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BACKGROUND While mammalian target of rapamycin inhibitors have revolutionized the management of angiofibroma in tuberous sclerosis complex (TS), physical modalities such as laser are still indicated for recalcitrant lesions. OBJECTIVE The authors performed a systematic review of the efficacy and safety of laser treatment for TS-related facial angiofibroma. METHODS The electronic databases such as MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to October 10, 2023, for eligible records. RESULTS Forty-seven articles met the inclusion criteria, representing a total of 217 patients with TS-related facial angiofibroma who received laser treatment. Several lasers have been trialed in patients including carbon dioxide (n 5 95, 43.7%), pulsed dye (n 5 21, 9.7%), argon (n 5 16, 7.4%), neodymium-doped: yttrium aluminum garnet (n 5 12, 5.5%), copper vapor (n 5 9, 4.1%), potassium titanyl phosphate (n 5 7, 3.2%), erbium: yttrium aluminum garnet (n 5 2, 0.9%), lasers and various combination therapies (n 5 55, 25.3%). CONCLUSION Potassium titanyl phosphate, pulsed dye, and neodymium-dopsed:yttrium aluminum garnet lasers are better suited to manage the vascular components of angiofibroma while ablative lasers such as erbium: yttrium aluminum garnet and carbon dioxide lasers may present better options for lesions with a prominent fibrous component. While several lasers have been trialed with broadly favorable results, the low level of evidence precludes definitive conclusions, and no single laser appears superior. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine if robotic-assisted lobectomy (RPL-4) is cost-effective and offers improved patient-reported health utility for patients with early-stage non--small cell lung cancer when compared with video-assisted thoracic surgery lobectomy (VATSlobectomy). Background: Barriers against the adoption of RPL-4 in publicly funded health care include the paucity of high-quality prospective trials and the perceived high cost of robotic surgery. Methods: Patients were enrolled in a blinded, multicentered, randomized controlled trial in Canada, the United States, and France, and were randomized 1:1 to either RPL-4 or VATS-lobectomy. EuroQol 5 Dimension 5 Level (EQ-5D-5L) was administered at baseline and postoperative day 1; weeks 3, 7, 12; and months 6 and 12. Direct and indirect costs were tracked using standard methods. Seemingly Unrelated Regression was applied to estimate the cost effect, adjusting for baseline health utility. The incremental cost-effectiveness ratio was generated by 10,000 bootstrap samples with multivariate imputation by chained equations. Results: Of 406 patients screened, 186 were randomized, and 164 analyzed after the final eligibility review (RPL-4: n= 81; VATS-lobectomy: n =83). Twelve-month follow-up was completed by 94.51% (155/164) of participants. The median age was 68 (60--74). There were no significant differences in body mass index, comorbidity, pulmonary function, smoking status, baseline health utility, or tumor characteristics between arms. The mean 12-week health utility score was 0.85 (0.10) for RPL-4 and 0.80 (0.19) for VATS-lobectomy (P=0.02). Significantly more lymph nodes were sampled [10 (8--13) vs 8 (5--10); P=0.003] in the RPL- 4 arm. The incremental cost/quality-adjusted life year of RPL-4 was $14,925.62 (95% CI: $6843.69, $23,007.56) at 12 months. Conclusion: Early results of the RAVAL trial suggest that RPL-4 is costeffective and associated with comparable short-term patient-reported health utility scores when compared with VATS-lobectomy. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Dietary and lifestyle changes are the first line of therapy for nonalcoholic fatty liver disease (NAFLD), the most prevalent liver disease in the western world. Nutrition literacy is the ability to understand nutrition information and implement that knowledge. We aimed to compare indicators of nutrition literacy in subjects with and without NAFLD in a representative US cohort. METHODS: In a cross-sectional study using data from the National Health and Nutrition Examination Survey 2017-2018 cycle, we included 2,938 adult subjects with complete dietary and vibration-controlled transient elastography data and no alternative reason for hepatic steatosis. Nutrition literacy was assessed using questionnaires. Diet perception accuracy was assessed by comparing self-reported diet quality with objective diet quality scores-the Healthy Eating Index and alternative Mediterranean diet score-to assess real-world application of nutrition knowledge. RESULTS: Nutrition literacy was not different between subjects with or without NAFLD (P = 0.17): more than 90% of subjects reported using nutrition labels, and most of them correctly identified the meaning of daily value. Subjects with NAFLD had a lower-quality diet (Healthy Eating Index, P = 0.018; alternative Mediterranean diet, P = 0.013) and rated their diet as poorer (P < 0.001). On self-assessment, only 27.8% of subjects overestimated their diet quality, while 37.5% consumed more calories than their self-assessed needs. Both accuracy measures were similar between subjects with NAFLD and those without (P = 0.71 and 0.63, respectively). Subjects with NAFLD were more likely to report being advised to lose weight (42.1% vs 16.5%, P < 0.001) or to attempt losing weight (71.9% vs 60.9%, P < 0.001). Diet quality was not better in subjects with NAFLD who received dietary recommendations. DISCUSSION: Subjects with NAFLD have poor diet quality despite receiving medical recommendations to lose weight and having nutrition literacy and perception that are comparable with subjects without NAFLD. Educational approaches may not be sufficient to promote weight loss and improve diet quality in NAFLD. [ABSTRACT FROM AUTHOR]

Introduction: 15% of patients with hip fracture older than 65 years in Israel have delayed surgery. The aim of this study was to determine which patient and/or organizational factors are associated with a delay of beyond 48 hours in hip fracture repair surgery. Methods: A retrospective cohort study of 281 patients with hip fracture who underwent surgery during 2019–2020. Characteristics of patients with early surgery (n = 40) and patients with delayed surgery (n = 241) were compared. Results: Presence of a cardiac disease (odds ratio [OR] = 1.38), pulmonary disease (OR = 1.21), or obesity (OR = 1.18) was identified as risk factors for surgical delay. Each additional comorbidity increased the risk. Most of the documented reasons for delay were medical, with antiplatelet therapy the most common (n = 8, 20%). Unavailable operating rooms were another common reason for delays (n = 8, 20%). In addition, a higher percentage of patients with delayed surgery were admitted in August and September (42.5%). Conclusions: It seems that most delays were for medical reasons. However, it is unclear whether allegedly clinically justified delays were indeed of benefit to the patients. Health care organizations should strive to minimize the impact of organizational factors on surgical delay. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: The aim of this study was to analyze esophageal cancer patients who previously underwent neoadjuvant therapy followed by a curative resection to determine whether additional adjuvant therapy is associated with improved survival outcomes. Summary Background Data: Neoadjuvant therapy followed by surgery is the standard of care for locally advanced esophageal cancer, whereas adjuvant therapy is typically employed for patients with residual disease. However, the role of adjuvant therapy after a curative resection is still uncertain. Methods: MEDLINE, EMBASE, and CENTRAL databases were searched for studies comparing patients with esophageal cancer who underwent neoadjuvant therapy and curative resection with and without adjuvant therapy. Primary outcome was overall survival (OS), and random effects meta-analysis was conducted where appropriate. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence. Results: Ten studies involving 6462 patients were included. When compared to patients who received neoadjuvant therapy and esophagectomy alone, adjuvant therapy groups experienced a significant decrease in mortality by 48% at 1 year (Risk Ratio (RR) 0.52, 95% confidence interval [CI] 0.41–0.65, P < 0.001, moderate certainty). This reduction in mortality was carried through to 5-year follow-up (RR 0.91, 95% CI 0.86–0.96, P < 0.001, moderate certainty). The difference between the adjuvant therapy and the control group was uncertain regarding the secondary outcomes. Conclusion: Adjuvant therapy after neoadjuvant treatment and esophagectomy with negative resection margins provide an improved OS at 1 and 5 years with moderate to high certainty of evidence, but the benefit for disease-free survival and locoregional/distal recurrence remain uncertain due to limited reporting of these outcomes. [ABSTRACT FROM AUTHOR]

This article discusses the use of topical sirolimus as an adjunct to pulsed dye laser (PDL) treatment for pediatric capillary malformations (CMs). The efficacy of this combination treatment has shown conflicting results in previous studies, and there is limited research specifically in the pediatric setting. The authors conducted a retrospective review of pediatric patients who received PDL treatment with adjuvant topical sirolimus. They found that all patients demonstrated significant improvement in cosmesis, although burns occurred in some treatment sessions. The study is limited by its small sample size and retrospective design, but the tolerability of sirolimus in pediatric patients suggests the need for further research to better understand its therapeutic potential. [Extracted from the article]

Fatty liver (FL) is associated with altered activity of hepatic drug‐metabolizing enzymes, but the clinical significance is unknown. Many anesthetic agents are metabolized in the liver. We aimed to determine whether FL impacts recovery from anesthesia as a surrogate for altered drug metabolism. This was a single‐center, retrospective, case‐control study of all adults who underwent anesthesia and concurrent abdominal imaging (n = 2,021) in a hospital setting. FL (n = 234) was identified through radiology reports. Anesthesia recovery, the primary endpoint, was defined by Aldrete's recovery score (RS, 0‐10), assessed following postanesthesia care unit (PACU) arrival, with RS ≥8 considered discharge eligible. FL and controls were compared using univariate and multivariate analyses, adjusting for confounders. A secondary matched‐pairs analysis matched FL and controls 1:1 for confounders. Time from airway removal to discharge eligibility was compared using multivariate Cox regression. On PACU arrival, 54.1% of FL were discharge eligible compared to 61.7% of controls (P = 0.03), with lower activity scores on univariate (P = 0.03) and multivariate analysis (P = 0.03). On matched‐pairs analysis, discharge eligibility, activity, consciousness, and total RSs were lower in FL (P ≤ 0.04 for all). Median time from airway removal to discharge eligibility was 43% longer in FL (univariate, P = 0.01; multivariate hazard ratio, 1.32; P = 0.046). To further exclude confounding by obesity, we performed a sensitivity analysis limited to a body mass index <30, where FL was still associated with lower activity (P = 0.03) and total RS (P = 0.03). Conclusion: Patients with FL have delayed recovery from anesthesia, suggesting altered drug metabolism independent of metabolic risk factors. [ABSTRACT FROM AUTHOR]

Background and Objectives: The Israeli National Program for Quality Indicators (INPQ) sets as its primary goal to promote high-quality health care within selected core areas in the Israeli health system. Surgical site infection is one of the most common types of acquired infections. The INPQ supports 3 distinct indicators concerning suitable antibiotic treatment in colorectal surgery, cesarean sections, and surgery for femoral neck fractures. Methods: We measured the number of patients who received prophylactic antibiotics, beginning an hour before the first cut and stopping after 24 hours in 1 of the 3 operations, according to the International Classification of Diseases, Ninth Revision (ICD-9) codes. Goals for success have been established annually according to the results of the previous year. Data computed for each operation included socioeconomic status, dates of hospitalization and release, date of death, date of birth, gender, date of operation, time of beginning and end of the operation, and time of beginning and end of anesthesia. Results: Within 3 to 5 years, we achieved a significant increase in appropriate prophylactic antibiotic use from 78% to 85%, 78% to 95%, and 66% to 88% for colorectal surgery (n = 9404), cesarean sections (n = 141 362), and femoral joint operations (n = 30 728), respectively. The mortality rate was lower, 1.85% versus 0.55% in patients who received proper antibiotic therapy (odds ratio [OR] = 3.141; 95% confidence interval [CI], 1.829-5.394, P< .0001), 0.031% versus 0.006% (OR = 6.741; 95% CI, 1.879-21.187; P= .003), and 5.59% versus 4.51% (OR = 1.253; 95% CI, 1.091-1.439; P= .001), respectively. Conclusion: Prophylactic antibiotic treatment is strongly recommended by medical guidelines. The experience of the INPQ supports this approach. We demonstrate a significant lower mortality rate in patients who have been properly treated. [ABSTRACT FROM AUTHOR]

The recently developed lipoprotein insulin resistance index (LP‐IR) incorporates lipoprotein particle numbers and sizes and is considered to reflect both hepatic and peripheral IR. As tissue IR is a strong component of nonalcoholic fatty liver disease (NAFLD) pathogenesis, we aimed to assess the degree by which LP‐IR associates with hepatic fat content. This was a single‐center retrospective analysis of patients with NAFLD. LP‐IR, the homeostasis model assessment of insulin resistance (HOMA‐IR), and adipose tissue IR (Adipo‐IR) were measured simultaneously. Liver fat content was estimated by FibroScan controlled attenuated parameter. Associations were assessed using Spearman's correlation and multivariate linear regression. The study included 61 patients. LP‐IR was correlated with HOMA‐IR (ρ = 0.30; P = 0.02), typically thought to reflect hepatic IR, but not with Adipo‐IR (ρ = 0.15; P = 0.25). Liver fat content was significantly associated with Adipo‐IR (ρ = 0.48; P < 0.001), LP‐IR (ρ = 0.35; P = 0.005), and to a lesser degree with HOMA‐IR (ρ = 0.25; P = 0.051). The association of liver fat with LP‐IR was limited to patients without diabetes (ρ = 0.60; P < 0.0001), whereas no association was seen in those with diabetes. In a multivariate model, Adipo‐IR, LP‐IR, and diabetes were independently associated with liver fat and together explained 35% of the variability in liver fat. Conclusion: LP‐IR is a reasonable measure of IR in non‐diabetic patients with NAFLD and is associated with hepatic fat content. Although adipose tissue is the major contributor to liver fat, the additional contribution of nonadipose tissues can be easily estimated using LP‐IR. [ABSTRACT FROM AUTHOR]

BACKGROUND: Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization. METHODS: This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant. RESULTS: Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P=0.002) after multivariate adjustment. CONCLUSIONS: Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality. [ABSTRACT FROM AUTHOR]