Citations

When encountering diseases of the anterior vitreous and peripheral retina (ie, the “middle segment” of the eye), vitreoretinal (VR) surgeons are specifically trained in surgical techniques for managing the vitreous and visualizing the peripheral retina during anterior vitrectomy, and therefore, they are well equipped to address the complications of surgery involving the anterior vitreous space. This clinical update reviews and compares the current literature discussing techniques and patient outcomes related to complete pars plana vitrectomy versus incomplete, subtotal pars plana vitrectomy, and addresses the proposition of developing an abridged training curriculum for non-VR surgeons to acquire the knowledge and skills required to perform these procedures. Recent studies confirmed that operating in the anterior vitreous carries potential risk of retinal tear, retinal detachment, and other adverse events that may cause vision loss. To mitigate these risks, studies suggest that the use of dedicated visualization equipment and illumination instruments is necessary for surgeons to safely perform anterior vitrectomy and recognize complications, should any occur. Performing VR surgery in the absence of wide-angle viewing systems, endoillumination, careful peripheral examinations, modern vitrectomy platforms, and appropriate training may lead to outcomes that are detrimental to patient safety.

Introduction: Life-support limits (i.e., code status), the first step in the continuum of palliation and end-of-life (EoL) care, stem from decisions made by patients and their providers to align care near the EoL with patients’ wishes. The pandemic created health care strain that may have influenced life-support limitation practices among patients with serious COVID-19. In this study, we examine variations in life-support limitations (do-not-resuscitate, DNR; do-not-intubate, DNI) depending on the hospital and period of hospitalization. Methods: We included all adults admitted to a hospital in the United States with COVID-19 from January 2020 to December 2021 using the VIRUS registry. Our outcome was any life-support limitation on admission (DNR, DNI, or both) using regression modeling. Main exposures were hospital and period of hospitalization (early vs. late pandemic). Covariates included age, sex, race/ethnicity, comorbidities, and hospitalization diagnoses. Results: There were 42,383 patients from 75 hospitals in the US. The median age was 63 (interquartile range: 50–75), 46.5% were female, and 37.5% were non-Hispanic White. The life-support limitation rate was 7.9%, and the palliative care consultation rate was 2.3%. The odds of life-support limitation were 1.86 (95% CI: 1.6–2.1) depending on the hospital, but the period of hospitalization was not associated with odds of life-support limitation. Older age was associated with the greatest increased odds (4.1 per standard deviation ∼ 17.9 years, 95% CI: 3.9–4.4), followed by comorbidities including paralysis (2.4, 95% CI: 1.8–3.0) and dementia (2.3, 95% CI: 2.0–2.6). Conclusions: After adjusting for patient-level factors, we report significant inter-hospital but no temporal variation in life-support limitation upon admission with COVID-19. Future studies should investigate specific practices that led to health care resilience to temporal practice variations in life-support limitation during the pandemic.

Abstract Matrix-producing tumors of the sinonasal region are diagnostically challenging, with a large number of similar-appearing neoplasms having different prognoses, treatment strategies, and genetic syndrome associations. Osteochondromyxoma (OCM) is a very rare tumor known to be associated with Carney complex. Since its initial description in 2001, fewer than 20 cases have been reported, with the sinonasal tract being an apparently favored site. Herein we describe 6 new cases of sinonasal OCM.OCM cases with available slides were retrieved from the surgical pathology files of the authors’ practices. The tumors arose in 4 boys and 2 girls, ranging from 4 to 17 years (mean, 9.5 years). All presented with nasal obstruction and a mass. Radiologically the tumors presented as indolent-appearing, heterogeneous, calcified, expansile masses. Histologically the tumors all consisted of bland, normochromatic spindled to stellate cells in a myxoid to collagenized stroma, with variable amounts of cartilage and bone formation. Mitotic activity was very low and necrosis was absent. All demonstrated complete loss of PRKAR1A expression by immunohistochemistry. Of these 6 cases, 3 had been originally diagnosed as nasal chondromesenchymal hamartomas, and one as osteosarcoma. Treatment and follow up information were available for 5 patients: all were treated with surgery, with one also receiving chemotherapy after an initial osteosarcoma diagnosis. At the time of last clinical follow-up, all 5 patients were alive, one with residual disease. No patient was known to have other stigmata of Carney complex.Although rare, OCM preferentially occurs in the sinonasal tract, and therefore may be encountered by head and neck pathologists. Given their predilection for young patients and overlapping morphologic features, OCM are easily misdiagnosed as other matrix-forming sinonasal tumors, especially nasal chondromesenchymal hamartoma. Immunohistochemical demonstration of PRKAR1A loss is valuable for confirming an OCM diagnosis, which should prompt clinical investigation for the possibility of Carney complex.

Abstract Objective To determine the effect of management before and during transplantation on the quality of donated organs. Improvement of preservation methods in cases involving brain death will lead to more effective organ procurement. Methods Data were collected from the 226 brain death cases enrolled in the 12-month study period. All cases, patients with a Glasgow Coma Scale (GCS) score of 3 points, appropriate age, and having medical indications for organ donation, were considered to confirm the criteria of brain death. Transplant outcome data were obtained from the transplant centers. Results The age of the deceased ranged between 1 year and 68 years, with a mean ± SD of 39.54 ± 17.28 years. There was no significant difference between the quality of organs regarding blood group and cause of brain death ( P > 0.05). However, there was a significant difference in the quality of organs regarding age, body mass index (BMI), and gender. There was a significant difference between the level of urea at admission time and procurement time ( P < 0.001), as well as between creatinine level at admission time and procurement time ( P < 0.001). There was also a significant difference between aspartate aminotransferase (AST) at admission time and procurement time ( P < 0.001), and between alanine aminotransferase (ALT) at admission time and procurement time ( P < 0.001). Conclusions Transplant outcomes using older donor livers and kidneys were comparable to those using younger or male donors. These findings provide further evidence that decision-making about organ quality is influenced by age and gender and emphasize the importance of transparency in organ acceptance practices.

Abstract Background Increased prevalence of reduced bone mineral density (BMD) is well documented in persons infected with human immunodeficiency virus (HIV), hepatitis C virus (HCV), or both. This study's purpose was to determine if an association exists between dietary calcium intake and BMD in these patients. Methods Participants were individuals with virologically suppressed HIV or untreated HCV monoinfections, those with HIV/HCV coinfection, and noninfected controls. The Hertzler-Frary dietary calcium questionnaire documented calcium intake with calcium amounts based on the US Department of Agriculture nutrient database. BMD was measured at baseline by dual-energy x-ray absorptiometry, and χ2 tests were used to assess the relationship between BMD and infection status. One-way analysis of covariance was used to compare calcium intake data with the prevalence of normal BMD and osteoporosis by infection group. Adjustments were made for race, age, body mass index, and smoking status. Spearman correlation was used to identify relationships between calcium intake from foods/beverages and BMD. Results A total of 452 men were recruited into the study. Osteoporosis and osteopenia were prevalent, but there was no association between infection group and BMD result (χ2(6) = 6.813; P = .34). Only HCV-infected patients with osteoporosis had lower calcium intake than patients with normal BMD (mean difference, 409 mg/d [95% confidence interval, 35–784 mg/d]; P = .03). Conclusions In this study population, dietary calcium intake was correlated with reduced BMD only in patients with HCV monoinfection.

Background Intracranial occlusions in embolic stroke of undetermined source are histopathologically similar to cardiac sources of embolism. Whether patients with embolic stroke of undetermined source and intracranial occlusion benefit from anticoagulation is unknown. Methods A multicenter retrospective cohort of adults with cryptogenic stroke was queried for patients with proximal or medium/distal vessel occlusion. The primary outcome was recurrent ischemic stroke, which was assessed in unadjusted and adjusted Cox proportional hazards models and repeated following 1:1 propensity score matching and biweight kernel density matching. Results Of the 2328 patients who were followed over a median of 1.31 years (interquartile range, 0.34–2.85), 999 (42.6%) had an intracranial occlusion. When compared with patients without an intracranial occlusion, those with an occlusion had fewer atherosclerotic vascular risk factors, more severe symptoms, and less severe cerebral microvascular disease. The rate of recurrent stroke was similar between patients with versus without an intracranial occlusion (6.8%/year [95% CI, 5.7–8.2] versus 7.0%/year [95% CI 6.0–8.1]; adjusted hazard ratio [HR], 1.09 [95% CI, 0.77–1.55]). There was no association between occlusion and recurrent stroke in the adjusted propensity score matching (HR, 1.01 [95% CI, 0.64–1.59]) or kernel density models (HR, 0.95 [95% CI, 0.62–1.45]). There was no interaction between occlusion and treatment with anticoagulation, sex, age, or high‐risk sources of embolism for the primary outcome in the unmatched and matched analyses. Conclusions Intracranial occlusion in patients with embolic stroke of undetermined source is not associated with a greater risk of recurrence when compared with patients without an intracranial occlusion. There was no difference in rate of recurrent stroke with anticoagulation when stratified by presence or absence of occlusion.

Introduction: The use of modular components provides several advantages in total knee arthroplasty (TKA), including exchange of the polyethylene insert while retaining the stable components in the revision TKA. Compared to full, non-modular component revision TKA, isolated polyethylene exchange (IPE) has the advantage of decreased morbidity, faster rehabilitation, and acceptable outcomes. Methods: A review of published literature on revision TKA was conducted, with a specific focus on studies evaluating the use of IPE for managing complications such as stiffness, instability, and periprosthetic joint infection (PJI). Results: IPE with downsizing may be considered for patients with mild stiffness and stable, well-positioned implants that have increased polyethylene thickness, though expectations for motion gain should be cautious. There is no clear consensus on IPE for instability. Some studies report high re-revision rates, while others show clinical and functional improvement when the TKA is well-aligned, well-fixed, and intraoperative gap balance is achieved. Additionally, irrigation and debridement with polyethylene exchange (IDPE) may be effective for acute TKA PJI management, particularly within the first two weeks of symptom onset. Conclusions: Based on current literature, IPE in aseptic TKA revisions may be effective for stiffness or instability when implants are well-fixed and well-aligned—particularly if polyethylene constraint can be adjusted for instability or downsized for stiffness. The role of IDPE in acute TKA PJI is better defined in the literature, with strong emphasis on its time-sensitive effectiveness—most notably within the first two weeks of symptom onset.

INTRODUCTION: Patients with inflammatory bowel disease (IBD) are at increased risk of herpes zoster and should receive the recombinant herpes zoster vaccine (RZV). We sought to assess the immunogenicity and safety of RZV series in patients receiving anti-tumor necrosis factor (TNF) therapy compared with those receiving vedolizumab. METHODS: This single-center prospective study enrolled patients with IBD on vedolizumab or anti-TNF monotherapy receiving RZV. Primary outcome assessed cell-mediated immunity (CMI) differences between groups postvaccination. Secondary outcomes included humoral response, sustained immunity, and safety monitoring for adverse events and IBD flares. Assessments occurred at baseline, 30, 240, and 425 days postvaccination. Statistical analyses included nonparametric Mann-Whitney U tests for between-group comparisons and Wilcoxon signed-rank tests for within-group changes, with significance set at P < 0.05. RESULTS: Thirty-three patients enrolled (16 vedolizumab, 17 anti-TNF). CMI responses increased postvaccination in both groups (median 56 cells/million [interquartile range {IQR} 21–102] vs 33 cells/million [IQR 11–73]; P = 0.13), with no significant difference between treatment groups. Both groups showed strong antibody responses to vaccination (preimmunization median: 349.9 mIU/mL [IQR 276.8–402.5] vs 90-day median: 605.0 mIU/mL [IQR 525.6–641.0]; P < 0.001). CMI responses remained elevated at both day 240 and 425 assessments. Antibody levels remained elevated through day 425 (549.1 mIU/mL, IQR 516.1–585.6), substantially higher than prevaccination levels. No IBD flares occurred; most adverse events were mild and transient. DISCUSSION: RZV demonstrated robust immunogenicity and favorable safety profile in patients with IBD receiving either vedolizumab or anti-TNF therapy. Both cellular and humoral immune responses persisted through 425 days postvaccination.