Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta-analysis.

BACKGROUND: Post-procedural aortic insufficiency (AI) continues to be prevalent following transcatheter aortic valve replacement (TAVR). While several studies have assessed the outcomes of moderate-severe AI following TAVR, the incidence, predictors, and outcomes of mild AI remain unclear. METHODS: A systematic literature review was performed to identify studies reporting on mild AI following TAVR. The primary outcome was pooled incidence of post-TAVR mild AI. Secondary outcomes included pooled incidence of mild AI at 30 days and long term. The pooled incidence of midterm mortality in patients with post-TAVR mild AI was also evaluated. The random effect generalized linear mixed-effects model with logit-transformed proportions and Hartung-Knapp adjustment was used to calculate pooled incidence rates. Meta-regression was performed to identify predictors of mild AI. RESULTS: The pooled analysis included 19,241 patients undergoing TAVR across 50 studies. The mean age of patients ranged from 73 to 85 years, and female patients ranged from 20.0% to 83.3%. The overall pooled incidence of post-TAVR mild AI was 56.1% (95% confidence interval [CI] 0.31-0.64). The pooled incidence of mild AI at 30 days was 33.7% (95% CI 0.12-0.37). At mean follow-up of 1.15 years, the pooled incidence of mild AI was 37.0% (95% CI 0.16-0.45). The overall pooled incidence of Midterm mortality (mean follow-up 1.22 years) in patients with mild AI was 14.8% (95% CI 0.10-0.25). At meta-regression, none of the explored variables correlated with a difference in mild AI incidence. CONCLUSIONS: In published studies to date, 50% of patients undergoing TAVR develop mild AI postoperatively. In 37% of patients, this persists in long term. Though the incidence of AI is likely improving with newer generation TAVR valves, the prevalence and outcomes of mild AI should be closely monitored as TAVR volume and indications expand to younger patients with long life expectancy. The long-term outcomes of mild AI remain unclear. Further dedicated studies on post-TAVR mild AI are needed.

Endoscopic Transaxillary Approach for Breast Augmentation: What does the Evidence Say and What Else Can be Done?

Breast augmentation is the most commonly performed aesthetic procedure. Transaxillary approach is one of the widely accepted techniques for breast augmentation. It has an advantage of the remote nature of the access incision related to the breasts, thereby reducing the visibility of the scar. This is a letter to the editor of the Aesthetic Plastic Surgery journal about the study by Nguyen and to on comparison of endoscopic transaxillary and periareolar techniques in breast augmentation. We have talked about the advantages of the transaxillary approach compared to other techniques and presented the evidence. We recommend future studies comparing the transaxillary, periareolar, and inframammary approaches for breast augmentation with a large cohort and systematic reviews on the same topic. Studies can also be done by combining the cell-assisted lipotransfer with fat graft and endoscopic transaxillary approach for breast augmentation to determine if it provides the best outcome with minimal complications.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Letter to the Editor: The Efficacy of Cell-Assisted Lipotransfer Versus Conventional Lipotransfer in Breast Augmentation: A Systematic Review and Meta-Analysis.

This is a letter to the editor about a meta-analysis titled "The efficacy of cell-assisted lipotransfer versus conventional lipotransfer in breast augmentation: a systematic review and meta-analysis" by Li and Chen published in the year 2021. The most frequently performed aesthetic procedure is breast augmentation surgery. In breast augmentation, cell-assisted lipotransfer (CAL) has received high recognition due to its positive outcomes. There are controversies in the medical literature on the use of CAL for breast augmentation. This meta-analysis by Li and Chen has concluded that CAL using ASC was superior to other methods as it improved fat survival rate in breast augmentation. We have written this letter to the editor of the Aesthetic Plastic Surgery journal about this meta-analysis because of its impactful information provided by this study to the medical literature for breast augmentation surgery using cell-assisted lipotransfer. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A rare case of extensive cutaneous spider angioma in Zieve's syndrome: A case report and review of literature.

Chronic alcoholism is a global public health problem showing increasing trends throughout the world. Alcoholic liver disease is one of the most important causes of mortality worldwide. Cutaneous features are one of the most frequent manifestations of liver disease and can often be a presenting feature. Spider angioma is one of the cutaneous manifestations in liver diseases. More than six spider nevi are considered abnormal. Here we present a case of a gentleman with a history of chronic alcohol intake and diagnosed with Zieve's syndrome, who presented with extensive cutaneous spider angioma.

Sarcoidosis: Various Presentations, Coexisting Diseases and Malignancies.

Sarcoidosis is a rare, chronic inflammatory disease with a characteristic non-caseating granuloma formation. It affects women more than men. The lung is the most commonly affected organ, however, extrapulmonary involvement is also seen. Sarcoidosis can affect any organ or tissue and can also involve multiple organs simultaneously. As a disease, it shares clinical symptoms with a variety of autoimmune, non-autoimmune disorders and malignancies. Not only it mimics clinically, but it also coexists with these diseases, posing a significant diagnostic challenge. During this literature review, we obtained data from the previously published PubMed articles within the last five years and reviewed the possible etiological association and clinical coexistence between sarcoidosis and other diseases/malignancies. We aimed to determine the common clinical manifestations, various complex presentations of sarcoidosis and pathophysiological considerations for the association, and to emphasize the link with other diseases, particularly thyroid disorders/malignancies. Physicians should be aware of these associated diseases and should always make a clinical suspicion when confronting a sarcoidosis patient. Thus, a comprehensive diagnostic evaluation for these associated conditions ought to be done in sarcoidosis patients to avoid any delay in the curative treatment for these coexisting diseases and to prevent substandard outcomes.

Contrast-Enhanced Ultrasound as a Main Radiological Diagnostic Method for Primary Liver Neoplasms and Hemangiomas.

Contrast-enhanced ultrasound (CEUS) is a relatively new approach for the definitive diagnosis of focal liver lesions (FLL). The essential advantages of CEUS are affordability, absence of radiation, and negligible nephrotoxicity-making this diagnostic approach more preferable. This review includes data from 39 different research studies published during the last 10 years, selected through the MeSH strategy in PubMed. We conclude that CEUS is a promising approach for diagnosing primary liver neoplasms and it is an excellent radiological approach for children and pregnant women because of the absence of radiation and nephrotoxicity. Studies showed that CEUS is a very good approach for the differentiation of a variety of hemangiomas and for a detailed description of those findings. Therefore, CEUS is an important and progressive method for the diagnosis of liver neoplasms. The regular use of CEUS will facilitate the diagnosis of primary liver lesions.

A Traditional Review of Sickle Cell Disease and the Associated Onset of Dementia: Hematological and Neurocognitive Crossroads.

Sickle cell trait and disease are potential risk factors for dementia and cognitive dysfunction in African Americans, as are genetic variants. This illness affects around 300 million people globally. Due to its ability to defend against severe malaria, it represents an evolutionary survival advantage. It has been shown that sickle cell disease and trait are independent risk factors for the prevalence and incidence of albuminuria and chronic renal disease. Sickle cell anemia impairs cognitive performance in people with minimal or mild manifestations of the genetic blood disorder, owing mostly to its cerebrovascular implications. Similarly, various cerebral minor vascular disorders, such as silent cerebral infarcts, have been linked to the sickle cell trait, which is associated with impaired cognitive ability. It has been found that patients with sickle cell disease have a significantly decreased subcortical and cortical brain volume. Adults and children with sickle cell disease have been documented to have attention-related issues, particularly reduced sustained attention.

Role of Rho-Associated Protein Kinase Inhibition As Therapeutic Strategy for Parkinson's Disease: Dopaminergic Survival and Enhanced Mitophagy.

The GTP-binding protein, Rho, plays a significant role in the cellular pathology of Parkinson's disease. The downstream effector of Rho, Rho-associated kinase (ROCK), performs several functions, including microglial inflammatory response and enhanced Parkin-mediated mitophagy. Its inhibition shows neuroprotective effects in carried studies. Parkinson's disease pathology also rests on incomplete removal of damaged mitochondria, leading to neuronal impairment. ROCK has different isoforms, inhibition of which have been shown to decrease the adverse changes in microglia. There has also been evidence of a decreased release of inflammatory cytokines and a reduction in degradation of dopaminergic neurons on the addition of ROCK inhibitors. Additionally, ROCK inhibitors have recently been shown to increase the activity of hexokinase 2 (HK2), relocating it to mitochondria, and therefore leading to upregulated mitochondrial targeting. Understanding the cellular basis of ROCK activity and its inhibition may help us advance in creating new strategies for the treatment of Parkinson's disease.

Kikuchi-Fujimoto Disease: A Rare Cause of Cervical Lymphadenopathy.

Kikuchi-Fujimoto disease (KFD) is a rare benign disease, clinically characterized by fever and tender cervical lymphadenopathy affecting the posterior cervical lymph nodes. This disease is usually accompanied by night sweats, rashes, and headaches. It generally affects young individuals, especially females, of Oriental-Asian origin. The etiology of KFD remains uncertain, but associations have been noted with viral diseases including Epstein-Barr virus (EBV), herpes simplex virus (HSV), and varicella-zoster virus (VZV), as well as autoimmune disorders including systemic lupus erythematosus (SLE) and Sjogren's syndrome. This review points out the etiology of KFD with cervical lymphadenopathy alongside its clinical presentation, histological highlights, lab investigations, complications, and treatment. Accurate diagnosis of this disease depends on lymph node excisional biopsy. Three histological patterns of KFD are recognized: proliferative, necrotizing, and xanthomatous. Distinction from lymphadenopathy-associated alternate disorders (e.g., SLE, malignancy, tuberculosis, or another infectious lymphadenitis) is essential to ensure appropriate therapy. This self-limited condition entails nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief with consideration of corticosteroids and hydroxychloroquine in severe cases.

Is it Necessary to Send Clinically Diagnosed Benign Skin and Subcutaneous Lesions Excised Under Local Anesthesia for Routine Histopathological Examination?

Background The common benign surgical lesions of skin and subcutaneous tissues like lipoma and sebaceous cysts are diagnosed clinically and treated by surgical excision under local anesthesia. The occurrence of malignancy in these lesions is extremely low, and routine histopathological examination (HPE) adds to increased costs and workload on pathologists. This study was undertaken to estimate the clinical concordance and the frequency of malignancy in these lesions. Methods A total of 1,815 HPE reports of clinically benign skin and subcutaneous lesions excised under local anesthesia from January 2014 to December 2018 were studied. Results Lipoma (31.3%) and sebaceous cyst (29.9%) were the common clinical diagnosis in our study. The clinical accuracy in the diagnosis of lipoma was 88.6%, and for sebaceous cyst, it was 72.7%. There were six reports of malignancy in our study from the clinically diagnosed benign skin and subcutaneous lesions (0.33%). None of the cases of lipoma and the sebaceous cyst had a malignancy in the final histopathology report. The frequency of malignancy in the rest of the lesions is 0.85% (six out of 699 cases); (p-value: 0.003). Discussion In the absence of red flag signs, lesions like lipoma, sebaceous cyst, corn, and callus can be discarded without an HPE. We advocate routine HPE of other solid lesions, cystic lesions with solid areas, and pigmented or ulcerated lesions, as the clinical concordance is low and there is a significant occurrence of malignancy in these lesions.

Role of Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II Score in Predicting Outcomes of Peritonitis Due to Hollow Viscous Perforation: A Prospective Observational Study.

Background The Acute Physiology and Chronic Health Evaluation II (APACHE II) is the most commonly used severity-of-disease scoring system in ICUs worldwide. There is a paucity of data describing the role of APACHE II score in predicting outcomes of peritonitis due to hollow viscous perforation. This study aims at identifying the importance of the APACHE II score in predicting outcomes of patients with peritonitis secondary to hollow viscus perforation. Methods The study is a prospective, observational study that included all the patients diagnosed with perforation peritonitis who underwent emergency laparotomy and were admitted to the Department of Surgery from May 2017 to May 2018. APACHE II scores were assigned to all patients in order to calculate their individual risk of mortality before undergoing emergency surgery. The accuracy in outcome prediction of the APACHE II system was assessed by means of receiver operating characteristic (ROC) curve and Pearson correlation coefficient and its significance test. Result A total of 50 patients with perforation peritonitis were included in this study. Peptic ulcer disease was the major etiology leading to perforation in 54% of patients, followed by gangrenous bowel. The mean APACHE II score was 9.54. Out of the 50 patients, seven patients succumbed to the illness. All the seven patients whose APACHE II score > 16 developed systemic complications, and three of them developed a local complication. Conclusion APACHE II score correlated well with the outcome in the current study, and APACHE II score also correlated well with the hospital and ICU stay.

Statins' Effect on Cognitive Outcome After Traumatic Brain Injury: A Systematic Review.

Traumatic brain injury (TBI), also known as the "Silent Epidemic," is a growing devastating global health problem estimated to affect millions of individuals yearly worldwide with little public recognition, leading to many individuals living with a TBI-related disability. TBI has been associated with up to five times increase in the risk of dementia among multiple neurologic complications compared with the general population. Several therapies, including statins, have been tried and showed promising benefits for TBI patients. In this systematic review, we evaluated the recent literature that tested the role of statins on neurological and cognitive outcomes such as Alzheimer's Disease and non-Alzheimer's dementia in survivors of TBI with various severities. We conducted a systematic search on PubMed, PubMed Central, MEDLINE, and Google Scholar. MeSH terms and keywords were used to search for full-text randomized clinical trials (RCTs), cross-sectional, case-control, cohort studies, systematic reviews, and animal studies published in English. Inclusion and exclusion criteria were applied, and the articles were subjected to quality appraisal by two reviewers. Our data search retrieved 4948 nonduplicate records. A total of 18 studies were included - nine human studies, and nine animal laboratory trials - after meeting inclusion, eligibility, and quality assessment criteria. Simvastatin was the most tested statin, and the oral route of administration was the most used. Eight human studies showed a significant neuroprotective effect and improvement in the cognitive outcomes, including dementia. Four randomized clinical trials with 296 patients showed that statins play a neuroprotective role and improve cognitive outcomes through different mechanisms, especially their anti-inflammatory effect; they were shown to lower tumor necrosis factor (TNF)-α and C-reactive protein (CRP) levels. Also, they decreased axonal injury and cortical thickness changes. In addition, four cohort studies compared a total of 867.953 patients. One study showed a decrease in mortality in statin-treated patients (p=0.05). Another study showed a reduction in the incidence of Alzheimer's disease and related dementias (RR, 0.77; 95% CI, 0.73-0.81), while one study showed a decreased risk of dementia after concussions by 6.13% (p=0.001). On the other hand, one cohort study showed no significant difference with the use of statins. In eight animal trials, statins showed a significant neuroprotective effect, improved cognitive outcomes, and neurological functions. Different molecular and cellular mechanisms were suggested, including anti-inflammatory effects, promoting angiogenesis, neurogenesis, increasing cerebral blood flow, neurite outgrowth, promoting the proliferation and differentiation of neural stem cells, and reducing axonal injury. On the contrary, one study showed no benefit and actual adverse effect on the cognitive outcome. Most of the studies showed promising neuroprotective effects of statins in TBI patients. Cognitive outcomes, especially dementia, were improved. However, the optimal therapeutic protocol is still unknown. Thus, statins are candidates for more advanced studies to test their efficacy in preventing cognitive decline in patients with TBI.

Virtual Reality as an Affirmative Spin-Off to Laparoscopic Training: An Updated Review.

Latest advancements in science lead to drastic improvements in patient health care. Techniques and technology evolved in surgery over the years have resulted in the improvement of patient outcomes by leaps and bounds. Open surgeries previously done for procedures like appendectomy and cholecystectomy evolved into laparoscopic minimally invasive procedures. Such procedures pose few challenges to the surgeons, like lack of tissue feedback and fulcrum effect of the abdominal wall. But training surgeons for such an advanced skill is still following conventional methods. These procedures can be effectively trained using Virtual Reality (VR), which can simulate operations outside the operating room (OR). To maximize the outcomes of VR training, knowledge on various strategies affecting the skills acquisition and retention in VR training is essential. This review collected information from PubMed, EMBASE, Cochrane Library (CENTRAL) databases. Data from the previous ten years are included in the review. This included documents, clinical trials, meta-analysis, randomized controlled trials, reviews, systematic reviews, letters to editors, and grey literature. After an advanced Medical Subject Headings (MeSH) search, we got 59,532 results, and after the application of filters, 189 results showed up. Out of these, studies that were not exclusively relevant to the use of VR in laparoscopic surgery were manually excluded, and a total of 35 articles were included in the study. VR is found to be an excellent training modality with promising outcomes. It helps the surgeons perform the surgery accurately at a faster pace and improves confidence and multitasking ability in OR. Instructor feedback from mentors and deliberate practice of trainees, and early introduction of haptics in VR resulted in the most effective outcomes of the VR training. Box trainers are also compared with VR trainers as they are the cheaper modalities of training. However, this area needs more research to conclude if box trainers can act as a cheaper alternative to VR training providing similar outcomes.

A Systematic Review on the Role of Βeta-Blockers in Reducing Cardiac Arrhythmias in Long QT Syndrome Subtypes 1-3.

Long QT syndrome (LQTS) is one of the most common inherited cardiac channelopathies with a prevalence of 1:2000. The condition can be congenital or acquired with 15 recognized genotypes; the most common subtypes are LQTS 1, 2, and 3 making up to 85%-90% of the cases. LQTS is characterized by delayed ventricular cardiomyocyte repolarization manifesting on the surface electrocardiogram (EKG) by a prolonged corrected QT (QTc) interval. The mainstay of treatment for this condition involves in part or combination medical therapy via ß-blockers as first-line (or other anti-arrhythmic), left cardiac sympathectomy, or implantable cardiac defibrillator placement. Given the high rate of adverse cardiac events (ACE) or sudden cardiac death (SCD) in this population of patients with this disease, this review seeks to highlight the genotype-specific treatment consensus in ß-blocker therapy of the most common subtypes. A database search of PubMed, PMC, and Medline was conducted to ascertain the most recent data in the last five years on the management of LQTS types 1-3 and the role of ß-blockers in reducing ACE in these types. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were adhered to in the study selection, and selected studies focused on humans, written in the English Language, and within the last five years of LQTS subtypes 1, 2, and 3. Eleven relevant studies were selected after considering inclusion criteria, exclusion criteria, and quality appraisal within the last five years, focusing on ß-blocker selection directed based on the subtypes of LQTS. Two meta-analyses, one cohort study, and eight reviews provided significant data that non-selective ß-blockers unequivocally are of benefit in these LQTS types. Summary of findings suggested nadolol followed by propranolol yields the best results in LQTS 1, while nadolol would yield the best effect in LQTS 2 and 3.

The Outcomes of the Patients Undergoing Harmonic Scalpel Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy has replaced conventional open cholecystectomy and has become the gold standard surgery for gall bladder pathologies. The harmonic scalpel is one of the instruments used to dissect and coagulate. Most surgeons accept the usage of the harmonic scalpel in laparoscopic cholecystectomy. The other standard method is electrocoagulation by electrocautery. The harmonic scalpel cholecystectomy has several advantages over other methods of laparoscopic cholecystectomy. Electrocoagulation by electrocautery produces smoke which can result in damage to lateral tissues, including the gall bladder. The clips are used along with electrocoagulation to seal cystic duct and cystic artery before dissection. There are various studies about bile leakage in the case of clip application. The harmonic scalpel uses ultrasonic energy to achieve hemostasis without bleeding, dissection, and gallbladder removal from the liver bed during laparoscopic surgery by causing coagulation of proteins. The patient outcome variables such as postoperative pain, duration of hospital stay, postoperative nausea and vomiting, surgical site infections, and other complications have not been compared in review articles. In this review, we collected the information from previously published studies and reviewed the outcomes of patients undergoing harmonic scalpel cholecystectomy. Harmonic scalpel cholecystectomy reduces the duration of hospital stay, duration of operation, intraoperative and postoperative complications, and postoperative pain. Thus the harmonic scalpel can be used instead of other instruments as it has better patient outcomes.

A Systematic Review of Fibrin Glue as an Ideal Treatment for the Pilonidal Disease.

Pilonidal sinus is an acquired condition caused by irritation to the hair follicles at the natal cleft, presenting with an abscess or chronic infection. It is prevalent in young adults affecting their productive lifestyle with morbidities. There are varieties of treatment options; however, there is no consensus yet for the ideal procedure. Less invasive procedures have evolved to replace the traditional surgical techniques, which cannot significantly reduce the risks of recurrence and wound complications despite extensive surgeries. We aimed to assess the effect of fibrin glue as a primary treatment after cleaning the sinus in pilonidal sinus disease. We searched for articles from PubMed®, Ovid MEDLINE®, Ovid EMBASE®, and Cochrane CENTRAL. Six studies that included 336 patients in total were analyzed. Fibrin glue treatment in these studies reported a quicker return to normal activities postoperatively, a low rate of infection, and an acceptable rate of recurrence. Thus, fibrin glue seems beneficial in the management of pilonidal disease. However, further high-quality studies are essential to support and confirm this evidence. Future research should also evaluate its cost and implications in the ambulatory service.