The Radiosurgery Society Working Groups on GRID, LATTICE, Microbeam, and FLASH Radiotherapies: 2022 - 2023 Advancements Symposium and Subsequent Progress Made.

PURPOSE: Since the inaugural workshop "Understanding High-Dose, Ultra-High Dose Rate and Spatially Fractionated Radiotherapy." hosted by the NCI and sponsored by the Radiosurgery Society (RSS), growing collaborations and investigations have ensued among experts, practitioners, and researchers. The RSS GRID, Lattice, Microbeam & FLASH (GLMF) Working Groups were formed as a framework for these efforts and have focused on advancing the understanding of the biology, technical/physical parameters, trial design, and clinical practice of these new radiation therapy modalities. METHODS AND MATERIALS: In view of the steadily increasing clinical interest in SFRT and FLASH, a full-day symposium entitled "Advancements in GRID, LATTICE, and FLASH Radiotherapy Symposium" was established in 2022 that immediately preceded the RSS scientific meeting. This well-attended symposium focused on clinical, technical, and physics approaches for SFRT, while closely examining relevant radiobiological underpinnings. Practical clinical trial development was a highlighted discussion. An additional section reviewed proton therapy and other particle-based techniques for the delivery of GRID and Lattice therapy. A treatment planning and delivery tutorial for GRID, Lattice, and proton GRID/Lattice was directed towards the real-world considerations for the development of new clinical GRID or LATTICE programs. An overall similar approach was applied to the discussion of FLASH. This report summarizes the content of the first GLMF Symposium and related work of the RSS GLMF Working Groups in the field of heterogeneous and ultra-high dose rate irradiation, over approximately 2 years. RESULTS: The GLMF Working Groups have continued to expand in membership and attendance, and several resultant trial concepts, research efforts, academic discussions, and peer-reviewed publications have followed as the number of institutions and practitioners utilizing SFRT and FLASH continues to grow. CONCLUSIONS: The GLFM Working Groups and the RSS continue to demonstrate excellent progress in proliferating use of and improving understanding of SFRT and ultra-high dose rate radiotherapy techniques.

Best practices and novel approaches for the preclinical development of drug-radiotherapy combinations for cancer treatment.

Drug-radiation combination therapy is a practical approach to improving clinical outcomes for many tumours. Unfortunately, most clinical combination studies combine drugs with radiotherapy empirically and do not exploit mechanistic synergy in cell death and the interconnectivity of molecular pathways of tumours or rationale for selecting the dose, fractionation, and schedule, which can result in suboptimal efficacy and exacerbation of toxic effects. However, opportunities exist to generate compelling preclinical evidence for combination therapies from fit-for-purpose translational studies for simulating the intended clinical study use scenarios with standardised preclinical assays and algorithms to evaluate complex molecular interactions and analysis of synergy before clinical research. Here, we analyse and discuss the core issues in the translation of preclinical data to enhance the relevance of preclinical assays, in vitro clonogenic survival along with apoptosis, in vivo tumour regression and growth delay assays, and toxicology of organs at risk without creating barriers to innovation and provide a synopsis of emerging areas in preclinical radiobiology.

A cell-free DNA colorectal cancer screening test promising enhanced accessibility and early detection.

Colorectal cancer (CRC) remains a significant global health challenge, with approximately 1.9 million new cases and 930,000 deaths reported in 2020. The highest incidence rates are observed in Australia/New Zealand and Europe, while lower rates are found in Africa and Southern Asia. Projections for 2040 indicate a rise to 3.2 million new cases and 1.6 million deaths, particularly in high development index regions, underscoring the need for improved prevention and detection. Despite advancements in screening methods and polyp removal, CRC mortality remains high in the United States due to non-adherence to recommended tests. Barriers such as cost and lack of insurance contribute to this issue. Cell-free DNA (cfDNA) blood-based testing offers a promising alternative, with studies showing 83.1% sensitivity for CRC and 89.6% specificity for advanced neoplasia, comparable to traditional screening methods but with reduced risk of adverse events. The recent FDA approval of the Shield blood test, which has demonstrated 83% efficacy in detecting late-stage CRC, represents a significant advancement. Incorporating cfDNA testing into screening protocols could improve accessibility and compliance, especially for those unwilling or unable to undergo more invasive procedures. Regular evaluation of cfDNA testing, including Shield, is essential for enhancing CRC screening strategies and patient outcomes.

Traditional and Complementary Medicine Use among Cancer Patients in Asian Countries: A Systematic Review and Meta-Analysis.

Globally, cancer patients frequently use T&CM during their treatment for various reasons. The primary concerns regarding the use of T&CM among cancer patients are the potential risks associated with interactions between pharmaceuticals and T&CM, as well as the risk of noncompliance with conventional cancer treatments. Despite the higher prevalence of T&CM use in Asia, driven by cultural, historical, and resource-related factors, no prior review has tried to estimate the prevalence and influencing factors of T&CM use and disclosure among cancer patients in this region. This study aims to examine the prevalence and disclosure rates of T&CM use among cancer patients in Asia to assess various factors influencing its use across different cancer treatment settings in Asia. Systematic research on T&CM use was conducted using four databases (PubMed, EMBASE, Web of Science, and CINAHAL) from inception to January 2023. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS). A random effects model was used to estimate the pooled prevalence of T&CM use, and data analysis was performed using Stata Version 16.0. Among the 4849 records retrieved, 41 eligible studies conducted in 14 Asian countries were included, involving a total of 14,976 participants. The pooled prevalence of T&CM use was 49.3%, ranging from 24.0% to 94.8%, and the disclosure rate of T&CM use was 38.2% (11.9% to 82.5%). The most commonly used T&CM modalities were herbal medicines and traditional medicine. Females were 22.0% more likely to use T&CM than males. A subgroup analysis revealed the highest prevalence of T&CM use was found in studies conducted in East Asia (62.4%) and those covered by both national and private insurance (55.8%). The disclosure rate of T&CM use to physicians remains low. Moreover, the factors influencing this disclosure are still insufficiently explored. Since the disclosure of T&CM use is a crucial indicator of patient safety and the quality of cancer treatment prognosis, future research should focus on identifying the determinants of non-disclosure.

Cardiac Arrhythmias in Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension: Mechanistic Insights, Pathophysiology, and Outcomes.

Arrhythmias are increasingly recognized as severe complications of precapillary pulmonary hypertension, encompassing pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Despite their significant contribution to symptoms, morbidity, in-hospital mortality, and potentially sudden death in PAH/CTEPH, there remains a lack of comprehensive data on epidemiology, pathophysiology, and outcomes to inform the management of these patients. This review provides an overview of the latest evidence on this subject, spanning from the molecular mechanisms underlying arrhythmias in the hypertrophied or failing right heart to the clinical aspects of epidemiology, diagnosis, and treatment.

Presentations of Waugh's syndrome:intra-luminal cecal cyst and trans-anal prolapsing intussusception: a case report.

BACKGROUND: Intussusception with intestinal malrotation is termed as Waugh's syndrome. The incidence of Waugh's syndrome is less than 1%. There are very few reported cases. Once presented, it is a pediatric surgical emergency. CASE PRESENTATION: We present here two cases of Waugh's syndrome: an 11-month-old male patient of Punjabi descent and a 4-month-old female patient of Afghan descent who presented to us with abdominal pain and bleeding per rectum. Abdominal sonography revealed an intussusception with a target sign. They were explored and perioperatively had intestinal malrotation alongside intussusception, thus a diagnosis of Waugh's syndrome was made. A right hemicolectomy and Ladd's procedure was performed. CONCLUSION: Waugh syndrome is a rare congenital anomaly but can present with vague abdominal symptoms. Once presented, it is a pediatric surgical emergency. The patient should be optimized followed by surgical exploration.

Optimizing GRID and Lattice Spatially Fractionated Radiation Therapy: Innovative Strategies for Radioresistant and Bulky Tumor Management.

Treating radioresistant and bulky tumors is challenging due to their inherent resistance to standard therapies and their large size. GRID and lattice spatially fractionated radiation therapy (simply referred to GRID RT and LRT) offer promising techniques to tackle these issues. Both approaches deliver radiation in a grid-like or lattice pattern, creating high-dose peaks surrounded by low-dose valleys. This pattern enables the destruction of significant portions of the tumor while sparing healthy tissue. GRID RT uses a 2-dimensional pattern of high-dose peaks (15-20 Gy), while LRT delivers a three-dimensional array of high-dose vertices (10-20 Gy) spaced 2-5 cm apart. These techniques are beneficial for treating a variety of cancers, including soft tissue sarcomas, osteosarcomas, renal cell carcinoma, melanoma, gastrointestinal stromal tumors (GISTs), pancreatic cancer, glioblastoma, and hepatocellular carcinoma. The specific grid and lattice patterns must be carefully tailored for each cancer type to maximize the peak-to-valley dose ratio while protecting critical organs and minimizing collateral damage. For gynecologic cancers, the treatment plan should align with the international consensus guidelines, incorporating concurrent chemotherapy for optimal outcomes. Despite the challenges of precise dosimetry and patient selection, GRID RT and LRT can be cost-effective using existing radiation equipment, including particle therapy systems, to deliver targeted high-dose radiation peaks. This phased approach of partial high-dose induction radiation therapy with standard fractionated radiation therapy maximizes immune modulation and tumor control while reducing toxicity. Comprehensive treatment plans using these advanced techniques offer a valuable framework for radiation oncologists, ensuring safe and effective delivery of therapy for radioresistant and bulky tumors. Further clinical trials data and standardized guidelines will refine these strategies, helping expand access to innovative cancer treatments.

Complete heart block associated with hepatitis A infection in a female child with fatal outcome.

Hepatitis A virus (HAV) infection can cause extra-hepatic manifestations like myocarditis. An 8-year-old female with HAV infection presented with fever, abdominal pain, vomiting, and icterus. She developed viral myocarditis with complete AV dissociation on ECG and was treated with a temporary pacemaker, but her condition worsened, and she died. Hepatitis A viral infection can be associated with viral myocarditis and complete heart block that can lead to cardiogenic shock and death eventually.

Trichotillomania, Trichophagia and Trichobezoar in a Male Paediatric Patient: A Case Report and Literature Review.

INTRODUCTION AND IMPORTANCE: Trichotillomania and tricophagia, characterized by compulsive hair-pulling and subsequent ingestion which results in a compact mass of hair called trichobezoar. It represents an uncommon psychiatric disorder, especially in young children. CASE PRESENTATION: This case report describes a distinctive and rare occurrence of trichotillomania, tricophagia and trichobezoar in a 11-year-old male child. Concerns raised by the parents regarding noticeable hair loss, who initially presented to medical outdoor patient with complaints of abdominal pain on and off from the last one year. He had a history of pica and weight-loss. He was then diagnosed with a gastric trichobezoar for which he was operated upon and a giant trichobezoar was retrieved from his stomach. Post-operatively patient remained admitted in ward and was discharged home on fifth post-operative day and sent for psychiatry evaluation. CLINICAL DISCUSSION: Trichotillomania and tricophagia often have roots in psychosocial stressors, anxiety, and depression. Children may engage in hair-pulling as a coping mechanism, especially in response to familial or environmental stressors. The literature emphasizes the importance of understanding the psychosocial context to tailor interventions effectively. CONCLUSION: Trichotillomania and tricophagia is very rare in paediatric population and if presents a multidisciplinary team comprising of a paediatrition, paediatric surgeon and paediatric psychiatrist should be involved and if diagnosed with a gastric trichobezoar should be removed surgically in order to prevent complications.

Thermal and hydraulic performance of ZnO/EG based nanofluids in mini tubes of different diameters: An experimental investigation.

The present experimental study investigates the thermal and hydraulic performance of Ethylene Glycol (EG)-based ZnO nanofluids (NFs) in circular minichannel test sections, each of 330 mm in length and 1.0-2.0 mm inner diameters. The experiments were conducted under steady-state constant heat flux and laminar flow conditions. The stable ZnO/EG-based NFs were synthesized using a standard two-step method in varying nanoparticles (NPs) loadings (0.012-0.048 wt%). The morphological characteristics, crystal structure, and specific surface area (SSA) showed that the NPs were sized in nm, possessing excellent crystal structure and enhanced surface area. Thermal conductivity (TC) and viscosity (VC) of the NFs were examined in the 20-60 °C temperature range. Both TC and VC possessed an increasing trend with the rise in concentration of the NPs. However, with the temperature rise, TC increased while the VC decreased and vice versa. The highest enhancements in TC and VC were 14.38 % and 15.22 %, respectively, at 40 °C and 0.048 wt% of NPs loading. The highest enrichment recorded in the local and average heat transfer coefficient (HTC) were 14.80 % and 13.48% in a minichannel with 1.0 mm inner diameter, respectively. It was directly proportional to the NPs loading and volume flow rate of the NFs. The friction factor was also directly proportional to the test section's inner cross-sectional area, while the pressure gradient showed an inverse behavior. An inverse relationship was recorded for the volume flow rate of the NFs and vice versa. Maximum friction factor and the pressure drop for all three minichannel test sections were recorded as 34.58 % and 32.16 %, respectively. The well-known Shah correlation predicted the local and average HTC within ±15.0 %, while the friction factor and the pressure gradient were well predicted by the Darcy correlation within the ±10.0 % range.

A uretheral stone causing urinary obstruction in a paediatric patient.

Urinary retention in pediatric patients is an uncommon presentation, particularly when attributed to urethral stones. We present the case of an 8 year old child who experienced acute urinary retention due to a urethral stone, an infrequent occurrence in this age group. Initial assessment revealed signs of obstructive voiding, prompting further investigation. Imaging studies confirmed the presence of a urethral stone causing complete obstruction. Management involved a multidisciplinary approach, incorporating surgical intervention. This case report underlines the need for awareness about the rare occurrence of urethral stones in pediatric age group which must be kept in mind while treating children.

Seroprevalence of SARS-CoV-2 antibodies in pediatric hospital surgical unit: a lower-middle-income country perspective.

BACKGROUND: The objective of our study was to measure and give insight into the seropositivity of anti-SARS-CoV-2 antibodies in the patients in our pediatric hospital surgical unit in Pakistan. METHODS: A prospective cohort study was conducted at a tertiary care pediatric hospital surgical unit in Pakistan between 1 January 2021 and 1 June 2021 on the enrolled neonates and children aged 1 day to 13 years. All patients from three different pediatric strata [neonates (<1 month), infants (1 to 12 months) and children (>1 year)] were enrolled in the study. RESULTS: Six-hundred patients were enrolled, and 426 patients were included in the study. Among 426 patients, 234 (54.9%) were male, and 192 (45.1%) were female. Overall only 118 (27.7%) patients developed symptoms. The other 308 (72.3%) were asymptomatic of which 28 (9.1%) had fever, 28 (9.1%) had cough, 38 (12.33%) had body aches, 292 (94.8%) had vomiting/diarrhea, and only 28 (9.1%) developed loss of smell and taste. Our results showed seropositivity of 27.7% (n = 118), while 72.3% (n = 308) had negative antibody titers. CONCLUSION: A much higher pediatric SARS-CoV-2 burden of 27.7% was found in our pediatric surgical unit than has previously been reported in the literature of 6.8% for children in pediatric hospitals or pediatric surgical units. Contrary to reporting early in the COVID-19 pandemic, this study determined that children experience a significant burden of COVID-19 infection. Thus, children appear very important in SARS-CoV-2 pandemic, from harboring the virus and further studies need to be done to find if they are transmitting the disease silently.

Enhancing Data Protection in Dynamic Consent Management Systems: Formalizing Privacy and Security Definitions with Differential Privacy, Decentralization, and Zero-Knowledge Proofs.

Dynamic consent management allows a data subject to dynamically govern her consent to access her data. Clearly, security and privacy guarantees are vital for the adoption of dynamic consent management systems. In particular, specific data protection guarantees can be required to comply with rules and laws (e.g., the General Data Protection Regulation (GDPR)). Since the primary instantiation of the dynamic consent management systems in the existing literature is towards developing sustainable e-healthcare services, in this paper, we study data protection issues in dynamic consent management systems, identifying crucial security and privacy properties and discussing severe limitations of systems described in the state of the art. We have presented the precise definitions of security and privacy properties that are essential to confirm the robustness of the dynamic consent management systems against diverse adversaries. Finally, under those precise formal definitions of security and privacy, we have proposed the implications of state-of-the-art tools and technologies such as differential privacy, blockchain technologies, zero-knowledge proofs, and cryptographic procedures that can be used to build dynamic consent management systems that are secure and private by design.

Ultrasound-Guided Versus Conventional Fluoroscopy-Guided Epidural Injection for Radiculopathy. A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Radiculopathy, a painful condition due to the irritation of a spinal nerve root, is a common neurosurgical presentation. Apart from its conventional treatment with pain killers and surgical management, it can also be managed with epidural steroid injections (ESIs). The objective of this study is to compare ultrasonography (USG) guidance with conventional fluoroscopy (FL) guidance for ESIs to treat radiculopathy. METHODS: PubMed, Embase, Clinicaltrials.gov, and Cochrane were systematically searched and randomized controlled trials comparing USG with conventional FL for ESIs in the case of radiculopathy were included. Web Revman was used for data analysis. RESULTS: The Literature search resulted in 640 studies, of which 7 studies were included in this meta-analysis after extensive screening. There was no statistically significant difference in pain reduction between USG and FL groups especially in the case of lumbosacral spinal level at 1 month [mean difference -0.12 (-0.47-0.23)] and at 3 months [mean difference 0.73 (-1.49, 2.96)]. Similarly, functional improvement after ESIs was comparable between the 2 groups. The Risk of inadvertent vascular puncture in USG-guided ESIs was lower as compared to conventional FL-guided ESIs [odds ratio 0.21 (0.07, 0.64)]. Furthermore, the procedure time in the USG group was also significantly lower as compared to FL group. CONCLUSION: USG-guided ESIs are not only comparable to conventional FL-guided ESIs in terms of pain control and functional improvement, particularly evident at the lumbosacral spinal level, but also have a lower risk of inadvertent vascular puncture.

National Cancer Institute Collaborative Workshop on Shaping the Landscape of Brain Metastases Research: challenges and recommended priorities.

Brain metastases are an increasing global public health concern, even as survival rates improve for patients with metastatic disease. Both metastases and the sequelae of their treatment are key determinants of the inter-related priorities of patient survival, function, and quality of life, mandating a multidimensional approach to clinical care and research. At a virtual National Cancer Institute Workshop in September, 2022, key stakeholders convened to define research priorities to address the crucial areas of unmet need for patients with brain metastases to achieve meaningful advances in patient outcomes. This Policy Review outlines existing knowledge gaps, collaborative opportunities, and specific recommendations regarding consensus priorities and future directions in brain metastases research. Achieving major advances in research will require enhanced coordination between the ongoing efforts of individual organisations and consortia. Importantly, the continual and active engagement of patients and patient advocates will be necessary to ensure that the directionality of all efforts reflects what is most meaningful in the context of patient care.

Data Provenance in Healthcare: Approaches, Challenges, and Future Directions.

Data provenance means recording data origins and the history of data generation and processing. In healthcare, data provenance is one of the essential processes that make it possible to track the sources and reasons behind any problem with a user's data. With the emergence of the General Data Protection Regulation (GDPR), data provenance in healthcare systems should be implemented to give users more control over data. This SLR studies the impacts of data provenance in healthcare and GDPR-compliance-based data provenance through a systematic review of peer-reviewed articles. The SLR discusses the technologies used to achieve data provenance and various methodologies to achieve data provenance. We then explore different technologies that are applied in the healthcare domain and how they achieve data provenance. In the end, we have identified key research gaps followed by future research directions.

Pathologic Complete Response Achieved in Early-Stage HER2-Positive Breast Cancer After Neoadjuvant Therapy With Trastuzumab and Chemotherapy vs. Trastuzumab, Chemotherapy, and Pertuzumab: A Systematic Review and Meta-Analysis of Clinical Trials.

Patients diagnosed with human epidermal growth factor receptor 2 (HER2)-positive breast cancer require treatment upfront because of the aggressive nature of this type of cancer. Patients with early-stage HER2-positive breast cancer are usually treated with neoadjuvant therapy. This neoadjuvant therapy comprises targeted therapy and chemotherapy. Targeted therapy is given with trastuzumab. Pertuzumab is either administered or not with trastuzumab as a targeted therapy. This systematic review and meta-analysis aim to find out and compare the benefit achieved in terms of pathologic complete response (pCR) by adding pertuzumab to the neoadjuvant treatment regimen for early-stage HER2-positive breast cancer patients. Various databases were searched to find out relevant clinical trials. After going through PubMed, Embase, and Cochrane, three clinical trials were shortlisted for this systematic review and meta-analysis. These three clinical trials were double-armed. Pertuzumab was present in one arm while being absent in one arm to assess the benefit of adding pertuzumab in terms of pCR achieved. Data were analyzed using RevMan Web (Cochrane, London, UK). The odds ratio and 95% confidence interval were calculated for the outcome. The Mantel-Haenszel method and random effect model were used for analysis. The risk of bias in studies was evaluated using the Cochrane risk of bias tool for randomized controlled trials (ROB2). The summary statistics showed that the incidence of pCR was more in the experimental group (having pertuzumab) as compared to the control group (without pertuzumab) with an odds ratio of 2.10 (95% CI: 1.56-2.83) with I2 = 0%. In three double-arm trials, there were 840 participants, 445 in the experimental group and 395 in the control group. A total of 203 (45%) patients out of 445 in the experimental group achieved pCR, whereas 127 (32%) patients out of 395 in the control group achieved pCR. Through the results of this study, it can be concluded that the rate of pCR achieved was higher in that arm in which pertuzumab was present compared to the study arm in which only trastuzumab was given as targeted therapy. Thus, it can be suggested that pertuzumab be added to the neoadjuvant regimen for early-stage HER2-positive breast cancer patients. This would result in achieving a better pCR. And by improving pCR rates, the survival outcomes of patients can be significantly improved.

Parasitological, molecular, and epidemiological investigation of Trypanosoma evansi infection among dromedary camels in Balochistan province.

Surra is a zoonotic disease caused by Trypanosoma evansi (T. evansi), which affects a wide variety of animals worldwide. The disease has a severe impact on the productivity, health, and working capacity of camels and causes mortality and extensive economic losses if not diagnosed early. This is the first comprehensive report on the prevalence of T. evansi infection in dromedaries in Balochistan province. In the present study, 393 blood samples (indigenous, n = 240; imported, n=153) were collected from one-humped camels (Camelus dromedarius) and were tested by molecular methods to estimate the prevalence of T. evansi in three districts (Pishin, Nushki, and Lasbella) of Balochistan province. The overall prevalence of T. evansi among examined camel samples was 28.24% (95% confidence interval (CI): 24.02-32.89%). The risk of T. evansi infection in adult camels (> 10 years) is higher than that in young ones (odd-ration (OR) = 2.7; 95% CI: 1.3357-5.3164%). Moreover, male camels were six times more likely to get an infection than female camels. The detection of T. evansi infection in camels sampled in summer and spring was 3.12- and 5.10-fold higher, respectively, than in camels sampled in winter. In conclusion, our findings showed a high rate of T. evansi infection in camels from the three districts. Our study emphasizes the need for a strict surveillance program and risk assessment studies as prerequisites for control measures.

Patterns and predictors of periodontal disease and tooth loss among users of smokeless tobacco.

BACKGROUND: Smokeless tobacco (SLT) products of several different types are widely used in several South Asian countries including Pakistan. These products are consumed in different forms and with different names. The study aims to determine adverse effects of the SLT consumption on periodontal tissues. METHODS: This cross sectional study was conducted in Karachi, Pakistan. It recruited 377 users of (SLT) with 231 males (61.3%) and 146 females (38.7%) of age 15 to 45 years. After obtaining informed consent, quantitative data were collected via a questionnaire followed by intra oral clinical examination to determine presence of periodontal diseases using community periodontal index (CPI). To determine the association between periodontal diseases and smokeless tobacco consumption habits, Chi Square test was conducted. RESULTS: Gingival recession (Class II-IV) (65.8%) was the most prevalent periodontal disease among SLT users. CPI score was high (CPI score 3 and 4) in 31.3% participants, whereas tooth loss was found in 21%. Among types of SLT products, gutka (28.6%) and betel quid (23.3%) were most commonly used. Using SLT for five or more years was found to be associated with a high CPI score, gingival recession (Class II-IV), moderate to severe tooth mobility, and presence of tooth loss. CONCLUSIONS: The study found statistically significant association between duration in years of using SLT and periodontal disease including gingival recession, tooth mobility and tooth loss. However, no significant results were found between retention during single use and frequency of SLT use per day. However, the link of these factors with the periodontal disease cannot be eliminated.

Fixed versus Adjustable differential pressure valves in case of idiopathic normal pressure hydrocephalus treated with ventriculoperitoneal shunt. A systematic review and meta-analysis of proportion.

INTRODUCTION: Idiopathic normal pressure hydrocephalus is a common cause of communicating hydrocephalus in adult age, presenting with classic Hakim-Adam's triad. Ventriculoperitoneal shunting is the treatment of choice in these cases. The main objective of this study is to compare the complication rate of Adjustable differential pressure valves with fixed differential pressure valves in these cases. LITERATURE SEARCH: We systematically searched PubMed/Medline, Embase, LILACS, and ClinicalTrials.gov from their date of inception to 30th Jan 2023. We included observational studies, Randomized Controlled Trials (RCTs), and comparative and noncomparative studies in the search. The literature search resulted in 1394 studies, and only 22 studies were eligible to be included in the meta-analysis. We performed the meta-analysis of proportion to compare incidence rates by performing a Freeman-turkey double arcsine transformation. RESULTS: The summary of the proportions of the incidence rate of complications was less for Adjustable Differential Pressure Valves (ADPV) as compared to Fixed Differential Pressure Valves (FDVP) but the confidence intervals overlapped. The summary proportion of surgical revision of shunt in the case of ADPV was 0.081 (95% CI (0.047, 0.115)), and in the case of FDPV was 0.173 (95% CI (0.047, 0.299)). Similarly, the summary proportion of subdural fluid collection in the case of ADPV was 0.090 (0.058, 0.122), and in the case of FDPV was 0.204 (0.132, 0.277). The incidence of complication was low in population implanted with DPV along with gravitational or anti-siphon unit (GASU). CONCLUSION: Complication rates in the case of ADPV plus GASU were the lowest. Though the summary proportion of complication rate in the case of ADPV was low as compared to FDPV, the statistical significance of this difference is doubted due to overlapping confidence intervals.