubMed databases were searched between June 1979- June 2021. A random effects model was performed to find the pooled incidence of pouch cancer. In addition, we also looked for risk factors for pouch cancers. Forty-six studies were included. In 19,964 patients with Ulcerative Colitis (UC) the pooled incidence of pouch cancer was 0.0030 (95% CI: 0.0016 -0.0055). In 3741 patients with Familial Adenomatous Polyposis (FAP) the pooled incidence of pouch cancer was 0.01 (95% CI: 0.01 - 0.02). In UC most pouch cancers were found to occur in the pouch body (0.59 (95% CI: 0.29-0.84)). The findings suggest that the pooled incidence of pouch cancer in UC is similar to that which was previously published, and this is the first meta-analysis to report a pooled incidence for pouch cancer in FAP.

The Role of Biomarkers in the Management of Colorectal Liver Metastases.

Simple SummaryColorectal cancer remains one of the most significant sources of cancer-related morbidity and mortality worldwide. The liver is the most common site of metastatic spread. Multiple modalities exist to manage and potentially cure patients with metastatic colorectal cancer. However, reliable biomarkers to assist with clinical decision-making are limited. Recent advances in genomic sequencing technology have greatly expanded our knowledge of colorectal cancer carcinogenesis and significantly reduced the cost and timing of the investigation. In this article, we discuss the current utility of biomarkers in the management of colorectal cancer liver metastases.Surgical management combined with improved systemic therapies have extended 5-year overall survival beyond 50% among patients with colorectal liver metastases (CRLM). Furthermore, a multitude of liver-directed therapies has improved local disease control for patients with unresectable CRLM. Unfortunately, a significant portion of patients treated with curative-intent hepatectomy develops disease recurrence. Traditional markers fail to risk-stratify and prognosticate patients with CRLM appropriately. Over the last few decades, advances in molecular sequencing technology have greatly expanded our knowledge of the pathophysiology and tumor microenvironment characteristics of CRLM. These investigations have revealed biomarkers with the potential to better inform management decisions in patients with CRLM. Actionable biomarkers such as RAS and BRAF mutations, microsatellite instability/mismatch repair status, and tumor mutational burden have been incorporated into national and societal guidelines. Other biomarkers, including circulating tumor DNA and radiomic features, are under active investigation to evaluate their clinical utility. Given the plethora of therapeutic modalities and lack of evidence on timing and sequence, reliable biomarkers are needed to assist clinicians with the development of patient-tailored management plans. In this review, we discuss the current evidence regarding biomarkers for patients with CRLM.

The Role of Indirect Calorimetry in Care of the Surgical Patient.

Purpose of ReviewThis is a review of recent literature on the role of indirect calorimetry in surgical nutrition.Recent FindingsAll critical care societal guidelines recommend the use of indirect calorimetry as the standard of care to determine energy needs. Recent studies confirm discrepancy between measured and equation-predicted energy expenditure and further demonstrate improved outcomes with indirect calorimetry-guided nutrition. Patients that undergo ECMO, CRRT and those with COVID-19 would benefit from the use of indirect calorimetry. SummaryIndirect calorimetry-guided nutrition is the standard of care in mechanically ventilated surgical patients.

Constructing a Theoretical Framework of the Urban Transformation Processes of the Port City Interface towards Resilient Egyptian Port Cities

Throughout history, Egyptian port cities had been formed together as an indissoluble twin in function and space. However, over the last century, most Egyptian ports have been transformed into a complex multi-layer entity with a continuous conflict between port and city actors, and hence, they have become increasingly separated from their cities in physical terms. This separation reflects how the port-city interface is shaped and governed. However, the Egyptian port cities did not receive enough studies to identify the urban transformation processes that shape the port-city interface. To help fill this gap, the research develops a conceptual-theoretical framework to understand urban transformation processes of the port-city interface and the forces that shape those transformations. This framework acts as a first step to form an assisting tool to understand and reframe the nature of the Egyptian case and how to move forward. To build this framework, the research critically reviews the normative literature available on urban planning/design, geography, politics, economy, and urban management of port cities worldwide. It follows the recent conceptualizations of the port city interface that focuses on the actors and societal relationships shaping the port city interface, rather than focusing only on its physical boundaries, dealing with the port city interface as a process, not only as a product. Furthermore, the research presents six European case studies as a manifestation of how governance and social integration influence the formation of the port-city interface. The research finds that understanding the port-city relationship through the lens of profiling urban transformation processes worldwide provides physical, governance and societal integration guidelines, that could help understand the Egyptian port-city relationship on one hand and plan/govern the relationship towards a resilient port city on the other.