Marks, Lisa

Background: Radiologically Isolated Syndrome (RIS) is defined as incidentally found MRI abnormalities that are radiographically indistinguishable from multiple sclerosis (MS) and is considered a presymptomatic disease state of MS. Age <37 years, infratentorial or spinal cord lesions, gadolinium-enhancing lesions on index imaging, and positive cerebrospinal fluid oligoclonal bands have been identified as risk factors for conversion to MS. There are no existing guidelines regarding the role of disease-modifying therapy (DMT) in RIS patients. Objective: The objective of this study was to critically assess the current evidence regarding the impact of initiating DMT for patients with RIS on the time to first clinical attack of MS. Methods: The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario with a clinical question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, medical librarian, and content experts in the field of neuroimmunology. Results: A multicenter, prospective, randomized, double-blind, placebo-controlled trial was chosen for critical appraisal. This trial examined the impact of treatment with dimethyl fumarate (DMF) versus placebo on the risk of conversion from RIS to MS over a 96-week study period. Patients in the DMF arm were found to have an 82% reduction in risk of clinical attack. DMF patients also had a smaller number of new/newly enlarging T2 hyperintense lesions compared with placebo. No subgroup analyses were performed to elucidate risk factors for conversion. Conclusions: While initiation of DMT in RIS does appear to reduce the time to first clinical attack of MS, the risk factors that should prompt initiation of DMT in this patient population require further study.

Background/Objectives: Although endoscopic dacryocystorhinostomy (DCR) has been widely accepted as the procedure of choice for nasolacrimal duct obstruction (NLDO) management due to most etiologies, concerns regarding the reactivation of disease and involvement of surrounding structures add to hesitation in its utilization for granulomatosis with polyangiitis (GPA) patients. No study has directly compared outcomes of external vs. endoscopic DCR in GPA patients. This information can be helpful for patient counselling and choosing a personalized surgical approach for the best results. Methods: A scoping review of the literature was performed in January 2024. The following databases were searched using a combination of MeSH (Medical Subject Headings) and keywords: Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science. This scoping review is not registered. Medical records of two GPA patients who underwent endoscopic DCR at our center were reviewed. Results: The search yielded 96 articles; 15 articles met the inclusion criteria for a full review. Six studies with 22 procedures reported 100% success with endoscopic DCR. Nine studies with 122 procedures reported success in 88.5% of cases with external DCRs. Additional perioperative immunosuppression was recommended in patients with severe mucosal inflammation. The case series presents the disease course, details of surgery, and perioperative management in two GPA patients with NLDO who underwent endoscopic DCR successfully. Conclusions: Endoscopic DCR was associated with equivalent or better success rates and lower complications compared to external DCR in GPA patients. Ensuring disease remission state and appropriate immunomodulatory therapy can help prevent the proposed risk of endonasal disease reactivation with endoscopic DCR.

ABSTRACTObjectivesTo achieve consensus among expert laser surgeons on standards for the prevention and management of adverse events from fully ablative laser resurfacing of the face.Materials and MethodsDelphi study with two rounds of ratings and revisions until consensus was achieved. The draft set of statements was developed by a steering committee based on expert clinical experience. This was followed by two rounds of rating and revisions completed by an expert panel, then a virtual consensus meeting. In both rounds, respondents rated the draft statements on a 9‐point Likert scale (1 = strongly disagree; 9 = strongly agree) and optionally provided comments. The consensus meeting was supplemented by the results of a systematic review of the literature (from 2000 to 2023).ResultsTwo rounds of Delphi survey were completed by 34 participants across four countries. Represented specialties were dermatology, facial plastic surgery, plastic surgery, and oculoplastic surgery. The initial 105 statements from round 1 expanded to 112 in round 2, with 96 statements achieving consensus. These included possible adverse events (11 statements); absolute and relative contraindications to treatment (5 statements); preoperative care and antimicrobial prophylaxis precautions (16 statements); intraoperative precautions (17 statements); postoperative care (21 statements); monitoring for and management of infection (16 statements); management of pigmentation changes (6 statements); and management of scarring and incipient scarring (4 statements).ConclusionAn international consensus statement was developed for the prevention and management of complications associated with fully ablative laser resurfacing of the face. While expert practices vary, key factors for optimizing outcomes include careful patient selection, counseling, and meticulous pre‐ and postoperative care. Further research will improve our understanding of this treatment technique.

Abstract Reconstruction of clival defects may be challenging in expanded endonasal skull base surgery. We conducted a systematic review to evaluate the outcomes of vascularized flaps used for clival reconstruction. The following databases were searched using a combination of Medical Subject Headings (MeSH) and keywords related to clival reconstruction in July 2024: Ovid Medline, Ovid Embase, Scopus, and Web of Science. Studies reporting outcomes of clival reconstruction with vascularized free and pedicled flaps in patients were selected for complete review. Twenty-three studies were included for detailed study. Clival reconstruction with free flaps was done in 18 patients; 17 had a successful repair, outcome was not reported for 1. Facial vessels were preferred for microvascular anastomosis. Radial artery forearm flap and anterolateral thigh flap were most utilized. Pedicled flaps were used in 68 patients, with reported success in 85.3%. Nasoseptal flap was the most common intranasal flap, used in 34 patients with successful reconstruction in 85.3%. Temporoparietal fascia flap was the most common extranasal flap, successfully used in 13 patients. Intranasal pedicled flaps, wherever available, were preferably used for primary reconstruction; extranasal flaps were the next choice. Free flaps were reserved for salvage reconstruction due to prior failed or unavailable local pedicled flaps. Satisfactory reconstructive outcomes are reported using pedicled and free flaps. The flap of choice is determined by the previous surgical history, radiotherapy, wound vascularity, defect size, overall health of the surrounding nasal mucosa, simultaneous clival surgery, and the preferred pedicle transposition route (free flaps).

Introduction: Trust and rapport between patients and physicians form the cornerstone of effective medical practice. A key factor influencing this trust is the patient’s perception of the physician’s appearance. Women physicians often face more rigorous expectations concerning their physical appearance compared to men physicians, creating a need to balance traditional professional attire with maintaining femininity and individuality. This review explores the unique challenges women physicians encounter in presenting a professional image. Methods: A narrative review was conducted using PubMed and Google Scholar to identify studies addressing both patient and physician perceptions of physician appearance. The search was limited to studies conducted in the United States and published between 2004 and 2024. Seven articles met the inclusion criteria and were selected for analysis. Results: The findings suggest that professional attire, particularly when combined with a white coat, is associated with higher perceptions of competence and professionalism. However, women physicians face ambiguity in meeting these expectations compared with men. In addition, women are more frequently mistaken for nurses, phlebotomists, or support staff based on their attire and appearance. Discussion: Overall, patients tend to prefer professional attire to physicians, but these preferences are influenced by cultural, demographic, and age-related factors. Women physicians, in particular, experience heightened scrutiny regarding their appearance and are subject to stricter norms than men physicians. This challenge is further amplified for young women trainees, who may struggle to convey professionalism due to their youthful appearance.

Purpose To systematically review the existing literature on the functional performance of athletes at the time of return‐to‐sport (RTS) clearance after anterior cruciate ligament reconstruction (ACLR). Methods A systematic literature search of the MEDLINE, EMBASE, Scopus, and Web of Science databases was performed. The inclusion criteria were original research reports with study populations of athletes who had undergone ACLR and had undergone objective functional testing immediately after clearance to RTS. Functional testing was stratified by hop tests, strength tests, kinetic assessment, and kinematic assessment, and data were extracted from each study using a standardized template. Results Of the 937 unique studies identified, 46 met the inclusion criteria. The average time between ACLR and functional testing was 7.9 months among the included studies. In 10 of 17 studies, patients were found to have an average quadriceps strength limb symmetry index of less than 90%. However, only 2 of 12 studies found the average hop test limb symmetry index to be less than 90%. Kinematics included reduced knee flexion angle and increased trunk flexion on landing in ACLR patients compared with matched controls. On evaluation of kinetics, ACLR patients showed reduced peak vertical ground reaction force, lower peak knee extension and knee flexion moments, and altered energy absorption contribution compared with matched controls. Conclusions This systematic review suggests that athletes show functional deficits at the time of RTS at an average of 7.9 months after ACLR. Traditional functional tests, such as strength and hop tests, are not able to accurately identify patients who continue to show deficits. The most common biomechanical deficits that persist after RTS clearance include diminished peak knee extension moment, decreased knee flexion angle, increased trunk flexion angle, reduced vertical ground reaction force, and increased hamstring central activation ratio during various functional gait and landing tasks. Level of Evidence Level III, systematic review of Level I to III studies.

Purpose To systematically review the relationship between functional testing at the time of return to sport (RTS) and short‐term outcomes, such as second anterior cruciate ligament (ACL) tear and return to a preinjury level of sport, among athletes who underwent anterior cruciate ligament reconstruction (ACLR). Methods A systematic literature search was performed in MEDLINE, EMBASE, Scopus, and Web of Science to identify studies examining athletes who underwent functional RTS testing and were followed for at least 12 months following ACLR. Studies were screened by 2 reviewers. A standardized template was used to extract information regarding study characteristics, ACLR information, functional test results, and risk factors associated with retear or reduced RTS. Results Of the 937 studies identified, 22 met the inclusion criteria. The average time between ACLR and RTS testing was 8.5 months. Single leg hop for distance performance had no association with retear risk in any study and no association with RTS rates in most studies. Quadriceps strength had conflicting results in relation to retear risk, whereas it had no relationship with RTS rates. Rates of reinjury and RTS were similar between patients who passed and did not pass combined hop and strength batteries. Asymmetric knee extension and hip moments, along with increased knee valgus and knee flexion angles, demonstrated increased risk of retear. Conclusions Individual hop and strength tests that are often used in RTS protocols following ACLR may have limited and inconsistent value in predicting ACL reinjury and reduced RTS when used in isolation. Combined hop and strength test batteries also demonstrate low sensitivity and negative predictive value, highlighting conflicting evidence to suggest RTS testing algorithm superiority. Level of Evidence Level IV, systematic review of Level I‐IV studies.