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The French Journal of Urology May 2024The incidence of localized renal cell carcinoma (RCC) is on the rise among individuals aged 70 and older. While the gold standard for treatment remains surgical...
INTRODUCTION
The incidence of localized renal cell carcinoma (RCC) is on the rise among individuals aged 70 and older. While the gold standard for treatment remains surgical resection, some elderly and frail patients with comorbidities are not eligible for this procedure. In selected cases, percutaneous thermal ablation, such as cryotherapy, microwave and radiofrequency, offers less invasive options. General anesthesia is sometimes necessary for such treatments, but most of the procedures can be conducted using mild or deep conscious sedation. This approach is preferably recommended for small cT1a tumors situated at a distance from the renal hilum and/or ureter. Active surveillance remains an alternative in the case of small low grade RCC although it may induce anxiety in certain patients. Recent research has highlighted the potentials of Stereotactic Ablative Body Radiotherapy (SABR) as a non-invasive, well-tolerated, and effective treatment for small renal tumors. This narrative review aims to explore recent advances in SABR for localized RCC, including appropriate patient selection, treatment modalities and administration, as well as efficacy and tolerance assessment.
MATERIAL AND METHODS
We conducted a literature review using the terms [Kidney cancer], [Renal Cell Carcinoma], [Stereotactic radiotherapy], [SBRT], and [SABR] in the Medline, PubMed, and Embase databases, focusing on prospective and relevant retrospective studies published in English.
RESULTS
Studies report local control rates ranging from 70% to 100% with SABR, highlighting its efficacy in treating RCC. The decline in glomerular filtration rate (GFR) is approximately -5 to -17 mL/min over the years following SABR. Common toxicities are rare, primarily CTCAE grade 1, include fatigue, nausea, chest or back pain, diarrhea, or gastritis.
CONCLUSION
Stereotactic Ablative Body Radiotherapy (SABR) may be considered as a viable option for patients with localized RCC who are not suitable candidates for surgery with a high local control rate and a favorable safety profile.. This approach should be discussed in a multidisciplinary meeting and results from ongoing clinical trials are awaited.
PubMed: 38823486
DOI: 10.1016/j.fjurol.2024.102660 -
Stroke and Vascular Neurology May 2024Transdural collaterals, originating mainly from the extracalvarial superficial temporal artery and intracalvarial middle meningeal artery via the external carotid artery...
BACKGROUND
Transdural collaterals, originating mainly from the extracalvarial superficial temporal artery and intracalvarial middle meningeal artery via the external carotid artery (ECA), have been observed after revascularisation surgery. However, the origin of these collaterals in patients with stroke with perfusion insufficiency is not yet known. Therefore, we studied the revascularisation patterns and characteristics based on the origin of these collaterals.
METHODS
We employed erythropoietin pretreatment and performed multiple burr holes under local anaesthesia to achieve transdural revascularisation in patients with acute stroke with perfusion insufficiency. After 6 months, we reassessed the transfemoral cerebral angiography to evaluate the revascularisation patterns. The collaterals were categorised into intracalvarial ECA-dominant (originating from the middle meningeal artery), extracalvarial ECA-dominant (originating from the superficial temporal or occipital artery) and balanced groups. We compared various imaging parameters among these groups.
RESULTS
Overall, 87 patients with 103 treated hemispheres were involved. Among them, 57.3% were classified as intracalvarial ECA-dominant, 20.4% as extracalvarial ECA-dominant and 22.3% as balanced. Most of the hemispheres with intracalvarial or extracalvarial collaterals (vs balanced collaterals) showed successful revascularisation (78/80 (97.5%) vs 12/23 (52.1%)), p<0.001). In ultrasonographic haemodynamic changes according to revascularisation pattern, only the intracalvarial ECA-dominant revascularisation was significantly associated with specific changes in ECA blood flow, leading to the conversion to a low-resistance ECA Doppler sonography waveform.
CONCLUSIONS
Our findings suggest that intracalvarial ECA-dominant revascularisation plays a crucial role in the formation of transdural collaterals following combined therapy. These distinct changes in ECA haemodynamics can be non-invasively identified through bedside ultrasound studies.
PubMed: 38821555
DOI: 10.1136/svn-2023-002831 -
Regional Anesthesia and Pain Medicine May 2024
PubMed: 38821538
DOI: 10.1136/rapm-2024-105461 -
World Neurosurgery May 2024Isthmic lumbar spondylolisthesis (ILS) is a prevalent spinal pathology. Radicular pain in patients is often attributed to L5-S1 ILS combined with foraminal stenosis...
BACKGROUND
Isthmic lumbar spondylolisthesis (ILS) is a prevalent spinal pathology. Radicular pain in patients is often attributed to L5-S1 ILS combined with foraminal stenosis (FS), making such patients prime candidates for surgical intervention. We herein aimed to elucidate the surgical technique and clinical outcomes of transforaminal endoscopic lumbar foraminotomy (TELF) in the treatment of L5-S1 ILS with FS.
METHODS
From September 2021 to December 2022, 20 consecutive patients were diagnosed with L5-S1 ILS with FS and underwent TELF. All patients were followed up for at least 12 months. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.
RESULTS
The mean age of the patients was 62.4 ± 10.9 years. The mean preoperative VAS score for low back, VAS score of the leg and ODI score were 5.1 ± 1.7, 7.4 ± 0.7, and 58.0 ± 8.4, respectively. These scores significantly improved to 1.8 ± 0.7, 1.5 ± 0.6, and 15.3 ± 7.1 at 12 months postoperatively, respectively (P<0.01). Evaluation based on the modified MacNab criteria revealed that 95.0% of patients achieved a good-to-excellent outcome. One patient underwent revision surgery.
CONCLUSIONS
TELF emerges as a potentially safe and effective surgical option for alleviating radicular pain in patients with L5-S1 stable ILS combined with FS. While our short-term clinical results are satisfactory, it is necessary to expand the sample size and extend the follow-up time to validate the effectiveness and long-term efficacy of TELF.
PubMed: 38821398
DOI: 10.1016/j.wneu.2024.05.145 -
Medical & Biological Engineering &... May 2024Anesthetic-induced brain activity study is crucial in avian cognitive-, consciousness-, and sleep-related research. However, the neurobiological mechanisms underlying...
Anesthetic-induced brain activity study is crucial in avian cognitive-, consciousness-, and sleep-related research. However, the neurobiological mechanisms underlying the generation of brain rhythms and specific connectivity of birds during anesthesia are poorly understood. Although different kinds of anesthetics can be used to induce an anesthesia state, a comparison study of these drugs focusing on the neural pattern evolution during anesthesia is lacking. Here, we recorded local field potentials (LFPs) using a multi-channel micro-electrode array inserted into the nidopallium caudolateral (NCL) of adult pigeons (Columba livia) anesthetized with chloral hydrate, pelltobarbitalum natricum or urethane. Power spectral density (PSD) and functional connectivity analyses were used to measure the dynamic temporal neural patterns in NCL during anesthesia. Neural decoding analysis was adopted to calculate the probability of the pigeon's brain state and the kind of injected anesthetic. In the NCL during anesthesia, we found elevated power activity and functional connectivity at low-frequency bands and depressed power activity and connectivity at high-frequency bands. Decoding results based on the spectral and functional connectivity features indicated that the pigeon's brain states during anesthesia and the injected anesthetics can be effectively decoded. These findings provide an important foundation for future investigations on how different anesthetics induce the generation of specific neural patterns.
PubMed: 38819673
DOI: 10.1007/s11517-024-03132-w -
International Journal of Medical... 2024This study aimed to investigate the impact of ultrasound-guided, bilateral, low level (T8-T9) deep serratus anterior plane (DSAP) blocks on postoperative recovery... (Randomized Controlled Trial)
Randomized Controlled Trial
This study aimed to investigate the impact of ultrasound-guided, bilateral, low level (T8-T9) deep serratus anterior plane (DSAP) blocks on postoperative recovery quality and postoperative analgesia in patients undergoing trans-subxiphoid robotic thymectomy (TRT). 39 patients undergoing TRT were randomized to receive either low DSAP block under general anesthesia (Group S) or the sham block (Group C) on each side. The primary outcome was the QoR-40 score at postoperative day (POD) 1. Secondary outcomes included numeric rating scale (NRS) scores over time, postoperative 48 hours opioid consumption, QoR-40 scores at POD 2, 30, and 90. The QoR-40 scores on POD1-2 were higher in Group S than in Group C [179.1 (4.9) vs 167.7 (2.8), P < 0.01; 187.7 (4.6) vs 178.1 (3), P < 0.01, respectively]. Pain scores were significantly lower in Group S, both during resting and motion at postoperative 6h, 12h, and 24h (P < 0.05 for each). The total amount of sufentanil consumed in the first 48 h was lower in Group S than in Group C [61.4 (4.9) vs 78.9 (4.6), P < 0.001]. The bilateral low DSAP blocks enhanced the QoR-40 for 2 days postoperatively, relieved postsurgical pain, and reduced opioid consumption during the early postoperative period in patients undergoing TRT.
Topics: Humans; Thymectomy; Female; Male; Robotic Surgical Procedures; Middle Aged; Pain, Postoperative; Nerve Block; Adult; Analgesics, Opioid; Pain Measurement; Treatment Outcome; Anesthesia, General
PubMed: 38818461
DOI: 10.7150/ijms.91797 -
Journal of Hand Surgery Global Online May 2024Surgeons across all subspecialties had to adapt to the Coronavirus disease 2019 pandemic to triage patients and steward hospital resources. Hand surgeons found...
Surgeons across all subspecialties had to adapt to the Coronavirus disease 2019 pandemic to triage patients and steward hospital resources. Hand surgeons found themselves in a unique position to move some hospital-based procedures to a clinic-based setting, which has now impacted their postpandemic practices. Performing procedures in the clinic using the wide-awake local anesthesia no-tourniquet technique is interestingly similar to minor surgeries traditionally carried out in a general surgery clinic. By abstracting institutional case volumes from orthopedic, hand, and general surgery departments from 2019 to 2022, we identified trends that further support the potential for clinic-based procedures in hand surgery. This communication provides a foundation to compare cost and surgical indications for wide-awake local anesthesia across surgical disciplines.
PubMed: 38817772
DOI: 10.1016/j.jhsg.2024.03.001 -
Journal of Hand Surgery Global Online May 2024The purpose of this study was to determine the safety and effectiveness of office-based carpal tunnel release with ultrasound guidance (CTR-US).
PURPOSE
The purpose of this study was to determine the safety and effectiveness of office-based carpal tunnel release with ultrasound guidance (CTR-US).
METHODS
In this prospective multicenter observational study, patients were treated with CTR-US in an office setting. Outcomes were time to resume normal daily activities, time to return to work, Boston Carpal Tunnel Questionnaire Symptom Severity Scale and Functional Status Scale scores, Michigan Hand Questionnaire, Numeric Pain Scale, EuroQoL-5 Dimension 5-Level score, procedure satisfaction, and adverse events over 6 months.
RESULTS
A total of 149 participants (226 hands) from seven centers underwent office-based CTR-US. The mean age was 58 years, 52% were women, and 68% were employed. The mean incision length was 5 mm, 52% had simultaneous bilateral procedures, and wide-awake local anesthesia no tourniquet was used in all cases. All procedures were completed as planned, with no conversions to open repair and mean intraoperative pain severity of 1.6 ± 1.5. The median time to resume normal activities was 2 days (interquartile range: 1-4 days) and return to work was 4 days (interquartile range: 1-5 days). Over 6 months, Boston Carpal Tunnel Questionnaire Symptom Severity Scale decreased by a mean of 1.7 points, Boston Carpal Tunnel Questionnaire Functional Status Scale decreased by 1.1 points, Michigan Hand Questionnaire Global score increased by 35 points, Numeric Pain Scale decreased by 3.7 points, and EuroQoL-5 Dimension 5-Level score increased by 0.11 points. At 6 months, 94% reported procedure satisfaction. Unilateral and simultaneous bilateral procedures were similarly effective. There was one (0.4%) adverse event, a nerve contusion treated with neurolysis and nerve wrap where the patient fully regained normal function within 7 weeks. There were no revisions for persistent or recurrent carpal tunnel syndrome symptoms.
CONCLUSIONS
Office-based CTR-US, performed either unilaterally or as simultaneous bilateral procedures, is well tolerated with a low complication rate and associated with rapid recovery, sustained improvement in symptoms and function, and high procedure satisfaction.
TYPE OF STUDY/LEVEL OF EVIDENCE
Therapeutic III.
PubMed: 38817765
DOI: 10.1016/j.jhsg.2023.12.005 -
Journal of Hand Surgery Global Online May 2024The purpose of this study was to gauge whether patients with preexisting mental health conditions have desirable outcomes when undergoing wide-awake local anesthesia...
PURPOSE
The purpose of this study was to gauge whether patients with preexisting mental health conditions have desirable outcomes when undergoing wide-awake local anesthesia with no tourniquet (WALANT) hand surgery.
METHODS
A retrospective review of 133 patients who underwent WALANT surgery by 2 senior authors from August 2019 to October 2020 was performed. Patients were administered a 10-question postoperative survey detailing perioperative pain, experience, and satisfaction concerning their procedure. Analysis was performed for patient responses to the questionnaire, demographics, comorbidities, and patient-reported outcomes using the Single Assessment Numeric Evaluation (SANE).
RESULTS
There were 61 patients identified as having a preexisting psychiatric diagnosis compared to 70 patients without who underwent WALANT surgery. Comparing psychiatric diagnosis and nonpsychiatric diagnosis cohorts, there was no significant difference in preoperative anxiety (3.75 vs 3.30), pain during procedure (0.67 vs 0.56), or pain after surgery (4.89 vs 4.26). There was a significantly higher pain score with preoperative injection in the psychiatric diagnosis cohort (4.07 vs 2.93). When asked if they would have a WALANT procedure again, 95.1% of patients in the psychiatric diagnosis cohort and 98.6% of patients in the nonpsychiatric diagnosis group said they would. There was no significant difference in average preoperative SANE scores (59.67 [no psych diagnosis] vs 61.70 [psych diagnosis]) or postoperative SANE scores (82.82 [no psych diagnosis] vs 81.06 [psych diagnosis]) between the two cohorts.
CONCLUSIONS
WALANT surgery was nearly as well tolerated in patients with a preexisting mental health diagnosis when compared to those without a preexisting diagnosis.
CLINICAL RELEVANCE
Surgeons who are currently or potentially performing WALANT surgery should not rule out patients as eligible candidates because of a prior diagnosis of a mental health condition.
PubMed: 38817758
DOI: 10.1016/j.jhsg.2023.12.012 -
AJNR. American Journal of Neuroradiology May 2024Hereditary hemorrhagic telangiectasia is an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectasias, recurrent epistaxis, and organ vascular...
BACKGROUND
Hereditary hemorrhagic telangiectasia is an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectasias, recurrent epistaxis, and organ vascular malformations including in the brain, which occur in about 10% of patients. These brain vascular malformations include high-flow AVMs and AVFs as well as low-flow capillary malformations. High-flow lesions can rupture, causing neurologic morbidity and mortality.
STATE OF PRACTICE
International guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia recommend screening children for brain vascular malformations with contrast enhanced MR imaging at hereditary hemorrhagic telangiectasia diagnosis. Screening has not been uniformly adopted by some practitioners who contend that screening is not justified. Arguments against screening include application of short-term data from the adult A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial of unruptured sporadic brain AVMs to children with hereditary hemorrhagic telangiectasia as well as concerns about administration of sedation or IV contrast and causing patients or families increased anxiety.
ANALYSIS
In this article, a multidisciplinary group of experts on hereditary hemorrhagic telangiectasia reviewed data that support screening guidelines and counter arguments against screening. Children with hereditary hemorrhagic telangiectasia have a preponderance of high-flow lesions including AVFs, which have the highest rupture risk. The rupture risk among children is estimated at about 0.7% per lesion per year and is additive across lesions and during a lifetime. ARUBA, an adult clinical trial of expectant medical management versus treatment of unruptured brain AVMs, favored medical management at 5 years but is not applicable to pediatric patients with hereditary hemorrhagic telangiectasia given the life expectancy of a child. Additionally, interventional, radiosurgical, and surgical techniques have improved with time. Experienced neurovascular experts can prospectively determine the best treatment for each child on the basis of local resources. The "watch and wait" approach to imaging means that children with brain vascular malformations will not be identified until a potentially life-threatening and deficit-producing intracerebral hemorrhage occurs. This expert group does not deem this to be an acceptable trade-off.
PubMed: 38816017
DOI: 10.3174/ajnr.A8195