bluuebunny/crossref_metadata_2025 huggingface dataset:
Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach
Authors: Garg Bhavuk , Mehta Nishank , Bansal Tungish , Shekhar Shubhankar , Khanna Puneet , Baidya Dalim Kumar
Published: December 2020

Study Design.

Retrospective, comparative.

Objective.

The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.

Summary of Background Data.

Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.

Methods.

Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016—dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.

Results.

A total of 812 patients were included – 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).

Conclusion.

Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.

Level of Evidence: 3
Mitogen-activating protein kinase pathway alterations in Langerhans cell histiocytosis
Authors: Jouenne Fanélie , Benattia Amira , Tazi Abdellatif
Published: December 2020

Purpose of review

Langerhans cell histiocytosis (LCH) is a rare disorder characterized by the infiltration of involved tissues by specialized dendritic cells. The demonstration of the constant activation of the mitogen-activated protein kinase (MAPK) pathway in LCH lesions has been a breakthrough in the understanding of the pathogenesis of this rare disease. We will summarize the current knowledge on MAPK alterations in LCH and the new therapeutic options indicated by these findings.

Recent findings

Since the description of the B-Raf proto-oncogene, serine/threonine kinase (BRAF)
V600E mutation in LCH lesions, several other molecular alterations affecting the MAPK pathway have been identified in most cases. Based on these driver alterations, LCH cells were shown to be derived from hematopoietic precursors, which yielded the current concept of LCH as a myeloid inflammatory neoplasia. MAPK pathway inhibitors have emerged as an innovative therapy in severe forms of LCH, resulting in virtually no acquired resistance. However, although they are highly effective, their effect is only temporary, as the disease relapses upon discontinuation of the treatment.

LCH is an inflammatory myeloid neoplastic disorder, driven by mutations activating the MAPK pathway. MAPK-targeted treatments represent an important stepforward in the management of patients with severe progressive LCH.
IPAA in Known Preoperative Crohn’s Disease: A Systematic Review
Authors: Lightner Amy L. , Jia Xue , Zaghiyan Karen , Fleshner Phillip R.
Published: December 2020

BACKGROUND:

Crohn’s disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure.

OBJECTIVE:

This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn’s disease.

DATA SOURCES:

A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews.

STUDY SELECTION:

The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn’s disease populations were selected.

INTERVENTION:

Ileal pouch anal anastomoses were constructed in patients who had Crohn’s disease diagnosed preoperatively or through proctocolectomy pathology.

MAIN OUTCOMES MEASURES:

The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate.

RESULTS:

Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified.

LIMITATIONS:

This investigation was limited by the small number of studies with significant study heterogeneity.

CONCLUSION:

In patients with known preoperative Crohn’s disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn’s disease, pouch failure rates remain higher than in patients with ulcerative colitis.
Optimization of Aztreonam in Combination With Ceftazidime/Avibactam in a Cystic Fibrosis Patient With Chronic Stenotrophomonas maltophilia Pneumonia Using Therapeutic Drug Monitoring: A Case Study
Authors: Cowart Mallory C. , Ferguson Chelsea L.
Published: December 2020

In this clinician-therapeutic drug monitoring (TDM) consultant interaction, the authors describe the use of TDM in an 11-year-old female patient with cystic fibrosis receiving ceftazidime/avibactam and aztreonam for the treatment of persistent pulmonary exacerbations caused by Stenotrophomonas pneumonia. Serum drug concentrations at a steady state confirmed inadequate antimicrobial exposure, and continuous infusions of both ceftazidime/avibactam and aztreonam were required to optimize the percentage of time when free drug remained above the minimum inhibitory concentration (MIC), known as fT > MIC. After dose adjustment, this continuous infusion strategy resulted in 100% target attainment for fT > MIC. This case illustrates the importance of TDM, and the logistical issues encountered with the use of alternative dosing strategies in pediatric patients with CF.
SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN SMALL CHOROIDAL MELANOMAS AND CHOROIDAL NEVI
Authors: Greig Eugenia Custo , Laver Nora V. , Mendonca Luisa S.M. , Levine Emily S. , Baumal Caroline R. , Waheed Nadia K. , Duker Jay S.
Published: December 2020

Purpose:

To evaluate the use of swept-source optical coherence tomography angiography to detect distinct vascular features in small choroidal melanomas and choroidal nevi.

Methods:

Patients with a choroidal nevus or a treatment-naïve choroidal melanoma were imaged with color fundus photography, ultrasound, and swept-source optical coherence tomography angiography (12 × 12 mm). High-risk features including overlying fluid, orange pigment, shaggy photoreceptors, acoustic hollowness, depth >2 mm, and basal diameter >5 mm were assessed. Optical coherence tomography angiography vascular markers included: choroidal vessel visualization, choroidal vessel depth, and choriocapillaris flow signal, assessed qualitatively by comparison with surrounding, unaffected choriocapillaris.

Results:

Twenty-nine lesions were included in this study, seven flat choroidal nevi, 17 elevated choroidal nevi, and 5 choroidal melanomas. Distinct vascular patterns were noted between flat nevi, elevated nevi, and small choroidal melanomas. Choroidal melanomas displayed two types of vasculature: “nevus-like” vasculature with straight parallel vessels and complex vasculature with vascular loops and crosslinking. Visualized choroidal vessels were significantly deeper in melanomas (110 µm) than elevated (84 µm) or flat nevi (70 µm). In a size-matched subanalysis of 5 elevated choroidal nevi and 5 choroidal melanomas, choroidal melanomas had increased mean choroidal vessel depth (P = 0.015), deepest choroidal vessel visualized (P = 0.034), and presence of a deep choroidal vessel >155 µm (P = 0.048).

Conclusion:

Swept-source optical coherence tomography angiography may detect distinct vascular features in choroidal nevi and small choroidal melanomas.
QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY PARAMETER VARIATIONS AFTER TREATMENT OF MACULAR NEOVASCULARIZATION SECONDARY TO AGE-RELATED MACULAR DEGENERATION
Authors: Arrigo Alessandro , Aragona Emanuela , Bordato Alessandro , Amato Alessia , Borghesan Federico , Bandello Francesco , Parodi Maurizio B.
Published: December 2020

Purpose:

Macular neovascularization (MNV) secondary to age-related macular degeneration can be characterized by quantitative optical coherence tomography angiography. The aim of the study was to assess the evolution of quantitative optical coherence tomography angiography parameters after 1 year of antivascular endothelial growth factor injections.

Methods:

Naive age-related macular degeneration–related MNV eyes were prospectively recruited to analyze optical coherence tomography and optical coherence tomography angiography parameters, including MNV vessel tortuosity (VT) and reflectivity, at baseline and at the end of the follow-up. Macular neovascularization eyes were categorized by a MNV VT cutoff, and quantitative parameter variations were documented after 1 year of treatment. We divided MNV eyes into Group 1 (MNV VT < 8.40) and Group 2 (MNV VT > 8.40).

Results:

Thrity naive age-related macular degeneration–related MNV eyes (30 patients) were included. Our cohort included 18 Type 1 MNV and 12 Type 2 MNV lesions. Baseline central macular thickness (411 ± 85 µm) improved to 323 ± 54 µm at 1 year (P < 0.01). Only Group 1 MNV displayed significant visual improvement. Macular neovascularization VT values remained stable over the follow-up in both subgroups. Group 2 MNV eyes showed increased MNV reflectivity and increased MNV area at the end of the follow-up. Quantitative retinal capillary plexa parameters were found to be worse in Group 2 MNV. Outer retinal atrophy occurred in 2 of the 18 eyes in MNV Group 1 (11%) and in 6 of the 12 eyes in MNV Group 2 (50%) after 1 year. Vessel density proved to be always worse in Group 2 than in Group 1.

Conclusion:

Macular neovascularization VT provides information on the blood flow and identifies two subgroups with different final anatomical and visual outcomes, regardless of the treatment effect.
OUTCOME OF REVISION PROCEDURES FOR FAILED PRIMARY MACULAR HOLE SURGERY
Authors: Maguire Matthew J. , Steel David H. , Yorston David , Hind Jennifer , El-Faouri Muhannd , Jalil Assad , Tyagi Pallavi , Wickham Louisa , Laidlaw Alistair H.
Published: December 2020

Purpose:

To analyze the outcomes of revision surgery for idiopathic full-thickness macular holes that have failed to close after primary surgery, and also to assess factors predicting success and to review the relative effect of adjunctive surgical techniques.

Methods:

A multicenter retrospective study. Anatomical closure rates and visual acuity change between pre and postrevision surgery were assessed. Hole size, age, symptom duration, surgical interval, and reduced hole size were analyzed as predictive factors for success. Effectiveness of adjunctive surgical techniques was reviewed.

Results:

Seventy-seven eyes were included in the study. Anatomical closure was achieved in 71% (55/77) cases. There was a median gain of 11 Early Treatment of Diabetic Retinopathy Score letters in all holes and 14 letters in closed holes. Full-thickness macular holes that increased in size by more than 10% following primary surgery had a closure rate of 50% compared with 80% in holes that reduced by 10% or stayed the same (P = 0.015). Increasing hole size is associated with a modest reduction in odds of closure (odds ratio = 0.99; P = 0.04). Surgical interval <2 months is not associated with better outcomes compared with >2 months (P = 0.14).

Conclusion:

Revision surgery for full-thickness macular holes that have failed to close after primary surgery is associated with high closure rates and significant visual gains.
Glaucoma care during the coronavirus disease 2019 pandemic
Authors: Vinod Kateki , Sidoti Paul A.
Published: December 2020

Purpose of review

The current article reviews the impact of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of ophthalmic, and specifically, glaucoma care.

Recent findings

Literature from the review period includes case series demonstrating the presence of severe acute respiratory syndrome coronavirus 2 RNA in the conjunctival secretions of patients with laboratory-confirmed COVID-19. The global ophthalmology community published reports outlining the enhanced infection control measures undertaken by different institutions around the world to mitigate transmission of the novel coronavirus. Telemedicine has been increasingly implemented in glaucoma practices to reduce in-office patient volume. New data regarding the efficacy and feasibility of tools for home monitoring of intraocular pressure, virtual visual field testing, and remote disc photography are reviewed.

COVID-19 has posed a global public health threat due to the severity of its contagion and associated morbidity and mortality. Glaucoma specialists have responded to the pandemic with innovative modifications to reduce viral transmission and optimize patient and staff safety in the office and operating room. The role of teleglaucoma has expanded and will continue to evolve as remote diagnostic devices undergo further refinement and validation.
Safety profile of minimally invasive glaucoma surgery
Authors: Vinod Kateki , Gedde Steven J.
Published: December 2020

Purpose of review

This article reviews the safety profile of trabecular meshwork/Schlemm's canal-based, subconjunctival, and suprachoroidal minimally invasive glaucoma surgery (MIGS).

Recent findings

Prospective randomized clinical trials and metaanalyses published during the 2019–2020 review period provided important data regarding the safety profile of trabecular meshwork/Schlemm's canal-based MIGS. Transient hyphema and intraocular pressure spikes are among the most common complications associated with this category of MIGS, but more serious adverse events such as cyclodialysis cleft formation may also occur. Trabecular bypass microstents and the intracanalicular scaffold are further subject to device-related complications, including malposition and obstruction. Recent case reports and retrospective case series have further characterized the safety profile of the subconjunctival gel stent, with adverse events ranging from self-limited hypotony to visually devastating endophthalmitis and suprachoroidal hemorrhage. Five-year results of the COMPASS XT study demonstrated significantly greater endothelial cell loss in patients randomized to receive CyPass Micro-Stent (Alcon Laboratories, Fort Worth, TX, USA) in combination with cataract surgery versus those who underwent cataract surgery alone, and ultimately led to a Food and Drug Administration Class I recall of the device.

Trabecular meshwork/Schlemm's canal-based procedures are generally among the safest MIGS, with mostly self-limited and nonvision-threatening complications. Subconjunctival gel stent insertion is associated with both bleb-related and stent-specific adverse events, which are similar to those observed with trabeculectomy and tube shunt surgery, respectively. Removal of the CyPass Micro-Stent from the market underscores the need for high-quality, long-term safety data regarding MIGS.
Enhanced Protection Against Diarrhea Among Breastfed Infants of Nonsecretor Mothers
Authors: Muthumuni Dhasni , Miliku Kozeta , Wade Kaitlin H. , Timpson Nicholas J. , Azad Meghan B.
Published: December 2020

Diarrhea is a major cause of infant mortality. Being a “nonsecretor” (having an inactive fucosyltransferase-2 gene) protects against diarrhea by inhibiting enteric infections. Breastfeeding also protects against diarrhea; however, the impact of maternal secretor status is unknown. In the ALSPAC cohort (N = 4971), we found that breastfeeding by nonsecretor mothers was especially protective against diarrhea, which could inform new prevention strategies.
Contribution of Bowman layer to corneal biomechanics
Authors: Torres-Netto Emilio A. , Hafezi Farhad , Spiru Bogdan , Gilardoni Francesca , Hafezi Nikki L. , Gomes Jose Alvaro P. , Randleman J. Bradley , Sekundo Walter , Kling Sabine
Published: December 2020

Purpose:

To compare the elastic modulus of thin corneal lamellas using 2D stress–strain extensometry in healthy ex vivo human corneal lamellas with or without the presence of Bowman layer.

Setting:

Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Switzerland; ELZA Institute, Dietikon, Switzerland; Department of Ophthalmology, Philipps University of Marburg, Germany.

Design:

Prospective experimental laboratory study.

Methods:

Healthy human corneas were stripped of Descemet membrane and the endothelium for Descemet membrane endothelial keratoplasty. After epithelium removal, corneas were divided into 2 groups. In Group 1, Bowman layer was ablated with an excimer laser (20 μm thick, 10 mm). In Group 2, Bowman layer was left intact. Then, a lamella was cut from the anterior cornea with an automated microkeratome. Elastic and viscoelastic material properties were analyzed by 2D stress–strain extensometry between 0.03 and 0.70 N.

Results:

Twenty-six human corneas were analyzed. The mean lamella thickness was 160 ± 37 μm in corneas with Bowman layer and 155 ± 22 μm in corneas without. No statistically significant differences between flaps with and without Bowman layer were observed in the tangential elastic modulus between 5% and 20% strain (11.5 ± 2.9 kPa vs 10.8 ± 3.7 kPa, P > .278).

Conclusions:

The presence or absence of Bowman layer did not reveal a measurable difference in corneal stiffness. This may indicate that the removal of Bowman layer during photorefractive keratectomy does not represent a disadvantage to corneal biomechanics.
PresbyPRK vs presbyLASIK using the SUPRACOR algorithm and micromonovision in presbyopic hyperopic patients: visual and refractive results at 12 months
Authors: Boucenna William , Hagège Alain , Lussato Mikhael , Morfeq Hussein , Kochbati Elias , Jany Benjamin , Froussart-Maille Françoise , Delbarre Maxime
Published: December 2020

Purpose:

To compare the visual outcome and refractive results between presbyopic photorefractive keratectomy (presbyPRK) and presbyopic laser in situ keratomileusis (presbyLASIK) in presbyopic hyperopic patients using micromonovision and the SUPRACOR algorithm.

Setting:

Percy Military Hospital and private Laser Victor Hugo Center, France.

Design:

Observational retrospective nonrandomized.

Methods:

Twenty-three patients who had undergone presbyPRK or presbyLASIK were included and followed up for 12-months. Far and near visual acuity without correction in monocular and binocular, measurement of distance visual acuity with correction in monocular, evaluation of spherical equivalent (SE), aberrometry, and patient satisfaction were measured and analyzed in this study.

Results:

The study included 26 eyes of 13 patients in the presbyLASIK group and 20 eyes of 10 patients in the presbyPRK group. The mean age was 55.43 ± 4.6 years. Uncorrected binocular distance visual acuity was 0.030 ± 0.05 logMAR in the presbyLASIK group and 0 logMAR in the presbyPRK group (P = .066). Binocular near visual acuity without correction was 0.21 ± 0.11 logMAR in the presbyLASIK group and 0.30 ± 0.15 logMAR in the presbyPRK group (P = .0398). For the dominant eyes, the SE was −0.08 ± 0.48 diopters (D) in the presbyLASIK group and 0.16 ± 0.82 D in the presbyPRK group (P = .3995). For nondominant eyes, the SE was −0.44 ± 0.50 D in the presbyLASIK group and 0.12 ± 0.65 D in the presbyPRK group (P = .0254).

Conclusions:

PresbyPRK and presbyLASIK were comparable in efficacy, stability, predictability, and safety. PresbyPRK could be a safe and effective surgical alternative for the hyperopic presbyopic patient.
Knot-free suture scleral fixation of dislocated intraocular lenses: clinical results of a novel surgical technique
Authors: Genç Selim , Esen Fehim
Published: December 2020

Purpose:

To describe and report surgical outcomes of a novel, knot-free technique to manage dislocated intraocular lenses (IOLs).

Setting:

Beyoglu Eye Education and Research Hospital, Istanbul, Turkey.

Design:

Retrospective observational clinical study.

Methods:

The files of 47 patients were retrospectively reviewed, and the patients who had a follow-up time of 6 months or more were included in this study. The surgery of every case was watched for the surgical complications and calculation of the surgical time. The postoperative complications and success rate were specifically tabulated.

Results:

Thirty-five eyes of 35 patients were included in this study (23 men, 12 women; mean age 63.1 ± 19.2 years). The mean follow-up time was 22.5 ± 9.9 months. The mean surgical time was 28.2 ± 6.8 minutes. Corrected distance visual acuity improved significantly after surgery (P = .001). Anatomic success rate was 97.1% after a single surgery. Most common complications included transient intraocular pressure (IOP) elevation (n = 2), persistent IOP elevation (n = 1), mild IOL tilt (n = 1), mild IOL decentration (n = 1), secondary IOL dislocation requiring intervention (n = 1), transient corneal edema (n = 1), and bullous keratopathy (n = 1).

Discussion:

Knot-free suture scleral fixation of dislocated IOLs was a minimally invasive approach for the management of dislocated IOLs and required only two 20-gauge corneal incisions without the need for scleral flaps or incisions. This technique had a low complication rate and delivered successful results in most cases.
Repeatability of intraoperative Hartmann-Shack wavefront sensing in cataract surgery
Authors: Georgiev Stefan , Hirnschall Nino , Fişuş Andreea-Dana , Ruiss Manuel , Hienert Julius , Leisser Christoph , Findl Oliver
Published: December 2020

Purpose:

To evaluate the repeatability of aphakic intraoperative wavefront aberrometry and compare it with preoperative and postoperative aberrometry.

Setting:

Department of Ophthalmology, Hanusch Hospital, Vienna, Austria.

Design:

Prospective case series.

Methods:

Patients scheduled for cataract surgery were each measured 3 consecutive times using Hartmann-Shack wavefront sensing (HS-WFS) preoperatively, intraoperatively in aphakia, and 2 months postoperatively after intraocular lens implantation by a single examiner. Intraclass correlation coefficients (ICCs) of spherical equivalent (SE) values were evaluated for each timepoint. Intrasubject standard deviation (Sw) as repeatability (Sr) with corresponding repeatability limit (

) and mean SE differences with corresponding limits of agreement (LoA) were calculated for comparison.

Results:

A high consistency of repeated measurements was found with ICCs above 0.9 for each of the 3 timepoints. Intraobserver repeatability (Sr) and repeatability limit (r) of intraoperative aberrometry SE measurements (30 eyes of 30 patients) were 0.34 diopters (D) and 0.95 D, respectively. The LoA for intraoperative aphakic SE across 3 consecutive measurements were −0.71 to +0.85 D. For comparison, Sr and r for phakic preoperative measurements in the cataractous state (30 eyes of 30 patients) and postoperative measurements in the pseudophakic state (24 eyes of 24 patients) were 0.33 D and 0.93 D and 0.23 D and 0.64 D, respectively. Similarly, the LoA for preoperative and postoperative SE measurements were −0.66 to +0.60 D and −0.27 to +0.45 D, respectively.

Conclusions:

HS-WFS test–retest reliability was high for all 3 timepoints, but the intraoperative setting resulted in a lower repeatability and broadened the agreement range.
Telehealth technology: Reducing barriers for rural residents seeking genetic counseling
Authors: Rhoads Sarah , Rakes Anna Laura
Published: December 2020

Many rural residents do not receive genetic counseling or testing when needed because of health care access barriers, such as lack of providers in rural areas and the requirement for rural residents to travel to larger cities for these services. Telehealth technology can reduce these barriers by allowing rural residents to receive genetic counseling through a two-way interactive audio/video secure connection in a local clinic setting or in their homes. Telegenetics is a satisfactory solution for both patient and provider and provides benefits for rural patients despite ethical, legal, and reimbursement considerations.
Peak Flow in Model Aorta Through Bi-Leaflet Mechanical Heart Valve with Varying Orientation
Authors: Satheesh Kumar H. , Sharma Shailendra D.
Published: December 2020

This study aims to numerically investigate the effect of bi-leaflet mechanical heart valve (BMHV) orientation on flow pattern in a realistic human aorta model with branches. The aorta model geometry is based on anatomical shape and dimensions involving aortic arch with twist and branches. Unsteady numerical simulations have been carried out to investigate the peak systolic flow in aorta through a BMHV installed at three different orientations, marked as 0°, 45°, and 90°. Velocity, vorticity, and strain fields were obtained in various cross sectional planes for all the cases to examine the spatial flow evolution starting from the sinus along the aortic arch. The valve leaflets were seen to produce small-scale stream wise contra-rotating vortices. These vortices changed their positions around the axis of aorta while advecting from one cross-sectional plane to another; thereby, clearly indicating swirl in the aortic flow. The net viscous dissipation energy loss (EL), obtained from strain field, was found to rise because of the presence of BMHV. The increase in the EL varied depending on the valve orientation as it changed from 43% for 0° to a maximum of 53% for 90° compared with no valve case. Similarly, the wall shear stress registered an increase by up to 4 Pa in the ascending aorta because the presence of BMHV; however, no significant effect of the valve orientation was noticed.
Adequate duration of therapy in severe fungal infections
Authors: Bassetti Matteo , Giacobbe Daniele R. , Berruti Marco , Del Puente Filippo , Vena Antonio
Published: December 2020

Purpose of review

To highlight recent findings on the adequate duration of antifungal therapy in patients with invasive fungal disease (IFD).

Recent findings

Plenty of published data available suggest that there is no additional clinical benefit at a certain point after initiation of antifungal treatment in patients with confirmed IFD. Moreover, the prolonged antifungal exposure can be associated with an increased risk of side effects and toxicity as well as striking risk for developing antifungal resistance or rising unnecessary healthcare costs. Recent data suggest that, in the presence of an adequate initial antifungal therapy and adequate source control of the infection, new stratified approaches integrating clinical judgment, biomarkers and microbiological eradication, should be considered as an alternative to the ‘one-size-fits-all’ treatment duration currently used worldwide.

The optimal duration of antifungal therapy is still an unresolved issue that depends by many key elements including the host; the pathogen and its microbiological eradication, the adequateness of initial antifungal therapy and the promptness of source control of the infection. In general, many patients with invasive candidiasis can be treated with a 2 weeks course of antifungal therapy. Longer antifungal course (6 weeks or more) is generally required for patients with invasive aspergilosis.
Monitoring the patient for a safe-assisted ventilation
Authors: Yoshida Takeshi , Fujino Yuji
Published: December 2020

Purpose of review

A growing evidence shows that injurious spontaneous breathing, either too weak or too strong, may injure lung and diaphragm. The purpose of review is to understand why we need monitoring for safe spontaneous breathing, and to know the target value of each monitoring to preserve safe spontaneous breathing during assisted ventilation.

Recent findings

Lung protection sometimes goes counter to diaphragm protection. For instance, silence of respiratory muscle activity is necessary to minimize lung injury from vigorous spontaneous effort in acute respiratory distress syndrome, but it may also have a risk of diaphragm atrophy. Thus, our current goal is to preserve spontaneous breathing activity at modest level during assisted ventilation. To achieve this goal, several monitoring/techniques are now available at the bedside (e.g., plateau pressure measurement, airway occlusion pressure, end-expiratory airway occlusion, esophageal balloon manometry, electrical impedance tomography). The target value of each monitoring is vigorously being investigated, facilitating ‘safe’ spontaneous breathing effort from the perspective of lung and diaphragm protection.

We summarize why we need monitoring for safe spontaneous breathing during assisted ventilation and what the target value of each monitoring is to facilitate ‘safe’ spontaneous breathing during assisted ventilation.
Bedside noninvasive monitoring of mechanically ventilated patients
Authors: Via Gabriele , Vasques Francesco , Hussain Arif , Barrett Nicholas A. , Camporota Luigi
Published: December 2020

Purpose of review

Among noninvasive lung imaging techniques that can be employed at the bedside electrical impedance tomography (EIT) and lung ultrasound (LUS) can provide dynamic, repeatable data on the distribution regional lung ventilation and response to therapeutic manoeuvres.

In this review, we will provide an overview on the rationale, basic functioning and most common applications of EIT and Point of Care Ultrasound (PoCUS, mainly but not limited to LUS) in the management of mechanically ventilated patients.

Recent findings

The use of EIT in clinical practice is supported by several studies demonstrating good correlation between impedance tomography data and other validated methods of assessing lung aeration during mechanical ventilation. Similarly, LUS also correlates with chest computed tomography in assessing lung aeration, its changes and several pathological conditions, with superiority over other techniques. Other PoCUS applications have shown to effectively complement the LUS ultrasound assessment of the mechanically ventilated patient.

Bedside techniques – such as EIT and PoCUS – are becoming standards of the care for mechanically ventilated patients to monitor the changes in lung aeration, ventilation and perfusion in response to treatment and to assess weaning from mechanical ventilation.
Preparedness of ICU networks for pandemics
Authors: Florio Gaetano , Zanella Alberto , Pesenti Antonio
Published: December 2020

Purpose of review

The recent COVID-19 outbreak has clearly shown how epidemics/pandemics can challenge developed countries’ healthcare systems. Proper management of equipment and human resources is critical to provide adequate medical care to all patients admitted to the hospital and the ICU for both pandemic-related and unrelated reasons.

Recent findings

Appropriate separate paths for infected and noninfected patients and prompt isolation of infected critical patients in dedicated ICUs play a pivotal role in limiting the contagions and optimizing resources during pandemics. The key to handle these challenging events is to learn from past experiences and to be prepared for future occurrences. Hospital space should be redesigned to quickly increase medical and critical care capacity, and healthcare workers (critical and noncritical) should be trained in advance.

A targeted improvement of hospital and ICU protocols will increase medical care quality for patients admitted to the hospital for any clinical reasons during a pandemic.
Hospital care: improving outcomes in type 1 diabetes
Authors: Boeder Schafer , Kulasa Kristen
Published: December 2020

Purpose of review

Caring for patients with type 1 diabetes (T1D) in the hospital presents unique challenges. This review provides an update on significant issues relevant to the inpatient management of T1D. Topics include trends in diabetic ketoacidosis (DKA), hypoglycemia, and adapting ambulatory technologies for inpatient use.

Recent findings

Rates of DKA in the United States are rising. Although socioeconomic status, health insurance coverage, and hemoglobin A1c are persistently associated with DKA in individuals with T1D, newer risk factors have also emerged. These include the off-label use of sodium-glucose cotransporter inhibitor medications, immune checkpoint inhibitor-induced diabetes, and infection with severe acute respiratory syndrome coronavirus 2. Hypoglycemia is common among hospitalized patients with T1D. Use of validated hypoglycemia risk prediction models and multidisciplinary care initiatives can reduce the risk of inpatient hypoglycemia. Finally, continuous glucose monitoring is being adapted for use in the hospital setting and has shown promise during the coronavirus disease 2019 (COVID-19) pandemic.

Evidence-based treatment algorithms, risk prediction calculators, multidisciplinary interventions, and wearable technology hold promise for improved outcomes in hospitalized patients with T1D.
The COVID-19 pandemic: impact on NHS England PET-CT services and lessons learnt
Authors: Wong Wai Lup , Ross Peter , Peters Kevin , Frenz Marion , Hai Tong , Ridgeon Alex , Toop Ralph , Strouhal Peter , Bomanji Jamshed
Published: December 2020

Purpose

The purpose of the study was to examine the impact of the first wave of COVID-19 on National Health Service (NHS) 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET-CT) scanning activity across England.

Methods

Monthly FDG PET-CT scanning activity was collected from 41/48 NHS England provider sites. Data from 31/41 sites were stratified by nononcology/oncology, cancer type, with lung cancer and lymphoma split into specific indications, turn-around times and delays due to radiotracer.

Results

In April and May 2020, a 32 and 31% decrease in activity was observed, a larger decrease for noncancer compared with cancer FDG PET-CT. In June 2020, activity started to recover with 6% fewer scans recorded compared with June 2019. Of the six most common indications, lung and oesophageal cancer had the largest decrease in activity and slowest recovery. Lymphoma and melanoma showed the smallest decrease and fastest recovery. Lung cancer scans for initial diagnosis/staging saw the largest fall and slowest recovery compared with scans for known lung cancer. There was no percentage increase in overall turn-around time compared with the same months in 2019, and no increase in turn-around time of more than 7 working days due to FDG supply during April and May 2020 compared with the 3 previous months.

Conclusions

There is no correlation between FDG PET-CT activity (fall and recovery) in England and the ability to provide the service by NHS England. It most likely reflects a combination of changes in health-seeking behaviour, NHS health policy and a decrease in the use of investigations that carry a high risk of COVID-19 transmission.
Mechanisms of autoimmune hepatitis
Authors: Cardon Anaïs , Conchon Sophie , Renand Amédée
Published: December 2020

Purpose of review

Autoimmune hepatitis (AIH) is a chronic disease characterized by a lymphocyte infiltrate in the liver. For decades, nonspecific immunosuppression has been used to limit chronic liver inflammation. The high risk of relapse, the treatments side effects, and the significant number of refractory patients are the main clinical issues that require efforts to understand AIH immune mechanisms.

Recent findings

The balance between regulatory CD4 T cells, known to control autoimmunity, and effector CD4 T cells, that recognize liver self-antigens and mediate the liver inflammation, appears central in AIH immune mechanisms. Recent advances in the identification of pathogenic auto-reactive CD4 T cells, and of new mechanisms of immune regulatory defects in AIH patients, give new insights into the pathophysiology of this disease.

In this review, we propose an overview of the central role of CD4 T cells (both regulatory and pathogenic) in mechanisms of AIH, with a focus on recent advances regarding defective regulatory mechanisms and immune profile of auto-reactive CD4 T cells. These findings may have implication for the orientation of new therapeutic strategies to treat AIH, such as regulatory T-cell infusion or targeting B cells and cytokines released by pathogenic CD4 T cells.
Deep dive to the secrets of the PREDIMED trial
Authors: Fernández-Lázaro César I. , Ruiz-Canela Miguel , Martínez-González Miguel Ángel
Published: December 2020

Purpose of review

The aim of this study was to briefly summarize the contribution of the PREDIMED (PREvención con DIeta MEDiterránea) trial on cardiovascular evidence and examine in depth its groundbreaking trajectory.

PREDIMED was conducted during 2003–2010 and represented the largest primary prevention trial ever testing the effects of changes in a complete food pattern (namely, the Mediterranean diet) on cardiovascular disease (CVD). Major contributions relied on the relevant changes in the food pattern attained by the behavioural intervention and their robust effect in reducing hard clinical end-points. Given some potential concerns, which were appropriately addressed with supporting analyses, this review is timely and relevant.

Recent findings

PREDIMED has continued contributing to the existing literature with extensive, robust and abundant new evidence on the benefits of the Mediterranean diet, particularly on cardiovascular health, including recent studies using high-throughput metabolomic techniques. After robustly addressing some controversies, the conclusions of the original trial remained unaltered.

The Mediterranean diet represents an effective and robust nutritional strategy against CVD in high cardiovascular risk populations. Recent findings from the PREDIMED have identified a metabolic signature of the Mediterranean diet that can objectively determine dietary adherence and predict CVD risk. This metabolomic signature opens up a new era for nutritional epidemiology and personalized nutrition.
Updates in techniques for improved visualization in sinus surgery
Authors: Khanwalkar Ashoke R. , Welch Kevin C.
Published: December 2020

Purpose of review

Adequate visualization during endoscopic sinus surgery (ESS) is one of the most critical aspects of performing well tolerated and successful surgery. The topic of visualization encompasses a broad spectrum of preoperative and intraoperative manoeuvres the surgeon can perform that aid in the understanding of the patient's anatomy and in the delivery of efficient surgical care.

Recent findings

Preoperative considerations to improve visualization include optimization of haemostasis through management of comorbidities (e.g. hypertension, coagulopathies), medication management (e.g. blood thinners) and systemic versus topical corticosteroids. New technologies allow preoperative visual mapping of surgical plans. Advances in knowledge of intraoperative anaesthesia have encouraged a move toward noninhaled anaesthetics to reduce bleeding. High definition cameras, angled endoscopes, 3D endoscopes and more recently augmented reality, image-guided surgery, and robotic surgery, represent the state of the art for high-quality visualization. Topical interventions, such as epinephrine, tranexamic acid and warm isotonic saline, can help to reduce bleeding and improve the operative field. Surgical manoeuvres, such as polyp debulking, septoplasty, carefully controlled tissue manipulation and a consistent repeatable approach remain fundamental to appropriate intraoperative surgical visualization.

This chapter delineates medical, technical and technological means – preoperatively and intraoperatively – to achieve optimized visualization of the surgical field in ESS.
Adolescent hip dysplasia: what are the symptoms and how to diagnose it
Authors: Ellsworth Bridget K. , Sink Ernest L. , Doyle Shevaun M.
Published: December 2020

Purpose of review

Adolescent and young adult hip dysplasia is a cause of hip pain which can lead to early hip osteoarthritis. This may result in early hip osteoarthrosis and possible total hip arthroplasty if dysplasia is not recognized and treated. Hip dysplasia in this population can be difficult to diagnose. It is important for primary care providers and pediatricians to recognize the symptoms, physical examination findings, and radiographic findings associated with adolescent hip dysplasia so that the patient can be referred to an orthopedist specializing in hip disorder. The current review includes the most up-to-date literature on the diagnosis of adolescent hip dysplasia.

Recent findings

Recent studies have shown that most patients presenting with symptomatic hip dysplasia present with insidious onset hip pain localized to either the groin or lateral aspect of the hip in a C-shape distribution around the inguinal crease. Patients most commonly see several different providers and have pain for a long period prior to accurate diagnosis. There are myriad radiographic measurements of hip dysplasia, many of which are described below that are helpful in initial diagnosis.

Adolescent and young adult hip dysplasia can be a cause of early, progressive hip osteoarthritis. Hip dysplasia is a term that represents a spectrum of disorder due to abnormal formation of the hip joint, resulting in an acetabulum that does not sufficiently cover the femoral head. The ability to recognize symptoms, physical examination findings, and radiographic evidence of adolescent hip dysplasia is critical so that the patient can be referred to the appropriate provider and receive timely treatment prior to the onset of degenerative hip disease. This article will focus mainly on the diagnosis of adolescent hip dysplasia. The standard for treatment of acetabular dysplasia in skeletally mature patients is the periacetabular osteotomy; however, nonoperative management and occasionally arthroscopic surgery can also be considered in cases of symptomatic borderline dysplasia.
Pediatric orthopedic mythbusters: the truth about flexible flatfeet, tibial and femoral torsion, W-sitting, and idiopathic toe-walking
Authors: Honig Evan L. , Haeberle Heather S. , Kehoe Clare M. , Dodwell Emily R.
Published: December 2020

Purpose of review

Myths, widely held but false or unproven beliefs, exist in pediatric orthopedics, with the most common examples related to flexible flatfeet, in-toeing/out-toeing, W-sitting, and toe-walking. Concerns regarding these findings and suggested treatments, unfounded in science, may be passed along verbally or published through various media, without citation. The current review investigates these myths and provides up to date recommendations on diagnosis and treatment (or lack of necessary treatment) for these common pediatric orthopedic findings.

Recent findings

Orthotics used in childhood do not alter foot development for flexible flatfeet. W-sitting is not associated with developmental dysplasia of the hip, and there is no scientific evidence to support that it leads to contractures, hip dislocations, or functional deficits.

Misinformation about normal variants of growth in childhood and suggested treatments are rampant and can be found published through various media without citation, as supportive scientific studies do not exist or existing studies refute the claims. Flexible flatfeet, in-toeing/out-toeing, W-sitting, and toe-walking typically improve throughout childhood without intervention. Physical therapy, orthotics and bracing have not been proven effective. Treatment is required in rare scenarios and should be directed by the orthopedic surgeon.
Systems biology approaches in solid organ transplantation
Authors: Kurian Sunil M. , Whisenant Thomas C. , Marsh Christopher L.
Published: December 2020

Purpose of review

Organ transplantation research has led to the discovery of several interesting individual mechanistic pathways, molecules and potential drug targets but there are still no comprehensive studies that have addressed how these varied mechanisms work in unison to regulate the posttransplant immune response that drives kidney rejection and dysfunction.

Recent findings

Systems biology is a rapidly expanding field that aims to integrate existing knowledge of molecular concepts and large-scale genomic and clinical datasets into networks that can be used in cutting edge computational models to define disease mechanisms in a holistic manner. Systems biology approaches have brought a paradigm shift from a reductionist view of biology to a wider agnostic assessment of disease from several lines of evidence. Although the complex nature of the posttransplant immune response makes it difficult to pinpoint mechanisms, systems biology is enabling discovery of unknown biological interactions using the cumulative power of genomic data sets, clinical data and endpoints, and improved computational methods for the systematic deconvolution of this response.

An integrative systems biology approach that leverages genomic data from varied technologies, such as DNA sequencing, copy number variation, RNA sequencing, and methylation profiles along with long-term clinical follow-up data has the potential to define a framework that can be mined to provide novel insights for developing therapeutic interventions in organ transplantation.
Cardiac evaluation of the kidney or liver transplant candidate
Authors: Levy Paul Emile , Khan Sadiya S. , VanWagner Lisa B.
Published: December 2020

Purpose of review

As the field of transplant has advanced, cardiac events have become the leading cause of morbidity and mortality after liver and kidney transplantation ahead of graft failure and infection. This trend has been bolstered by the transplantation of older and sicker patients who have a higher burden of cardiovascular risk factors, accentuating the need to determine which patients should undergo more extensive cardiac evaluation prior to transplantation.

Recent findings

Computed tomography coronary angiography with or without coronary artery calcium scoring is now preferred over stress imaging in most transplant candidates for assessment of coronary artery disease. Assessment of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended, particularly in liver transplant candidates who are at high risk of cirrhotic cardiomyopathy, for which new diagnostic criteria were recently published in 2019.

Cardiac evaluation of liver and kidney transplant candidates requires a global assessment for both short and long-term risk for cardiac events. Imaging of cardiac structure and function using transthoracic echocardiography with tissue doppler imaging and strain imaging is recommended. Risk stratification should consider both the anatomic and functional consequences of coronary artery disease in transplant candidates.

Video abstract

http://links.lww.com/MOT/A27