PD-L1 Immunohistochemistry in Gastric Cancer: Comparison of Combined Positive Score and Tumor Area Positivity Across 28-8, 22C3, and SP263 Assays.

PURPOSE: The clinical application of PD-L1 immunohistochemistry (IHC) testing is complicated by the availability of multiple IHC assays, scoring algorithms, and cutoffs. This study assessed the analytical comparability of three commercially available PD-L1 assays and two scoring algorithms used to assess PD-L1 status in gastric cancer (GC) samples. METHODS: Serial sections of 100 resected GC samples, with PD-L1 expression levels across the dynamic range, were stained with three in vitro diagnostic-grade PD-L1 assays (28-8, 22C3, and SP263). Three trained pathologists blindly and independently scored slides using combined positive score (CPS) and tumor area positivity (TAP) algorithms. Comprehensive statistical analyses were performed to evaluate analytical concordance. Digital image analysis (DIA) was used to objectively compare the technical performance of each assay by simulating CPS and TAP. RESULTS: Comparable staining patterns were observed with these three PD-L1 assays. Despite discernible variation in staining intensity, reproducible evaluations of PD-L1 positivity were observed. Inter- and intra-assay assessments of all three assays, using either CPS or TAP and the same PD-L1 cutoffs, demonstrated moderate to almost-perfect (interassay Cohen's kappa [κ] range, 0.47-0.83) and substantial to almost-perfect (intra-assay κ range, 0.77-1.00) agreement. Interpathologist assessment exhibited a significant level of concordance (intraclass correlation coefficient ≥0.92). No difference in technical performance was observed using DIA. CONCLUSION: This study highlights analytical concordance in PD-L1 testing between three major PD-L1 assays when TAP and CPS are applied. Comparability of the technical assay performance was further supported by independent DIA. These observations support cross-application flexibility of the different PD-L1 assays and scoring algorithms to characterize PD-L1 expression in GC.

Fragility fractures of the pelvis: First 48 cases of surgical treatment at a level 1 trauma center in France.

INTRODUCTION: Longer life expectancy is accompanied by a higher incidence of fragility fractures of the pelvis (FFP), which has repercussions on mortality and nursing home admissions. Given the paucity of data at French healthcare facilities, we carried out a retrospective study to (1) evaluate how surgical treatment of FFP with posterior displacement (type III and IV according to Rommens and Hofmann) affects a patient's pain, functional status and ability to stay at home and (2) evaluate the postoperative complications and mortality rate. HYPOTHESIS: Surgery for posteriorly displaced FFP will relieve pain and preserve the patient's independence. METHODS: All the patients over 65 years of age who were operated on for a posterior FFP between January 2015 and August 2020 were included in this prospective, single-center study. The demographics, fracture type, details of the surgical treatment, complications and mortality were analyzed. Pain (visual analog scale, VAS), functional status (Activity of Daily Living [ADL] and Instrumental Activity of Daily Living [IADL]), mobility (Parker score) and rates of nursing home admissions were compared before the fracture, after surgery and at a mean follow-up of 28 months (minimum follow-up of 1 year). RESULTS: Forty-eight patients with a mean age of 75 years were included. Twenty-four of these patients (50%) had at least two comorbidities. The FFPs were either type IV (31/48; 65%) or type III (17/48; 35%). The mean VAS for pain was significantly lower on the first day postoperative (3.5 versus 4.8; p=0.02). This significant reduction continued upon discharge from the hospital (1.95; p=0.003) and persisted at the mean follow-up of 28 months (2.2; p=0.64). The complication rate was 15% (7/48) and the mortality rate at the final review was 15% (7/48). Among the surviving patients, 81% (29/36) returned to living at home. The ADL (5.1 versus 5.8; p=0.09), IADL (5.9 versus 6.9; p=0.15) and Parker score (6.8 versus 8.2; p=0.08) at the final review were not significantly different from the values before the fracture. CONCLUSION: This is the first French study of patients operated on for an FPP. Fixation of posteriorly displaced fractures allows surviving patients to retain their mobility. Pain relief is achieved quickly and maintained during the follow-up period. Thus, our initial hypothesis is affirmed. The complication rate is not insignificant; given the complexity of this surgery, percutaneous treatment is preferable. LEVEL OF EVIDENCE: IV; retrospective study.

PITX2 as a Sensitive and Specific Marker of Midgut Neuroendocrine Tumors: Results from a Cohort of 1157 Primary Neuroendocrine Neoplasms.

As neuroendocrine tumors (NETs) often present as metastatic lesions, immunohistochemical assignment to a site of origin is one of the most important tasks in their pathologic assessment. Because a fraction of NETs eludes the typical expression profiles of their primary localization, additional sensitive and specific markers are required to improve diagnostic certainty. We investigated the expression of the transcription factor Pituitary Homeobox 2 (PITX2) in a large-scale cohort of 909 NET and 248 neuroendocrine carcinomas (NEC) according to the immunoreactive score (IRS) and correlated PITX2 expression groups with general tumor groups and primary localization. PITX2 expression (all expression groups) was highly sensitive (98.1%) for midgut-derived NET, but not perfectly specific, as non-midgut NET (especially pulmonary/duodenal) were quite frequently weak or moderately positive. The specificity rose to 99.5% for a midgut origin of NET if only a strong PITX2 expression was considered, which was found in only 0.5% (one pancreatic/one pulmonary) of non-midgut NET. In metastases of midgut-derived NET, PITX2 was expressed in all cases (87.5% strong, 12.5% moderate), whereas CDX2 was negative or only weakly expressed in 31.3% of the metastases. In NEC, a fraction of cases (14%) showed a weak or moderate PITX2 expression, which was not associated with a specific tumor localization. Our study independently validates PITX2 as a very sensitive and specific immunohistochemical marker of midgut-derived NET in a very large collective of neuroendocrine neoplasms. Therefore, our data argue toward implementation into diagnostic panels applied for NET as a firstline midgut marker.

The complete mitochondrial genome of a species of Cirrhipathes de Blainville, 1830 from Kaua'i, Hawai'i (Hexacorallia: Antipatharia).

This study reports the first mitogenome from the antipatharian (black coral) genus Cirrhipathes (GenBank accession number ON653414). The 20,452 bp mitochondrial genome of Cirrhipathes cf. anguina LS-2022 consists of 13 protein-coding genes, two rRNA genes, and two tRNA genes (trnM and trnW). The mitogenome is typical of other antipatharian families, including an A + T biased (64.1%) base composition and cytochrome c oxidase subunit I (COX1) intron with embedded homing endonuclease gene (HEG). A phylogenetic tree based on complete mitogenome sequences of currently available antipatharians indicates Cirrhipathes cf. anguina LS-2022 is sister and closely related to Stichopathes sp. SCBUCN-8849. However, it seems unlikely that intergeneric taxa share 99.97% similarity across their complete mitogenomes, raising questions about the current taxonomy of this group. This study highlights the need for additional vouchered antipatharian species to be sequenced so phylogenetic relationships can be compared with accepted taxonomy.

Pluripotency of a founding field: rebranding developmental biology.

The field of developmental biology has declined in prominence in recent decades, with off-shoots from the field becoming more fashionable and highly funded. This has created inequity in discovery and opportunity, partly due to the perception that the field is antiquated or not cutting edge. A 'think tank' of scientists from multiple developmental biology-related disciplines came together to define specific challenges in the field that may have inhibited innovation, and to provide tangible solutions to some of the issues facing developmental biology. The community suggestions include a call to the community to help 'rebrand' the field, alongside proposals for additional funding apparatuses, frameworks for interdisciplinary innovative collaborations, pedagogical access, improved science communication, increased diversity and inclusion, and equity of resources to provide maximal impact to the community.

Modified Low-Flow Arthroscopic Sandwich Technique for Complex Osteochondral Lesions of the Talus.

Treatment of osteochondral lesions of the talus proves to be challenging given the unique anatomy of the intra-articular surface and associated complexity of larger lesions. Simple bone marrow-stimulating procedures for large complex lesions often lead to poor results with increased risk of lesion progression, refractory pain, and associated functional limitations. Other methods of osteochondral autografts or allografts often require osteotomies, bone windows, or fibrin glue, which are associated with donor pain and nonunion. Thus, for larger and cystic lesions, we report our experience using a modified low-flow arthroscopic sandwich technique consisting of autologous cancellous bone graft, followed by a viable cryopreserved cartilage fiber, cartilage allograft matrix putty.

[Antiagregants, anticoagulants and proximal femur fracture]. / Antiagrégants, anticoagulants oraux directs et fracture du fémur proximal.

Hip fractures are common in the elderly, particularly due to an increased susceptibility to falls and greater bone frailty, especially in women. The consequences of such events are potentially serious. Early management (< 48 hours) significantly reduces the mortality and postoperative complications. Because of their comorbidities, older people are often on antiplatelet therapy, anticoagulant therapy, or both. However, there are no definitive recommendations for the perioperative management of antiplatelet and anticoagulant treatment in the early surgery of hip fractures. The purpose of this article is to review the management of these patients.

Les fractures de la hanche sont fréquentes chez les personnes âgées, notamment en raison d'une prédisposition accrue aux chutes et d'une plus grande fragilité des os, principalement chez les femmes. Les conséquences de tels événements sont potentiellement graves. Une prise en charge précoce (< 48 heures) diminue de manière significative la mortalité et les complications postopératoires. En raison de leurs comorbidités, les personnes âgées sont souvent sous traitement antiagrégant, anticoagulant ou les deux. Or il n'existe pas de recommandations définitives quant à la gestion périopératoire des traitements antiagrégants et anticoagulants de la chirurgie urgente de la fracture du fémur. Le but de cet article est de faire le point sur la prise en charge de ces patients.

Do we need to fix the anterior fracture component in insufficiency fractures of the pelvis? A biomechanical comparison on an FFP type IIIc fracture in an osteoporotic pelvic bone model.

There is a growing understanding of the specific characteristics of insufficiency fractures of the pelvis and of general requirements for the treatment of affected patients with focus on early mobilization and effective pain reduction as the main goals of therapy. While there is consensus on the significance of achieving stability of the dorsal pelvic ring structures there is still an open discussion about the potential benefits of additional stabilization of an anterior fracture component. Within a biomechanical test setup, two established methods of dorsal fracture fixation were tested under axial loading (25-1200 N; 1000 test cycles) on an explicit osteoporotic bone model (n = 32) with a standardized FFP type IIIc fracture with and without additional fixation of the anterior fracture component. Dorsal fixation was performed with and long and a short 7.3 mm cannulated screw in S1 in one group (n = 16), and a trans sacral bar with an additional short 7.3 mm cannulated screw in S1 in the other group (n = 16). Half of the samples received a 7.3 mm cannulated retrograde transpubic screw for anterior fixation. The fixation with the trans sacral bar and the additional anterior screw fixation showed the highest rate of stability (p = 0.0014), followed by the double SI-screw fixation with stabilization of the anterior fracture (p = 0.0002). During testing, we observed the occurrence of new sacral fractures contralateral to the initial fracture in 22/32 samples. The results let us assume that stabilization of an additional anterior fracture component relevantly improves the stability of the entire ring construct and might prevent failure of the dorsal stabilization or further fracture progression.

Artificial Intelligence in Neuroradiology: A Review of Current Topics and Competition Challenges.

There is an expanding body of literature that describes the application of deep learning and other machine learning and artificial intelligence methods with potential relevance to neuroradiology practice. In this article, we performed a literature review to identify recent developments on the topics of artificial intelligence in neuroradiology, with particular emphasis on large datasets and large-scale algorithm assessments, such as those used in imaging AI competition challenges. Numerous applications relevant to ischemic stroke, intracranial hemorrhage, brain tumors, demyelinating disease, and neurodegenerative/neurocognitive disorders were discussed. The potential applications of these methods to spinal fractures, scoliosis grading, head and neck oncology, and vascular imaging were also reviewed. The AI applications examined perform a variety of tasks, including localization, segmentation, longitudinal monitoring, diagnostic classification, and prognostication. While research on this topic is ongoing, several applications have been cleared for clinical use and have the potential to augment the accuracy or efficiency of neuroradiologists.

Should Penicillin Allergy Testing Be Included as Part of Preoperative Testing?

INTRODUCTION: Penicillin allergy is the most commonly reported drug allergy in the United States. Patients labeled with penicillin allergy are at risk of receiving broad-spectrum antibiotics for surgical site infection prophylaxis, which can lead to increased antibiotic resistance, higher morbidity, suboptimal antibiotic therapy, and higher medical costs. This study aimed to determine the true prevalence of penicillin allergy among surgical patients and to decrease the unnecessary use of broad-spectrum antibiotics. METHODS: A retrospective chart review was performed of patients who underwent urogynecologic surgery in 2017. In 2018, a quality initiative was started, and all patients reporting penicillin allergies were offered antibiotic allergy testing as part of their preoperative testing. RESULTS: In 2017, 15% of patients reported penicillin allergy and 52% of them received surgical prophylaxis with broad-spectrum antibiotics. In 2018, 463 patients underwent surgery, 55 of whom reported penicillin allergy and were offered penicillin allergy testing. 35 (64%) agreed to proceed with testing, and of those tested, 33 (94%) tested negative for penicillin allergy. CONCLUSIONS: 94% of patients with stated penicillin allergy who consented to allergy testing proved to have negative test. Penicillin allergy testing should be considered as part of preoperative management.

Combined Free Flaps for Optimal Orthoplastic Lower Limb Reconstruction: A Retrospective Series.

Background and Objectives: Open fracture of the lower limb can lead to substantial bone and soft tissue damage, resulting in a challenging reconstructive scenarios, especially in presence of bone or periosteal loss, with a relevant risk of non-union. This work analyzes outcomes of using a double approach for orthoplastic reconstruction, adopting the free medial condyle flap to solve the bone defects, associated to a second free flap for specific soft tissue coverage. Indications, outcomes and reconstructive rationales are discussed. Materials and Methods: A retrospective investigation was performed on patients who underwent complex two-flap microsurgical reconstruction from January 2018 to January 2022. Inclusion criteria in this study were the use of a free femoral condyle periostal/bone flap together with a second skin-only flap. Only distal third lower limb reconstructions were included in order to help equalize our findings. Out of the total number of patients, only patients with complete pre- and post-operative follow-up (minimum 6 months) data were included in the study. Results: Seven patients were included in the study, with a total of 14 free flaps. The average age was 49. Among comorbidities, four patients were smokers and none suffered from diabetes. Etiology of the defect was acute trauma in four cases and septic non-union in three cases. No major complications occurred, and all flaps healed uneventfully with complete bone union. Conclusions: Combining a bone periosteal FMC to a second skin free flap for tailored defect coverage allowed achievement of bone union in all patients, despite the lack of initial bone vascularization or chronic infection. FMC is confirmed to be a versatile flap for small-to-medium bone defects, especially considering its use as a periosteal-only flap, with minimal donor site morbidity. Choosing a second flap for coverage allows for a higher inset freedom and tailored reconstruction, finally enhancing orthoplastic success.

Graded BMP signaling within intestinal crypt architecture directs self-organization of the Wnt-secreting stem cell niche.

Signals from the surrounding niche drive proliferation and suppress differentiation of intestinal stem cells (ISCs) at the bottom of intestinal crypts. Among sub-epithelial support cells, deep sub-cryptal CD81+ PDGFRAlo trophocytes capably sustain ISC functions ex vivo. Here, we show that mRNA and chromatin profiles of abundant CD81- PDGFRAlo mouse stromal cells resemble those of trophocytes and that both populations provide crucial canonical Wnt ligands. Mesenchymal expression of key ISC-supportive factors extends along a spatial and molecular continuum from trophocytes into peri-cryptal CD81- CD55hi cells, which mimic trophocyte activity in organoid co-cultures. Graded expression of essential niche factors is not cell-autonomous but dictated by the distance from bone morphogenetic protein (BMP)-secreting PDGFRAhi myofibroblast aggregates. BMP signaling inhibits ISC-trophic genes in PDGFRAlo cells near high crypt tiers; that suppression is relieved in stromal cells near and below the crypt base, including trophocytes. Cell distances thus underlie a self-organized and polar ISC niche.

Discordance of HER2-Low between Primary Tumors and Matched Distant Metastases in Breast Cancer.

We examined differences in HER2 expression between primary tumors and distant metastases, particularly within the HER2-negative primary breast cancer cohort (HER2-low and HER2-zero). The retrospective study included 191 consecutive paired samples of primary breast cancer and distant metastases diagnosed between 1995 and 2019. HER2-negative samples were divided into HER2-zero (immunohistochemistry [IHC] score 0) and HER2-low (IHC score 1+ or 2+/in situ hybridization [ISH]-negative). The main objective was to analyze the discordance rate between matched primary and metastatic samples, focusing on the site of distant metastasis, molecular subtype, and de novo metastatic breast cancer. The relationship was determined by cross-tabulation and calculation of Cohen's Kappa coefficient. The final study cohort included 148 paired samples. The largest proportion in the HER2-negative cohort was HER2-low [primary tumor 61.4% (n = 78), metastatic samples 73.5% (n = 86)]. The discordance rate between the HER2 status of primary tumors and corresponding distant metastases was 49.6% (n = 63) (Kappa -0.003, 95%CI -0.15-0.15). Development of a HER2-low phenotype occurred most frequently (n = 52, 40.9%), mostly with a switch from HER2-zero to HER2-low (n = 34, 26.8%). Relevant HER2 discordance rates were observed between different metastatic sites and molecular subtypes. Primary metastatic breast cancer had a significantly lower HER2 discordance rate than secondary metastatic breast cancer [30.2% (Kappa 0.48, 95%CI 0.27-0.69) versus 50.5% (Kappa 0.14, 95% CI -0.03-0.32)]. This highlights the importance of evaluating potentially therapy-relevant discordance rates between a primary tumor and corresponding distant metastases.

Multistain deep learning for prediction of prognosis and therapy response in colorectal cancer.

Although it has long been known that the immune cell composition has a strong prognostic and predictive value in colorectal cancer (CRC), scoring systems such as the immunoscore (IS) or quantification of intraepithelial lymphocytes are only slowly being adopted into clinical routine use and have their limitations. To address this we established and evaluated a multistain deep learning model (MSDLM) utilizing artificial intelligence (AI) to determine the AImmunoscore (AIS) in more than 1,000 patients with CRC. Our model had high prognostic capabilities and outperformed other clinical, molecular and immune cell-based parameters. It could also be used to predict the response to neoadjuvant therapy in patients with rectal cancer. Using an explainable AI approach, we confirmed that the MSDLM's decisions were based on established cellular patterns of anti-tumor immunity. Hence, the AIS could provide clinicians with a valuable decision-making tool based on the tumor immune microenvironment.

Return to sports and short-term follow-up of 101 cases of medial patellofemoral ligament reconstruction using gracilis tendon autograft in children and adolescents.

INTRODUCTION: An acute patellofemoral dislocation is the most common acute knee injury in children. Recent studies suggest up to 40% of immature patients may develop recurrent instability. MPFL reconstruction has become a mainstay for the treatment of patellofemoral instability. Aim of the recent study is to show our experiences of MPFL reconstruction in patellar instability in immature patients using a gracilis autograft in respect to return to sport, growth plate disorders and short-term results. MATERIALS AND METHODS: A total of 101 patients (50 females, 51 males) were included in this retrospective study. Mean age at time of operation was 14.8 ± 1.6 years. Primary outcome measures included patient satisfaction, Kujala score, recurrent instability, return to normal activity, return to sports, clinical leg axis and complications. Mann-Whitney U test was used for statistical analysis and alpha was set at p < 0.05 to declare significance. RESULTS: At a mean follow-up of 32.0 ± 12.1 months 90/101 patients could be followed-up. 84% of all patients were satisfied or very satisfied with the result at latest follow-up. 86.6% of all patients were able to return to sports, 2.3% had a relevant deviation of the clinical leg axis, but symmetrical. In sum complication rate was 2.9%. Redislocation rate was 0.9% (1/101). Kujala Score improved significantly from 47.1 preoperatively to 85.3 postoperatively (p < 0.01). CONCLUSION: Anatomic MPFL reconstruction using gracilis tendon allograft tissue is a safe procedure in children and adolescents with low risk of recurrent instability.

Internal fixation of radiation-induced fragility fractures of the pelvis: a case series.

BACKGROUND: The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE: The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS: A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS: Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION: RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE: III, retrospective study.

Mortalidade por suicídio na 5a mesorregião de perícia Santa Catarina: Análise dos casos / Mortalidad por suicidio en el mesoregion experto de la 5a fronteira de Santa Catarina / Mortality by suicide in the 5th fronteira de Santa Catarina expert mesoregion

Objetivo: analisar o perfil dos óbitos por suicídio necropsiados pelo Instituto Geral de Perícias/Chapecó, entre janeiro 2007 e dezembro 2016. Método: estudo exploratório descritivo retrospectivo, obteve aprovação ética do Comitê de Ética em Pesquisa com Seres Humanos (CEP/UFFS) sob parecer no 1.826.221. Dados obtidos nos registros de necropsia e declarações de óbito de mortes por suicídio, organizados em planilhas eletrônicas, analisados pelo teste qui quadrado, e discutidos com base na literatura. Resultados: analisados 335 óbitos. À análise estatística univariada, significância para sexo, faixa etária, escolaridade e situação conjugal. Análise de tendência temporal apontou incremento nas taxas entre 30-39 anos e acima de 60 anos. Conclusão: o fortalecimento de políticas públicas voltadas à saúde mental é necessário.(AU)

Objective: to analyze the profile of deaths by suicide autopsied by the Instituto Geral de Perícias/Chapecó, between January 2007 and December 2016. Method: a retrospective descriptive exploratory study, which obtained ethical approval from the Ethics Committee for Research with Human Beings (CEP/UFFS) under opinion No. 1,826,221. Data obtained from autopsy records and death certificates of deaths by suicide, organized in electronic spreadsheets, analyzed by the chi-square test, and discussed based on the literature. Results: analyzed 335 deaths. Univariate statistical analysis revealed significance for sex, age group, education and marital status. Time trend analysis showed an increase in rates between 30-39 years and over 60 years. Conclusion: the strengthening of public policies aimed at mental health is necessary.(AU)

Objetivo: analizar el perfil de las muertes por suicidio autopsiadas por el Instituto Geral de Perícias/Chapecó, entre enero de 2007 y diciembre de 2016. Método: estudio exploratorio descriptivo retrospectivo, obtuvo aprobación ética del Comité de Ética en Investigación con Seres Humanos (CEP/ UFFS) bajo dictamen N° 1.826.221. Datos obtenidos de autopsias y certificados de defunción de muertes por suicidio, organizados en hojas de cálculo electrónicas, analizados por la prueba de chi-cuadrado y discutidos con base en la literatura. Resultados: se analizaron 335 defunciones. El análisis estadístico univariado reveló significancia para sexo, grupo de edad, educación y estado civil. El análisis de tendencia temporal mostró un aumento en las tasas entre 30-39 años y mayores de 60 años. Conclusión: es necesario el fortalecimiento de las políticas públicas dirigidas a la salud mental.(AU)

Presumed cytomegalovirus retinitis late after kidney transplant / Retinite presumida por citomegalovírus tardiamente após um transplante renal

Abstract Cytomegalovirus (CMV) retinitis is a rare manifestation of CMV invasive disease and potentially threatening to vision in immunocompromised individuals. Clinical suspicion is fundamental since it is an unusual entity with a progressive and often asymptomatic installation over a long period. The authors report a 70-year-old man with diabetic nephropathy who underwent a kidney transplant (KT) in August 2014 with good clinical evolution. No previous CMV infection or episodes of acute rejection were reported. Five years after transplant, he was admitted due to a reduced visual acuity of the left eye with seven days of evolution with associated hyperemia, without exudate. The ophthalmologic evaluation was compatible with acute necrosis of the retina and presumed associated with CMV infection. He had a progressive improvement after ganciclovir initiation. CMV retinitis is one of the most serious ocular complications in immune-suppressed individuals and can lead to irreversible blindness, and because of that, early diagnosis and treatment remains crucial in obtaining the best visual prognosis in affected patients. Secondary prophylaxis with ganciclovir is not consensual, neither is the safety of reintroducing the antimetabolite in these cases.

Resumo A retinite por citomegalovírus (CMV) é uma manifestação rara de doença invasiva por CMV e potencialmente ameaçadora para a visão em indivíduos imunocomprometidos. A suspeita clínica é fundamental, uma vez que se trata de uma entidade incomum, com uma instalação progressiva e frequentemente assintomática durante um longo período. Os autores relatam um homem de 70 anos de idade com doença renal do diabetes que foi submetido a um transplante renal (KT) em Agosto de 2014 com boa evolução clínica. Nenhuma infecção anterior por CMV ou episódios de rejeição aguda foram relatados. Cinco anos após o transplante, ele foi internado devido a uma acuidade visual reduzida do olho esquerdo com sete dias de evolução com hiperemia associada, sem exsudato. A avaliação oftalmológica foi compatível com a necrose aguda da retina e presumivelmente associada à infecção por CMV. Ele teve uma melhora progressiva após o início do ganciclovir. A retinite por CMV é uma das complicações oculares mais graves em indivíduos imunossuprimidos e pode levar à cegueira irreversível e, por isso, o diagnóstico e o tratamento precoces continuam sendo cruciais para obter o melhor prognóstico visual em pacientes afetados. A profilaxia secundária com ganciclovir não é consensual, tampouco a segurança de reintroduzir o antimetabólito nestes casos.

Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures.

Background: With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs. Methods: A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery. Results: 56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication. Conclusions: Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients. Level of Evidence: Prognostic, Level III.