Operative Techniques in Otolaryngology-Head and Neck Surgery

Locoregional flaps in pediatric anterior skull base surgery Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Christopher Pool, Neerav Goyal, Jessyka G. Lighthall Management of skull base defects involves the separation of the cranial cavity from the nasal cavity in order to prevent cerebrospinal fluid leak, pneumocephalus, and intracranial infection. The size and location of the defect as well as donor tissue available will determine the type of reconstruction. Reconstruction options include free tissue grafts, locoregional flaps, and microvascular free flaps. In children, the size of potential flaps must be considered as well as the length of the pedicle, as often these differ in children. This article will discuss numerous reconstructive options, focusing on locoregional flaps in skull base reconstruction. In addition to outlining the surgical technique for each type, we will review considerations in pediatric patients for each reconstructive option.

Special considerations for nasoseptal flap use in children Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Edward C. Kuan, Ryan M. Carey, James N. Palmer, Nithin D. Adappa The introduction of the vascularized pedicled nasoseptal flap has revolutionized endoscopic skull base surgery, providing a highly versatile option to repair even the most complex skull base defects. Though demonstrated with outstanding results in adult patients, there is limited experience in the pediatric population. Early investigation found that there are limitations in utilization of the nasoseptal flap in children due to craniofacial restrictions. More recently, these concerns have been mitigated, and nasoseptal flaps are reliably used in reconstructing even the largest skull base defects in the youngest patients. Preoperative planning and review of imaging and meticulous intraoperative dissection are essential for successful reconstructive outcomes.

Open anterior skull base surgery in the pediatric population: anatomy, approaches, and considerations Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Tristan Tham, Peter Costantino The objectives of this paper are to synthesize the existing literature on open approaches to the anterior skull base in children. First, we review the developmental anatomy of the anterior skull base. Next, we describe the most commonly used open approaches to the anterior skull base and other adjunctive procedures. Lastly, we review the reconstructive options and comment important pediatric-specific considerations. Our review reports the variety of open approaches to access the anterior skull base in children. Detailed preoperative planning, taking age-related considerations into account, is necessary in order to plan to type and extent of access and reconstruction.

Surgical management of clival chordomas in children Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Carl H. Snyderman, Paul A. Gardner, Elizabeth C. Tyler-Kabara Objective: Describe the surgical management of clival chordomas in the pediatric population, with an emphasis on techniques of endoscopic endonasal surgery. Finding: Endoscopic endonasal approaches to the clivus provide access from posterior clinoids to foramen magnum. The clivus is divided into thirds (superior, middle, and inferior), each with corresponding vascular and neural structures. The abducens nerve is at greatest risk for injury due to spread of tumor within the interdural space to Dorello's canal. Despite decreased pneumatization of the sinuses in pediatric patients, the same techniques can be applied to this population. The contralateral transmaxillary approach enhances the ability to achieve a gross total resection when tumor extends laterally into the petrous apex. A multi-layer reconstruction with vascularized tissue minimizes the risk of cerebrospinal fluid leak. Conclusion: Endoscopic endonasal surgery can be safely applied to the pediatric population and provides the best opportunity for complete surgical excision for most tumors.

Treatment of fibro-osseous lesions at the pediatric skull base Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Jeffrey C. Rastatter, Jeffrey Leonard, Patrick C. Walz Fibro-osseous lesions of the pediatric skull base are loosely associated group of bony lesions that are all uncommonly occurring clinical entities. Management differs significantly amongst the fibro-osseous lesions but clinical and radiographic presentation can overlap significantly. Fibro-osseous lesions include fibrous dysplasia, ossifying fibroma, osteoma, and aneurysmal bone cyst in addition to even less common lesions such as giant cell tumor of bone and osteosarcoma. In this chapter, the fibro-osseous lesions affecting the pediatric skull base will be reviewed with an emphasis on the clinical, radiographic, and management differences between diagnoses.

The endoscopic endonasal approach for pediatric craniopharyngiomas Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Ian J. Koszewski, Hermes G. Garcia, William Parkes, Chandala Chitguppi, Mindy R. Rabinowitz, Gurston G. Nyquist, James J. Evans, Marc R. Rosen Craniopharyngiomas are rare but challenging tumors of the ventral skull base affecting primarily pediatric patients. In select cases, the endoscopic endonasal approach represents an appropriate surgical option when tumor resection is favored. However, nuances of the pediatric nasal corridor must be carefully considered to optimize both tumor resection and skull base reconstruction. Here we review pertinent developmental details, options for creation of an optimal endonasal corridor, principles of tumor resection, and techniques for reconstruction. Considerations for intraoperative and postoperative patient care are also reviewed.

Endoscopic transsphenoidal pituitary surgery in children Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Edward C. Kuan, Phillip B. Storm, James N. Palmer, Nithin D. Adappa With increasing adoption of endoscopic techniques and improved knowledge of skull base anatomy and approaches, transsphenoidal pituitary surgery is now being performed on patients of all ages. Surgical principles are similar between pediatric and adult patients, but there are special considerations for the pediatric population in terms of instrumentation, surgical anatomy, and postoperative care. Wide exposure to the sella, oftentimes to accommodate multiple instruments and the endoscope, is frequently necessary. Persistent collaboration among the otolaryngology, neurosurgery, and anesthesiology teams is of critical importance to ensure optimal outcomes.

Pediatric skull base surgery: Encephaloceles and cerebrospinal fluid leaks Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Jacob G. Eide, Patrick Walz, Tord D. Alden, Jeffrey C. Rastatter In recent years, endoscopic endonasal approaches to the pediatric skull base have become an increasingly popular method for treatment of a variety of malignant and benign lesions. These approaches have largely evolved from experience in adult patients and can be an excellent alternative to open procedures in carefully selected patients. Pediatric encephaloceles can be addressed via open craniotomy, transpalatal, and endoscopic endonasal methods. The surgical approach should be dictated by the anatomy of the patient as well as the size and location of the encephalocele in question. Pediatric cerebrospinal fluid leaks can occur due to iatrogenic causes during skull base resections or sinus surgery, as well as from traumatic injury. Multiple options for repair of cerebrospinal fluid leaks exist, but endoscopic nasoseptal flaps are among the most commonly utilized reconstruction options.

Surgical management of juvenile nasopharyngeal angiofibroma Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Meghan N. Wilson, Daniel W. Nuss, Brad E. Zacharia, Carl H. Snyderman Juvenile nasopharyngeal angiofibromas are benign yet aggressive anterior skull base tumors that occur almost exclusively in male adolescents. Diagnosis is typically made through radiographic findings and clinical characteristics; biopsy is not recommended due to the vascular nature of the disease. As with most tumors, there is a spectrum of tumor extent and invasion. In juvenile nasopharyngeal angiofibromas, one of the most important components of extent is the vascular supply. Once the vascular supply is identified, a systematic approach to resection can be planned. The majority of these tumors can be excised endoscopically, and those approaches are the focus of this article.

Surgical management of nasal dermoid lesions Publication date: March 2019 Source: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume 30, Issue 1 Author(s): Craig Miller, Scott Manning, Randall Bly Nasal dermoids are the most common congenital midline nasal lesions. They often present as a midline pit or nasal mass and arise from incomplete or failed regression of the dural diverticulum during embryogenesis. Management requires complete resection of the tract and an appropriate surgical approach is based on location, extent, and presence and/or degree of intracranial extension. Classically requiring an open craniotomy for resection, newer strategies employ a minimally disruptive approach to fully excise the lesion and the tract to prevent recurrence. This article presents details on embryology, imaging work up, and surgical technique for resection of these lesions either via an open approach or with an endoscopic-assisted method.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Atherosclerosis

Achilles tendon ultrasonography – A useful screening tool for cardiovascular risk estimation in patients with severe hypercholesterolemia Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): Sandra Kutkienė, Žaneta Petrulionienė, Aleksandras Laucevičius, Rimantė Čerkauskienė, Artūras Samuilis, Virginija Augaitienė, Aurelija Gedminaitė, Gintarė Bieliauskienė, Akvilė Šaulytė-Mikulskienė, Justina Staigytė, Emilija Petrulionytė, Urtė Gargalskaitė, Eglė Skiauterytė, Gabija Matuzevičienė, Milda Kovaitė, Irena Nedzelskienė Abstract Background and aims Achilles tendon lesions have long been associated with genetic defects in lipid metabolism and increased risk of cardiovascular diseases (CVD). With this study we aimed to evaluate the usefulness of Achilles tendon ultrasonography in identifying people at greater risk among subjects with severe hypercholesterolemia (SH) in a high-risk population. Methods During the period of 2016–2017 a total of 213 participants were enrolled in this case-control study. Data of 110 patients with SH and 103 age and sex matched controls without dyslipidaeplemia and established CVD was collected. Results Achilles tendinopathy (AT) was present in 42.7% of subjects with SH and in 29.1% of controls (p = 0.039). Stronger association between SH and AT was seen in women – 24.1% vs 2.0% (p = 0.001). SH increased odds of AT by 1.815 (95% CI, 1.028–3.206). Prevalence of AT was higher in males despite presence (SH+) or absence (SH−) of severe hypercholesterolemia (SH+ 60.7% vs 24.1%, SH− 55.8% vs 2.0%, p < 0.001). AT was associated with higher proportion of subjects exceeding normal mean values of TC (80.5% vs 52.9%, p = 0.001), LDL-C (76.6% vs 52.2%), TG (54.5% vs. 22.1%), ApoB (57.1% vs 22.2%), ApoE (44.0% vs 22.4%) levels and ApoB/ApoA ratio (46.1% vs 21.5%) (p = 0.001) and family history of premature coronary heart disease (CHD). Conclusions AT is more prevalent among subjects with SH and is associated with higher levels of TC, TG, LDL-C, ApoB, ApoE, ApoB/ApoA ratio, family history of premature CHD. SH increases the odds of developing AT.

Investigating the association between familial hypercholesterolemia and perceived depression Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): Nien-Tzu Chang, Ta-Chen Su Abstract Background and aims Inherited familial hypercholesterolemia (FH) increases cardiovascular risks, but perceived depression in FH is unknown. This study aims to explore the association between the FH and perceived depression. Methods This study was a hospital-based design, we started to recruit clinical diagnosis of phenotypic FH since 2014 for the Ten Countries Study in the Asia-Pacific region. We consecutively recruited 302 FH patients and other 414 comparison subjects (214 subjects with hypertriglyceridemia and 200 subjects with normal lipid controls) from the special lipid clinic of National Taiwan University Hospital, Taipei. All participants received cardiovascular health examinations and completed a self-reported questionnaire, including the Center for Epidemiologic Studies Depression Scale (CES-D) for assessment of the psychosocial depression. Results Clinical FH patients had a higher risk of perceived depression, with an odds ratio (95% confidence intervals) of possible depression by 1.50 (1.07–2.11) and probable depression by 1.73 (1.10–2.75) than those of the non-FH groups after adjusted relevant cardiovascular risk factors. FH patients with a family history of coronary heart disease (CHD) had higher domain-specific depression scores than those of controls. In addition, this study found that FH patients with lower educational levels also had a higher risk of depression compared with those in control groups. Conclusions Patients with clinical phenotype of FH are associated with subjectively perceived depression, particularly among FH patients with a family history of CHD. Graphical abstract

Establishing a familial hypercholesterolaemia register - The first year Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): Myra Tilney Abstract Background and aims Familial hypercholesterolemia (FH) is an autosomal dominant condition raising the risk of premature cardiovascular disease up to twentyfold.[1] [2] It is under-diagnosed and undertreated, in spite of availability of effective treatment. Registers are recommended to assist in the recognition and improvement of the condition since treatment reduces morbidity and mortality. Disease registers enable longitudinal review and the application of continuous quality improvement methodology. The aims of this paper are to describe the process of setting up a new FH register in Malta based on phenotype, the preliminary results achieved, the barriers encountered, how these were overcome, and future plans for development. Methods The registry was established as an observational clinical study designed for a small healthcare system with limited resources. Effective process design requires attention to standards, capacity, outcome measurement and feedback, which have been incorporated. Results 43 individuals have been registered applying Dutch Lipid Clinic Network standards, including 9 Definite, 16 Probable and 18 Possible FH. Cascade testing has identified three younger, and one older FH individuals; amenable risk factors and target outcomes are available for feedback and action. Barriers included insufficient infrastructure, limited stakeholder involvement, time limitations impacting clinical care and data collection, poor recognition, awareness and referral, and limited cascade testing. Overcoming these required persistence, reorganizing clinical work, with some assistance from clinic nurses, forward planning to involve patients and raising FH awareness through presentations to various audiences. Conclusions During this year the register was established and is functional: awareness is being raised. Future steps will target process improvement for effectiveness and sustainability.

Percutaneous coronary intervention for a Chinese familial hypercholesterolemia homozygous under the guidance of optical coherence tomography Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): Zesen Liu, Jie Peng, Shilong Wang, Tao Jiang, Weicong Zhang, Chun Zhang, Yan Chen, Kang Meng, Jie Lin Abstract Homozygous familial hypercholesterolemia developed into severe cardiovascular consequences early. Untreated HoFH usually cannot survive over 30 years old. Acute coronary syndrome(ACS) caused by plaque rupture is one of the main causes of death in HoFH. As the highest resolution intravascular imaging technique, optical coherence tomography(OCT) can clearly show the thickness and structural characteristics of atherosclerotic plaque caps. In this study, a Chinese male HoFH received percutaneous coronary intervention for unstable angina. After analyzed his genetic and follow-up data, OCT was performed during interventional therapy. Multiple lipid rich plaques accompanied with inflammatory cell infiltration and a thin-cap fibroatheroma(TCFA) were noted, which reflected the vulnerability of plaques. The utility of OCT had certain guiding significance for strategy of interventional therapy and the long-term drug management. And this case suggested that it was important to undergo OCT examination for patients with HoFH who required percutaneous coronary intervention.

Familial hypercholesterolemia in China half a century: A review of published literature Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): Jie Peng, Xue Wu, Shilong Wang, Shuang Zhang, Xumin Wang, Zesen Liu, Jing Hong, Pucong Ye, Jie Lin Abstract Aims To investigate the status of familial hypercholesterolemia (FH) research and the characteristics of patients with FH in China. Methods Published papers in Chinese or English language from PubMed, SinoMed and CNKI databases from 1971 to March 2018 were searched using 'Familial hypercholesterolemia', 'Chinese' and 'Han' as keywords. A systematic review of studies on familial hypercholesterolemia was then conducted. Results A total of 391 articles were found, in which 22% were in English and 78% were in Chinese; approximately 43% are case reports and 34% are genetic reports according to the study type; 52% discussed the status of the disease and 11% investigated the subclinical status according to the study content. Furthermore, 96% of the articles were published by tertiary hospitals and 46% were conducted by cardiologists. The first expert consensus was issued in February 2018. Of the 163 case reports published before 2018, 48.7% used the Chinese FH clinical diagnostic criteria and 34.4% did not clearly indicate the diagnostic criteria. The incidence rates of low-density lipoprotein receptor (LDLR) and apolipoprotein B (APOB) mutations were 82% and 9%, and proprotein convertase subtilisin/kexin type 9 (PCSK9) mutations were rare in Chinese patients with FH. However, the data on lipid-lowering treatment rates, compliance rates and cardiovascular events in FH remain insufficient. Conclusions Large-scale epidemiological investigation of FH has not been demonstrated, the recognition of FH remains rudimentary, and the guidelines are incomplete in China. The diagnosis and management of Chinese FH needs to be improved.

Variable expression and penetrance in Portuguese families with Familial Hypercholesterolemia with mild phenotype Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): I.M. Gaspar, A. Gaspar Abstract Familial hypercholesterolemia is an Mendelian dominant disorder characterized by defects of the low density lipoprotein receptor (LDLR) that result in a defective removal of LDL from plasma, which promotes deposition of cholesterol in the skin (xanthelasma), tendons (xanthomas), and arteries (atherosclerosis). Diagnosis severe clinical phenotype FH with Dutch Lipid Clinic Network Criteria, encompassing history of premature ASCVD, tendon xanthomas, and a family history of hypercholesterolemia and premature ASCVD in relatives is rare in the Portuguese FH patients. There is a variability of the phenotype in FH individuals with clinical diagnosis or genetic mutation (carriers and patients) probably due to environmental factors in the last century, a Mediterranean diet, or a diet without fat food, trans fat food, no smoking, no sedentary life that can interfere with our metabolism, or are consequences of polygenic, epigenetic, acquired defects, modifiers genes and beta-globin asymptomatic carriers. We have several concepts/mechanisms in genetics that are transversal to hereditary diseases and common in FH, such as somatic mosaicism, germinal mosaicism, variable expression and variable penetrance of mutations. A negative blood genetic test result does not exclude FH, because the pathogenic LDLR mutation can be expressed only in the liver (a mutation in somatic tissue) or occasionally there is a vertical transmission from partner to future child by a mutation on germinal line - germinal mosaicism. Unlike north European countries, the most FH carriers and patients had less severe phenotypes, for example with have children and young adult carriers with LDL-R mutation had normal TC and LDL-C, old women had a milder phenotype without ASCVD events, tendon xanthomas are seen in <1% patients, and most homozygous FH patients are under combined therapy.

The frequency of familial hypercholesterolemia amongst patients in the outpatient clinic of the tertiary specialized cardiology center in Kyrgyzstan Publication date: March 2019 Source: Atherosclerosis Supplements, Volume 36 Author(s): O.S. Lunegova, A.E. Mirrakhimov, E. Hodzhiboboev, E.E. Bektasheva, K.V. Neronova, U.M. Toktomamatov, U. Zakirov, A. Asanbaev, R.A. Arapova, S.S. Abilova, A.S. Kerimkulova, E.M. Mirrakhimov Abstract Background Familial hypercholesterolemia (FH) is frequently underdiagnosed. Prevalence of the FH in Kyrgyzstan is unknown. Aim to investigate the prevalence of FH amongst patients in the outpatient settings of the tertiary cardiologic center in Kyrgyzstan. Methods Retrospective observational study was conducted using the database of the laboratory of biochemistry and electronic database of outpatient department of the National Center of Cardiology and internal diseases. Patient with the level of total cholesterol (TC) ≥7,5 mmol/l and/or low density lipoprotein cholesterol (LDL-C) ≥ 4,9 mmol/l without signs of secondary hyperlipidemia were included in the analysis. FH was defined using Dutch Lipid Clinic Network criteria. Results according to the laboratory database levels of TC and LDL-C was conducted in 8281patiens and 525 of them had a high lipid levels. After exclusion of patients with secondary hyperlipidemia, high level of triglycerides and pregnant women – 91 patients were included in the analysis. Among them the definite FH was revealed in 2 (2,2%) patients, probable FH - in 6 (6,6%), and possible in 76 (83,5%), and in 7,7% there were no signs of FH. Conclusion Frequency of potential FH (definite and probable) in our analysis was low. To understand the real prevalence of FH in a Kyrgyz population epidemiological study is needed.

Epidemiology of cardiovascular risk factors in two population-based studies Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 35 Author(s): Elena Olmastroni, Evgeny V. Shlyakhto, Aleksandra O. Konradi, Oxana P. Rotar, Asiiat S. Alieva, Maria A. Boyarinova, Andrea Baragetti, Liliana Grigore, Fabio Pellegatta, Elena Tragni, Alberico L. Catapano, Manuela Casula Abstract We aimed to compare cardiovascular risk factors prevalence in Italy and Russia through cross-sectional database analysis. The study has been based on data from ESSE-RF and from baseline of PLIC study, two population-based epidemiological studies aimed to investigate prevalence of risk factors and evaluating contribution of traditional and new risk factors into morbidity and cardiovascular mortality. A total of 2203 patients with left and right intima-media thickness (IMT) measurements constituted the source population (1205 from PLIC study and 998 from ESSE-RF study). Sample of ESSE-RF study had slightly more diabetic and hypertensive individuals, while the percentage of subjects with high cholesterol value was lower than in the other sample (67.1% vs 79.9%). The median LDL-C value was higher among individuals not treated with statins in the PLIC sample (p < 0.001), while was comparable among subjects receiving statin therapy. On the other hand, the percentage of individuals with positive cardiovascular history was higher in ESSE-RF sample. This could also explain the higher mean IMT value (0.71 ± 0.17 vs 0.63 ± 0.13) in the whole sample, and among patients without past cardiovascular events (regardless of statin treatment), despite some differences in major risk factors. Despite Russian and Italian populations are culturally and geographically different, they are not so different based on characteristics analyzed.

Notch, BMP and WNT/β-catenin network is impaired in endothelial cells of the patients with thoracic aortic aneurysm Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 35 Author(s): Aleksandra Kostina, Hanna Bjork, Elena Ignatieva, Olga Irtyuga, Vladimir Uspensky, Daria Semenova, Shohreh Maleki, Alexey Tomilin, Olga Moiseeva, Anders Franco-Cereceda, Mikhail Gordeev, Giuseppe Faggian, Anna Kostareva, Per Eriksson, Anna Malashicheva Abstract Cellular and molecular mechanisms of thoracic aortic aneurysm are still not clear and therapeutic approaches are mostly absent. The role of endothelial cells in aortic wall integrity is emerging from recent studies. Although Notch pathway ensures endothelial development and integrity, and NOTCH1 mutations have been associated with thoracic aortic aneurysms, the role of this pathway in aneurysm remains elusive. The purpose of the present work was to study functions of Notch genes in endothelial cells of patients with sporadic thoracic aortic aneurysm. Aortic endothelial cells were isolated from aortic tissue of patients with thoracic aortic aneurysm and healthy donors. Gene expression of Notch and related BMP and WNT/β-catenin pathways was estimated by qPCR; WNT/β-catenin signaling was studied by TCF-luciferase reporter. To study the stress-response the cells were subjected to laminar shear stress and the expression of corresponding genes was estimated by qPCR. Analyses of mRNA expression of Notch genes, Notch target genes and Notch related pathways showed that endothelial cells of aneurysm patients have dysregulated Notch/BMP/WNT pathways compared to donor cells. Activity of Wnt pathway was significantly elevated in endothelial cells of the patients. Cells from patients had attenuated activation of DLL4, SNAIL1, DKK1 and BMP2 in response to shear stress. In conclusion endothelial cells of the patients with thoracic aortic aneurysm have dysregulated Notch, BMP and WNT/β-catenin related signaling. Shear stress-response and cross-talk between Notch and Wnt pathways that normally ensures aortic integrity and resistance of endothelial cells to stress is impaired in aneurysmal patients.

Large artery stiffness according to different assessment methods in adult population of St.Petersburg Publication date: September 2018 Source: Atherosclerosis Supplements, Volume 35 Author(s): A.S. Alieva, O.P. Rotar, A.V. Orlov, M.A. Boyarinova, E.V. Moguchaya, A.N. Rogoza, A.O. Konradi, E.V. Shlyakhto Abstract Objective The aim of the present study was to assess the prevalence of increased arterial stiffness by different diagnostic methods and its association with cardiovascular risk in Russian population-based cohort. Design and methods In terms of Russian epidemiological study ESSE-RF a random selection of 452 apparently healthy Saint-Petersburg inhabitants aged 25–65 years was performed. Fasting lipids, glucose and blood pressure measurements were performed. We used 3 diagnostic methods of arterial stiffness assessment: pulse wave velocity by applanation tonometry (SphygmoCor - PWV-S) and pulse wave velocity by volumetric sphygmography (VaSera - PWV-V), and cardio-ankle vascular index (CAVI) by VaSera. Results 341 (75,4%) had normal parameters of arterial stiffness assessed by all methods. Spearmen's coefficient of correlation and "kappa" coefficient for PWV-S and CAVI were 0,74 and 0,04, for PWV-S and PWV-V - 0,10 and 0,06, for CAVI and PWV-V - 0,28 and 0,03, respectively. There was a significant correlation between cardiovascular risk (defined by SCORE) and PWV-S (r = 0,38, p < 0,001) and a non-significant trend of increasing CAVI along with cardiovascular risk (r = 0,35, p = 0,14). Conclusions Different methods of arterial stiffness assessment showed a weak correlation with each other. Carotid-femoral pulse wave velocity detected by applanation tonometry is associated with high cardiovascular risk score and might be considered as better additional risk marker for cardiovascular risk stratification.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Urban Health

Utilization of Advance Care Planning for Homeless Adults: Case Studies Abstract Given the barriers to advance care planning (ACP) and low utilization of outpatient advance directives in hospital settings, it is unclear if ACP in primary care for adults who have experienced homelessness is effective and a valuable use of clinical time. As part of our ACP Project, we examined the feasibility and outcomes of ACP in primary care for patients who have experienced homelessness. We found that such efforts had significant impacts on patients' hospital care and allowed their wishes to be honored when they lost capacity for medical decision-making, particularly at the end of life. Here, we present six case studies demonstrating the outcomes of ACP in primary care for homeless adults and highlight lessons learned. To our knowledge, this is the first case series showing how ACP for homeless adults in primary care has been utilized during hospital care. Based on our findings, we believe that outpatient ACP even for the most socially vulnerable patients is feasible, often impactful, and should be integrated into routine primary care.

Urban Commuter Campus Students' Perspectives on Sexual Violence: Implications for Response and Prevention Abstract Sexual violence victimization is unacceptably common in the US, with nearly half of women and one in five men reporting lifetime sexual coercion and/or unwanted sexual contact; much violence occurs in campus settings. The majority of sexual violence prevention programs designed to date were not developed around the needs of urban commuter campus students. The present study explored qualitatively how these students conceptualize sexual violence and prevention. Face-to-face in-depth interviews were conducted with students on how they recognized sexual violence and understood prevention. Interviews were audiotaped, transcribed, and analyzed. Commuter students used "gut feelings" to identify sexual violence, reporting minimal direct consent communication. Intersecting social identities and multiple, concurrent roles limit the potential impact of existing prevention programs. Further research to design and evaluate tailored sexual violence prevention programming for urban commuter campus students is needed.

The Pre-exposure Prophylaxis (PrEP) Continuum of Care and Correlates to Initiation Among HIV-Negative Men Recruited at Miami Gay Pride 2018 Abstract While the national HIV infection rate is decreasing, the highest rates of infections continue among men who have sex with men (MSM), particularly minority MSM. It is important to understand attitudes, knowledge, and behaviors surrounding HIV prevention methods, such as pre-exposure prophylaxis (PrEP). In the present study, we created a snapshot of the PrEP continuum of care and identified participant demographic and sources of PrEP awareness factors that were associated with PrEP initiation. Data were collected using anonymous paper–based surveys employing a venue intercept procedure. A total of 188 HIV–negative men completed the survey at Miami Gay Pride 2018. Participants answered questions regarding demographics, PrEP use, and sources of PrEP awareness. The sample was majority Hispanic (55.4%), gay (83.0%), and single (57.7%). The constructed PrEP continuum revealed that a low proportion of those identified as PrEP naïve (n = 143) for HIV infection had PrEP interest (49/143). Moreover, among those who initiated PrEP (n = 45), a high proportion were retained in a PrEP program (37/45), with approximately half achieving medication adherence (25/45). Age group, PrEP knowledge, and source of PrEP awareness were all significantly associated with PrEP initiation. In areas with high HIV infection rates, studies like these offer crucial insight on how public health practitioners should proceed in the goal of decreasing HIV transmission rates. More research is needed to increase PrEP uptake and adherence.

Expanding a Comprehensive Strategy for Overdose Prevention in the USA

Willingness to Use Safe Consumption Spaces among Opioid Users at High Risk of Fentanyl Overdose in Baltimore, Providence, and Boston Abstract Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system.

Transactional Sex among Men Who Have Sex with Men: Differences by Substance Use and HIV Status Abstract Exchanging money, drugs, and other goods for sex has been associated with sexual risk behaviors and increased STIs/HIV. While female sex work is well described, data on men who exchange sex for money or goods are more limited. This paper examined the prevalence and correlates of transactional sex among young men who have sex with men, especially focusing on substance use and HIV status. We conducted a cohort study of 511 participants recruited between August 2014 and December 2017 in Los Angeles, CA. Eligible participants were: (1) between 18 and 45 years of age; (2) male; and (3) if HIV-negative, reported condomless anal intercourse with a male partner in the past 6 months. By design, half were HIV-positive and half HIV-negative. At baseline and semi-annual follow-up visits, computer-assisted self-interviews were used to collect information on demographics, sexual behaviors including transactional sex which was defined as exchange of money, drugs, or a place to stay for anal intercourse. Laboratory testing was conducted for current STI/HIV status. The average age of participants was 31.4 years with 43% identifying as African American, followed by 36% as Hispanic/Latino. The prevalence of recent transactional sex across 1486 study visits was 17% (n = 255), with 74% of those reporting exchanging sex for drugs. The prevalence of transactional sex was higher among those who reported unstable housing (32 vs. 11%; p value < .01), concurrent sexual partnerships (26 vs. 9%; p value < .01), and transgender sex partners (40 vs. 15%; p value < .01). Those who reported receiving money, drugs, or shelter for sex were also more likely to report giving money, drugs, shelter for sex than men who did not report exchange sex (77 vs. 11%; p value < .01). Based on multivariable analyses after adjusting for age and race/ethnicity, HIV viral load was independently associated with transactional sex [adjusted odds ratio (AOR) = 1.4; 95% confidence interval (CI) 1.1–1.7) per log10 increase]. Additionally, those testing positive for an STI were nearly twice as likely to report transactional sex as compared to those without STIs (AOR = 1.9; 95% CI 1.2–3.5). These findings underscore the relatively high prevalence of transactional sex and its potential role in ongoing HIV transmission among this cohort of high-risk HIV-negative and HIV-positive men who have sex with men.

The Prison and Transition Health (PATH) Cohort Study: Study Protocol and Baseline Characteristics of a Cohort of Men with a History of Injecting Drug Use Leaving Prison in Australia Abstract People who inject drugs (PWID) are disproportionately represented among individuals who experience imprisonment and often have more complex physical and mental health needs than people in prison without injecting histories. The trajectories of PWID after prison release are poorly understood, hampering the development of effective strategies to address their distinct health needs. The Prison and Transition Health (PATH) Cohort Study is characterising the post-release trajectories of incarcerated male PWID in Victoria, Australia. We outline study methodology and baseline characteristics of participants prior to their release. Four hundred participants were recruited from three prisons and completed researcher-administered baseline interviews covering socio-demographics, social supports, physical health, mental health, alcohol and other drug use, and pre-release and transitional service utilisation. The median age among participants was 36 years (IQR 30–42), and they reported a median of five (IQR 3–9) previous adult incarcerations. Almost half (49%) were reliant on government payments prior to incarceration. One quarter (25%) of participants reported removal from their parents' care as children and 64% reported being a parent or primary caregiver to children. Most participants (81%) reported a previous mental health diagnosis and 44% reported three or more diagnoses. The most common drugs injected prior to incarceration were crystal methamphetamine (80%) and heroin (62%), and most (85%) reported being under the influence of drugs at the time of committing offences for which they were currently incarcerated. Injecting drug use during their current sentence was reported by 40% of participants, and 48% reported engaging with some form of drug treatment during their current sentence. Study participants are characterised by significant mental health and substance use morbidities, social disadvantage and criminogenic histories that present challenges for the provision of post-release support services. Data from the PATH Cohort Study will help inform strategies to improve the health and social outcomes of this population.

Beliefs Associated with Pharmacy-Based Naloxone: a Qualitative Study of Pharmacy-Based Naloxone Purchasers and People at Risk for Opioid Overdose Abstract Drug overdose is the leading cause of unintentional death in the USA and the majority of deaths involve an opioid. Pharmacies are playing an increasingly important role in getting naloxone—the antidote to an opioid overdose—into the community. The aim of the current study was to understand, from the perspective of those who had obtained naloxone at the pharmacy, whose drug using status and pain patient status was not known until the interviews were conducted, as well as those who had not obtained naloxone at the pharmacy but were at risk for overdose, factors that impact the likelihood of obtaining pharmacy-based naloxone (PBN). Fifty-two participants from two New England states were interviewed between August 2016 and April 2017. We used a phenomenological approach to investigate participants' beliefs about pharmacy-based naloxone. The social contextual model was chosen to structure the collection and analysis of the qualitative data as it takes into account individual, interpersonal, organizational (pharmacy), community, and societal influences on a specific health behavior. Of the 52 people interviewed, 24 participants had obtained naloxone from the pharmacy in the past year, of which 4% (n = 1) self-disclosed during the interview current illicit drug use and 29% (n = 7) mentioned using prescribed opioid pain medication. Of the 28 people who had not obtained naloxone from the pharmacy, 46% (n = 13) had obtained an over the counter syringe from a pharmacy in the past month and had used an opioid in the past month, and 54% (n = 15) had used a prescribed opioid pain medication in the past month but did not report a syringe purchase. Several main themes emerged from the interview data. Individual-level themes were as follows: helplessness and fear, naloxone as empowerment to help, and past experiences at the pharmacy. Interpersonal-level themes were as follows: concern for family and friends, and sources of harm reduction information. Themes associated with pharmacy-level influence were as follows: perceived stigma from pharmacists, confusion at the pharmacy counter, and receptivity to pharmacists' offer of naloxone; community-level themes were as follows: community caretaking and need for education and training. Finally, themes at the societal-level of influence were as follows: generational crisis, and frustration at lack of response to opioid crisis. Overall our findings reveal factors at multiple levels which may play a role in likelihood of obtaining naloxone at the pharmacy. These factors can be used to inform interventions seeking to increase provision of pharmacy-based naloxone.

Access to Health Care Services among Young People Exchanging Sex in Detroit Abstract Within the related epidemics of sex exchange, drug use, and poverty, access to health care is shaped by intersecting identities, policy, and infrastructure. This study uses a unique survey sample of young adults in Detroit, who are exchanging sex on the street, in strip clubs, and at after-hours parties and other social clubs. Factors predicting access to free or affordable health care services, such as venue, patterns of sexual exchange influence, drug use and access to transportation, were examined using multivariable logistic regression and qualitative comparative analysis. The most significant predictors of low access to health care services were unstable housing and lack of access to reliable transportation. In addition, working on the street was associated with decreased access to services. Coordinated policy and programming changes are needed to increase health care access to this group, including improved access to transportation, housing, and employment, and integration of health care services.

Men in Community Correction Programs and Their Female Primary Sex Partners: Latent Class Analysis to Identify the Relationship of Clusters of Drug Use and Sexual Behaviors and HIV Risks Abstract Existing research indicates that justice-involved individuals use a variety of different drugs and polysubstance use is common. Research shows that different typologies of drug users, such as polydrug users versus users of a single drug, have differing types of individual-, structural-, and neighborhood-level risk characteristics. However, little research has been conducted on how different typologies of drug use are associated with HIV risks among individuals in community corrections and their intimate sex partners. This paper examines the different types of drug use typologies among men in community correction programs and their female primary sex partners. We used latent class analysis to identify typologies of drug use among men in community correction programs in New York City and among their female primary sex partners. We also examined the associations between drug use typologies with sexual and drug use behaviors that increase the risk of HIV acquisition. The final analysis included a total of 1167 participants (822 male participants and 345 of their female primary sex partners). Latent class analyses identified three identical typologies of drug use for both men and their female primary sex partners: (1) polydrug use, (2) mild polydrug users with severe alcohol and marijuana use, and (3) alcohol and marijuana users. Men and women who were classified as polydrug users and mild polydrug users, compared to those who were classified as alcohol and marijuana users, tended to be older and non-Hispanic Caucasians. Polydrug users and mild polydrug users were also more likely to have risky sex partners and higher rates of criminal justice involvement. There is a need to provide HIV and drug use treatment and linkage to service and care for men in community correction programs, especially polydrug users. Community correction programs could be the venue to provide better access by reaching out to this high HIV risk key population with increased rates of drug use and multiple sex partners.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Surgical Endoscopy

Identifying the needs for teaching fundamental knowledge of laparoscopic surgery: a cross-sectional study in Japan Abstract Background Recently, laparoscopic surgery (LS) has become a more common procedure than traditional open surgery. Although LS-related adverse events have been reported, there is no formal, standardized curriculum to teach the fundamentals of LS in Japan. Understanding surgeons' knowledge regarding LS is crucial for developing an educational curriculum. The purpose of this study was to determine the baseline knowledge on LS of surgeons and surgical trainees in Japan. Methods Participants completed 24 multiple-choice questions testing basic cognitive knowledge of LS and a questionnaire regarding the status of laparoscopic education. The examination was developed according to the 13 content domains of the Fundamentals of Laparoscopic Surgery (FLS) program. Scores were compared between post-graduate year (PGY) > 5 and PGY 1–5 participants. Data are expressed as median scores and interquartile ranges. Wilcoxon signed-rank test was used for statistical analysis. Results A total of 195 surgeons and surgical trainees from 10 teaching hospitals (PGY1–5: 66, PGY > 5: 129) across Japan completed the examination. The median score in the entire cohort was 75 [67; 83] %, with significantly higher scores in the PGY > 5 group compared to the PGY1–5 group (79 [75; 83] % vs. 67 [58; 75] %, p < 0.001). The differences in performance were due to better scores for PGY > 5 group on the sections "equipment," "patient considerations," "abdominal access," "tissue handling," "hemorrhage and hemostasis," "tissue approximation," and "exiting the abdomen." Overall, the median scores in the "energy sources" and "establishment and physiology of the pneumoperitoneum" subsections were lower than in other domains. All participants agreed on the need for fundamental knowledge and a formal educational curriculum. Conclusions Compared to experienced surgeons, surgical trainees had lesser knowledge about performing LS. Regardless of the years of experience, there are crucial knowledge gaps in specific areas regarding safe LS that should be addressed by implementing an educational curriculum.

Laparoscopic management for aberrant hepatic duct in children with choledochal cysts Abstract Background The aim of the current study is to evaluate efficacy of laparoscopic treatment for aberrant hepatic duct (AHD) in children with cholecochal cysts (CDC). Methods CDC children with AHDs who successfully underwent laparoscopic ductoplasties and hepaticojejunostomies between October 2001 and October 2017 were reviewed. The AHD variations were categorized into four subtypes and the surgical management varied according the subtypes. Results Sixty CDC patients with AHDs were reviewed. The mean age at surgery was 3.91 years. Two patients with Type 2 anomaly developed bile leaks after primary surgeries, and underwent laparoscopic anastomosis of AHD to jejunum in redo surgeries. In the remaining 58 patients, the average operative time was 3.75 h. The mean postoperative hospital stay was 6.02 days. The mean duration for full diet resumption was 2.25 days. The mean drainage time was 4.05 days. The median follow-up period was 30 months. Two patients with giant cysts had fluid collections, and were cured by drainages. One patient encountered duodenal injury at perforation site, and underwent laparoscopic repair. None of the patients had anastomotic stenosis, bile leak, cholangitis, intrahepatic reflux, pancreatic leak, pancreatitis, Roux-loop obstruction, or adhesive intestinal obstruction. Postoperative liver function tests and serum amylase level normalized within 1 year. Conclusions Recognition and treatment based on different subtypes of AHDs effectively prevent relevant complications. Individualized laparoscopic ductoplasty and hepaticojejunostomy is an efficacious management for AHDs in CDC children.

The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample Abstract Background Robotic-assisted surgery (RAS) with its advantages continues to gain popularity among surgeons. This study analyzed the increased costs of RAS in common surgical procedures using the National Inpatient Sample. Methods Retrospective analysis of the 2012–2014 Healthcare Cost and Utilization Project-NIS was performed for the following laparoscopic/robotic procedures: cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy (TAH). Patients with additional concurrent procedures were excluded. Costs were compared between the laparoscopic procedures and their RAS counterparts. Total costs and charges for cholecystectomy (the most common procedure in the dataset) were compared based on the payer and characteristics of hospital (region, rural/urban, bed size, and ownership). Results A total of 91,630 surgeries (87,965 laparoscopic, 3665 robotic) were analyzed. The average cost for the laparoscopic group was $10,227 ± $4986 versus $12,340 ± $5880 for the robotic cases (p < 0.001). The overall and percentage increases for laparoscopic versus robotic for each procedure were as follows: cholecystectomy $9618 versus $10,944 (14%), ventral hernia repair $10,739 versus $13,441 (25%), right colectomy $12,516 versus $15,027 (20%), left colectomy $14,157 versus $17,493 (24%), sigmoidectomy $13,504 versus $16,652 (23%), abdominoperineal resection $17,708 versus $19,605 (11%), and TAH $9368 versus $9923 (6%). Hysterectomy was the only procedure performed primarily using RAS and it was found to have the lowest increase in costs. Increased costs were associated with even higher increases in charges, especially in investor-owned private hospitals. Conclusion RAS is more costly when compared to conventional laparoscopic surgery. Additional costs may be lower in centers that perform a higher volume of RAS. Further analysis of long-term outcomes (including reoperations and readmissions) is needed to better compare the life-long treatment costs for both surgical approaches.

Regional cost analysis for laparoscopic cholecystectomy Abstract Background Laparoscopic cholecystectomy is the most common procedure performed by general surgeons in the United States, with approximately 600,000 procedures performed annually. As the cost of care rises, there is increasing emphasis on utilization and quality. Our objective was to evaluate the cost of laparoscopic cholecystectomy in our health system and to compare the operative times and outcomes at high- and low-cost centers. Methods We evaluated all laparoscopic cholecystectomies performed in our system over a 1-year period. The operating room supply costs and procedure durations were obtained for each of the hospitals. The American College of Surgeons National Surgical Quality Improvement Program outcomes and demographics were compared to the costs for each hospital. Results During the study period, 7601 laparoscopic cholecystectomies were performed at 20 hospitals (170–759/hospital) by 227 surgeons. The average cost per case ranged from $296 at the lowest cost center to $658 at the highest cost center. The average operative time varied between sites from 46 to 95 min. There was no association between cost and operative time or case volume. There was a slight trend toward increased cost with higher number of emergency procedures, but this was not well correlated (R2 = 0.03). The patient demographics and comorbidities were similar between sites. There were no significant differences in postoperative complications between high- and low-cost centers. The items with the greatest increase in cost were disposable trocars, disposable hook cautery, disposable endoscissors, and disposable clip appliers. We estimate that a savings of over $300/case is possible by using reusable instruments, which would result in an annual savings of $1.3 million for our health system, and $285 million nationwide. Conclusion Performing laparoscopic cholecystectomy with reusable instruments can significantly decrease costs and does not increase operative time or postoperative complications.

Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center Abstract Introduction Published data regarding robot-assisted hiatal hernia repair are mainly limited to small cohorts. This study aimed to provide information on the morbidity and mortality of robot-assisted complex hiatal hernia repair and redo anti-reflux surgery in a high-volume center. Materials and methods All patients that underwent robot-assisted hiatal hernia repair, redo hiatal hernia repair, and anti-reflux surgery between 2011 and 2017 at the Meander Medical Centre, Amersfoort, the Netherlands were evaluated. Primary endpoints were 30-day morbidity and mortality. Major complications were defined as Clavien–Dindo ≥ IIIb. Results Primary surgery 211 primary surgeries were performed by two surgeons. The median age was 67 (IQR 58–73) years. 84.4% of patients had a type III or IV hernia (10.9% Type I; 1.4% Type II; 45.5% Type III; 38.9% Type IV, 1.4% no herniation). In 3.3% of procedures, conversion was required. 17.1% of patients experienced complications. The incidence of major complications was 5.2%. Ten patients (4.7%) were readmitted within 30 days. Symptomatic early recurrence occurred in two patients (0.9%). The 30-day mortality was 0.9%. Redo surgery 151 redo procedures were performed by two surgeons. The median age was 60 (IQR 51–68) years. In 2.0%, the procedure was converted. The overall incidence of complications was 10.6%, while the incidence of major complications was 2.6%. Three patients (2.0%) were readmitted within 30 days. One patient (0.7%) experienced symptomatic early recurrence. No patients died in the 30-day postoperative period. Conclusions This study provides valuable information on robot-assisted laparoscopic repair of primary or recurrent hiatal hernia and anti-reflux surgery for both patient and surgeon. Serious morbidity of 5.2% in primary surgery and 2.6% in redo surgery, in this large series with a high surgeon caseload, has to be outweighed by the gain in quality of life or relief of serious medical implications of hiatal hernia when counseling for surgical intervention.

Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway Abstract Background Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery. Methods We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4 days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50–75%), positive evidence (75–95%), strong evidence (95–99%), and very strong evidence (> 99%). Results There were 323 patients analyzed (mean age 63.5 years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48 h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3 ml/kg/h for laparoscopic and 5 ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI. Conclusions The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.

Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates Abstract Background Post-prostatectomy urinary incontinence is an adverse event leading to significant distress. Our aim was to evaluate immediate urinary continence (UC) recovery in a single-surgeon prospective randomized comparative study between the traditional robot-assisted laparoscopic radical prostatectomy (TR-RALP) and the Retzius-sparing RALP (RS-RALP), for the treatment of the clinically localized prostate cancer (PCa). Methods 102 consecutive PCa patients were prospectively randomized to TR-RALP (57) or RS-RALP (45). Postoperative continence was defined as patient-reported absence of leakage or use of 0 pads/day. The immediate continence rate and 95% confidence interval (CI 95%) were calculated for each treatment. Univariable and multivariate logistic regressions were used to assess predictors of immediate continence following RALP. Continence rates from 1 to 6 months were calculated by Kaplan–Meier curves; log-rank test was used for the curve comparison. Two analyses were performed, considering a per-protocol (PP) population regarding all randomized patients that received nerve-sparing RALP and an Intention-To-Treat (ITT) population regarding all randomized patients that received RALP. Results In the PP analysis, the rates of immediate continence were 12/40 (30%) (CI 95% 17–47%) for the TR-RALP and 20/39 (51.3%) (CI 95% 35–68%) for the RS-RALP (p = 0.05). In the ITT analysis, the corresponding rates were 12/57 (21%) (CI 95% 11–34%) for the TR-RALP and 23/45 (51%) (CI 95% 36–66%) for the RS-RALP (p = 0.001). Median time to continence was 21 days for the TR-RALP and 1 day for RS-RALP, respectively (p = 0.02). The relative Kaplan–Meier curves regarding continence resulted statistically different when compared with the log rank test (p = 0.02). In the multivariate analysis, lower age and the Retzius-sparing approach were significantly associated to earlier continence recovery. Conclusions The Retzius-sparing approach significantly reduces time to continence following RALP. Further studies are required to confirm the reproducibility of our results and investigate the role of the RS-RALP as an additional "protective" factor for postoperative continence in the elderly population.

Temporary simultaneous two-arterial occlusion for reducing operative blood loss during laparoscopic myomectomy: a randomized controlled trial Abstract Background To evaluate the efficacy and safety of temporary simultaneous two-arterial occlusions (TESTO) in terms of operative blood loss during laparoscopic myomectomy. Methods A total of 62 patients with symptomatic myomas were randomly assigned to either the experimental group or the control group. In the experimental group, the uterine arteries and utero-ovarian arteries were temporarily occluded with laparoscopic bulldog clamps. The primary outcome measures were operative blood loss and change in hemoglobin. Results There were no differences in baseline demographics between the two groups. The amounts of operative blood loss (56.3 ± 42.8 mL vs. 138.2 ± 48.8 mL, p < 0.001) and change in hemoglobin (1.0 ± 0.5 g/dL vs. 1.7 ± 1.1 g/dL, p = 0.002) were significantly lower in the experimental group than that in the control group. The total operative time was not significantly different between the two groups. However, it took less time for myoma enucleation (13.1 ± 14.6 min vs. 17.6 ± 10.4 min, p = 0.006) and for uterine suturing (19.5 ± 10.7 min vs. 24.6 ± 8.8 min, p = 0.006) in the experimental group than that in the control group. None of patients in both groups developed operative complications. Conclusion The use of the TESTO procedure is effective in reducing operative blood loss and hemoglobin loss without causing morbidity during laparoscopic myomectomy.

Real-time in vivo optical biopsy using confocal laser endomicroscopy to evaluate distal margin in situ and determine surgical procedure in low rectal cancer Abstract Background In low rectal cancer, a negative distal margin (DM) is necessary for R0 radical resection, and therefore, the choice of surgical procedure is dependent on whether the planned transection rectum has residual cancer or not. Currently, surgeons choose surgical procedures according to intraoperative in vitro DM frozen sections. This study aimed to investigate the feasibility of real-time in vivo optical biopsy using confocal laser endomicroscopy (CLE) to evaluate DM in situ and determine the surgical procedure in low rectal cancer. Methods Optical biopsy using CLE was performed when the rectum was dissected at the levator ani plane and rectum transection was ready. For negative DM, the surgical procedure of low anterior resection (LAR) was chosen. For positive DM, the surgical procedure of abdominoperineal resection (APR) was chosen. The specimen at the site of the planned transection rectum underwent intraoperative frozen section and routine pathological procedures. Results Eighteen patients underwent real-time in vivo optical biopsy using CLE in surgery. Eleven patients' CLE images of DM showed a regular, round crypt, and round luminal opening covered by a simple layer of columnar epithelial cells and goblet cells. LAR was then performed. Pathology revealed that the 11 DMs were negative, and the median length of the DMs was 2.0 cm. The remaining seven patients' CLE images of the planned transection rectum showed the loss of crypt architecture and irregular epithelial layer with loss of goblet cells. APR was then performed. Pathology confirmed cancer invasion, and the median distance from tumor to dentate line was 1.0 cm. The sensitivity, specificity, and accuracy of CLE optical biopsy of DM were 85.71%, 100%, and 94.44%, respectively. Conclusions It is feasible to perform real-time in vivo optical biopsy using CLE to evaluate DM in situ and determine the surgical procedure in low rectal cancer.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis Abstract Background Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis. Methods A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case–control studies (CCS) that compared LA with OA for complicated appendicitis. Results Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71–1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31–0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19–0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13–0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42–1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04–0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03). Conclusion These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Rheumatology

An Update on Diagnosis and Classification of Axial Spondyloarthritis Abstract Purpose of Review To summarize the most relevant recent progress to diagnose and classify patients with axial spondyloarthritis (axSpA). Recent Findings A substantial proportion of new studies focused on the diagnosis and classification of patients with axSpA. Efforts have been concentrated on setting the best strategy to refer patients with suspected axSpA and evaluating the utility of different tools during the diagnostic work-up, especially of imaging techniques. On top of this, researchers have worked on addressing some concerns raised about the employment of the Assessment of SpondyloArthritis international Society classification criteria, especially those related to the validity and misuse of the criteria, providing valuable data on this regard. Summary Recent findings emphasize that classification should serve a completely different purpose than diagnosis. In addition, they highlight the importance to consider the limitations for imaging acquisition, the appropriate context, and differential diagnosis when interpreting imaging findings during the diagnostic work-up of patients with suspected axSpA.

Skeletal Muscle Wasting and Its Relationship With Osteoarthritis: a Mini-Review of Mechanisms and Current Interventions Abstract Purpose of Review Osteoarthritis (OA) is a subset of joint disorders resulting in degeneration of synovial joints. This leads to pain, disability and loss of independence. Knee and hip OA are extremely prevalent, and their occurrence increases with ageing. Similarly, loss of muscle mass and function, sarcopenia, occurs during ageing. Recent Findings Little is known about the impact of muscle wasting on OA progression; nevertheless, it has been suggested that muscle wasting directly affects the stability of the joints and loss of mobility leads to gradual degeneration of articular cartilage. The molecular mechanisms underlying muscle wasting in OA are not well understood; however, these are probably related to changes in gene expression, as well as epigenetic modifications. Summary It is becoming clear that skeletal muscle wasting plays an important role in OA development and/or progression. Here, we discuss mechanisms, current interventions, such as exercise, and potentially novel approaches, such as modulation of microRNAs, aiming at ameliorating OA symptoms through maintaining muscle mass and function.

The Role of Chondrocyte Morphology and Volume in Controlling Phenotype—Implications for Osteoarthritis, Cartilage Repair, and Cartilage Engineering Abstract Purpose of Review Articular chondrocytes are exclusively responsible for the turnover of the extracellular matrix (ECM) of hyaline cartilage. However, chondrocytes are phenotypically unstable and, if they de-differentiate into hypertrophic or fibroblastic forms, will produce a defective and weak matrix. Chondrocyte volume and morphology exert a strong influence over phenotype and a full appreciation of the factors controlling chondrocyte phenotype stability is central to understanding (a) the mechanisms underlying the cartilage failure in osteoarthritis (OA), (b) the rationale for hyaline cartilage repair, and (c) the strategies for improving the engineering of resilient cartilage. The focus of this review is on the factors involved in, and the importance of regulating, chondrocyte morphology and volume as key controllers of chondrocyte phenotype. Recent Findings The visualisation of fluorescently-labelled in situ chondrocytes within non-degenerate and mildly degenerate cartilage, by confocal scanning laser microscopy (CLSM) and imaging software, has identified the marked heterogeneity of chondrocyte volume and morphology. The presence of chondrocytes with cytoplasmic processes, increased volume, and clustering suggests important early changes to their phenotype. Results from experiments more closely aligned to the normal physico-chemical environment of in situ chondrocytes are emphasising the importance of understanding the factors controlling chondrocyte morphology and volume that ultimately affect phenotype. Summary An appreciation of the importance of chondrocyte volume and morphology for controlling the chondrocyte phenotype is advancing at a rapid pace and holds particular promise for developing strategies for protecting the chondrocytes against deleterious changes and thereby maintaining healthy and resilient cartilage.

ILC3 in Axial Spondyloarthritis: the Gut Angle Abstract Purpose of Review A growing body of evidence supports the relevance of the interleukin-23/interleukin-17 (IL-23/IL-17) pathway for the pathogenesis of axial spondyloarthritis (axSpA) and its treatment. Recently, innate lymphoid cells (ILC), a heterogeneous family of immune effector cells, have been identified as a relevant contributor in tissue homeostasis, partially via IL-23/IL-17 axis. This review describes the biology and the origins of the group 3 ILCs (ILC3s) in humans, focusing on their role in the pathogenesis of axSpA. Recent Findings Clinical trials showed the effectiveness of IL23/IL-17 axis inhibition in both spondyloarthritis (SpA) and Inflammatory Bowel Disease (IBD). Recent findings confirm the high prevalence of subclinical gut inflammation in patients with SpA. Translational data in humans have demonstrated an increase in the number of ILC3s responsive to IL-23 and producing either IL-22 or IL-17 in the gut of SpA patients. The observation of gut-derived ILC3s in circulation and at inflamed tissues in patients with SpA suggest a recirculation of ILCs from mucosal site to lymphoid tissues and possibly enthesis and joints. Summary Multiple observations demonstrate the expansion of IL-17- and IL-22-producing ILC3 in the subclinically inflamed gut of SpA patients. These innate immune cells, also observed in normal entheses, seem to be able to re-circulate from the gut to inflamed tissues of SpA patients, thus contributing to the disease perpetuation. The development of tools that can provide access to diseased tissue from sacroiliac joint and spinal entheses will provide valuable knowledge on the role of ILC3 in axSpA pathogenesis.

Emerging Immunomodulatory Therapies and New Treatment Paradigms for Axial Spondyloarthritis Abstract Purpose of Review The purpose of this review is to educate the reader about the evolving classification of axial spondyloarthritis (AxSpA) and describe recent treatment data from clinical trials of medications with mechanisms of action other than TNF inhibition. The review will also address emerging treatment strategies for AxSpA. Recent Findings New and more sensitive classification schema for AxSpA find that the prevalence of the disease is more than twice that of the historic definition of ankylosing spondylitis (AS), when patients without radiographically observable damage to the sacroiliac joints are included. TNF inhibitors have shown efficacy in the full spectrum of disease. IL-17 inhibitors, e.g., secukinumab and ixekizumab and janus kinase (JAK) inhibitors, have shown good efficacy and relatively good safety in radiographically defined AxSpA and are being tested in non-radiographic (nr) AxSpA. Several immunomodulatory medicines approved for psoriasis, psoriatic arthritis, and rheumatoid arthritis have not shown efficacy in AxSpA, highlighting the importance of conducting good-quality, placebo-controlled trials in this condition. Treatment strategies such as "treat to target" and tapering therapy are being studied. Summary There remains a large unmet need to identify and adequately treat the full spectrum of AxSpA. The use of TNF inhibitors has improved our ability to achieve remission or low disease activity in AxSpA. Newer medicines with different mechanisms of action, e.g., IL-17 or JAK inhibition, are also showing similar ability. Continued research, including identification of new targets of treatment, is critical.

In the Real World: Infections Associated with Biologic and Small Molecule Therapies in Psoriatic Arthritis and Psoriasis Abstract Purpose of Review To summarize our most current understanding of the real world risk of infections associated with biologic and small molecule therapies in the setting of psoriatic disease. Recent Findings Patients with psoriasis or psoriatic arthritis are at increased risk for infection from both their disease and some of their therapies. There is little real world data for biologic and small molecule therapies; however, ustekinumab and biologics inhibiting IL-17 or IL-23 appear to have reduced risk estimates compared to anti-TNF therapies. Apremilast seems to have little infectious signal with limited real world data, and for JAK inhibitors, limited real world data suggest a higher risk of herpes zoster. Summary Recently approved targeted and small molecule therapies for psoriasis carry infectious risks for patients, although they appear to vary across mechanism of action. As these treatments become more widespread, and additional therapies are approved, it will be imperative to evaluate their safety in the context of real world data.

Correction to: Cell Senescence in Lupus The original version of this article unfortunately contained mistakes.

Treatment Strategies in ANCA-Associated Vasculitis Abstract Purpose of Review The long-term survival of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) has improved dramatically as a direct result of evolving therapy. This review summarizes evidence-based treatment strategies with currently approved immunosuppressive medications to serve as a guide for practitioners in the management of patients with AAV. Recent Findings Targeted therapy aimed at minimizing treatment-related adverse effects while optimizing effectiveness is a propagated approach. Such tailored therapy considers disease severity and is especially warranted in those at high risk for relapsing vasculitis. Summary As treatment options for AAV become available, the need to tailor therapy has become increasingly relevant to optimize patient outcomes.

Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review Abstract Purpose of Review Patients with chronic pain, especially primary or centralized pain, have elevated rates of psychosocial trauma and intrapersonal or intrapsychic conflict. To address these risk factors and potentially reduce pain, the authors developed emotional awareness and expression therapy (EAET). This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base. Recent Findings Four initial trials (between 2006 and 2011) demonstrated the efficacy of earlier versions of EAET. Four recent randomized, controlled trials of different EAET durations (1 to 8 sessions) and formats (individual or group) in patients with fibromyalgia, irritable bowel syndrome, pelvic pain, or medically unexplained symptoms support the earlier findings. EAET reliably reduces pain and interference, although improvements in anxiety and depression are less reliably achieved and may be delayed. The largest and best conducted trial found superiority of EAET over cognitive-behavioral therapy for fibromyalgia. Patient retention in EAET is high, and adverse events are rare. Summary EAET merits inclusion as a treatment option for primary pain conditions, and it may be the preferred treatment for some patients. Research is needed on EAET with other pain conditions and samples, using better controls and comparison conditions, and on additional ways to motivate and help patients engage in successful emotional processing.

Osteoporosis Pathophysiology, Epidemiology, and Screening in Rheumatoid Arthritis Abstract Purpose of Review To review the burden of osteoporosis (OP) in rheumatoid arthritis (RA) and to describe the OP screening strategies applied in RA. Recent Findings RA is an inflammatory condition that predisposes patients to development of OP. OP in RA has a multifactorial pathogenesis with systemic inflammation and glucocorticoid use playing major roles. Newer studies have reported an intriguing association between RA autoantibodies and the development of OP. OP screening strategies in RA patients include clinical and vitamin D assessment, biochemical markers of bone remodeling, and bone imaging evaluations, particularly dual-energy X-ray absorptiometry (DXA). Summary Fragility fractures are an important comorbidity of RA. OP screening strategies are both feasible and effective in RA patients and recommended by most specialty organizations. Given the considerable exposure to factors related to OP development, such as pro-inflammatory cytokines and glucocorticoid treatment, special attention should be directed to biochemical and DXA results in RA patients.

Alexandros Sfakianakis
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alsfakia@gmail.com