Therapeutic Complications Research Articles

What We Know So Far About ECG for Pancreatic Pseudocysts

Background: Endoscopic cysto-gastrostomy (ECG) has become the treatment of choice for pancreatic pseudocysts (PPCs). Endoscopic drainage of PPCs requires the creation of an anastomosis between the lumen of the PPCs and the lumen of the gastrointestinal tract. Various types of stents are used for this purpose. The aim of the study is to compare the indications, quantity, and results of using double pigtail plastic stents (DPPSs) and lumen-apposing fully covered metal stents (LAMSs) in ECG. Methods: A retrospective analysis was conducted of 39 patients (24 men, 15 women) treated for PPCs in the Department of Digestive Tract Surgery and the Department of Gastroenterology and Hepatology between October 2018 and February 2023. The mean age of patients was 51.13 (28–77). Data about etiology, cyst diameter, type, and complications of the stents were collected. Results: DPPSs were placed in smaller cysts (108 vs. 140 millimeters, p = 0.04) and were maintained for a longer duration compared to LAMSs (106 vs. 34 days, p = 0.001). Cyst recurrence was reported less frequently in patients with a LAMS (0 (0%) vs. 4 (19.05%), p = 0.05) and the therapeutic success was non-significantly higher in the LAMS group compared to the DPPS group (100% vs. 85.71%), p = 0.095. Conclusions: Both DPPSs and LAMSs are characterized by high therapeutic success and low complication rates in patients undergoing ECG for PPCs.

Multifaceted Heparin: Diverse Applications beyond Anticoagulant Therapy

Heparin, a naturally occurring polysaccharide, has fascinated researchers and clinicians for nearly a century due to its versatile biological properties and has been used for various therapeutic purposes. Discovered in the early 20th century, heparin has been a key therapeutic anticoagulant ever since, and its use is now implemented as a life-saving pharmacological intervention in the management of thrombotic disorders and beyond. In addition to its known anticoagulant properties, heparin has been found to exhibit anti-inflammatory, antiviral, and anti-tumorigenic activities, which may lead to its widespread use in the future as an essential drug against infectious diseases such as COVID-19 and in various medical treatments. Furthermore, recent advancements in nanotechnology, including nano-drug delivery systems and nanomaterials, have significantly enhanced the intrinsic biofunctionalities of heparin. These breakthroughs have paved the way for innovative applications in medicine and therapy, expanding the potential of heparin research. Therefore, this review aims to provide a creation profile of heparin, space for its utilities in therapeutic complications, and future characteristics such as bioengineering and nanotechnology. It also discusses the challenges and opportunities in realizing the full potential of heparin to improve patient outcomes and elevate therapeutic interventions.

Iatrogenic needle penetrating injury of cervical spinal cord: a case of fatal therapeutic complication.

A 52-year-old woman with of neck pain underwent percutaneous neck injection of local anesthetic and a corticosteroid without image guidance. She collapsed asystolic during the procedure was resuscitated and then died after 2 weeks in the intensive care unit with hypoxic encephalopathy. Complete postmortem examination included additional posterior neck dissection and cervical spinal cord removal with intact dura mater. The entire cervical spinal cord with the dura and leptomeninges was embedded in an oriented sequence of several paraffin blocks. Serial sections of each selected blocks were then studied to locate a putative puncture site. Serial sections from the third and fourth cervical levels (C3-C4) were stained with luxol fast blue-hematoxylin-eosin, iron stain, trichrome stain, and immunostained for b-amyloid precursor protein, and CD68. Histological examination revealed a linear needle track with a subacute healing reaction. The path included the dorsal spinal dura, arachnoid, and the left dorsal column. Clinicopathological correlation and the cause of death are discussed. Careful planning, dissection, sampling, and oriented serial sectioning with immunostaining were key points to document the injuries and understand this case.

Prostate Cancer and Obesity: Current Hypotheses and Challenges

Prostate cancer is the most common cancer diagnosed in males in the United States. Known prostate cancer risk factors include age, ethnicity, and genetic factors. There is some data suggesting that obesity is a risk factor for numerous aspects related to prostate cancer including prostate cancer development, biochemical recurrence, and prostate cancer mortality. Moreover, there may be potential therapeutic complications in the obese patient. Weight loss has also been shown to benefit the patient with prostate cancer. Finally, obesity may affect the microbiome and other molecular pathways such alterations in adipokine signaling, insulin and the insulin-like growth factor 1 pathway, and effects on the tumor microenvironment (e.g.: ectopic/periprostatic fat). The purpose of this review is to discuss the most current hypotheses on the relationship between obesity and prostate cancer across this broad spectrum of potential relationships.

Long-term outcomes of lower extremity arteriovenous grafts

Objective: To evaluate the long-term outcomes of lower extremity arteriovenous graft (AVG) in hemodialysis patients. Methods: Hemodialysis patients with lower extremity AVG from August 2015 to July 2023 in the Department of Vascular Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine were enrolled. Therapeutic effects and complications of AVG were retrospectively analyzed. Results: A total of 83 cases aged (58.9±13.3) years were enrolled, including 25 males and 58 females. The success rate of the operation was 100% (83/83), and no perioperative complications occurred. The follow-up time [M (Q1, Q3)] was 38.4 (22.6, 55.3) months, with a follow-up rate of 92.8% (77/83). There were 9 cases (11.7%) of puncture site infection, 5 cases (6.5%) of pseudoaneurysm, 2 cases (2.6%) of seroma, 3 cases (3.9%) of lower limb ischemia, 48 cases (62.3%) of stenosis and 24 cases (31.2%) of thrombosis during the follow-up period. The 6-month, 1-year, 2-year, 3-year and 5-year primary patency rates after surgery were 78.9%, 61.2%, 39.0%, 27.0% and 16.3%, respectively, assisted primary patency rates were 93.5%, 82.5%, 74.9%, 68.0% and 53.0%, respectively, and secondary patency rates were 96.1%, 94.7%, 93.1%, 91.3% and 75.3%, respectively. Conclusion: For patients whose vascular resources of upper limbs are exhausted, lower extremity AVG is a safe and effective hemodialysis vascular access.

Acute cholangitis: a state-of-the-art review.

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Molecular Docking of Nigella Sativa L. with PXR Receptors and the Effect of Thymoquinone on PXR Expression in HepG2 Cells

ABSTRACT. The interaction between herbal remedies and drugs is a fascinating phenomenon that might cause therapeutic complications in patients. Warfarin is an anticoagulant drug that provides anti-blood-clotting effects by inhibiting the formation of vitamin K-dependent coagulation factors, and warfarin interacts with the nuclear receptor PXR, subsequently modulating cytochrome P450 during the metabolism process. St. John's wort, an herbal medicine with antidepressant effects, can alter the pharmacokinetics of warfarin. Thymoquinone is one of the active compounds in N. sativa and has pharmacological activities such as anticoagulant, antidiabetic, diuretic, antidepressant, and anti-inflammatory effects. In this study, we investigated the compounds in Nigella sativa (N. sativa) against pregnane X receptor (PXR) and evaluated the impact of thymoquinone (TQ) administration on PXR expression in HepG2 cells. The molecular docking analysis was conducted utilizing the Molecular Operating Environment (MOE) with the PXR (PDB ID: 7AXJ). At the same time, the PXR gene expression was measured using RT-PCR instruments. The RMSD value in docking represents the deviation criteria between the native ligand position and the redocking position result, indicating the capability of MOE and PDB qualification for performing molecular docking. The docking analysis showed that warfarin had the strongest binding energy (7AXJ -6.0507) by forming hydrogen binding type on Arg410. Despite TQ being the major component, it also displayed a high affinity for the two PDB IDs (7AXJ -4.5962). Furthermore, the concurrent administration of warfarin and TQ (19.27 μM) in HepG2 cells showed a significant reduction in the relative mRNA expression of the PXR gene. Given the above-mentioned findings, our study adequately enables us to predict the mechanism behind herb-drug interactions (HDIs) implicating N. sativa, specifically the TQ compound to warfarin metabolism via the activation of the PXR receptor. Keywords: Thymoquinone, expression mRNA, PXR, molecular docking, HepG2 cells.

In silico analysis of the protein-protein interaction of the SARS-CoV-2 spike protein

The pandemic caused by the SARS-CoV-2 virus has represented a global challenge with a significant impact on public health since its emergence in 2019. Understanding the interactions between this virus and the human immune system is essential for the development of new strategies more effective therapies and diagnoses. This study aimed to predict epitopes for SARS-CoV-2 T and B cells, as well as evaluate the interaction of the spike protein with other viral proteins, using bioinformatics methods. SARS-CoV-2 protein sequences were collected from UniProt. Epitopes for T cells were predicted in silico using specific HLA alleles from the Bahia population. Epitopes for B cells were predicted using the IEDB server with multiple methods based on amino acid features. Protein-protein interaction was analyzed using the STRING database. The result is 10,671 peptides related to various SARS-CoV-2 viral proteins, including the spike, essential for the infection and pathogenesis of COVID-19. In addition to spike, proteins such as ORF3a, ORF7a, and ORF8 showed significant immunogenic potential. Protein-protein interaction analysis revealed that proteases such as TMPRSS2 and TMPRSS11D are crucial for viral entry and are potential therapeutic targets. This study expands the understanding of the molecular interactions of SARS-CoV-2, highlighting new therapeutic targets and clinical complications associated with COVID-19. The results provide valuable insights for the development of targeted therapeutic strategies and improved diagnostics, contributing to the mitigation of the global pandemic.

Soft tissue sarcomas of the proximal adductor area of the thigh: Indications, results and complications at medium follow-up in a series of 43 surgically treated patients

IntroductionWhen Soft Tissue Sarcomas are localized in the groin area, they pose specific challenges due to their proximity to important structures. These tumors exhibit elevated complication rates and a higher local recurrence rate compared to their locations in other limbs. The objective of this paper is to analyze a series of patients affected by soft tissue sarcomas in the adductor area of the proximal thigh. The analysis aims to elucidate the epidemiology, diagnostic and therapeutic approaches, complications, and outcomes. Additionally, the study seeks potential prognostic factors and to determine patients at a heightened risk of postoperative complications. Patients and methodsall patients who underwent surgeries for primary soft tissue sarcomas of the adductor area between October 2006 and March 2022 in a tertiary research hospital were valued. Epidemiology, tumor characteristics and therapeutic approaches were analyzed to identify risk factors for complications and local recurrences; survival was considered a secondary outcome. ResultsThe series comprised 43 patients, 26 males and 17 females, with an average age of 63.3 years. The most frequent histology was liposarcoma, followed by undifferentiated forms. All patients reported the presence of masses, with associated pain in 27.9% of cases. Limb-sparing surgery was performed in 86.0% of cases. Early and late complications were experienced by 34.9% and 20.0% of patients, respectively, with wound dehiscence being the most frequent problem. The recurrence rate was 9.3%, with no recurrences observed in low-grade patients. At an average follow-up of 51 months, 18 patients (41.9%) were alive, two of which with distant metastases. ConclusionThe present series provides evidence that when Soft Tissue Sarcomas localized in the groin area are managed in specialized centers, the rates of recurrence and complications are not significantly different from those observed in other anatomical sites.

Evaluating the efficacy and suggesting technical optimizations for endoscopic lumbar interbody fusion across different lumbar spondylolisthesis types

PurposeTo evaluate the efficacy of the endoscopic lumbar interbody fusion technique across different types of lumbar spondylolisthesis, specifically Grade I and Grade II, and suggest technical optimizations based on therapeutic outcomes, complications, and patient satisfaction for both grades. MethodsWe analyzed data from 57 L4 to 5 spondylolisthesis patients, all categorized as either Grade I or Grade II, comprising 31 males and 26 females. Of these, 36 were diagnosed with Grade I and 21 with Grade II. All subjects underwent the endoscopic lumbar interbody fusion procedure. Primary evaluation metrics included pre and post-operative Vasual Analogue Scale（VAS） pain scores, Osewewtry Disability Index（ODI） functional scores, surgical duration, intraoperative blood loss, degree of spondylolisthesis correction, complications, and patient satisfaction levels. ResultsAt a minimum of 6 months post-operation, the VAS score for the Grade I cohort reduced from an initial 7.30 ± 0.69 to 2.97 ± 0.47, while the Grade II cohort saw a decrease from 7.53 ± 0.56 to 3.37 ± 0.62 (P = 0.0194). The ODI score in the Grade I group declined from 66.88 ± 5.15 % pre-operation to 29.88 ± 6.36 % post-operation, and in the Grade II group, it decreased from 69.33 ± 5.27 % to 34.66 ± 6.01 % (P = 0.0092). The average surgical duration for the Grade I group stood at 155.72 ± 17.75 min, compared to 180.38 ± 14.72 min for the Grade II group (P < 0.001). The mean intraoperative blood loss for the Grade I group was 144.58 ± 28.61 ml, whereas the Grade II group registered 188.23 ± 9.41 ml (P < 0.001). Post-surgery, 83 % of the Grade I patients achieved a correction degree exceeding 80 %, and 61 % of the Grade II patients surpassed 50 % (P = 0.0055). Complication rates were recorded at 8 % for Grade I and 16 % for Grade II. Patient satisfaction reached 94 % in the Grade I cohort and 90 % in the Grade II cohort. ConclusionEndoscopic lumbar interbody fusion showcases promising therapeutic outcomes for both Grade I and Grade II lumbar spondylolisthesis. However, surgeries for Grade II spondylolisthesis tend to be lengthier, more challenging, involve greater blood loss, and have a heightened complication risk. Tailored technical adjustments and enhancements are essential for addressing the distinct spondylolisthesis types.

Meta-analysis and systematic review of gout prevalence in the heart/lung transplantation population.

Gout may complicate solid organ transplantation with potentially serious consequences. An accurate prevalence of gout in this population is unknown. This study aimed to estimate the prevalence of gout in the heart and/or lung transplantation population through a systematic review and meta-analysis. MEDLINE, Embase, PsycINFO, CENTRAL and Cochrane Library (inception to February 2022) were searched for studies that reported the prevalence and/or incidence of gout in heart and/or lung transplant recipients. Two authors extracted outcomes data. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were the prevalence of pre- or post-transplant gout expressed as a prevalence rate (95% CI). Secondary outcomes included risk factors for gout, adverse events, and therapeutic complications of gout treatment. Ten studies were included. Gout prevalence (PR) was 8% pre-transplant (PR = 0.08; 95% CI: 0.05-0.12; 4 studies n = 651) and 6% post-transplant (PR = 0.06; 95% CI: 0.06-0.06; 10 studies n = 45,298). Post-transplant gout prevalence in heart transplant recipients was almost three times higher than lung transplant recipients (PR = 0.16; 95% CI: 0.13-0.20 vs. PR = 0.06; 95% CI: 0.05-0.06 respectively). Patients with a pre-transplant history of gout had a higher risk of developing post-transplant gout than patients without (RR = 3.61; 95% CI: 2.19-5.95). Factors associated with gout and outcomes for heart and/or lung transplant recipients with gout were comprehensively reviewed from the included studies. Gout is highly prevalent in heart and/or lung transplant patients. Pre-transplant gout is predictive of developing symptomatic post-transplant gout. This has significant implications for management of heart/lung transplant patients. https://www.crd.york.ac.uk/, PROSPERO (CRD42020190632).

Comparison of the efficacy and complications of tolterodine and α-adrenergic receptor blockers in improving ureteral stent-related symptoms: A systematic review and meta-analysis.

We conducted a systematic evaluation of the therapeutic efficacy and complications of tolterodine and α-adrenergic receptor blockers in alleviating ureteral stent-related symptoms. Until August 2023, we conducted a comprehensive literature search on PubMed, Embase, Web of Science, and Cochrane Library to identify randomized controlled trials evaluating the efficacy and complications of tolterodine and α-adrenergic receptor blockers in treating ureteral stent-related symptoms. Two reviewers independently screened studies and extracted data. The scores from various domains of the Ureteral Stent Symptom Questionnaire (USSQ) were summarized and compared, and statistical analysis was performed using RevMan 5.4.0 software. A total of 8 studies met the inclusion criteria for our analysis. These studies were conducted at different centers. All studies were randomized controlled trials, involving a total of 487 patients, with 244 patients receiving α-adrenergic receptor blockers and 243 patients receiving tolterodine. The results showed that tolterodine demonstrated significantly better improvement in body pain (MD, 1.56; 95% CI [0.46, 2.66]; p = 0.005) (MD, 0.46; 95% CI [0.12, 0.80]; p = 0.008) (MD, 3.21; 95% CI [1.89, 4.52]; p = 0.00001) among patients after ureteral stent placement compared to α-adrenergic receptor blockers at different time points. Additionally, at 4 weeks, tolterodine showed superior improvement in general health (MD, 0.15; 95% CI [0.03, 0.27]; p = 0.01) and urinary symptoms (MD, 1.62; 95% CI [0.59, 2.66]; p = 0.002) compared to α-adrenergic receptor blockers, while at 6 weeks, tolterodine showed better improvement in work performance (MD, -1.60; 95% CI [-2.73, -0.48]; p = 0.005) compared to α-adrenergic receptor blockers. Additionally, the incidence of dry mouth (RR, 4.21; 95% CI [1.38, 12.87]; p = 0.01) is higher with the use of tolterodine compared to α-adrenergic receptor blockers. However, there were no significant statistical differences between the two drugs in other outcomes. This meta-analysis suggests that tolterodine is superior to α-adrenergic receptor blockers in improving physical pain symptoms after ureteral stent placement, while α-adrenergic receptor blockers are more effective than tolterodine in enhancing work performance. Additionally, the incidence of dry mouth is higher with the use of tolterodine compared to α-adrenergic receptor blockers. However, higher-quality randomized controlled trials are needed to further investigate this issue.

Robot-Assisted Partial Cystectomy for Deep Infiltrating Endometriosis of the Bladder With the Hugo RAS System

ObjectiveInvolvement of the lower urinary tract is found in 0.2 to 2.5% of all deep infiltrating endometriosis (DIE) [1,2]. The bladder is the most affected organ with a prevalence of up to 80% of cases [3]. Patients with bladder endometriosis are often symptomatic (dysuria, hyperactive bladder, recurrent urinary tract infections, and hematuria). Surgery is the gold standard treatment for this condition when medical therapy fails [1,2]. Several studies have shown the feasibility, effectiveness, and safety of the laparoscopic approach [4] but data about robotic-assisted approach are missing in literature. Currently, novel platforms are entering the market and the Hugo™RAS (Medtronic, Minneapolis, USA) is a new system (HRS) consisting of an open console with 3D-HD screen and a multimodular bedside units. Even if some series are already available for radical cystectomies for oncologic purposes [5], a full description of DIE surgery performed with HRS is still lacking. Aim of this video-article is to show our technique and surgical setup to carry out a complex case of anterior compartment DIE. DesignA step-by-step explanation of surgical technique with narrated video footage. SettingTertiary Level Academic Hospital “IRCCS Azienda Ospedaliero—Universitaria di Bologna” Bologna, Italy. InterventionA 36-year-old nulliparous woman affected by DE was referred to our center due to severe dyspareunia, dysuria with hematuria and postvoiding pain not responsive to oral progestins. The preoperative work up consisted of a gynecological examination, pelvic ultrasound and MRI that showed the presence of an endometriotic nodule of the bladder base. All possible therapeutic strategies and related complications have been discussed with the patient before the signature of the informed consent. To carry out the procedure a “straight” port placement in a “compact” docking configuration [6] was installed. After developing the paravesical spaces bilaterally, the bladder nodule was approached in a latero-medial direction then a partial cystectomy with macroscopical free margins was performed. A double layer horizontal running suture with barbed thread was used to repair the bladder wall. ConclusionTo the best of our knowledge, this is the first case of bladder endometriotic nodule excision performed with HRS. We explained our technique and robotic set-up to successfully manage a compelx case of DIE of the bladder. Video Abstract [Display omitted]

Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review.

Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.

Small Incision Apocrine Glands Excision Combining Original Vacuum Sealing Drainage Technique for the Treatment of Axillary Bromhidrosis

Aim: To observe the therapeutic effect by small incision apocrine glands excision combining original vacuum sealing drainage technique in treating axillary bromhidrosis and its complication. Methods: 120 patients with bromhidrosis were included and randomly divided into two groups. Observation group (60 patients) by small incision apocrine glands excision combining original vacuum sealing drainage technique. Control group (60 patients) by regular small incision apocrine glands excision and rubber drains typically were placed. Results: Therapeutic effect and complications in two groups were compared. Total effective rate in both groups was 100%. 5 patients in observation group (8.33%) had epidermal erosion or dehiscence at medial margin of the incision and 21 patients control group (35.00%) had epidermal erosion or dehiscence at medial margin of the incision. Incidence in control group is obviously higher than that in observation group and such a difference has statistical significance. Conclusion: Complication incidence is significantly reduced by small incision apocrine glands excision with application of original vacuum sealing drainage technique than regular small incision apocrine glands excision and rubber drains.

Effect of quick acupuncture combined with rehabilitation therapy on improving motor and swallowing function in patients with stroke.

To investigate the effect of quick acupuncture combined with rehabilitation therapy on motor and swallowing function of patients with stroke. A retrospective study. Single center study. One hundred and twenty patients with stroke were divided into control and observation group based on the therapeutic regimen. Control group (n = 60) only received rehabilitation therapy, and observation group (n = 60) received rehabilitation therapy combined with quick acupuncture. Acupuncture was performed once a day, and 6 times/week for 4 consecutive weeks. The simplified Fugl-Meyer assessment scale and Barthel index were used to assess limb motor function and daily living ability. The Dysphagia Outcome Severity Scale and Swallowing Quality of Life questionnaire were conducted to estimate the dysphagia severity and life quality of patients with swallowing disorders. The therapeutic efficacy and complications after treatment were analyzed and counted. After treatment, the scores of the observation group were significantly improved compared with the control group (P < 0.05). In the observation group, the therapeutic efficacy was 93% (n = 56); the complication rate was 5% (n = 3); the therapeutic efficacy of the control group was 75% (n = 45); and the complication rate was 25% (n = 15), indicating that the therapeutic efficacy of the observation group is better and the incidence of complications is lower than that of the control group. This study suggests that rehabilitation therapy combined with rapid acupuncture therapy has a potential therapeutic effect on the relief of swallowing and motor dysfunction after stroke.

A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial

AbstractInhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.

Performance and safety of percutaneous cholangioscopy: a systematic review and meta-analysis.

Percutaneous cholangioscopy (PerC) offers an alternative for patients with an inaccessible biliary tree. This systematic review and meta-analysis aimed to evaluate the performance of this technique. A search in Medline, Cochrane and ClinicalTrials.gov databases was performed for studies assessing PerC up to October 2022. The primary outcome was diagnostic success, defined as successful stone identification or stricture workup. Secondary outcomes included therapeutic success (stone extraction, stenting) and complication rate. A subgroup analysis compared previous-generation and modern cholangioscopes. We performed meta-analyses using a random-effects model and the results were reported as percentages with 95% confidence interval (CI). Fourteen studies (682 patients) were eligible for analysis. The rate of diagnostic success was 98.7% (95%CI 97.6-99.8%; I2=31.19%) and therapeutic success was 88.6% (95%CI 82.8-94.3%; I2=74.92%). Adverse events were recorded in 17.1% (95%CI 10.7-23.5%; I2=77.56%), of which 15.9% (95%CI 9.8-21.9%; I2=75.98%) were minor and 0.6% (95%CI 0.1-1.2%; I2=0%) major. The Spyglass system showed null heterogeneity for all outcomes; compared with older-generation endoscopes it offered comparable diagnostic success, but yielded significantly superior therapeutic success (96.1%, 95%CI 90-100%; I2=0% vs. 86.4%, 95%CI 79.2-93.6%; I2=81.41%; P=0.02]. PerC, especially using currently available cholangioscopes, is associated with high diagnostic and therapeutic success.

Novel hemicraniectomy: Preserving temporal structures in severe traumatic brain injury patients

ObjectiveThis study evaluates the efficacy and safety of Novel Hemicraniectomy Technique (NHT) in Severe Traumatic Brain Injury (STBI) patients. MethodsA retrospective analysis of 79 STBI patients who underwent decompressive hemicraniectomy was conducted. The study compared 25 patients treated with NHT and 54 patients treated with Classic Decompressive Craniectomy (CDC), focusing on therapeutic effects, complications, intracranial pressure, and prognosis. ResultsNHT resulted in shorter surgery duration (101.4 ± 11.8 min, p = 0.008) and greater decompressive effects (21.4 ± 5.6 mmHg, p = 0.018). It also prevented temporal muscle injury (0.0 %, p = 0.026), superficial temporal artery injury (0.0 %, p = 0.009), and masticatory dysfunction (5.9 %, p = 0.040). However, NHT showed no significant advantages in intracranial pressure normalization time (3.5 ± 0.9 days, p = 0.679), hospital stay length (34.3 ± 10.4 days, p = 0.805), intraoperative blood loss reduction (284.0 ± 82.6 ml, p = 0.190), or Glasgow Outcome Scale (GOS) scores (2.8 ± 0.9, p = 0.814) and prognosis (32.0 %, p = 0.831) compared to CDC. ConclusionNHT offers shorter surgery duration (101.4 ± 11.8 min vs 107.7 ± 8.2 min), superior decompressive effects (21.4 ± 5.6 mmHg vs 17.7 ± 6.9 mmHg), and better protection of temporal structures, but does not significantly reduce complications or improve prognosis compared to CDC. Prospective studies with larger sample sizes are needed to better understand the potential benefits of NHT in STBI treatment.

Outcomes of Central Neck Dissection for Papillary Thyroid Carcinoma in Primary Versus Revision Setting.

Surgery in the central compartment after previous thyroidectomy involves an increased risk of injury to critical organs, including the parathyroids and recurrent laryngeal nerve. Contrastingly, primary central neck dissection involves a relatively low operative risk. This study aimed to compare the outcomes of central neck dissection in primary versus revision settings with respect to the lymph node yield and complication rates. This single-center prospective study included patients who underwent primary or revision neck dissection surgery for histologically confirmed thyroid malignancy between January 2018 and January 2022. We included 30 patients who underwent total thyroidectomy with primary central neck dissection and 29 patients who underwent central neck dissection following remote thyroidectomy with or without previous central dissection. There was no significant between-group difference in postoperative complications, including permanent hypocalcemia and recurrent laryngeal nerve injury. However, both groups showed a significant postoperative decrease in calcium levels even though calcium and parathyroid hormone levels were within reference range. Although many surgeons fear revision central neck dissection, it appears to have similar therapeutic outcomes and complication rates as primary neck dissection for papillary thyroid cancer. Specifically, there were no between-group differences in the lymph node yield, hypoparathyroidism, or recurrent laryngeal nerve paralysis. Patients with normocalcemia showed a significant postoperative reduction in calcium levels, suggesting subclinical parathyroid insufficiency.