Parental experience of hypoglossal nerve stimulator implantation in adolescents with Down Syndrome and obstructive sleep apnea.

PURPOSE: The purpose of this study is to explore the experience of parents in deciding whether to participate in a clinical trial of the insertion of the Hypoglossal Nerve Stimulator (HNS) to treat their adolescent with Down Syndrome (DS) and Obstructive Sleep Apnea (OSA). DESIGN AND METHODS: A qualitative descriptive design with interviews was used to gather parental experiences from those who consented to HNS for their adolescent with DS and OSA. Interviews were conducted, audiotaped, and transcribed. Basic content analysis was followed to interpret the data. Using a process of data debriefing/engagement, codes were generated, and field/reflective notes were used to assure trustworthiness of the data. RESULTS: Parents, 13 mothers/2 fathers, participated. Three themes were identified: Parents experience desperation about acceptance of standard of care for their adolescent with DS and OSA. This desperation led parents to seek information/insights from social media and they came to rely on those sites to explore options, ultimately leading them to HNS clinical trial. Finally, parents had a desire to share experience with HNS implantation. CONCLUSIONS: Parents described being desperate at acceptance of standards of care for OSA. They shifted reliance on experts and parents by searching social media pages to explore options for treatment of OSA. Parents wished to share experiences with the HNS implantation. PRACTICE IMPLICATIONS: Nurses play a role in preparing for the HNS by instructing/educating parents. Nurses can identify supportive social media sites for parents during the HNS decision and suggest ways to measure outcomes of HNS.

Comparação entre os resultados do implante de um segmento de arco longo versus dois segmentos de arco tradicional no tratamento de pacientes com ceratocone / Comparison between the results of implanting a long-arch segment versus two standard arch segments for treatment of keratoconus patients

RESUMO Objetivo: Analisar retrospectivamente as alterações na ceratometria e no astigmatismo corneano obtidas após cirurgia de implante de anel intraestromal, comparando o uso de um segmento de arco longo versus o implante de dois segmentos de comprimento de arco tradicional. Métodos: A partir de um estudo transversal, obtivemos os dados de 94 olhos de pacientes diagnosticados com ceratocone, que foram submetidos ao implante de anel corneano. Eles foram divididos em dois grupos, dependendo do tipo de implante recebido: Grupo A, um segmento de arco longo; Grupo B, dois segmentos tradicionais. Todos os segmentos implantados possuíam 250µ de espessura. Os dados do pré-operatório dos dois grupos foram comparados, para garantir que as amostras eram similares (as diferenças encontradas entre os dois grupos não eram estatisticamente significativas). As variáveis analisadas no pré e no pós-operatório foram acuidade visual com correção, ceratometria, astigmatismo corneano e refração. Resultados: A amostra que recebeu apenas um segmento de arco longo (Grupo A) obteve redução da ceratometria média de 4,42D (8,7%) e do astigmatismo corneano de 2,43D (40,4%). Já na amostra dos olhos que receberam dois segmentos de arco tradicional (Grupo B), houve redução média de 2,66D (5,1%) em relação à ceratometria média e redução média de 2,11D (34,8%) em relação ao astigmatismo corneano. A redução obtida na ceratometria média no Grupo A foi maior que a obtida no Grupo B (diferença estatisticamente significativa). A redução obtida no astigmatismo do Grupo A não foi estatisticamente significante, se comparada com o resultado obtido no Grupo B (considerando p≤0,05). Conclusão: Foi demonstrado que o uso de um segmento de arco longo possui maior capacidade de aplanação corneana, se comparado com o uso de dois segmentos com comprimento de arco tradicional. Em relação à redução do astigmatismo, os dois grupos mostraram resultados equivalentes.

ABSTRACT Purpose: To retrospectively analyze the changes in corneal keratometry and astigmatism after intrastromal ring surgery, comparing the use of one long arch segment versus two traditional arc length segments. Methods: A cross-sectional study obtained data from 94 eyes of patients diagnosed with keratoconus that underwent surgical treatment with corneal ring implant. They were divided into two groups according to the type of implant received: one long-arch segment (Group A) or two traditional segments (Group B), both 250 microns thick. Preoperative data from the two groups were compared to ensure that the samples were similar (the differences between the two groups were not statistically significant). The variables (pre and post-operatively) analyzed were: best corrected visual acuity, keratometry, corneal astigmatism and refraction. Results: Group A, which received one long arch segment, showed a Km decrease of 4.42D (8.7%) and a corneal astigmatism reduction of 2.43D (40.4%). Group B, where the eyes acquired two traditional arch segments, showed an average Km decrease of 2.66D (5.1%) and corneal astigmatism reduction of 2.11D (34.8%). The mean keratometry (Km) reduction obtained was statistically significant (p≤0.05) when comparing both groups (A and B). The mean corneal astigmatism reduction was not statistically significant (p≤0.05) when comparing both groups (A and B). Conclusions: One long-arch segment has been demonstrated to have a greater capacity to reduce corneal curvature when compared to the use of two traditional-sized arch segments. No significant differences were found regarding the reduction of corneal astigmatism after comparing the results obtained in both groups.

Hypoglossal Nerve Stimulator Implantation in an Ambulatory Surgery Center Versus Hospital.

OBJECTIVES/HYPOTHESIS: Hypoglossal nerve stimulator (HGNS) implantation is highly effective in treating obstructive sleep apnea (OSA) in select patient populations that are intolerant of continuous positive airway pressure. Implantation surgery is traditionally performed in hospital outpatient departments (HOPD) due to concern about anesthetic effects and airway manipulation in an OSA population. In this study, we examined complications and efficiency of HGNS implantation in an ambulatory surgery center (ASC) versus HOPD. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with HGNS implantation performed between May 2015-January 2021 at our HOPD or ACS were included. Patient-related characteristics, surgical times, and postoperative complications were obtained via chart review. Reimbursement data on a national level for Medicare patients were calculated based on publicly available data from the Center for Medicare Services. Patient characteristics, surgical times, and complications were summarized as medians with interquartile ranges (IQRs) and proportions in each surgical setting group as appropriate. These were compared between surgical setting groups via Wilcoxon rank-sum testing and χ2 testing. RESULTS: A total of 122 patients were included. Patients in the HOPD group had significantly higher median apnea-hypopnea index (AHI) (42.0 [IQR 27.9-51.0]) compared to the ASC group (31.0 [IQR 21.0-44.2], P = .005). The intervals between in-room and case start, case finish and out-of-room, and time in the postoperative area were significantly shorter in the ASC group compared to the HOPD group. Reimbursement on a national level was estimated at 18% lower for patients with surgery performed at the ASC. There was no significant difference in postoperative complications. CONCLUSIONS: HGNS implantation in an ASC is safe and more efficient than in a HOPD, and may also be more cost-effective. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:706-710, 2022.

Training for users of myoelectric multigrip hand prostheses: a scoping review.

BACKGROUND: Training is crucial to develop the ability to operate a myoelectric prosthetic hand and use it in daily life. Multigrip prostheses, with their wider repertoire of functions, require further training. Because studies show that prosthesis abandonment is an issue and the advanced functions are not used to the expected extent, the question of what training should be offered to patients arises. If the available training methods were synthesized, the training could be improved to the benefit of the people who are fitted with a multigrip prosthesis. OBJECTIVE: To critically examine the content of published sources for training of users with myoelectric multigrip hand prostheses. STUDY DESIGN: Scoping review. METHODS: A literature search covering the period 2007-2020 in the databases PubMed, CINAHL, and Allied and Complementary Medicine Database, as well as gray literature from prosthesis manufacturers, identified 2,005 sources. After full-text review of 88 articles and four user manuals from manufacturers, nine sources were included and analyzed in their entirety. RESULTS: We found few descriptions of multigrip prosthesis training, and no source described all training phases in detail. Integration of the prosthesis and training in daily activities was described least. Few sources actually described how to perform training in multigrip functions, and none described how to integrate these functions in daily life. CONCLUSIONS: Existing training instructions for using multigrip prosthetic hands are inadequate, providing poor guidance to clinicians and insufficient training for patients. Further research is needed into the efficiency of various training methods.

Neurophysiological responses of globus pallidus internus during the auditory oddball task in Parkinson's disease.

Parkinson's disease can be associated with significant cognitive impairment that may lead to dementia. Deep brain stimulation (DBS) of the subthalamic nucleus is an effective therapy for motor symptoms but is associated with cognitive decline. DBS of globus pallidus internus (GPi) poses less risk of cognitive decline so may be the preferred target. A research priority is to identify biomarkers of cognitive decline in this population, but efforts are hampered by a lack of understanding of the role of the different basal ganglia nuclei, such as the globus pallidus, in cognitive processing. During deep brain stimulation (DBS) surgery, we monitored single units, beta oscillatory LFP activity as well as event related potentials (ERPs) from the globus pallidus internus (GPi) of 16 Parkinson's disease patients, while they performed an auditory attention task. We used an auditory oddball task, during which one standard tone is presented at regular intervals and a second deviant tone is presented with a low probability that the subject is requested to count and report at the end of the task. All forms of neuronal activity studied were selective modulated by the attended tones. Of 62 neurons studied, the majority (51 or 82%) responded selectively to the deviant tone. Beta oscillatory activity showed an overall desynchronization during both types of attended tones interspersed by bursts of beta activity giving rise to peaks at a latency of around 200 ms after tone onset. cognitive ERPs recorded in GPi were selective to the attended tone and the right-side cERP was larger than the left side. The averages of trials showing a difference in beta oscillatory activity between deviant and standard also had a significant difference in cERP amplitude. In one block of trials, the random occurrence of 3 deviant tones in short succession silenced the activity of the GPi neuron being recorded. Trial blocks where a clear difference in LFP beta was seen were twice as likely to yield a correct tone count (25 vs 11). The data demonstrate strong modulation of GPi neuronal activity during the auditory oddball task. Overall, this study demonstrates an involvement of GPi in processing of non-motor cognitive tasks such as working memory and attention, and suggests that direct effects of DBS in non-motor GPi may contribute to cognitive changes observed post-operatively.

People with amputations in rural Sierra Leone: the impact of 3D-printed prostheses.

We report the case of a man with a transhumeral amputation in a rural area of Sierra Leone. The patient had fractured his humerus during a football match. Due to lack of transportation and medical centres nearby, the patient was seen by a traditional healer. Although the traditional healer expected the fractured bone to heal within 3 days, the open fracture became infected. This finally resulted in a transhumeral amputation. The patient began to have a lack of self-confidence and felt excluded from society. He could not afford a conventionally fabricated prosthesis. Fourteen years later, the patient received a lightweight three-dimensional-printed arm prosthesis developed at the Masanga Hospital. The patient was very satisfied because the prosthesis met his criteria of aesthetics and functionality. His story highlights the socioeconomic hardship of being a person with an amputation in Sierra Leone and the need for affordable technological solutions.

Comparative Study between Subcutaneous and Endovascular Defibrillator Recipients Regarding Tolerance to the Implant Procedure and Perception of Quality of Life. / Estudo Comparativo entre Receptores de Desfibriladores Subcutâneos e Transvenosos em Relação à Tolerância ao Procedimento de Implante e Percepção da Qualidade de Vida.

BACKGROUND: The totally subcutaneous implantable cardioverter-defibrillator (S-ICD) is a safe alternative to the conventional transvenous ICD (TV-ICD) system to prevent sudden death. OBJECTIVE: To compare the impact of the type of ICD system and surgical technique on patients' quality of life, as well as the severity of discomfort and pain, between S-ICD and TV-ICD recipients. METHODS: Consecutively implanted patients with an S-ICD system were matched with patients with a TV-ICD system. In addition, patients undergoing S-ICD implantation after removal of a TV-ICD due to complications were included. Quality of life (measured with the 12-item short-form health survey) and severity of pain and discomfort were evaluated. Statistical significance was defined as p < 0.05. RESULTS: A total of 64 patients implanted with S-ICD or TV-ICD under local anesthesia and conscious sedation were analyzed. Patients with S-ICD and TV-ICD systems did not differ significantly in quality of life scores. S-ICD patients had a higher level of perioperative pain; no differences were found regarding severity of intraoperative pain. The magnitude of aesthetic discomfort and sleep disturbances did not differ between groups. An S-ICD was implanted in 7 additional patients after removal of a TV-ICD. All but one of these patients recommended the S-ICD system. CONCLUSIONS: The type of ICD system and the surgical technique have negligible impact on patients' quality of life. These results suggest that conscious sedation, provided by an experienced electrophysiology team, could be considered as an alternative to general anesthesia to manage patients undergoing S-ICD implantation.

FUNDAMENTO: O cardioversor-desfibrilador implantável subcutâneo (S-CDI) é uma alternativa segura ao sistema convencional do CDI transvenoso (TV-CDI) para evitar morte súbita. OBJETIVO: Comparar o impacto do tipo de sistema de CDI e técnica cirúrgica na qualidade de vida dos pacientes, bem como a gravidade do desconforto e da dor, entre receptores de S-CDI e TV-CDI. MÉTODOS: Pacientes consecutivamente implantados com um sistema S-CDI foram pareados com pacientes com um sistema TV-CDI. Além disso, foram incluídos os pacientes submetidos ao implante de S-CDI após a remoção de um TV-CDI, devido a complicações. Foram avaliadas a qualidade de vida (medida com o questionário de saúde de 12 itens) e a gravidade da dor e desconforto. Significância estatística foi definida como p < 0,05. RESULTADOS: Foram analisados 64 pacientes implantados com S-CDI ou TV-CDI sob anestesia local e sedação consciente. Pacientes com sistemas S-CDI e TV-CDI não diferiram significativamente nos escores de qualidade de vida. Os pacientes com S-CDI apresentaram maior nível de dor peri-operatória; nenhuma diferença foi encontrada em relação à gravidade da dor intra-operatória. A magnitude do desconforto estético e dos distúrbios do sono não diferiu entre os grupos.O S-CDI foi implantado em 7 pacientes adicionais após a remoção de um TV-CDI. Todos exceto um desses pacientes recomendaram o sistema S-CDI. CONCLUSÕES: O tipo de sistema de CDI e a técnica cirúrgica têm impacto insignificante na qualidade de vida dos pacientes. Estes resultados sugerem que a sedação consciente, fornecida por uma equipe experiente de eletrofisiologia, pode ser considerada uma alternativa à anestesia geral para o manejo de pacientes submetidos ao implante de S-CDI.

Estudo Comparativo entre Receptores de Desfibriladores Subcutâneos e Transvenosos em Relação à Tolerância ao Procedimento de Implante e Percepção da Qualidade de Vida / Comparative Study between Subcutaneous and Endovascular Defibrillator Recipients Regarding Tolerance to the Implant Procedure and Perception of Quality of Life

Resumo Fundamento O cardioversor-desfibrilador implantável subcutâneo (S-CDI) é uma alternativa segura ao sistema convencional do CDI transvenoso (TV-CDI) para evitar morte súbita. Objetivo Comparar o impacto do tipo de sistema de CDI e técnica cirúrgica na qualidade de vida dos pacientes, bem como a gravidade do desconforto e da dor, entre receptores de S-CDI e TV-CDI. Métodos Pacientes consecutivamente implantados com um sistema S-CDI foram pareados com pacientes com um sistema TV-CDI. Além disso, foram incluídos os pacientes submetidos ao implante de S-CDI após a remoção de um TV-CDI, devido a complicações. Foram avaliadas a qualidade de vida (medida com o questionário de saúde de 12 itens) e a gravidade da dor e desconforto. Significância estatística foi definida como p < 0,05. Resultados Foram analisados 64 pacientes implantados com S-CDI ou TV-CDI sob anestesia local e sedação consciente. Pacientes com sistemas S-CDI e TV-CDI não diferiram significativamente nos escores de qualidade de vida. Os pacientes com S-CDI apresentaram maior nível de dor peri-operatória; nenhuma diferença foi encontrada em relação à gravidade da dor intra-operatória. A magnitude do desconforto estético e dos distúrbios do sono não diferiu entre os grupos.O S-CDI foi implantado em 7 pacientes adicionais após a remoção de um TV-CDI. Todos exceto um desses pacientes recomendaram o sistema S-CDI. Conclusões O tipo de sistema de CDI e a técnica cirúrgica têm impacto insignificante na qualidade de vida dos pacientes. Estes resultados sugerem que a sedação consciente, fornecida por uma equipe experiente de eletrofisiologia, pode ser considerada uma alternativa à anestesia geral para o manejo de pacientes submetidos ao implante de S-CDI.

Abstract Background The totally subcutaneous implantable cardioverter-defibrillator (S-ICD) is a safe alternative to the conventional transvenous ICD (TV-ICD) system to prevent sudden death. Objective To compare the impact of the type of ICD system and surgical technique on patients' quality of life, as well as the severity of discomfort and pain, between S-ICD and TV-ICD recipients. Methods Consecutively implanted patients with an S-ICD system were matched with patients with a TV-ICD system. In addition, patients undergoing S-ICD implantation after removal of a TV-ICD due to complications were included. Quality of life (measured with the 12-item short-form health survey) and severity of pain and discomfort were evaluated. Statistical significance was defined as p < 0.05. Results A total of 64 patients implanted with S-ICD or TV-ICD under local anesthesia and conscious sedation were analyzed. Patients with S-ICD and TV-ICD systems did not differ significantly in quality of life scores. S-ICD patients had a higher level of perioperative pain; no differences were found regarding severity of intraoperative pain. The magnitude of aesthetic discomfort and sleep disturbances did not differ between groups. An S-ICD was implanted in 7 additional patients after removal of a TV-ICD. All but one of these patients recommended the S-ICD system. Conclusions The type of ICD system and the surgical technique have negligible impact on patients' quality of life. These results suggest that conscious sedation, provided by an experienced electrophysiology team, could be considered as an alternative to general anesthesia to manage patients undergoing S-ICD implantation.

Twelve-month Durability of a Fully-implanted, Nickel-sized and Shaped Tibial Nerve Stimulator for the Treatment of Overactive Bladder Syndrome with Urgency Urinary Incontinence: A Single-Arm, Prospective Study.

OBJECTIVES: To evaluate the safety and efficacy of the eCoin - a nickel-sized, primary battery-powered, neuromodulation device for the treatment of urgency urinary incontinence which is implanted in the lower leg in a 20-minute procedure under local anesthesia. A feasibility clinical trial was conducted and the results after 1 year of treatment with the eCoin are presented. METHODS: A total of 46 participants with refractory urgency urinary incontinence were included in this prospective, single-arm, open-label study. This study was conducted at 7 sites in the United States and New Zealand. Participants in this study were implanted with the eCoin in the lower leg over the tibial nerve and activated after 4 weeks. Bladder diary data and validated quality-of-life instruments, collected at 3, 6, and 12 months' post-activation, were compared to baseline values. RESULTS: Responders were defined as those who had a ≥50% reduction in reported episodes of urgency urinary incontinence. At 12 months', 65% of participants were considered responders with 26% of participants achieving complete continence. The median number of urgency urinary incontinence episodes per day decreased from 4.2 at baseline to 1.7 at 12 months'. Seventy percent of participants reported feeling "better", "much better", or "very much better" on the Likert 7-point maximum scale. One participant experienced a related serious adverse event. CONCLUSION: The eCoin is a safe and effective treatment for urgency urinary incontinence associated with overactive bladder syndrome, with significant reduction or complete resolution of symptoms and no significant safety concerns.

Applying a Human Factors Approach to Improve Patient Experience with Sacral Neuromodulation.

OBJECTIVES: To apply a human factors approach, the study of interactions between humans and complex systems, to investigate patient preparedness, satisfaction, and perceived usability with sacral neuromodulation (SNM) and develop interventions aimed at improving patient experience. MATERIALS AND METHODS: Ten patients with overactive bladder undergoing staged SNM were observed, and data including pre-operative preparedness, satisfaction, perceived usability and barriers impacting patient experience were collected. Interventions were developed and an additional ten patients were observed. All patients were English-speaking and at least 18 years of age. RESULTS: Pre-intervention patients had difficulty understanding the risks of the procedure, did not know what to expect post-operatively and were unsatisfied with pre-operative materials. Interventions included: A pre-procedure educational video and informational sheet, detailed discharge instructions; and a nursing inservice. Pre-operative preparedness (Stage I: U = 100, z = 3.785, P = .000; Stage II: U = 80, z = 2.864, P = .003), post-operative satisfaction (Stage I: U = 100, z = 3.788, P = .000; Stage II: U = 77.5, z = 2.665, P = .006.) and perceptions of usability (Stage I: U = 77.00, z = 2.056, P = .043.; Stage II: U = 80.50, z = 2.308, P = .019) increased significantly after the intervention. CONCLUSION: Our observations highlight the value of implementing a human factors approach to identify and mitigate barriers impacting patient experiences with SNM. Through the implementation of systems-level interventions (ie, interventions that impact the non-clinical aspects of surgery such as patient and/or staff education), significant improvements can be made.

Progress of radiotherapy after breast-conserving surgery combined with silicone prosthesis reconstruction.

Breast cancer is the malignant tumor with the highest incidence in women. The standard treatment for early breast cancer is radical surgery combined with radiotherapy, but many studies have shown that adjuvant radiotherapy after breast-conserving surgery combined with silicone prosthesis reconstruction is gradually expected to become the new standard treatment because this method can obtain a good local tumor control rate, and has a cosmetic effect. Compared with myocutaneous flap reconstruction, silicone prosthesis implantation has the advantages of less trauma, simple operation, beautiful appearance, and no overlap of donor areas during reconstruction. It is a safe and feasible surgical method without worrying about necrosis and atrophy of myocutaneous flap. This emerging combination therapy may become the best mode of early breast cancer treatment.

Electrophysiological Study-Guided Permanent Pacemaker Implantation in Patients With Conduction Disturbances Following Transcatheter Aortic Valve Implantation.

Conduction disturbances remain common following transcatheter aortic valve implantation (TAVI). Aside from high-degree atrioventricular block (HAVB), their optimal management remains elusive. Invasive electrophysiological studies (EPS) may help stratify patients at low or high risk of HAVB allowing for an early discharge or permanent pacemaker (PPM) implantation among patients with conduction disturbances. We evaluated the safety and diagnostic performances of an EPS-guided PPM implantation strategy among TAVI recipients with conduction disturbances not representing absolute indications for PPM. All patients who underwent TAVI at a single expert center from June 2017 to July 2020 who underwent an EPS during the index hospitalization were included in the present study. False negative outcomes were defined as patients discharged without PPM implantation who required PPM for HAVB within 6 months of the initial EPS. False positive outcomes were defined as patients discharged with a PPM with a ventricular pacing percentage <1% at follow-up. A total of 78 patients were included (median age 83.5, 39% female), among whom 35 patients (45%) received a PPM following EPS. The sensitivity, specificity, positive and negative predictive values of the EPS-guided PPM implantation strategy were 100%, 89.6%, 81.5%, and 100%, respectively. Six patients suffered a mechanical HAVB during EPS and received a PPM. These 6 patients showed PPM dependency at follow-up. In conclusion, an EPS-guided PPM implantation strategy for managing post-TAVI conduction disturbances appears effective to identify patients who can be safely discharged without PPM implantation.

Application of ultrasound during electrode implantation for sacral neuromodulation in patients with neurogenic bladder secondary to spinal cord disease: a retrospective study.

PURPOSE: To compare the use of intraoperative ultrasound with X-ray fluoroscopy during sacral neuromodulation lead electrode placement in patients with neurogenic bladder secondary to spinal cord disease. METHODS: We reviewed the medical records of 52 patients who underwent sacral neuromodulation (SNM) lead electrode implantation under fluoroscopy or ultrasound guidance from July 2016 to July 2019. The operating time, number of electrode contacts with stimulus responses, minimum voltage that causes a stimulus response, and rate of standard lead electrode placement were used to assess the differences between the two methods. All patients were evaluated by recording bladder diaries, postvoid residual volumes before and during the testing period. Permanent SNM implantation is acceptable if symptoms improve by at least 50%. RESULTS: The operating time decreased from 87.1 ± 25.19 min in the X-ray group to 68.2 ± 25.20 min (p < 0.05) in the ultrasound group. The number of electrode contacts with stimulus responses, rate of standard lead electrode placement, and implantable pulse generator (IPG) placement rate were not significantly different between the two groups (p > 0.05). There was no radiation exposure during the operation in the ultrasound group. No incisional infections, hematomas, or other critical complications were reported in either groups. CONCLUSION: Ultrasound can be applied to safely place lead electrode for sacral neuromodulation and leads to no radiation exposure to the patient, surgeon, and operating room staff and a shortened operating time while maintaining the same efficacy as X-ray.

Comparison of Visual, Tomographic, and Biomechanical Outcomes of 360 Degrees Intracorneal Ring Implantation With and Without Corneal Crosslinking for Progressive Keratoconus: A 5-Year Follow-up.

PURPOSE: To evaluate the long-term (5 years) results of 360 degrees intracorneal ring (ICR) implantation with and without corneal crosslinking (CXL) in patients with progressive keratoconus (KCN). METHOD: This historical cohort study was performed on 35 eyes with progressive KCN, which was randomly divided into 2 groups. Fourteen patients were implanted only with ICR, and 21 patients with KCN were treated with ICR plus CXL simultaneously. Uncorrected distance visual acuity (UCDVA), corrected distance visual acuity (CDVA), and refractive components were collected from patients' medical records. The biomechanical properties of patients were measured using the Corvis ST (Oculus, Inc, Weltzar, Germany). Corneal topography and aberrometry parameters were also recorded from the Pentacam HR device (Oculus). RESULTS: Both UCVA and CDVA increased in both groups after ICR implantation; however, this improvement was more significant in the ICR plus CXL group (P = 0.002 and P = 0.001, respectively). The mean improvement of CDVA in patients with ICR implantation with and without CXL was 0.56 ± 0.67 and 0.33 ± 0.61, respectively. A comparison of the long-term postoperative Tomographic and Biomechanical Index between 2 groups showed a better result in the ICR plus CXL group (P = 0.012). Topographic findings of the anterior corneal surface (flat-K, steep-K, mean-K, and astigmatism) after surgery were significantly better than before surgery in both groups (P < 0.05). CONCLUSIONS: Although ICR implantation alone might halt the KCN progression with acceptable visual, topographic, and biomechanical outcomes, the combination of ICR and CXL has an adjuvant and synergistic effect, especially in long-term follow-up.

Randomized Pilot Study: Anal Inserts Versus Percutaneous Tibial Nerve Stimulation in Patients With Fecal Incontinence.

BACKGROUND: Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence in whom other conservative treatments have failed. OBJECTIVE: We aimed to compare anal inserts and percutaneous tibial nerve stimulation. DESIGN: This was an investigator-blinded randomized pilot study. SETTINGS: The study was conducted at a large tertiary care hospital. PATIENTS: Adult patients with passive or mixed fecal incontinence were recruited. INTERVENTIONS: Patients were randomly assigned to receive either the anal inserts or weekly percutaneous tibial nerve stimulation for a period of 3 months. MAIN OUTCOME MEASURES: The primary end point was a 50% reduction of episodes of fecal incontinence per week as calculated by a prospectively completed 2-week bowel diary. Secondary end points were St Mark's incontinence score, International Consultation on Incontinence Questionnaire-Bowel scores (for bowel pattern, bowel control, and quality of life), use of antidiarrheal agents, estimates of comfort and acceptability. RESULTS: Fifty patients were recruited: 25 were randomly assigned to anal inserts and 25 were randomly assigned to percutaneous tibial nerve stimulation. All completed treatment. A significant improvement of scores in the 2-week bowel diary, the St Mark's scores and the International Consultation on Incontinence Questionnaire-Bowel scores, was seen in both groups after 3 months of treatment. A reduction of ≥50% fecal incontinence episodes was reached by 76% (n = 19/25) by the anal insert group, compared with 48% (n = 12/25) of those in the percutaneous tibial nerve stimulation group (p = 0.04). The St Mark's fecal incontinence scores and the International Consultation on Incontinence Questionnaire-Bowel scores for bowel pattern, bowel control, and quality of life (p = 0.01) suggest similar improvement for each group. LIMITATIONS: A realistic sample size calculation could not be performed because of the paucity of objective prospective studies assessing the effect of the insert device and percutaneous tibial nerve stimulation. CONCLUSIONS: Both anal insert and percutaneous tibial nerve stimulation improved the symptoms of fecal incontinence after 3 months of treatment. The insert device appeared to be more effective than percutaneous tibial nerve stimulation. Larger studies are needed to investigate this further. See Video Abstract at http://links.lww.com/DCR/B460. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov No. NCT04273009. ESTUDIO PILOTO ALEATORIZADO DE INSERCIONES ANALES CONTRA LA ESTIMULACIN PERCUTNEA DEL NERVIO TIBIAL EN PACIENTES CON INCONTINENCIA FECAL: ANTECEDENTES:Las inserciones anales y la estimulación percutánea del nervio tibial (PTNS) se pueden ofrecer a las personas con incontinencia fecal que han fallado en otros tratamientos conservadores.OBJETIVO:Nuestro objetivo fue comparar inserciones anales y estimulación percutánea del nervio tibial.DISEÑO:Este fue un estudio piloto aleatorio ciego para investigadores.AJUSTE:El estudio se realizó en un hospital de atención terciaria.PACIENTES:Se reclutaron pacientes adultos con incontinencia fecal pasiva o mixta.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir inserciones anales o estimulación del nervio tibial percutáneo semanal durante un período de tres meses.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fue una reducción del 50% de los episodios de incontinencia fecal por semana, según lo calculado mediante un diario intestinal de dos semanas completado de forma prospectiva. Los criterios de valoración secundarios fueron la puntuación de incontinencia de St Mark, las puntuaciones del ICIQ-B (para patrón intestinal, control intestinal y calidad de vida), uso de agentes antidiarreicos, estimaciones de comodidad y aceptabilidad.RESULTADOS:Se reclutaron 50 pacientes: 25 fueron asignados al azar a inserciones anales y 25 a PTNS. Todo el tratamiento completado. Se observó una mejora significativa de las puntuaciones en el diario intestinal de dos semanas, la puntuación de St Mark y la puntuación del ICIQ-B en ambos grupos después de 3 meses de tratamiento. Se alcanzó una reducción de ≥ 50% de los episodios de incontinencia fecal en un 76% (n = 19/25) en el grupo de inserción anal, en comparación con el 48% (n = 12/25) de los del grupo de estimulación percutánea del nervio tibial (p = 0,04). Las puntuaciones de incontinencia fecal de St Mark, las puntuaciones del ICIQ-B para el patrón intestinal, el control intestinal y la calidad de vida (p = 0,01) sugieren una mejora similar para cada grupo.LIMITACIONES:No se pudo realizar un cálculo realista del tamaño de la muestra debido a la escasez de estudios prospectivos objetivos que evaluaran el efecto del dispositivo de inserción y la estimulación percutánea del nervio tibial.CONCLUSIONES:Tanto la inserción anal como la estimulación percutánea del nervio tibial mejoraron los síntomas de incontinencia fecal después de 3 meses de tratamiento. El dispositivo de inserción parecia ser más efectivo que la estimulación percutánea del nervio tibial. Se necesitan estudios más amplios para investigar esto más a fondo. Consulte Video Resumen en http://links.lww.com/DCR/B460.NÚMERO DE REGISTRO DE PRUEBA:Clinicaltrials.gov No. NCT04273009.

In vivo performance of Al2O3-Ti bone implants in the rat femur.

BACKGROUND: Alumina-titanium (Al2O3-Ti) biocomposites have been recently developed with improved mechanical properties for use in heavily loaded orthopedic sites. Their biological performance, however, has not been investigated yet. METHODS: The aim of the present study was to evaluate the in vivo biological interaction of Al2O3-Ti. Spark plasma sintering (SPS) was used to fabricate Al2O3-Ti composites with 25 vol.%, 50 vol.%, and 75 vol.% Ti content. Pure alumina and titanium were also fabricated by the same procedure for comparison. The fabricated composite disks were cut into small bars and implanted into medullary canals of rat femurs. The histological analysis and scanning electron microscopy (SEM) observation were carried out to determine the bone formation ability of these materials and to evaluate the bone-implant interfaces. RESULTS: The histological observation showed the formation of osteoblast, osteocytes with lacuna, bone with lamellar structures, and blood vessels indicating that the healing and remodeling of the bone, and vasculature reconstruction occurred after 4 and 8 weeks of implantation. However, superior bone formation and maturation were obtained after 8 weeks. SEM images also showed stronger interfaces at week 8. There were differences between the composites in percentages of bone area (TB%) and the number of osteocytes. The 50Ti composite showed higher TB% at week 4, while 25Ti and 75Ti represented higher TB% at week 8. All the composites showed a higher number of osteocytes compared to 100Ti, particularly 75Ti. CONCLUSIONS: The fabricated composites have the potential to be used in load-bearing orthopedic applications.

Prosthetic reconstruction of a patient with an irradiated total rhinectomy with navigated surgical placement of a single zygomatic implant: A clinical report.

This clinical report details the rehabilitation of a patient who underwent a total rhinectomy, subsequent adjuvant radiation therapy, and eventual prosthetic rehabilitation but then developed an empirically diagnosed medical adhesive intolerance. With the aid of digital planning and real time navigation, 2 zygomatic implants were placed by using a flapless surgical approach followed by early delivery of an interim prosthesis. In spite of the failure of 1 craniofacial implant, definitive restoration was accomplished by using a titanium bar, double magnetic attachments, and a new silicone prosthesis.

Revisiting Forel Field Surgery.

BACKGROUND: Lesioning the Forel field or the subthalamic region is considered a possible treatment for tremoric patients with Parkinson disease, essential tremor, and other diseases. This surgical treatment was performed in the 1960s to 1970s and was an alternative to thalamotomy. Recently, there has been increasing interest in the reappraisal of stimulating and/or lesioning these targets, partly as a result of innovations in imaging and noninvasive ablative technologies, such as magnetic resonance-guided focused ultrasonography. OBJECTIVE: We wanted to perform a thorough review of the subthalamic region, both from an anatomic and a surgical standpoint, to offer a comprehensive and updated analysis of the techniques and results reported for patients with tremor treated with different techniques. METHODS: We performed a systematic review of the literature, gathering articles that included patients who underwent ablative or stimulation surgical techniques, targeting the pallidothalamic pathways (pallidothalamic tractotomy), cerebellothalamic pathway (cerebellothalamic tractotomy), or subthalamic area. RESULTS: Pallidothalamic tractotomy consists of a reduced area that includes pallidofugal pathways. It may be considered an interesting target, given the benefit/risk ratio and the clinical effect, which, compared with pallidotomy, involves a lower risk of injury or involvement of vital structures such as the internal capsule or optic tract. Cerebellothalamic tractotomy and/or posterior subthalamic area are other alternative targets to thalamic stimulation or ablative surgery. CONCLUSIONS: Based on the significant breakthrough that magnetic resonance-guided focused ultrasonography has meant in the neurosurgical world, some classic targets such as the pallidothalamic tract, Forel field, and posterior subthalamic area may be reconsidered as surgical alternatives for patients with movement disorders.