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Background: The role of minimally invasive surgery (MIS) in locally advanced colorectal cancers (CRCs) suspected of direct invasion to adjacent organs or structures remains controversial. The aim o...

Background Cholecystectomy in patients with hematologic malignancies remains poorly understood. Methods We retrospectively evaluated patients with hematologic malignancies who underwent cholecystectomy at a single institution. Results Of 313 patients who presented for evaluation of abdominal pain, 64 underwent cholecystectomy for acute cholecystitis (34.4%), gangrenous cholecystitis (21.9%), chronic cholecystitis (23.4%), and cholelithiasis (20%). Most had a history of hematopoietic cell transplantation (62.5%) and/or immunosuppressive medication within 30 days of consultation (82.8%). Ultrasound had a 39% false-negative rate for acute nongangrenous cholecystitis. Operative time was 92 ± 39 min, 7 were performed open, 10 had intraoperative transfusions, and 4 had grade 3+ complications. Intraoperative transfusion was associated with increased postoperative length of stay (p = 0.03). Open procedure, operative time, estimated blood loss, intraoperative transfusion, and complications were not associated with timing of surgery. Conclusions Patients with hematologic malignancies can safely undergo cholecystectomy. Length of postoperative stay for inpatients is associated with intraoperative blood transfusion.

Blood stream infection (BSI) is a potentially lethal complication in patients receiving extracorporeal membrane oxygenation (ECMO). It may be particularly common in patients with veno-venous ECMO due to their long hospitalization in the intensive care unit. Given that these patients have concurrent indwelling central venous catheters (CVC), it is unclear whether the ECMO circuit, CVC, or both, contribute to BSI. This study evaluated the risk factors associated with BSI in patients receiving veno-venous ECMO in a single institution study of 61 patients from 2016 through 2019. All ECMO catheters and the circuit oxygenator fluid were aseptically collected and analyzed for microorganisms at the time of decannulation. New BSI was diagnosed in 15 (24.6%) patients and increased mortality by threefold. None of the ECMO catheters or oxygenator fluid were culture positive. BSI increased with CVC use of over 8 days and was significantly lowered when CVC were exchanged by day 8 compared with patients with exchanges at later points (15.0% vs. 42.8%, p = 0.02). Median length of CVC use in the BSI-negative and BSI-positive group were 6.3 ± 5.0 and 9.4 ± 5.1, respectively (p = 0.04). In summary, BSI is a potentially lethal complication in patients receiving ECMO. Indwelling CVC, not the ECMO circuitry, is the likely contributor for BSI, and exchanging CVC by day 8 can reduce the incidence of BSI.

Background Incidentally discovered low-grade gliomas (iLGGs) are poorly reported in the literature and little is still known about their effects on white-matter structure. In this study, we investigated whether iLLG growth in either hemisphere could affect main white-matter association tracts and cortico-spinal tract. Methods We retrospectively analyzed white-matter integrity in a group of 18 patients with iLGG having a mostly preserved cognitive status [1]. We identified two groups of patients, 13 having iLGG in left hemisphere (LH) five in right hemisphere (RH) and maximum lesion overlap in inferior frontal gyrus and in medial frontal areas, respectively. A group of healthy controls (n = 20) was included. We carried out a univariate analysis of variance to inspect potential effect of interaction between hemisphere harboring the lesion (i.e., LH or RH) and hemisphere taken into account on number of streamlines and fractional anisotropy (FA) of reconstructed white-matter tracts. Results The sole significant interaction concerned left arcuate fasciculus, with patients with iLGG in LH having a lower number of streamlines than healthy controls; interaction involving FA was not significant for any of the fascicles. Lack of any other significant findings indicates overall preserved white matter. Conclusions iLGG size and growth pattern could explain why white-matter status did not markedly differ with respect to the healthy controls. Findings therefore support evidence that iLGGs represent the earlier phase in natural history of LGGs and are discussed in a clinical perspective and in support to safe early surgery.

BACKGROUND Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013. METHODS Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. RESULTS There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p

Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances in surgical technique, outcomes remain poor for this patient group, and optimum treatment has yet to be established. We aimed to assess the treatment and outcomes of patients in our institution in the context of previous studies. All patients from 2008 to 2018 who underwent surgical management for hypopharyngeal tumours with pharyngo-laryngo-esophagectomy and flap-based reconstruction were included in the study. Demographic and outcome data were collected, and patient-reported outcomes were solicited from surviving patients using the EORTC QLQ HN 43 questionnaire. Thirty patients were assessed, in which 12 had gastric pull-ups, 16 had free jejunum flaps, and 2 had free anterolateral thigh flaps. There was a 38% five-year survival rate. Overall, the rates of stricture (10.7%) and fistula (7.1%) were low. The majority of patients (53.6%) returned to a normal diet within three months with a soft or puree diet in 35.7% of patients. Some form of speech was possible in 92.9% of patients. The average questionnaire score for surviving patients was 87.3, with good outcomes related to eating and swallowing, but poorer outcomes for speech and communication. This study showed that outcomes for patients receiving complex reconstruction following hypopharyngeal tumour resection are improving over time. There is still scope for improvement of patient outcomes and refinement of optimum surgical management strategies.

Purpose: The current study aimed to report the perioperative complications of the modified Stoppa approach for the treatment of pelvic bone fractures. Methods: We analyzed 48 consecutive operations in 45 patients who were treated with internal fixation using the modified Stoppa approach between March 2016 and July 2018. This included three revision operations. The mean age of the patients was 54.5 years, and the patients included 35 male patients and 10 female patients. All fractures occurred as a consequence of high-energy trauma and 70.3% had associated injuries at the time of the fracture. The mean Injury Severity Score was 9.03±5.60. The perioperative complications found during and immediately after surgery were recorded and were classified into three categories: vascular injuries, nerve injuries, and other complications. Results: Overall, 14 perioperative complications (29.2%) in 14 cases were identified. The most common complications were nerve injuries, which occurred in seven cases, all involving the obturator nerve. Uncontrollable vascular injuries occurred in six cases, which required additional incisions and support of vascular surgeons or postoperative interventions. Additionally, one case of peritoneal tearing occurred, which required help from an abdominal surgeon. Conclusions: While the modified Stoppa approach seems to be a viable method to treat pelvic fractures, significant perioperative complications may occur, suggesting that surgeons should pay careful attention to minimize the damage to other structures and that appropriate support from other surgical departments is paramount.

Thrombopoietin receptor agonists (TPO-RAs) are used to treat bone marrow failure in aplastic anemia (AA). Treatment with TPO-RAs, cyclosporine A (CsA) and anti-thymocyte globulin (ATG) induces remission and a sustained response. However, the efficacy of TPO-RAs without ATG remains unclear. We retrospectively assessed 45 patients with AA refractory to CsA and naïve for ATG treatment who received eltrombopag without ATG at our hospital during 2017-2021. Of these, 28 (62%) achieved a hematologic response in at least one lineage after six months of treatment, and 38 (84%) achieved best response at any point during the follow-up period. Four patients (25%) achieved trilineage responses during the follow-up period. Five patients switched from eltrombopag to romiplostim because of adverse events or lack of efficacy. Two developed hematologic malignancies. Eltrombopag was effective even in elderly ATG-ineligible patients with severe AA. The two-year overall survival rate was 84.3%, with a median follow-up of 26.3 months. Time from diagnosis to eltrombopag treatment initiation tended to affect the response (p = 0.0727), but no factors that significantly predicted hematologic response were identified. In conclusion, patients who are ineligible for ATG treatment because of age, complications, or even severe AA should nevertheless be considered for TPO-RA treatment.

Background The number of primary and revision shoulder arthroplasties performed each year continues to increase. Relative value units (RVUs) are currently used by the Centers for Medicare and Medicaid Services (CMS) to determine physician reimbursement based on time, effort, and complexity of services rendered. Compared to primary shoulder arthroplasty, revision shoulder arthroplasties are often more technically challenging, have longer operative times, and pose a greater risk of intraoperative and postoperative complications. This study aims to compare surgeon reimbursement between primary and revision shoulder arthroplasty. Methods Utilizing a single institution shoulder arthroplasty database, we identified patients who underwent primary or revision shoulder arthroplasty between February 2011 and December 2013 by a single shoulder and elbow fellowship trained surgeon with over 20 years of experience at the time of data collection. The RVUs for primary and revision shoulder arthroplasty were obtained from the CMS Physician Fee schedule. Physician reimbursement for primary and revision shoulder arthroplasty was calculated using the CMS RVU to dollar conversion factor of $34.8921 per RVU. The RVU was divided by operative time to calculate an RVU/min for primary and revision shoulder arthroplasty. Monetary reimbursement per minute, case, day, and year was subsequently calculated. Results A total of 190 primary and 100 revision shoulder arthroplasties were performed during the study period. Mean RVU for primary shoulder arthroplasty was 22.13 ± 0.00 vs. 26.24 ± 1.10 for revision shoulder arthroplasty (P Conclusion While the RVU/case is higher for revision shoulder arthroplasty, the difference does not account for the additional operative time and complexity compared to primary shoulder arthroplasty. In light of this data, the current RVU reimbursement model should be reevaluated to account for these differences between primary and revision shoulder arthroplasty. Level of Evidence Level III; Retrospective Comparative Study

Introduction : General surgery residents often feel unprepared to perform pediatric surgery procedures since case volume and experience may be low. Previously, we successfully implemented a simulation-based training (SBT) module for placement of a silastic silo for gastroschisis. Therefore, we designed a single institution pilot study to assess whether SBT for placement of a percutaneous peritoneal drain for perforated necrotizing enterocolitis (NEC) was feasible and lead to skill acquisition and increased confidence. Methods : Our newly created NEC module within our pediatric surgery SBT curriculum for general surgery residents was used. Residents completed two simulation sessions three months apart with confidence testing before and after each session. Skill acquisition and performance were assessed using a standardized case scenario and procedure checklist. Changes in residents’ confidence and performance were determined using Wilcoxon Signed-Rank Tests. Results : Nine post-graduate-year three general surgery residents completed this curriculum. Following completion, residents reported improved confidence completing each step of the procedure initially (p = 0.005) and at 3 months (p = 0.008) with improved technical scores (p = 0.011). The number of residents deemed proficient significantly improved (p = 0.031). Conclusion : Implementation of SBT module for perforated NEC was feasible and improved residents’ confidence and proficiency completing the procedure.

OBJECTIVES Patients with abdominal aortic aneurysms undergoing EVAR with larger device diameters (34- to 36-mm) have worse outcomes due to proximal fixation failure and need for reintervention. We examine outcomes relating to standard fenestrated repair (FEVAR) with larger device diameters, and investigate whether a similar relationship exists. MATERIAL AND METHODS Retrospective review of a prospectively maintained, single institution database of patients treated with the Cook ZFEN device between 2012-2017. Outcomes were stratified by device diameter into normal-diameter (ND,≤ 32 mm) and large-diameter (LD,34-36 mm). Primary endpoints were need for reintervention and composite type I/III endoleak. RESULTS 100 consecutive patients treated were identified for inclusion. Overall mean age was 73.6 years and mean aortic diameter was 59.1 mm. Mean follow-up was 22 months. A total of 26 (26%) patients were treated with LD devices. Number of target vessels per patient was 2.8 in both groups. Infrarenal neck length and diameter were significantly different in the LD and ND patients, respectively (2.6 mm vs 4.7 mm (P

To define risk factors and perioperative outcomes for matrix stones and compare these outcomes with struvite and calcium stone cohorts.A retrospective cohort study comparing matrix stones (n=32), struvite stones (n=23) and a matched, calcium stone control group (n=32) was performed. Two-way ANOVA was used to compare the groups for continuous variables. Chi-square tests were used to compare categorical variables. Significance was set at P.05. All statistical tests were performed using R (v1.73).We identified no differences in age, gender, or BMI between the three groups. Matrix and struvite stones were more likely to have a history of prior stone surgery and recurrent UTIs compared to calcium stones (P=.027 and P.001, respectively). Struvite stones were more likely to present as staghorn calculi compared to matrix or calcium stones (56.5% vs 21.7% vs 18.8%, P=.006). There were no significant differences in postoperative stone free rates (P=.378). No significant differences in postoperative infectious complications were identified. Matrix stones were more likely to have Candida on stone culture compared to the struvite or calcium stones (P.0001).Matrix and struvite stones were more likely have a history of stone surgery and preoperative recurrent UTIs. Struvite stones were more likely to present as staghorn calculi. Matrix stones were more likely to have Candida present in stone cultures. However, no difference in postoperative infectious outcomes or stone free rates were identified. Further study with larger cohorts is necessary to distinguish matrix stone postoperative outcomes from struvite and calcium stones.

Objectives : Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described. Methods : We studied all elective EVAR from 2010-2018 in a single institution. Late endoleaks were defined as those appearing after one year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival. Results : Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92% and 81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine one-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P=.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P=.02), neck length 60 degrees (HR 3.4 [1.5-7.9], P=.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. Two patients had proximal degeneration and 5 experienced graft migration. There were two ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years). Conclusion : Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.

Background The effectiveness of virtual dermatology curricula in developing countries remains unclear despite an urgent need due to the pandemic and other factors. Objective To compare a virtual dermatology curriculum deployed in Gondar, Ethiopia with a traditional in-person course. Methods We developed a free, on-line dermatology course. 104 trainees from the University of Gondar, Ethiopia, completed the course. Pre- and post-course surveys measuring self-reported proficiency were administered. End-of-Course surveys were distributed to elicit feedback on the course. Performance on final examinations was compared to a historical control group, which did not participate in the course but received standard in-person training. Results Compared to historical controls (n = 236), the pilot cohort (n = 104) averaged over 4 points higher on the final exam (P < .0001). Most participants were satisfied with all aspects of the on-line course and desire at least a component of virtual learning in the future. Limitations This pilot study was performed at a single institution, and the participants were not randomized. Further studies in demographically diverse cohorts are needed to validate the results. Conclusion This dermatology curriculum is a free, innovative platform that can be adapted for dermatology trainees in resource-limited settings.

Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned.A single-center, retrospective review of medical records was conducted from March 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access.We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient. Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO.Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

One purported benefit of the direct anterior approach (DAA) for total hip arthroplasty (THA) is a lower rate of postoperative dislocation.An institutional database was used to identify 8840 primary THAs performed from 2003 to 2020 including 5065 (57%) performed using the DAA and 3775 (43%) performed via the posterior approach (PA). Direction and mechanism of dislocation were determined from chart review. Outcomes were compared using Kaplan-Meier survivorship with dislocation as the endpoint and a Cox multivariate regression was used to investigate factors associated with dislocation. The mean follow-up was 1.7 ± 2.0 years for the DAA and 3.1 ± 3.3 years for the PA.The 0.5% (26/5065) incidence of dislocation among DAA hips was significantly less than the 3.3% (126/3775) among PA cases (P.001). The majority of dislocations were posterior (DAA 57%, PA 79%) and occurred during activities of daily living (DAA 82%, PA 77%). Five-year survivorship was significantly higher for the DAA group compared to the PA group (99.1% vs 95.4%, P.001). Dislocation risk was 4.9 times higher for the PA compared to the DAA (hazard ratio = 4.9, 95% confidence interval = 3.2-7.5, P.001). Increasing head diameter reduced the risk (hazard ratio = 0.70, 95% confidence interval = 0.57-0.86, P.001). The 0.2% incidence (10/5065) of revision for instability among the DAA group was significantly lower than the 1.1% (43/3775) rate for the PA group (P.001).Compared to primary THAs performed with the PA, DAA cases had a lower risk of dislocation, higher survivorship with dislocation as an endpoint, and a lower risk of revision for instability in this single institution cohort.

PURPOSE To compare visual outcomes in children with moderate bilateral astigmatism treated with glasses with those who were merely observed. DESIGN Retrospective case series. METHODS The medical records of all children 1 to

Purpose The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies. Methods Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed. Results Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n = 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n = 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases. Conclusion Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present. Level of Evidence IV, case series, treatment study

Clinical Practice Points • Testicle is an uncommon site for myeloid sarcomas and pose a diagnostic and therapeutic challenge to urologists. Herein we present our single-institution experience with diagnosis and management of six patients with testicular myeloid sarcomas. In our experience, clinical history and immunohistochemical findings are of great importance for diagnosis of testicular myeloid sarcomas. Systemic chemotherapy is recommended. Unilateral orchiectomy or testicular biopsy combined with radiotherapy could be used for patients with need to preserve testicle.

Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.

To evaluate our institutional outcomes utilizing Cs-131 prostate brachytherapy (PB) for the intermediate-risk (IR) group of prostate cancer patients.We reviewed a prospectively collected database of men treated with Cs-131 PB between 2006 and 2019. Patients with less than 24-months follow-up were excluded. Patients were classified as IR if they had one of the following factors: Gleason Score 7, prostate specific antigen10 but20 ng/mL, or T2b-c on clinical exam. We defined unfavorable-IR (UIR) as having either Grade Group 3,1 IR factors, or ≥50% positive core biopsies. The Kaplan-Meier method was used to estimate actuarial event-time probabilities for biochemical freedom from disease (BFD).A total of 335 patients with a median follow-up of 70.1 months (IQR 48.3-106.3 months) were identified. Androgen deprivation therapy (ADT) was used in 7.2% of patients. Favorable-IR (FIR) patients were commonly treated with PB alone (91.8%). FIR patients who underwent PB alone had a 5-year BFD of 98.1%. UIR patients were commonly treated with external beam radiotherapy plus PB (61.2%). These patients had 5-year BFD of 91.1%. The 5-year BFD for UIR patients treated without ADT was 90.9%, whereas it was 95.0% among UIR patients treated with ADT (log-rank p = 0.83).FIR patients have excellent outcomes when treated with PB alone. External beam radiotherapy plus PB is a reasonable treatment approach for UIR patients. Future studies may elucidate which IR patients would benefit from treatment intensification.

BACKGROUND The COVID-19 pandemic altered residency recruitment in the 2021 application cycle. As a result, many programs adapted by creating virtual opportunities to connect with applicants such as clerkships, open houses, meet and greets, and interviews. Recent research has explored applicant impressions on virtual interviews and open houses, but none have assessed the utility of meet and greets, optimal structure, or desired topics to be addressed. METHODS We hosted two virtual meet and greets for otolaryngology applicants and subsequently conducted a structured survey to assess the benefit, gather insight into desired topics, and determine how future sessions could be optimized. RESULTS Twenty of 65 participants responded to the survey (31% response rate). The majority of participants learned about the event through social media (n = 15) or online resources such as OtoMatch or HeadMirror (n = 12). Desired topics to be addressed included faculty-resident relationships (85%), research (80%), the city of Madison (75%), breadth and depth of faculty (75%), and ability to train residents for future positions and fellowships (75%), among others. Overall, participants found the events helpful in conveying the culture and environment, exposure to faculty and residents, addressing questions, and providing insight into intangible aspects of the program. The main area of improvement identified was related to having breakout rooms, longer sessions, and varying the topics for breakout rooms. CONCLUSION Virtual meet and greets facilitate outreach and provide opportunities for applicants to engage with residency programs and demonstrate interest. While initially implemented due to the COVID-19 pandemic, they will likely remain helpful in generating interest, reaching broader audiences, and possibly facilitating a successful match. It is critical to understand and incorporate the content that applicants wish to learn about at virtual meet and greets to best address questions, highlight key features, and demonstrate the intangible aspects of a residency program.

Background: Due to its specific physical characteristics, proton irradiation is especially suited for irradiation of chordomas and chondrosarcoma in the axial skeleton. Robust plan optimization renders the proton beam therapy more predictable upon individual setup errors. Reported experience with the planning and delivery of robustly optimized plans in chordoma and chondrosarcoma of the mobile spine and sacrum, is limited. In this study, we report on the clinical use of robustly optimized, intensity modulated proton beam therapy in these patients.Methods: We retrospectively reviewed patient, treatment and acute toxicity data of all patients with chordoma and chondrosarcoma of the mobile spine and sacrum, treated between 1 April 2019 and 1 April 2020 at our institute. Anatomy changes during treatment were evaluated by weekly cone-beam CTs (CBCT), supplemented by scheduled control-CTs or ad-hoc control-CTs. Acute toxicity was scored weekly during treatment and at 3 months after therapy according to CTCAE 4.0.Results: 17 chordoma and 3 chondrosarcoma patients were included. Coverage of the high dose clinical target volume was 99.8% (range 56.1-100%) in the nominal and 80.9% (range 14.3-99.6%) in the voxel-wise minimum dose distribution. Treatment plan adaptation was needed in 5 out of 22 (22.7%) plans. Reasons for plan adaptation were either reduced tumor coverage or increased dose to the OAR.Conclusions: Robustly optimized intensity modulated proton beam therapy for chordoma and chondrosarcoma of the mobile spine is feasible. Plan adaptations due to anatomical changes were required in approximately 23 percent of treatment courses. (C) 2021 The Authors. Published by Elsevier B.V.

Objective The evaluation of women with perimenopausal abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB) to detect endometrial cancer (EC) and its precursors is not standardized and can vary widely. Consequently, costs associated with the workup and management undoubtedly vary. This study aimed to quantify costs of AUB/PMB evaluation to understand the healthcare burden associated with securing a pathologic diagnosis. Methods Women ≥45 years of age presenting to a single institution gynecology clinic with AUB/PMB for diagnostic workup were prospectively enrolled February 2013–October 2017 for a lower genital tract biospecimen research study. Clinical workup of AUB/PMB was determined by individual provider discretion. Costs of care were collected from administrative billing systems from enrollment to 90 days post enrollment. Costs were standardized and inflation-adjusted to 2017 US Dollars (USD). Results In total, there were 1017 women enrolled with 5.6% diagnosed with atypical hyperplasia or endometrial cancer (EC). Within the full cohort, 90-day median cost for AUB/PMB workup and management was $2279 (IQR $512–4828). Among patients with a diagnostic biopsy, median 90-day costs ranged from $2203 (IQR $499–3604) for benign or disordered proliferative endometrium (DPE) diagnosis to $21,039 (IQR $19,084-24,536) for a diagnosis of EC. Conclusions The costs for diagnostic evaluation of perimenopausal AUB and PMB vary greatly according to ultimate tissue-based diagnosis. Even reassuring benign findings that do not require further intervention—the most common in this study's cohort—yield substantial costs. The development of sensitive, specific, and more cost-effective diagnostic strategies is warranted.

Background: Stomach cancer is the fifth most common malignancy. In 2012, 952,000 cancers were diagnosed worldwide, which led to 723,000 deaths. Elderly men are the most frequently observed category of gastric cancer patients, mostly affecting the antrum. The objective of this study was to analyze the association of age with sex, tumor sites, types of surgical intervention, and diagnosed anatomical pathologies in cases of gastric cancer. Methods: This cross-sectional descriptive study analyzed the associations between age, sex, tumor sites, types of surgical intervention, and diagnosed anatomical pathologies among the total gastric cancer incidences during medical treatments from January 2016 to May 2019. The study samples were collected from the total gastric cancer respondents who met the inclusion criteria during medical treatments within the study period. Results: Gastric cancer was most frequently observed among females (56%) and those aged 50–70 years old (47%). Most respondents had advanced stages of gastric cancer at first enrollment at our institution. The most frequently found tumor site was the corpus (43%). The most frequently performed type of surgical intervention was jejunostomy feeding (26%), and the most frequently diagnosed anatomical pathology was adenocarcinoma with poorly differentiation (39%). Overall, age had statistically significant correlations with sex (p 50 years old), gastric cancer was more prevalent in women than men, and the gastric tumor tended to be more distal. Non-cardia gastric cancers were more prevalent than cardia gastric cancers.

We sought to evaluate the feasibility of esophageal carcinoma (EC) surgery in cases requiring dialysis. Among 250 consecutive patients undergoing surgical resection for EC, three on maintenance dialysis were identified. We retrospectively analyzed their clinical characteristics. The three dialyzed patients were all males, 39-77 years old at EC surgery. The operations were thoracoscopic esophagectomy with nodal clearance (Case 1), cervical esophageal resection without thoracic procedures (Case 2), and thoracoscopic esophagectomy without reconstruction, emergently conducted for tumor bleeding (Case 3). Reoperation had been required for postoperative abdominal hematoma in Case 1. Postoperative tracheostomy had been performed due to severe pneumonia in Case 2. EC surgery for dialyzed patients, despite appearing to be feasible, might be associated with a high risk of life-threatening morbidities. To minimize surgical risk, therapeutic decision-making for such cases should be based on the balance between radicality and safety.

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer. ispartof: CANCERS vol:15 issue:4 ispartof: location:Switzerland status: published

Background:Adrenal gland metastases (AGMs) are common in advanced-stage melanoma, occurring in up to 50% of patients. The introduction of immune checkpoint inhibitors (ICIs) has markedly altered the outcome of patients with melanoma. However, despite significant successes, anecdotal evidence has suggested that treatment responses in AGMs are significantly lower than in other metastatic sites. We sought to investigate whether having an AGM is associated with altered outcomes and whether ICI responses are dampened in the adrenal glands.Patients and Methods:We retrospectively compared ICI responses and overall survival (OS) in 68 patients with melanoma who were diagnosed with an AGM and a control group of 100 patients without AGMs at a single institution. Response was determined using RECIST 1.1. OS was calculated from time of ICI initiation, anti–PD-1 initiation, initial melanoma diagnosis, and stage IV disease diagnosis. Tumor-infiltrating immune cells were characterized in 9 resected AGMs using immunohistochemical analysis.Results:Response rates of AGMs were significantly lower compared with other metastatic sites in patients with AGMs (16% vs 22%) and compared with those without AGMs (55%). Patients with AGMs also had significantly lower median OS compared with those without AGMs (3.1 years vs not reached, respectively). We further observed that despite this, AGMs exhibited high levels of tumor-infiltrating immune cells.Conclusions:In this cohort of patients with melanoma, those diagnosed with an AGM had lower ICI response rates and OS. These results suggest that tissue-specific microenvironments of AGMs present unique challenges that may require novel, adrenal gland–directed therapies or surgical resection.

PURPOSE: Children with myelomeningocele are known to be consumers of substantial healthcare resources, with many early hospital encounters. The purpose of this study was to survey the extent of medical and surgical care that patients with myelomeningocele receive during the first four years of life. METHODS: Clinical and demographic data were collected on newborn infants with open myelomeningocele from the Children’s of Alabama Spina Bifida Web Tracker, a prospective, comprehensive spina bifida database. Additional data pertaining to all hospital admissions, surgical procedures, and clinic visits were collected from the medical record. RESULTS: One hundred and fourteen subjects with a primary diagnosis of myelomeningocele between 2004 and 2015 were included. Males slightly predominated (55%), 61.4% were Caucasian, 11% Hispanic/Latino; 28% had a mid-lumbar functional lesion level. Over the first four years of life, 688 total surgical procedures were performed (an average of 86 per child): 438 in year 1, 100 in year 2, 84 in year 3, and 66 in year 4. The mean number of hospital visits was 40.5. Total average drive time per patient over 4 years being 103.8 hours. Average number of nights spent in the hospital was 51. CONCLUSION: Children with myelomeningocele need multiple hospitalizations, surgeries, and medical encounters in the first 4 years of life. These data will be valuable when counselling new parents and prospective parents of children with this condition.

Objective: Supraventricular tachycardia, one of the most common conditions requiring emergency cardiac intervention in newborns, is also the most common symptomatic tachyarrhythmia in newborns. Therefore, early diagnosis and treatment approach is important. Method: Demographic findings, clinical findings, and treatment approaches of newborns hospitalized with the diagnosis of supraventricular tachycardia between January 2011 and November 2020 in the Neonatal Intensive Care Unit of our hospital were evaluated retrospectively. Results: Thirty-eight patients without congenital heart disease (except secundum-type atrial septal defect) and diagnosed with supraventricular tachycardia were evaluated retrospectively. The mean week of gestation was 38.2 ± 1.8, the mean age at diagnosis was 10.7 ± 10.1 days, the number of patients with heart failure was 8 (21%), the number of patients with Wolff-Parkinson White syndrome was 8 (21%), the number of patients with fetal arrhythmia was 6 (15.7%) and the mean number of hospitalization days was 15.7±13.5. The patients were given adenosine in the first stage and propranolol, amiodarone, propafenone and flecainide in the second stage as medical treatment. Cardioversion was performed in 5 (13%) patients due to resistant supraventricular tachycardia. Conclusion: Early diagnosis and treatment of supraventricular tachycardia are very important in terms of reducing morbidity and mortality. Therefore, we think that increasing awareness of supraventricular tachycardia among clinicians following newborn babies will enable newborns with supraventricular tachycardia to receive early diagnosis and treatment., Objective: Supraventricular tachycardia, one of the most common conditions requiring emergency cardiac intervention in newborns, is also the most common symptomatic tachyarrhythmia in newborns. Therefore, early diagnosis and treatment approach is important.Method: Demographic findings, clinical findings, and treatment approaches of newborns hospitalized with the diagnosis of supraventricular tachycardia between January 2011 and November 2020 in the Neonatal Intensive Care Unit of our hospital were evaluated retrospectively.Results: Thirty-eight patients without congenital heart disease (except secundum-type atrial septal defect) and diagnosed with supraventricular tachycardia were evaluated retrospectively. The mean week of gestation was 38.2 ± 1.8, the mean age at diagnosis was 10.7 ± 10.1 days, the number of patients with heart failure was 8 (21%), the number of patients with Wolff-Parkinson White syndrome was 8 (21%), the number of patients with fetal arrhythmia was 6 (15.7%) and the mean number of hospitalization days was 15.7±13.5. The patients were given adenosine in the first stage and propranolol, amiodarone, propafenone and flecainide in the second stage as medical treatment. Cardioversion was performed in 5 (13%) patients due to resistant supraventricular tachycardia.Conclusion: Early diagnosis and treatment of supraventricular tachycardia are very important in terms of reducing morbidity and mortality. Therefore, we think that increasing awareness of supraventricular tachycardia among clinicians following newborn babies will enable newborns with supraventricular tachycardia to receive early diagnosis and treatment.

BACKGROUND: Thermal ablation is an effective treatment for patients with metastatic colon and rectal cancer and allows surgeons to offer curative intent therapy to patients who are otherwise not candidates for resection. We aimed to report outcomes of a single institution experience using microwave ablation (MWA) with or without resection to treat five or more liver metastases. METHODS: In this retrospective cohort study, the University of Minnesota Division of Surgical Oncology liver surgery database was queried to identify all patients who underwent thermal ablation of five or more colorectal liver metastases (CRLM) between 2012–2018. We reviewed patient, disease, and tumor characteristics and measured local, intrahepatic, and extrahepatic recurrence (EHR) rates. We also calculated median overall survival (OS) and disease-free survival (DFS). RESULTS: Ten patients identified had five or more (range, 5–18) tumors ablated with or without combined liver and bowel resection. Median age was 50, and most patients were male (70%) and Caucasian (90%). Four patients received ablation alone (5–12 lesions), while six had combined resection and ablation (5–18 lesions). Ablation was performed laparoscopically in six patients, and four had ablations without resection. All patients received pre- and post-operative chemotherapy. A median of 7 tumors were ablated per patient. Median follow-up was 2.3 years. Among 75 tumors ablated, ablation site recurrence (ASR) (within 1 cm of ablation site) was seen in three with a per-lesion recurrence rate of 4%. Intrahepatic recurrence (IHR) occurred in 6 (60%) patients and EHR in 1 (10%). Five patients underwent retreatment of IHR during follow-up. Median OS was 3 years and DFS was 7.1 months. At the time of last follow up, 6 patients were disease-free. CONCLUSIONS: Thermal ablation can provide acceptable DFS and OS, even with high volume metastatic colorectal cancers. Future efforts should be focused on defining selection criteria for those most likely to benefit from this aggressive approach.

Purpose: This study was performed to assess the effect of prophylactic lymphovenous anastomosis on the prevention of arm lymphedema after axillary lymph node dissection for breast cancer treatment.Methods: Among 69 women referred to undergo axillary lymph node dissection from January 2020 to June 2020, 21 were assigned to the treatment group and 48 to the control group. In the treatment group, 21 patients underwent prophylactic lymphovenous anastomosis for the prevention of breast cancer-related lymphedema. The other 48 patients in the control group did not undergo any preventive surgical treatment. Prophylactic lymphovenous anastomosis was performed at the same time as axillary lymph node dissection and breast cancer surgery. Postoperatively, all patients underwent circumferential measurements at 1, 3, and 6 months and lymphography at 6 months after the surgery. Results: None of the patients in the treatment group had lymphedema after the surgery (0%). In the control group, lymphedema occurred in nine patients (18.8%, p=0.049). No significant differences in the arm circumference were observed in the treatment group during follow-up (p>0.05), whereas the arm circumference in the control group showed a significant increase at 1, 3, and 6 months after axillary lymph node dissection (p0.05). Conclusion: Prophylactic lymphovenous anastomosis represents a valid super microsurgical technique for the primary prevention of breast cancer-related lymphedema.

PURPOSE To compare the efficacy and safety of 177Lu-DOTATATE plus radiosensitizing capecitabine and octreotide long-acting release (LAR) as first-line systemic therapy in advanced well-differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs). MATERIALS AND METHODS Data of consecutive patients of advanced inoperable or metastatic grade 1 or 2 GEP-NETs treated with first-line 177Lu-DOTATATE plus radiosensitizing capecitabine or octreotide LAR from September 2012 to December 2019 were collected and analyzed for response, toxicity, and survival outcomes. RESULTS Seventy-six patients (median age: 53 years; range 14-81 years) with treatment-naïve advanced grade 1 or 2 GEP-NETs were included. Thirty-six patients received a median cumulative dose of 27.3 GBq of 177Lu-DOTATATE intravenously at 8-12 weeks' intervals along with 1,250 mg/m2 oral capecitabine on days 0-14 of each cycle of 177Lu-DOTATATE, whereas 40 patients were administered 30 mg octreotide LAR intramuscularly every 4 weeks. Using response evaluation criteria in solid tumor 1.1, the objective response rate was 38% in the 177Lu-DOTATATE arm compared with 15% in the octreotide LAR arm ( P = .025), whereas the disease control rates were 88% and 67% in 177Lu-DOTATATE and octreotide LAR arms, respectively ( P = .035). The median durations of progression-free survival in the 177Lu-DOTATATE and octreotide LAR arms were 54 months and 16 months, respectively ( P = .017), whereas the median overall survival was not reached and not significantly different across both the arms. Of the treatment-related adverse events, no major difference was observed in the occurrence of grade 3 or 4 toxicities between the two treatment arms. CONCLUSION First-line systemic 177Lu-DOTATATE plus radiosensitizing capecitabine achieved better radiologic response and longer progression-free survival compared with octreotide LAR in patients with advanced grade 1 or 2 GEP-NETs. Future randomized controlled trials are, however, required to determine the best treatment sequence for the treatment-naïve patients with advanced GEP-NETs.

Timely identification and management of sepsis in surgical patients is crucial, and transfer status may delay optimal treatment of these patients. The objective of this study was to compare in-house and 90-day mortality between patients primarily admitted or transferred into the surgical ICU (SICU) at a tertiary referral center.All patients admitted to the SICU with a diagnosis of sepsis (Sepsis III) were reviewed at a single institution between 2014 to 2019 (n = 1489). Demographics, comorbidities, and sepsis presentation were compared between transferred (n = 696) and primary patients (n = 793). Primary outcomes evaluated were in-house and 90 day mortality in an unmatched and propensity score matched cohorts. A P value0.05 was considered statistically significant.Transfer patients were more likely to have obesity (60% versus 49%, P0.005), a higher median SOFA (6 (4-8) versus 5 (3-8), P = 0.007), and require vasopressors on admission (42% versus 35%, P = 0.004). Compared to primary patients, transfer patients exhibited higher rates of respiratory failure (76% versus 69%, P = 0.003), in-house (30% versus 17%, P0.005), and 90 day mortality (36% versus 24%, P0.005). After matching, transferred patients were associated with 75% and 83% increased odds of in-house and 90 day mortality after controlling for age, sex, race, comorbidities, BMI, and sepsis severity.Transfer status is associated with an over 80% increase in the odds of 90 day mortality for patients admitted to the SICU with sepsis. Aggressive patient identification and earlier transfer of those at higher risk of death may reduce this effect.

Purpose To establish an infection rate following primary arthroscopic rotator cuff repair (ARCR) from a single institutional database and to ascertain whether there is a relationship between the use of preoperative corticosteroid injection (CSI) and the risk of postoperative infection. Methods All medical records at a single institution were retrospectively reviewed to identify patients who had undergone arthroscopic repair from January 2016 to December 2018. Patient charts were reviewed for CSI treatment within 6 months of surgery, superficial or deep infection within 2 months postoperatively, and specific treatment of the infection. Patient characteristics were summarized by descriptive statistics using means with standard deviations for continuous variables and frequencies with percentages for categorical variables. A χ2 correlation analysis was performed to determine the association between receiving an injection and having an infection. Results A total of 1773 patients were included for analysis with an average age of 59.24 ± 9.4 years. The overall infection rate was 0.11% (2/1773 patients). Both patients were treated with oral antibiotics. Of the included patients, 616 had a preoperative CSI within 6 months of their surgery, and 102 injections were administered within 1 month of surgery. None of these patients had a postoperative infection. A χ2 correlation analysis showed a negligible relationship between preoperative injections and postoperative infection (φ = 0.02, χ2 = 0.84). Conclusions Through this single-institution, large cohort retrospective review, we found an overall 0.11% rate of postoperative infection following primary arthroscopic RCR. In addition, we found no correlation between the use of preoperative CSI ahead of elective ARCR at any time point and risk of developing a postoperative infection. Infection is uncommon following ARCR, and preoperative steroid injection did not increase infection risk in our study population. Level of Evidence Level IV, therapeutic case series.

Introduction Coronavirus Disease-19 (COVID-19) was declared a pandemic in March 2020. States issued stay-at-home orders and hospitals cancelled non-emergent surgeries. During this time, we anecdotally noticed more admissions for perforated appendicitis. Therefore, we hypothesized that during the months following the COVID-19 pandemic declaration, more children were presenting with perforated appendicitis. Materials and Methods This is a retrospective cohort study reviewing pediatric patients admitted at a single institution with acute and/or perforated appendicitis between October 2019 to May 2020. Interval appendectomies were excluded. COVID-19 months were designated as March, April, and May 2020. Additional analysis of March, April, and May 2019 was performed for comparison purposes. Analyzed data included demographics, symptoms, white blood cell count, imaging findings, procedures performed, and perforation status. Statistical analysis was performed. Results During the study period, 285 patients were admitted with the diagnosis of acute appendicitis with 95 patients being perforated. We identified a significant increase in perforated appendicitis cases in the three COVID-19 months compared with the preceding five months (45.6% vs 26.4%; P

Background Long-term dysphonia may persist after thyroid surgery even in the absence of overt nerve injury. Therefore, we evaluated long-term dysphonia after thyroidectomy using a validated survey. Methods Patients undergoing thyroidectomy at a single institution from 1990 to 2018 were surveyed via telephone to complete the Voice Handicap Index-10 Survey. Individuals with documented nerve injury were excluded. Results In total, 308 patients completed the survey (mean age 51 ± 14 years, 78% female). Median time since surgery was 10.7 (interquartile range 2.3–17.5) years. The mean Voice Handicap Index-10 Survey score was 2.6 ± 5.2. Of the 113 (37%) patients who reported subjective dysphonia, the mean Voice Handicap Index-10 Survey score was 7.1 ± 6.5. Twenty-two (7.1%) patients had a Voice Handicap Index-10 Survey score above the empiric normative cutoff of 11, with a mean score of 17.6 ± 6.8. The most frequent complaints included “The clarity of my voice is unpredictable” (N = 71, 23%), “People have difficulty understanding me in a noisy room” (N = 70, 23%), and “I feel as though I have to strain to produce voice” (N = 65, 21%). Conclusion Long-term follow-up of patients after thyroidectomy suggests that more than 30% without nerve injury report dysphonia. Research to further assess the etiology and impact of these changes on quality of life is needed.

OBJECTIVE The authors aimed to examine the relationship between mesial temporal subregion ablation volume and seizure outcome in a diverse cohort of patients who underwent stereotactic laser amygdalohippocampotomy (SLAH) for mesial temporal lobe epilepsy (MTLE). METHODS Seizure outcomes and pre- and postoperative images were retrospectively reviewed in patients with MTLE who underwent SLAH at a single institution. Mesial temporal subregions and the contrast-enhancing ablation volume were manually segmented. Pre- and postoperative MR images were coregistered to assess anatomical ablation. Postoperative MRI and ablation volumes were also spatially normalized, enabling the assessment of seizure outcome with heat maps. RESULTS Twenty-eight patients with MTLE underwent SLAH, 15 of whom had mesial temporal sclerosis (MTS). The rate of Engel class I outcome at 1 year after SLAH was 39% overall: 47% in patients with MTS and 31% in patients without MTS. The percentage of parahippocampal gyrus (PHG) ablated was higher in patients with an Engel class I outcome (40% vs 25%, p = 0.04). Subregion analysis revealed that extent of ablation in the parahippocampal cortex (35% vs 19%, p = 0.03) and angular bundle (64% vs 43%, p = 0.02) was positively associated with Engel class I outcome. The degree of amygdalohippocampal complex (AHC) ablated was not associated with seizure outcome (p = 0.30). CONCLUSIONS Although the AHC was the described target of SLAH, seizure outcome in this cohort was associated with degree of ablation for the PHG, not the AHC. Complete coverage of both the AHC and PHG is technically challenging, and more work is needed to optimize seizure outcome after SLAH.

WHO grade II progestin-related meningiomas have been reported in recent series but we found no previous study describing their long-term outcome. Our study aimed to evaluate patients operated on for high-grade intracranial meningioma and who underwent long-term exposure to high dose of cyproterone acetate, nomegestrol acetate, and chlormadinone acetate. Our study retrospectively included 9 patients with high-grade progestin-related intracranial meningioma between December 2006 and September 2021. In each patient, clinico-radiological follow-up was performed every 6 months after diagnosis and treatment withdrawal recommendation. The mean progestative exposure was 11.4 years. Edema existence or absence of cleft sign on MRI were the key factors for surgical indication. All patients underwent surgery. Adjuvant radiotherapy was indicated in 1 patient, and Gamma Knife radiosurgery was proposed in 2 other patients for a second location of meningioma. Six patients harbored a grade II chordoid meningioma subtype with 100% PR expression and 3 patients a grade II atypical meningioma subtype with lower PR expression. The mean follow-up was 8.1 years and none of the 9 patients presented with a recurrence. Patients with grade II progestin-related meningiomas have less tumor recurrence after surgery than patients with sporadic grade II meningiomas, especially after progestin withdrawal. The presence/appearance of peri-meningioma edema and the absence of cleft sign before volumetric change should suggest the existence of an underlying WHO grade II meningiomas. In these cases, surgical resection may immediately be considered and adjuvant radiotherapy should be reserved for proven recurrence cases.

Salivary gland tumours present a pleomorphic and complex morphology and, apart from the most common neoplasms with well-established histopathological criteria, may create diagnostic difficulty for histopathologists. The majority of salivary gland tumours occur in the parotid gland and the use of ultrasound guided parotid biopsy (US-PB) has increased. US-PB in contrast with fine needle aspiration (FNA), which is an easy and relatively painless technique, is performed under local anaesthesia, usually by radiologists. US-PB offers some advantages over the FNA such as tumour grading and the possibility of performing immunohistochemistry. We report our experience of the diagnostic value of US-PB in a large, referral centre in the United Kingdom.

The incompetent bicuspid aortic valve (BAV) can be repaired using various techniques. This study presents a prospective comparison of external and subcommissural aortic annuloplasty.Fifty consecutive patients (38 males, age: 43.9 ± 15.8 years) with BAV insufficiency with or without aortic dilatation underwent valve repair in a single institution. They were prospectively allocated to one of two groups based on the aortic annulus stabilization technique: 25 patients were operated on using the subcommissural annuloplasty (SCA) and 25 using the external complete annuloplasty (EA). Transthoracic echocardiography was performed in all patients before the operation and 1 and 3 years after the operation. Moreover, mortality and morbidity at 7 years were evaluated.In prospective echocardiographic comparison, EA was associated with smaller diameter of the aortic annulus (24.1 ± 2.6 mm vs. 25.8±2.1 mm, p .05) and lower mean and peak transvalvular gradients (7 ± 4 mmHg vs. 13 ± 4 mmHg, p = .02 and 15.3 ± 9.7 mmHg vs. 20.7 ± 5.6 mmHg, p = .03, respectively). No patients died or required reoperation due to recurrent insufficiency at 6,81 (interquartile range-0,17) years after the operation. The Kaplan-Meier actuarial freedom from aortic regurgitation (AR) grade =2 or gradient20 mmHg at 35.1 ± 3.6 months years was 96% (24 out of 25) for patients who had external annuloplasty and amounted to 76% (19 out of 25) for those who had SCA, p = .05).External annuloplasty performed during repair of the BAV is associated with better hemodynamics at medium-term follow-up compared to SCA.