Repetitive negative thinking as a unique transdiagnostic risk factor for suicidal ideation

Repetitive negative thinking (RNT) is a transdiagnostic symptom observed across mood and anxiety disorders and is characterized by frequent, distressing thoughts that are perceived as uncontrollable. Specific forms of RNT have been linked to increased suicide risk. However, most work examining links between RNT and suicide has been conducted within specific disorders and subtypes of RNT (e.g., rumination in individuals with depression). The present study aimed to investigate associations between transdiagnostic RNT and suicidal ideation. We hypothesized RNT would be associated with suicide risk beyond disorder-specific clinical symptoms. Fifty-four participants with mood, anxiety, and/or traumatic stress disorders completed an interview assessing suicidal risk (Columbia-Suicide Severity Rating Scale (C-SSRS)) and self-report questionnaires assessing transdiagnostic RNT, depression, and anxiety. Based on C-SSRS, we divided participants into high or low suicide risk groups. We analyzed the relationship between suicidal risk group and RNT and found that RNT was uniquely associated with suicidal risk group, controlling for depression and anxiety severity. Our results suggest including assessments of RNT may have clinical utility for understanding the degree of suicide risk in individuals and point to the potential utility of including clinical interventions to target this symptom for those at high risk of suicide.

Is Minimally Invasive Spinal Surgery Superior to Endoscopic Spine Surgery in Postoperative Radiologic Outcomes of Lumbar Spine Degenerative Disease? A Systematic Review

BACKGROUND

 Minimally invasive spinal surgery (ESS) are both well-established surgical techniques for lumbar spinal stenosis; however, there is limited literature comparing the efficacy of the two techniques with respect to radiologic decompression data.

METHODS

 In this review, PubMed, Google Scholar, and Scopus databases were systematically searched from inception until July 2022 for studies that reported the radiologic outcomes of endoscopic and minimally invasive approaches for decompressive spinal surgery, namely, the spinal canal area, neural foraminal area, and neural foraminal heights.

RESULTS

 Of the 378 articles initially retrieved using MeSH and keyword search, 9 studies reporting preoperative and postoperative spinal areas and foraminal areas and heights were finally included in our review. Of the total 581 patients, 391 (67.30%) underwent MISS and 190 (32.70%) underwent ESS. The weighted mean difference between the spinal canal diameter in pre- and postoperative conditions was 56.64 ± 7.11 and 79.52 ± 21.31 mm2 in the MISS and ESS groups, respectively. ESS was also associated with a higher mean difference in the foraminal area postoperatively (72 ± 1 vs. 35.81 ± 11.3 mm2 in the MISS and ESS groups, respectively), but it was comparable to MISS in terms of the foraminal height (0.32 ± 0.037 vs. 0.29 ± 0.03 cm in the MISS and endoscopic groups, respectively).

CONCLUSIONS

 Compared with MISS, ESS was associated with improved radiologic parameters, including spinal canal area and neural foraminal area in the lumbar spinal segments. Both techniques led to the same endpoint of neural decompression when starting with a more severe compression. However, the present data do not allow the correlation of the radiographic results with the related clinical outcomes.

Hyperglycaemia is a causal risk factor for upper limb pathologies

BACKGROUND

Diabetes (regardless of type) and obesity are associated with a range of musculoskeletal disorders. The causal mechanisms driving these associations are unknown for many upper limb pathologies. We used genetic techniques to test the causal link between glycemia, obesity and musculoskeletal conditions.

METHODS

In the UK Biobank's unrelated European cohort (N = 379 708) we performed mendelian randomisation (MR) analyses to test for a causal effect of long-term high glycaemia and adiposity on four musculoskeletal pathologies: frozen shoulder, Dupuytren's disease, carpal tunnel syndrome and trigger finger. We also performed single-gene MR using rare variants in the GCK gene.

RESULTS

Using MR, we found evidence that long-term high glycaemia has a causal role in the aetiology of upper limb conditions. A 10-mmol/mol increase in genetically predicted haemoglobin A1C (HbA1c) was associated with frozen shoulder: odds ratio (OR) = 1.50 [95% confidence interval (CI), 1.20-1.88], Dupuytren's disease: OR = 1.17 (95% CI, 1.01-1.35), trigger finger: OR = 1.30 (95% CI, 1.09-1.55) and carpal tunnel syndrome: OR = 1.20 (95% CI, 1.09-1.33). Carriers of GCK mutations have increased odds of frozen shoulder: OR = 7.16 (95% CI, 2.93-17.51) and carpal tunnel syndrome: OR = 2.86 (95% CI, 1.50-5.44) but not Dupuytren's disease or trigger finger. We found evidence that an increase in genetically predicted body mass index (BMI) of 5 kg/m2 was associated with carpal tunnel syndrome: OR = 1.13 (95% CI, 1.10-1.16) and associated negatively with Dupuytren's disease: OR = 0.94 (95% CI, 0.90-0.98), but no evidence of association with frozen shoulder or trigger finger. Trigger finger (OR 1.96 (95% CI, 1.42-2.69) P = 3.6e-05) and carpal tunnel syndrome [OR 1.63 (95% CI, 1.36-1.95) P = 8.5e-08] are associated with genetically predicted unfavourable adiposity increase of one standard deviation of body fat.

CONCLUSIONS

Our study consistently demonstrates a causal role of long-term high glycaemia in the aetiology of upper limb musculoskeletal conditions. Clinicians treating diabetes patients should be aware of these complications in clinic, specifically those managing the care of GCK mutation carriers. Upper limb musculoskeletal conditions should be considered diabetes complications.

Image-guided Interstitial Brachytherapy in the Treatment of Primary and Recurrent Vulvovaginal Gynaecological Malignancies

AIMS

To evaluate the use, outcomes and toxicities of high dose rate brachytherapy (HDRB) to the vulvovaginal region in previously irradiated and radiotherapy-naïve patients for primary or recurrent gynaecological malignancies.

MATERIALS AND METHODS

From January 2010 to December 2020, 94 women with a median age of 64 years (range 31-88 years) were treated with interstitial HDRB for vulvovaginal disease. Treatment details, including cumulative radiotherapy doses, were recorded together with reported toxicity, using Common Terminology Criteria for Adverse Events (CTCAE) grading. Dosimetric parameters, including D90, V100 and V150 together with treatment response at 3 months, overall survival, relapse-free survival and long-term toxicity data, were collated from referring centres.

RESULTS

The median follow-up was 78 months (range 2-301). Primary sites of disease included vagina (37), endometrium (29), vulva (16), ovary (7) and cervix (5). Eighty-six (91.5%) patients were treated with curative intent, eight (8.5%) were palliative treatments. Fifty patients received HDRB for recurrent disease, 39 patients for primary disease and five as part of adjuvant treatment. The anatomical site of disease treated with HDRB ranged from vagina (76), vulva (14) and peri-urethral sites (four). The 2- and 5-year local relapse-free survival rates were 76% and 72%, respectively; 15 patients experienced local failure only, whereas six patients had local and nodal/distant failure. The median time to local recurrence was 8 months (range 2-88 months). The 2- and 5-year overall survival rates for all patients were 67% and 47%, respectively; the median overall survival was 59 months. Seventy-nine (84%) patients had a complete response measured with imaging at 3 months. Grade 3 toxicity was reported in 14 patients (14.8%).

CONCLUSION

This retrospective series suggests the use of interstitial brachytherapy for vulvovaginal gynaecological malignancy to be an effective and safe treatment option. Good local control was achieved with a tolerable toxicity profile; it is a valuable treatment modality.

Application of the model-informed drug development paradigm to datopotamab deruxtecan dose selection for late-stage development

To replace the conventional maximum tolerated dose (MTD) approach, a paradigm for dose optimization and dose selection that relies on model-informed drug development (MIDD) approaches has been proposed in oncology. Here, we report our application of an MIDD approach during phase I to inform dose selection for the late-stage development of datopotamab deruxtecan (Dato-DXd). Dato-DXd is a TROP2-directed antibody-drug conjugate being developed for advanced/metastatic non-small cell lung cancer (NSCLC) and other tumors. Data on pharmacokinetics (PKs), efficacy, and safety in NSCLC were collected in the TROPION-PanTumor01 phase I dose-expansion and -escalation study over a wide dose range of 0.27-10 mg/kg administered every 3 weeks. Population PK and exposure-response analyses were performed iteratively at three data cutoffs to inform dose selection. The 6 mg/kg dose was identified as the optimal dose by the second data cutoff analysis and confirmed by the subsequent third data cutoff analysis. The 6 mg/kg dose was more tolerable (i.e., lower rates of interstitial lung disease, stomatitis, and mucosal inflammation) than the MTD (8 mg/kg) and was more efficacious than 4 mg/kg (simulated mean objective response rate: 23.8% vs. 18.6%; mean hazard ratio of progression-free survival: 0.74) - a candidate dose studied just below 6 mg/kg. Therefore, the 6 mg/kg dose was judged to afford the optimal benefit-risk balance. This case study demonstrated the utility of an MIDD approach for dose optimization and dose selection.

Outcomes of Patients with a Mechanical Heart Valve and Poor Anticoagulation Control on Warfarin

BACKGROUND

 Patients with a mechanical heart valve (MHV) require oral anticoagulation. Poor anticoagulation control is thought to be associated with adverse outcomes, but data are limited.

OBJECTIVE

 To assess the risks of clinical outcomes in patients with a MHV and poor anticoagulation control on warfarin.

PATIENTS/METHODS

 We conducted a retrospective study of consecutive patients undergoing MHV implantation at a tertiary care center (2010-2019). Primary outcome was a composite of ischemic stroke, systemic embolism, or prosthetic valve thrombosis. Major bleeding and death were key secondary outcomes. We constructed multivariable regression models to assess the association between time in therapeutic range (TTR) on warfarin beyond 90 days after surgery with outcomes.

RESULTS

 We included 671 patients with a MHV (80.6% in aortic, 14.6% in mitral position; mean age 61 years, 30.3% female). Median follow-up was 4.9 years, mean TTR was 62.5% (14.5% TTR <40%, 24.6% TTR 40-60%, and 61.0% TTR >60%). Overall rates of the primary outcome, major bleeding, and death were 0.73, 1.41, and 1.44 per 100 patient-years. Corresponding rates for patients with TTR <40% were 1.31, 2.77, and 3.22 per 100 patient-years. In adjusted analyses, every 10% decrement in TTR was associated with a 31% increase in hazard for the primary outcome (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.13-1.52), 34% increase in major bleeding (HR: 1.34, 95% CI: 1.17-1.52), and 32% increase in death (HR: 1.32, 95% CI: 1.11-1.57).

CONCLUSION

 In contemporary patients with a MHV, poor anticoagulation control on warfarin was associated with increased risks of thrombotic events, bleeding, and death.

DENTAL CAVITIES IN PEOPLE WITH TYPE 2 DIABETES MELLITUS: AN ANALYSIS OF RISK INDICATORS

Diabetes is associated with a greater number of dental cavities. It is unclear, therefore, how potential risk factors such as salivary glucose, glycemic control and blood sugar could impact the onset of dental caries between people that have type 2 diabetes (T2D). Aim of the study - analyzing the risk factors for oral cavity disease in T2D patients. We analyzed the patient data including their dietary habits, dental hygiene practices, age and control of glycemic. The Indian dataset was used. Individual patient observations include the patient's diabetes classification as a range of medical attributes such as age, pregnancy, pedigree, glucose, body mass index, skin, blood pressure and insulin. The research discovered a significant correlation between poorly managed glycemic levels and dental caries are more prevalent in people with T2DM. High sugar consumption and poor oral hygiene habits have been identified as risk factors. These results highlight the need for integrating diabetes treatment measures with dental care to reduce dental caries in this susceptible group. Utilizing dental cavities into account improves oral health and has a positive impact on health outcomes for those with type 2 diabetes.

INVESTIGATING THE EFFECT OF NICOTINE FROM CIGARETTES ON THE GROWTH OF ABDOMINAL AORTIC ANEURYSMS: REVIEW

Separating aneurysmal arterial disease from atherosclerosis and further occlusive artery conditions, it is a vascular degenerative disorder. Within the vascular tree, there is a regionalization of the propensity to produce aneurysms and the different locations result in different clinical processes. As the predominant risk factor for ubrenal abdominal aortic aneurysm (AAA), smoking is one of the most common manifestations of aneurysmal illness. For AAA compared to atherosclerosis, smoking is a far bigger risk factor. Along with contributing to the pathophysiology of AAA, smoking raises the likelihood that established AAA will rupture as well as its rate of expansion. The development of improved models for animals that are reliant on smoke or smoke constituents is helping to determine the mechanistic connection between AAA and smoking. According to the processes, there are long-lasting changes in the function of inflammatory and vascular smooth muscle cells. Focused on AAA, this review looks at the medical, epidemiology and mechanical evidence that links smoking to aneurysms.

Public Health Data Applications Using the CDC Tracking Network: Augmenting Environmental Hazard Information With Lower-Latency NASA Data

Exposure to environmental hazards is an important determinant of health, and the frequency and severity of exposures is expected to be impacted by climate change. Through a partnership with the U.S. National Aeronautics and Space Administration, the U.S. Centers for Disease Control and Prevention's National Environmental Public Health Tracking Network is integrating timely observations and model data of priority environmental hazards into its publicly accessible Data Explorer (https://ephtracking.cdc.gov/DataExplorer/). Newly integrated data sets over the contiguous U.S. (CONUS) include: daily 5-day forecasts of air quality based on the Goddard Earth Observing System Composition Forecast, daily historical (1980-present) concentrations of speciated PM2.5 based on the modern era retrospective analysis for research and applications, version 2, and Moderate Resolution Imaging Spectroradiometer (MODIS) daily near real-time maps of flooding (MCDWD). Data integrated into the CDC Tracking Network are broadly intended to improve community health through action by informing both research and early warning activities, including (a) describing temporal and spatial trends in disease and potential environmental exposures, (b) identifying populations most affected, (c) generating hypotheses about associations between health and environmental exposures, and (d) developing, guiding, and assessing environmental public health policies and interventions aimed at reducing or eliminating health outcomes associated with environmental factors.

Tumor treating fields for the treatment of glioblastoma: Current understanding and future perspectives

Background

This review focuses on the recently published evidence on tumor treating fields (TTFields) administered alone or in combination with locoregional and systemic options for treating glioblastoma (GBM) in the past ten years. The aim is to critically summarize the novelty and results obtained with this innovative tool, which is becoming part of the armamentarium of neurosurgeons and neuro-oncologists.

Methods

A comprehensive search and analysis were conducted on pivotal studies published in the past ten years. Furthermore, all completed clinical trials, whose results were published on clinicaltrials.gov, were examined and included in the present review, encompassing both recurrent (r) and newly diagnosed (n) GBM. Finally, an additional examination of the ongoing clinical trials was also conducted.

Results

Recent trials have shown promising results both in patients with nGBM and rGBM/progressive (rGBM), leading to Food and Drug Administration approval in selected patients and the Congress of Neurological Surgeons to include TTFields into current guidelines on the management of GBM (P100034/S001-029). Recently, different randomized trials have demonstrated promising results of TTFields in combination with standard treatment of n- and rGBM, especially when considering progression-free and overall survival, maintaining a low rate of mild to moderate adverse events.

Conclusion

Optimal outcomes were obtained in nGBM and progressive disease. A possible future refinement of TTFields could significantly impact the treatment of rGBM and the actual standard of care for GBM, given the better safety profile and survival effects.

EARLY IMPLANT OUTCOMES IN ADULTS WITH DENTAL DECAY TREATED WITH PHOTODYNAMIC TREATMENT

A fast implant is a kind of implant to place in the cavity right away after dental extraction. These implants are shown to maintain cervical marrow and reduce the number of surgery operations required for patients. The Photodynamic treatment (PDT) uses antimicrobial processes to supplement nonsurgical periodontal therapy. Combined through the scaling and root planning (SRP), and PDT is more effective. This study aims to assess the effects of PDT on initial findings with dental implants (DI) placed in patients having gum disease with SRP against patients who do not at the 12-month follow-up point. An aggregate of 25 implants were inserted in 16 patients, 12 of whom were in the test group (TG) and 13 of whom were in the control group (CG). SRP is conducted toward rapid implant assignment in the control site, while PDT as an adjunct to SRP (SRP + PDT) is executed prior to instant implant insertion in test sites. At the beginning, 4 months, 8 months, and 12 months, gingival index, radiovisiographs, inquiring pocket intensity, clinical attachment level, and plaque index were obtained. Basic durability was assessed after implant insertion, and the recovery index was measured a week later. In this analysis, Analysis of Variance (ANOVA) technique is used to predict tooth decay earlier. The CG experienced 1.10 mm of mean marginal bone loss after the 12-month research period, compared to 0.97 mm for the (SRP + PDT) group. After reaching the CG and TG, the differences in plaque score and probe depth were noteworthy. Clinical indicators compared to the basis in a year revealed unquestionable improvement, including the probing depth gingival index, plaque index and clinical attachment level. Twelve months were spent monitoring the implants in both groups. The little bone loss improved, although it isn't clinically important. The endurance rate for rapid implants in the PDT grouping is the same as that of the group that underwent SRP. The impact of PTD is utilized as a supplement to SRP. Yet, the consequence is marginal. Because of the improved results with PDT, it is used successfully as an addition to SRP.

INNOVATIONS IN FOCUS: MECHANISTIC DISEASE THEORIES, CLIMATE DYNAMICS, AND HOST-PARASITE ADAPTATIONS

Infectious illnesses are predicted to experience a range of intricate responses from climate change, with some likely to rise, others to fall and many expected to undergo changes in prevalence. The study uses extensive data on global temperature variations and infectious illness transmission in people and animals. We now know a lot more about how the temperature changes across the world and whether or not the spread of infectious diseases impacts people as well as animals. Three primary topics of research are investigated in this paper: improving mechanical disease modelling, investigating the role of environmental variation in sickness dynamics, and understanding the consequences of temperature imbalances between parasites and hosts. By incorporating the latest data stemming from these advancements into weather-disease models and bridging critical knowledge gaps, enhancing our ability to forecast the probable effect of rising temperatures on the prevalence of diseases among both human and animal communities is possible. Through the establishment of important information gaps and the incorporation of new findings into models of climate-disease relationships, it will be possible to predict the effects of changes in climatic averages, variations and extremes on people and wildlife health.

A Phase I Trial of Focal Salvage Stereotactic Body Radiation Therapy for Radiorecurrent Prostate Cancer

PURPOSE/OBJECTIVE(S)

Locally recurrent prostate cancer after radiotherapy (RT) is an increasingly recognized entity with no standard management. NCT03253744 was a phase I trial with a primary objective of identifying the maximally tolerated dose (MTD) of a course of image-guided, focal, salvage stereotactic body radiotherapy (SBRT) for patients with local recurrence after prior definitive RT. Additional objectives included biochemical control and imaging response on mpMRI and 18F-DCFPyL (PSMA) PET/CT.

MATERIALS/METHODS

SBRT was prescribed to three dose levels (DLs): 40Gy (DL1), 42.5Gy (DL2), and 45Gy (DL3) in 5 fractions. The prescription dose was delivered to a PTV defined by mpMRI and PSMA imaging and biopsy confirmed tumor volume. Dose escalation followed a 3+3 design with a 3-patient expansion at the MTD. Toxicities above baseline were scored using CTCAE v5.0 criteria for two years after completion of SBRT. Escalation was halted if 2 dose limiting toxicities (DLTs) were observed. DLTs were defined as any persistent (>4 days) grade 3 toxicity occurring within the first 3 weeks after SBRT, and any grade 3 GU or grade 4 GI toxicity thereafter. Imaging response was compared between baseline and 6-months by the Wilcoxon signed rank test.

RESULTS

Between 08/2018 and 05/2022, 8 patients underwent salvage SBRT to 11 intraprostatic lesions with a median follow-up of 27 months. No DLTs were observed on DL1. Two patients were enrolled on DL2 and both experienced grade 3 GU toxicities, prompting de-escalation and expansion (n = 6) on DL1, the MTD. The most common toxicities were grade 2 GU toxicities: acute urinary urgency/frequency, acute weak urinary stream, and noninfective cystitis. One patient at DL1 had a self-limited episode of grade 2 GI toxicity (proctitis). No grade 3 GI toxicities were observed. All but two patients achieved an undetectable PSA nadir. Only one of these experienced biochemical failure (nadir + 2.0) at 33 months with suspicion of distant metastatic failure on restaging PET/CT. Imaging response was demonstrated by MRI in all lesions with heterogeneity in volumetric response (6% to 100%). A significant (p<0.01) response on PSMA PET/CT was observed for all measured parameters (SUVMax, SUVMean, GTVPSMA, Total Lesion PSMA [SUVMean × GTVPSMA]). Of the 11 lesions, 1 (9%) demonstrated a complete response (CR) by MRI and 9 (82%) by PSMA PET/CT. A single lesion increased in volume by 0.06 cc (16%) at 6-month PSMA PET/CT compared to baseline in the only patient who did not achieve an undetectable PSA nadir and did not have imaging suggestive of distant failure.

CONCLUSION

On this phase I dose escalation study of salvage SBRT for isolated intraprostatic local failure after definitive RT, the MTD was 40Gy in 5 fractions. producing a 100% 24-month bPFS, with one late failure at 33 months occurring after the 24-month study period. The most frequent clinically significant toxicity was late grade 2 GU toxicity. Imaging response was demonstrated in all lesions on MRI and PSMA PET/CT with exception of a single lesion.

Patterns of Locoregional Pancreatic Cancer Recurrence after Total Neoadjuvant Therapy and Implications on Optimal Neoadjuvant Radiation Treatment Volumes

PURPOSE/OBJECTIVE(S)

Neoadjuvant treatment for patients with localized pancreatic adenocarcinoma (PDAC) has improved survival duration. As survival increases, local disease control becomes even more important. We sought to understand the patterns of locoregional recurrence following total neoadjuvant therapy (TNT) and determine the impact of treatment volumes on recurrence.

MATERIALS/METHODS

Patients with PDAC managed with neoadjuvant chemotherapy and chemoradiation (TNT) followed by surgery who developed an isolated locoregional or simultaneously locoregional and distant recurrence were identified. Locoregional recurrences were individually contoured utilizing commercially available software. When available, original neoadjuvant dose distributions were registered to the scans on which the locoregional recurrences were contoured. Recurrences where then classified as in-field (> 95% of prescription dose), marginal (50-95% of prescription dose), or out of field (< 50% of prescription dose). Target volumes were created using four commonly utilized PDAC contouring guidelines to characterize the relationship of the local recurrence to the RT dose distribution.

RESULTS

Of 474 patients treated with TNT and surgery, 80 (17%) patients developed a locoregional recurrence with or without distant recurrence, visible on diagnostic imaging. Of the 80 patients, 56 (70%) had tumors in the pancreatic head; 46 (57.5%) were borderline resectable, 23 (28.8%) locally advanced, and 11 (13.6%) resectable. The most common initial neoadjuvant therapies were FOLFIRINOX (57.5%) and gemcitabine/nab-paclitaxel (18.8%). Chemoradiation included concurrent gemcitabine (47.5%) or 5-fluorouracil (26.3%). RT dose distributions were available for 38 patients; 22 (57.9%) had in-field failures, 9 (23.7%) marginal failures, and 7 (18.4%) out of field failures. Each published contouring atlas covered a relatively low percentage of recurrences, which are summarized in Table 1. Regions at particularly high likelihood of recurrence that were under covered on existing atlases included: aortic-diaphragmic junction, retro-pancreatic duodenal nodal basin, and the region to the right of the superior mesenteric artery (SMA).

CONCLUSION

We present the largest series (to our knowledge) of mapped locoregional recurrences for patients being treated with TNT in PDAC. These recurrences differ substantially from established atlases and highlight anatomical regions of highest priority for RT coverage. A novel visual contouring volume highlighting these regions will be presented which will strive to advance the use of RT in the TNT setting.

Functional endoscopic sinus surgery: assessing the readability and quality of online information

INTRODUCTION

The aim of this study was to assess the readability and quality of online information on functional endoscopic sinus surgery (FESS).

METHODS

The term 'functional endoscopic sinus surgery' was entered into the Google, Bing and Yahoo search engines. The first 30 websites for each search engine were screened. Readability was assessed using the Flesch-Kincaid Reading Ease Score (FRES), Flesch-Kincaid Grade (FKG), Simple Measure of Gobbledygook (SMOG) Index, and Gunning Fog Index (GFI). Quality was assessed using the DISCERN instrument. Spearman's correlation between quality and readability was calculated.

RESULTS

Thirty-three websites met the inclusion criteria. The mean and standard deviations for the FRES, FKG, SMOG, GFI, and DISCERN scores were 49 (13.1), 10.9 (2.5), 10.2 (1.9), 13.6 (2.4), and 51.1 (12.8), respectively. A positive correlation was noted between the FRES and DISCERN (R=0.357, p=0.041).

CONCLUSIONS

Online information on FESS is generally written above the recommended reading levels and of fair quality.

Pathogenesis and management of multiple sclerosis revisited

BACKGROUND

Multiple sclerosis is an autoimmune chronic inflammatory disease characterized by selective destruction of myelin in the CNS neurons (including optic nerve). It was first described in the 19th century and remained elusive owing to the disease's unique relapsing and remitting course. The widespread and debilitating prevalence of multiple sclerosis (MS) has prompted the development of various treatment modalities for its effective management.

METHODS AND OBJECTIVES

A literature review was conducted using the electronic databases PubMed and Google Scholar. The main objective of the review was to compile the advances in pathogenesis, classifications, and evolving treatment modalities for MS.

RESULTS

The understanding of the pathogenesis of MS and the potential drug targets for its precise treatment has evolved significantly over the past decade. The experimental developments are also motivating and present a big change coming up in the next 5 years. Numerous disease-modifying therapies (DMTs) have revolutionized the management of MS: interferon (IFN) preparations, monoclonal antibodies-natalizumab and ocrelizumab, immunomodulatory agents-glatiramer acetate, sphingosine 1-phosphate receptor 1 (S1PR1) modulators (Siponimod) and teriflunomide. The traditional parenteral drugs are now available as oral formulations improving patient acceptability. Repurposing various agents used for related diseases may reinforce the drug reserve to manage MS and are under trials. Although at a nascent phase, strategies to enhance re-myelination by stimulating oligodendrocytes are fascinating and hold promise for better outcomes in patients with MS.

CONCLUSIONS

The recent past has seen staggering inclusions to the management of multiple sclerosis catalyzing a significant turnabout in our approach to diagnosis, treatment, and prognosis. Since the advent of DMTs various other oral and injectable agents have been approved. The advances in MS therapeutics and diagnostics have laid the ground for further research and development to enhance the quality of life of afflicted patients.

ADVANCEMENTS IN MINIMALLY INVASIVE SURGERY: A COMPREHENSIVE ANALYSIS OF ROBOTIC SURGERY, ENDOSCOPIC TECHNIQUES, AND NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY

The term "Natural Orifice Transluminal Endoscopic Surgery" (NOTES) defines a surgical approach that leverages the body's natural orifices to access the abdominal cavity, presenting a patient-centric perspective by highlighting its potential to eliminate abdominal wall aggression, mitigate postoperative discomfort, and offer benefits comparable to laparoscopic surgery. This comprehensive paper aims to not only review the existing landscape of NOTES techniques but also to propose advancements in flexible tools augmenting established endoscopic platforms, while also exploring the revolutionary concept of robotic structures grounded in micromechatronics and communication technologies. The thorough analysis encompasses the assessment of advantages and limitations associated with flexible devices and robotic platforms, coupled with an in-depth evaluation of the current array of devices used in NOTES, informed by pertinent literature. The authors' comprehensive approach entails scrutinizing technological breakthroughs and offering viable solutions, fostering a comprehensive understanding. Furthermore, the study encompasses an exhaustive evaluation and juxtaposition of state-of-the-art NOTES devices, supplemented by a nuanced discourse on the merits and demerits of flexible devices and robotic platforms, with a focused emphasis on their inherent strengths and weaknesses. Within this context, the discourse extends to strategic suggestions aimed at refining extant designs and cultivating robust, dependable autonomous robotic platforms purpose-built for NOTES. This narrative encapsulates the multifaceted exploration of benefits, challenges, and potential remedies directed towards enhancing prevailing designs and forging a dependable foundation for the future of NOTES.

POSTCHOLECYSTECTOMY SYNDROME: UNDERSTANDING THE CAUSES AND DEVELOPING TREATMENT STRATEGIES FOR PERSISTENT BILIARY SYMPTOMS AFTER GALLBLADDER REMOVAL

Persistent biliary symptoms following gallbladder removal, known as postcholecystectomy (PCS), can significantly impact patients' quality of life. The term PCS describes biliary symptoms that emerge or continue after the surgical removal of the gallbladder. Cholecystectomy is generally a safe procedure; however, some individuals may still experience symptoms of the biliary system thereafter. Biliary stones are more likely to be retained in patients who arrive later. Many of those people won't have a known reason for their condition. Therefore, this group will have fewer therapy alternatives. After a cholecystectomy, up to 10% of individuals may develop PCS. Patients with cholecystectomy procedures can appear with extra-biliary and associated biological illnesses. A wide range of therapeutic options are available for PCS, each having a different chance of being the cause of the condition. The purpose of this study is to present an overview of the many causes of PCS, as well as the effectiveness and prevalence of various treatments. PCS has a variety of etiologies, many of which may be related to extra-biliary reasons that may exist before the operation. From the beginning, an endoscopy of the upper gastrointestinal tract may be necessary when symptoms first appear. Biliary rocks are more likely to be retained in patient presentations that are postponed. PCS has various causes, including extra-biliary conditions that could have existed before operations. Initial symptoms might involve higher digestive problems. As a result, this group will only have a few therapeutic alternatives.

INNOVATIONS IN ORTHOPEDIC SURGERY: MINIMALLY INVASIVE TECHNIQUES FOR JOINT REPLACEMENT AND REPAIR

The scientists compared the outcomes of a minimally invasive operation approach (MIO) to a conventional poster lateral (PL) method in overall hip replacement (OHR) in terms of itchiness, damage to muscles, and bleeding. The factors that researchers examined were the levels of Haemoglobin (Hg), a marker for oxygen depletion, the quantity of Interleukin-6 (IL6), a marker for inflammation, the heart-type fatty acid binding protein (HTFABP), and the health of the muscles. The study's findings showed that IL6 content increased beyond pre-operative levels as a result of the two surgeries. At 6 hours after surgery, the mean IL6 concentration in the PL group was 79.6 pg/ml while in the MIO group it was 76.4 pg/ml. The highest values after 24 hours of therapy were 100 pg/ml in the PL group and 92.3 pg/ml in the MIO category. In each category, IL6 levels had dropped up to this point. The post-operative mean HTFABP concentration in the MIO organization was greater (12.5 mg/l) than in the PL organization (18.3 mg/l) in terms of muscle damage. One day after surgery, however, it reached an apex and began to decline in both groups. The amounts of Hg lost throughout the procedure decreased for both sets. 12.5 g/dl of mercury was present. The MIO grouping had PL 72 hours following a procedure, while the PL grouping had 10.3 g/dl. Between the two surgical methods, there were no obvious differences in bleeding, muscle damage, or edema. These results led the researchers to draw the conclusion that there were little differences between the MIO anterior method and the traditional PL technique in terms of muscle damage, blood loss, or irritability. The lack of a learning curve in the study may account for the lack of alterations seen, they hypothesized, rendering the use of the term "MIO" in describing the approach as less traumatizing dubious. The study's methodology, sample sizes, and all other relevant material were left out, making it impossible to evaluate the study's validity and generalizability in its entirety.

LAPAROSCOPIC APPROACH TO A GIANT RUPTURED SPLENIC CYST: A CHALLENGING CASE REPORT

Splenic cysts are rare; their absence of an epithelial wall determines whether they're real cysts or pseudocysts. Spontaneous nonparasitic actual tumors are those that develop early in life at the anterior pole of the splenic and are typically epidermoid, dermoid, or endodermal. Surgical therapy is suggested for symptomatic, large (more than 5 cm) cysts or complicated. Inhaling splenic excision is a substitute for surgery, depending on the quantity, location, connection to the hilus, and dimension of the tumors. With an emphasis on less invasive treatments that preserve the spleen, laparoscopic methods have already established themselves as the accepted method for treating numerous disorders, including splenic cysts. They describe the effective decapsulation of a massive epidermoid spleen tumor under a prolonged, partially endoscopic technique. Laparoscopy, an operation commonly referred to as surgery with minimally invasive or keyhole surgery, is a technique that makes many tiny incisions in the belly to carry out different surgical procedures.

In silico interrogation of the miRNAome of infected hematopoietic cells to predict processes important for human cytomegalovirus latent infection

Human cytomegalovirus (HCMV) latency in CD34+ progenitor cells is the outcome of a complex and continued interaction of virus and host that is initiated during very early stages of infection and reflects pro- and anti-viral activity. We hypothesized that a key event during early infection could involve changes to host miRNAs, allowing for rapid modulation of the host proteome. Here, we identify 72 significantly upregulated miRNAs and three that were downregulated by 6hpi of infection of CD34+ cells which were then subject to multiple in silico analyses to identify potential genes and pathways important for viral infection. The analyses focused on the upregulated miRNAs and were used to predict potential gene hubs or common mRNA targets of multiple miRNAs. Constitutive deletion of one target, the transcriptional regulator JDP2, resulted in a defect in latent infection of myeloid cells; interestingly, transient knockdown in differentiated dendritic cells resulted in increased viral lytic IE gene expression, arguing for subtle differences in the role of JDP2 during latency establishment and reactivation of HCMV. Finally, in silico predictions identified clusters of genes with related functions (such as calcium signaling, ubiquitination, and chromatin modification), suggesting potential importance in latency and reactivation. Consistent with this hypothesis, we demonstrate that viral IE gene expression is sensitive to calcium channel inhibition in reactivating dendritic cells. In conclusion, we demonstrate HCMV alters the miRNAome rapidly upon infection and that in silico interrogation of these changes reveals new insight into mechanisms controlling viral gene expression during HCMV latency and, intriguingly, reactivation.

Prior immunization against an intracellular antigen enhances subsequent red blood cell alloimmunization in mice

Antibodies against red blood cell (RBC) alloantigens can increase morbidity and mortality among transfusion recipients. However, alloimmunization rates can vary dramatically, as some patients never generate alloantibodies after transfusion, whereas others not only become alloimmunized but may also be prone to generating additional alloantibodies after subsequent transfusion. Previous studies suggested that CD4 T-cell responses that drive alloantibody formation recognize the same alloantigen engaged by B cells. However, because RBCs express numerous antigens, both internally and externally, it is possible that CD4 T-cell responses directed against intracellular antigens may facilitate subsequent alloimmunization against a surface RBC antigen. Here, we show that B cells can acquire intracellular antigens from RBCs. Using a mouse model of donor RBCs expressing 2 distinct alloantigens, we demonstrate that immune priming to an intracellular antigen, which would not be detected by any currently used RBC compatibility assays, can directly influence alloantibody formation after exposure to a subsequent distinct surface RBC alloantigen. These findings suggest a previously underappreciated mechanism whereby transfusion recipient responders may exhibit an increased rate of alloimmunization because of prior immune priming toward intracellular antigens.

FOXP3 TSDR Measurement Could Assist Variant Classification and Diagnosis of IPEX Syndrome

Pathogenic FOXP3 variants cause immune dysregulation polyendocrinopathy enteropathy X-linked (IPEX) syndrome, a progressive autoimmune disease resulting from disruption of the regulatory T cell (Treg) compartment. Assigning pathogenicity to novel variants in FOXP3 is challenging due to the heterogeneous phenotype and variable immunological abnormalities. The number of cells with demethylation at the Treg cell-specific demethylated region (TSDR) is an independent biomarker of IPEX. We aimed to investigate if diagnosing IPEX at presentation with isolated diabetes could allow for effective monitoring of disease progression and assess whether TSDR analysis can aid FOXP3 variant classification and predict disease course. We describe a large genetically diagnosed IPEX cohort (n = 65) and 13 individuals with other monogenic autoimmunity subtypes in whom we quantified the proportion of cells with FOXP3 TSDR demethylation, normalized to the number with CD4 demethylation (%TSDR/CD4) and compare them to 29 unaffected controls. IPEX patients presenting with isolated diabetes (50/65, 77%) often later developed enteropathy (20/50, 40%) with a median interval of 23.5 weeks. %TSDR/CD4 was a good discriminator of IPEX vs. unaffected controls (ROC-AUC 0.81, median 13.6% vs. 8.5%, p < 0.0001) with higher levels of demethylation associated with more severe disease. Patients with other monogenic autoimmunity had a similar %TSDR/CD4 to controls (median 8.7%, p = 1.0). Identifying increased %TSDR/CD4 in patients with novel FOXP3 mutations presenting with isolated diabetes facilitates diagnosis and could offer an opportunity to monitor patients and begin immune modulatory treatment before onset of severe enteropathy.

A42 LIVE DONOR LIVER TRANSPLANTATION IN PRIMARY SCLEROSING CHOLANGITIS: AN INDICATOR OF AN ORGAN ALLOCATION SYSTEM NOT ADDRESSING PATIENT NEED

Background

Liver transplantation is frequently lifesaving for people living with primary sclerosing cholangitis (PSC). However, patients are waitlisted for liver transplant (LT) according to the MELD-Na score, which may not accurately reflect the burden of living with PSC.

Purpose

We sought to describe and analyze the clinical trajectory for patients with PSC referred for LT, in a mixed deceased donor/live donor transplant programme.

Method

This was a retrospective cohort study from November 2012 to December 2019 including all patients with PSC referred for assessment at the University Health Network Liver Transplant Clinic. Patients who required multiorgan transplant or re-transplantation were excluded. Liver symptoms, hepatobiliary malignancy, MELD-Na progression, and death were abstracted from chart review. Competing Risk analysis was used for timing of LT, transplant type, and death.

Result(s)

Of 172 PSC patients assessed, 144 (84%) were listed, of whom 106/144 (74%) were transplanted. Mean age was 47.6 years and 66% were male. During follow-up through to 2021, 23/144 (16%) were removed from the waitlist due to infection, clinical deterioration, liver-related mortality or new cancer; 3 had clinical improvement. At the time of listing, 118/144 (81.95%) had a potential Living Donor (pLD) of whom 94 were transplanted: 64 live donor and 30 deceased donor. Patients with pLD had 79% lower mortality (p<0.001), and higher rates of transplantation (80% vs 46%). Exception points were granted to 13/172 (7.5%) patients.

Conclusion(s)

In a high-volume North American liver transplant centre, most patients with PSC assessed for transplant were listed and subsequently transplanted. However, this was a consequence of patients engaging in live donor transplantation. Our findings support the concern from patients with PSC that MELD-Na allocation does not adequately address their needs.

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CIHR, Other

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This study was supported by PSC Partners Canada, Canadian Institutes of Health Research (CIHR), Toronto General and Western Hospital Foundation.

Disclosure of Interest

None Declared

A141 DUPILUMAB IMPROVES CLINICAL, SYMPTOMATIC, ENDOSCOPIC, AND HISTOLOGIC ASPECTS OF EOE, REGARDLESS OF PRIOR SWALLOWED TOPICAL STEROID USE

Background

Swallowed topical corticosteroids (STC) are a first-line treatment for eosinophilic esophagitis (EoE) but are not uniformly effective. Dupilumab (DPL), a fully human monoclonal antibody, blocks the shared receptor component for IL-4/IL-13, key and central drivers of type 2 inflammation. In Parts A and B of the phase 3 LIBERTY-EoE-TREET (NCT03633617) study, weekly DPL 300mg improved clinical, symptomatic, histologic, and endoscopic aspects of EoE and was generally well tolerated in adult and adolescent patients (pts) with EoE.

Purpose

To assess the efficacy of weekly DPL 300mg vs placebo (PBO) at Week 24 in pts from Parts A and B with/without prior history of STC use, and from Part B with/without a history of inadequate response, intolerance, or contraindication to STCs.

Method

Pts who received STCs for EoE within 8 weeks prior to baseline were excluded from the study. Co-primary endpoints at Week 24 were the proportion achieving peak eosinophil count (PEC) ≤6/high-power field (hpf) and the absolute change in Dysphagia Symptom Questionnaire (DSQ) score. Other secondary endpoints at Week 24 included: % change in PEC; absolute change in Histologic Scoring System (HSS) grade and stage scores and Endoscopic Reference Score (EREFS); % change in DSQ score.

Result(s)

At baseline, in Parts A and B combined, 84/122 (69%) and 87/118 (74%) of DPL- and PBO-treated pts had history of STC use. For pts treated with DPL vs PBO PEC≤6/hpf was achieved by 59.5% vs 3.4% of pts with, and 57.9% vs 12.9% without, prior STC use. Difference vs PBO (95% CI) in the absolute change in DSQ score was −13.27 (−18.03, −8.50) vs −5.21 (−12.41, 2.00) for pts with/without prior STC use. Difference vs PBO (95% CI) for pts with/without prior STC use were: % change in PEC −80.76 (−97.77, −63.75)/−84.87 (−112.16, −57.58); absolute change in EoE-HSS grade −0.77 (−0.87, −0.66)/−0.57 (−0.77, −0.38) and stage −0.77 (−0.87, −0.66)/−0.55 (−0.73, −0.36); absolute change in EREFS −3.86 (−4.70, −3.02)/−2.59 (−4.16, −1.02); % change in DSQ −34.5 (−47.75, −21.22)/-14.9 (−35.21, 5.36). DPL was generally well tolerated in the intent-to-treat population; the most common TEAEs for DPL/PBO were injection-site reactions (37.7/33.3%). In Part B, 38/80 (48%) and 39/79 (49%) of DPL- and PBO-treated pts had inadequate response/intolerance/contraindication to STCs. For DPL vs PBO PEC≤6/hpf was achieved by 55.3% vs 7.7% with, and 61.9% vs 5.0% of pts without, inadequate response/intolerance/contraindication to STC. Difference vs PBO (95% CI) for absolute change in DSQ score was −11.55 (−19.06, −4.04)/−7.08 (−13.75, −0.42) for pts with/without inadequate response/intolerance/contraindication to STCs.

Conclusion(s)

Conclusion: Regardless of prior STC use, in this pooled analysis from Part A and Part B of the EoE TREET Phase 3 Study, weekly DPL 300mg demonstrated substantial improvements in clinical, histologic, and endoscopic study endpoints at Week 24 in adults and adolescents with EoE.

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Other

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Research sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.

Disclosure of Interest

A. Bredenoord Shareholder of: SST, Grant / Research support from: Bayer, Nutricia, SST, Consultant of: Arena Pharmaceuticals, AstraZeneca, Calypso Biotech, Dr Falk, EsoCap, Gossamer Bio, Laborie, Medtronic, RB Pharma, Regeneron Pharmaceuticals, Inc., Robarts Clinical Trials, E. Dellon Grant / Research support from: Research funding; Adare Pharma Solutions, Allakos, GSK, Meritage Pharma, Miraca Life Sciences, Nutricia, Receptos/BMS, Regeneron Pharmaceuticals, Inc., Shire. Educational grant; Allakos, Banner Pharmaceuticals, Holoclara, Consultant of: Abbott, Adare Pharma Solutions, Aimmune Therapeutics, Alivio Therapeutics, Allakos, Arena Pharmaceuticals, AstraZeneca, Banner Pharmaceuticals, Biorasi, Calypso Biotech, Enumeral, EsoCap, Gossamer Bio, GSK, Receptos/BMS, Regeneron Pharmaceuticals, Inc., Robarts Clinical Trials, Salix Pharmaceuticals, Shire/Takeda, A. Lucendo Grant / Research support from: Dr Falk, Regeneron Pharmaceuticals, Inc., Consultant of: Dr Falk, EsoCap, M. Collins Grant / Research support from: Receptos/BMS, Regeneron Pharmaceuticals, Inc., Shire, Consultant of: Allakos, AstraZeneca, BMS, EsoCap, Regeneron Pharmaceuticals, Inc., Shire, A. Khodzhayev Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., X. Sun Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., K. Patel Employee of: Sanofi, B. Beazley Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., A. Shabbir Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc.

A64 THE UPTAKE AND IMPACT OF AN ELECTRONIC CIRRHOSIS ADMISSION ORDER SET: AN EARLY EXPERIENCE AT A SINGLE CENTRE

Background

Cirrhosis is a chronic disease that confers high morbidity and mortality. It is a leading cause for hospital admissions and leads to significant healthcare resource utilization. Several guidelines outline recommendations to provide best practice to hospitalized patients with cirrhosis. Despite studies supporting a reduction in mortality when guideline based care is followed, this is achieved in less than 50% of hospitalized patients with cirrhosis¹. Standardized electronic order sets can be a potential tool to improving clinical outcomes and bridging this gap in care.

Purpose

Since March 2021, an electronic cirrhosis admission order set has been available for at our hospital site. Using administrative data, we aimed to describe our early experience with: a) order set uptake by various services, b) characteristics of the population in which the order set was used versus not used, and explore c) the impact of order set use on in-hospital mortality.

Method

In this single centre cohort study, patients with cirrhosis were identified based an administrative data algorithm containing codes for cirrhosis and complications. This data was used to retrieve parameters such as patient age, sex, primary admitting service, resource intensity weight (RIW), Charlson comorbidity index (CCI) and in-hospital mortality. The chi-squared test and independent samples t-test were used to compare characteristics of patients in whom the order set was used versus not used. Multivariable logistic regression was used to determine the impact of order set use on in-hospital mortality. P value significance was established at <0.05.

Result(s)

A total of 825 patients were included in the analysis. The overall mean age (standard deviation) of patients was 58.5 (14.2) years with 57.5% being male. Average length of stay was 11.3 days with a mean CCI of 3.2 (2.3) and RIW of 3.3 (7.2). The primary admitting service was Gastroenterology in 36.1%, Internal Medicine in 35.6% and other services in 28.3% of cases. Of those admitted, the order set was used in 27.2% of cases. The overall in-hospital mortality of patients was 14.2%.

Mean age, sex and CCI were not significantly different in patients admitted with the order set versus without. In patients admitted with the order set compared to without, RIW was significantly lower (2.06 (2.62) versus 3.80 (8.2), p<0.001), as was length of stay (9.5 (11.8) days compared to 12.0 (18.6) days, p =0.03) and in-hospital mortality (8.5% versus 16.3%, p =0.003). On multivariable regression analysis (Table 1), after adjustment for age, RIW and CCI, use of the order set was associated with lower in-hospital mortality (odds ratio 0.53 (95% CI 0.3 to 0.9), p=0.02).

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Conclusion(s)

Uptake of the electronic cirrhosis admission order set was modest at only 27% of eligible admissions. Although it appears to be associated with lower in-hospital mortality, a chart review is in process to assess if this association still holds after accounting for the impact of additional confounders.

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None

Disclosure of Interest

None Declared

Ischemic Colitis Secondary to Olanzapine and Clonidine Use in a Patient With a History of Laxative Abuse

Ischemic colitis is the most common type of intestinal ischemia and is caused by an acute arterial occlusion, thrombosis, or hypoperfusion of the mesenteric vasculature. This case centers around a 39-year-old female with a past medical history significant for a 20-year history of stimulant laxative abuse, chronic constipation, bipolar disorder, and anxiety that presented with ischemic colitis following 21 days of obstipation. At the time of presentation, the patient was taking olanzapine 15 mg daily for the treatment of bipolar disorder and clonidine 0.2 mg three times daily for anxiety. Over the course of her hospitalization, the patient was found to have a high stool burden, including calcified stool, contributing to ischemic colitis. She was successfully treated with a clonidine taper, multiple enemas, and laxatives. Pharmacological agents that induce constipation have been shown to increase the risk of colonic ischemia by increasing intraluminal pressure in the colon. Atypical antipsychotics block peripheral anticholinergic and anti-serotonergic receptors, limit gastrointestinal muscle contractions, and delay intestinal transit.

DSENet: Directional Signal Extraction Network for Hearing Improvement on Edge Devices

In this paper, we propose a directional signal extraction network (DSENet). DSENet is a low-latency, real-time neural network that, given a reverberant mixture of signals captured by a microphone array, aims at extracting the reverberant signal whose source is located within a directional region of interest. If there are multiple sources situated within the directional region of interest, DSENet will aim at extracting a combination of their reverberant signals. As such, the formulation of DSENet circumvents the well-known crosstalk problem in beamforming while providing an alternative and perhaps more practical approach to other spatially constrained signal extraction methods proposed in the literature. DSENet is based on a computationally efficient and low-distortion linear model formulated in the time domain. As a result, an important application of our work is hearing improvement on edge devices. Simulation results show that DSENet outperforms oracle beamformers, as well as state-of-the-art in low-latency causal speech separation, while incurring a system latency of only 4 ms. Additionally, DSENet has been successfully deployed as a real-time application on a smartphone.

Microdiscectomy for Lumbar Intervertebral Disc Prolapse: Is Fixation Required?

Introduction Microdiscectomy, as of now, is considered the gold standard for the treatment of herniated lumbar disc. It preserves motion at the spinal segment and does not alter the local spinal anatomy significantly, resulting in a “functional and mobile” spine. Development of increasingly better-quality implants has seen their indiscriminate use in cases without any demonstrable instability. We see an increasing number of patients of lumbar disc prolapse being treated by fixation and fusion procedures, without any clear indication or evidence supporting such practice. This adds to the operating time, blood loss, cost of surgery and leads to loss of motion at the spinal segment resulting in a “stiff and immobile spine.” Our 10-year experience of treating lumbar disc herniation by micro-discectomy makes a strong case for preserving the spinal motion segment wherever possible and to use fixation very judiciously only in cases of proven instability.

Materials and Methods A total of 295 cases of lumbar disc prolapse operated by the first author from January 2013 to April 2022 were analyzed. All the patients had unilateral or bilateral radicular pain. Preoperatively instability was ruled out by dynamic X-rays. All the patients were operated in prone position on Wilson's frame. Microdiscectomy was done through the inter-laminar space. Patient outcomes and complications were analyzed.

Results There was no mortality in our series. All the patients had significant relief of lower limb pain with improved visual analog scale scores postoperatively. The patients were followed up for 6 months. There were complications in 17 patients, all of which were treated successfully with a good outcome. None of the complications were attributable to failure of doing fixation.

Conclusion Lumbar disc prolapse can be treated effectively by microdiscectomy. Fixation should be reserved for only those cases with demonstrable preoperative instability.

Giant Parathyroid Adenoma: A Case Report

Parathyroid adenomas rarely weigh more than 4 grams. Our patient had a 5.3-gram adenoma causing bilateral knee pain limiting mobility, constipation, low back pain, and frontal headache. Presenting with calcium of greater than 17 mg/dl, the patient was treated with two rounds of hemodialysis, calcitonin, Zoledronate, and aggressive IV hydration to decrease calcium levels before parathyroidectomy. The patient then went on to develop the hungry bone syndrome, which was treated with calcium carbonate and calcitriol. This rare giant parathyroid adenoma presents a unique opportunity to learn about the pathogenesis and treatment of longstanding hyperparathyroidism causing hypercalcemia-associated symptoms and hungry bone syndrome after parathyroidectomy.

The Use of Palliative Radiotherapy in the Treatment of Lung Cancer

There have been significant advances in the systemic treatment of stage IV lung cancer, which is now recommended first line in patients with adequate fitness. This includes some patients with brain metastases due to the increased understanding of the central nervous system penetration of targeted therapies. The trials evidence base for palliative radiotherapy pre-dated this routine use of systemic therapy in our practice, which means that the sequence and role of palliative radiotherapy are not currently well defined in the first-line treatment setting. However, due to its efficacy in symptom control, radiotherapy remains a core component in the palliative management of lung cancer, particularly in the second-line setting and those unsuited to primary systemic treatment. This overview focuses on the evidence behind palliative radiotherapy to the thorax and brain for non-small cell and small cell lung cancer and the potential for future studies, including the TOURIST Trial Platform, to guide the future direction of these treatments.