Acknowledgement and use of advance care directives and goals of care by emergency department staff: a mixed method post intervention study.

INTRODUCTION: Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. METHOD: We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients' clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. RESULTS: In the observational period, 22,335 patients attended the ED and 19% (n = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age (p = 0.054; CI ranging from - 0.065 to 7.768). The response rate for the cross-sectional survey was 12% (n = 340) in contrast to earlier study with 28% (n = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. CONCLUSION: After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).

Advancements in Modern Treatment Approaches for Central Post-Stroke Pain: A Narrative Review.

PURPOSE OF REVIEW: Central post-stroke pain (CPSP) poses a multifaceted challenge in medical practice, necessitating a thorough and multidisciplinary approach for its diagnosis and treatment. This review examines current methods for addressing CPSP, highlighting both pharmacological and non-pharmacological therapies. It covers the mechanisms and clinical effectiveness of these treatments in managing CPSP and emphasizes the importance of personalized treatment plans, given the varied causes of CPSP. RECENT FINDINGS: Recent advancements have illuminated diverse treatment modalities for CPSP. Pharmacotherapy spans from conventional analgesics to anticonvulsants and antidepressants, tailored to mitigate the neuropathic characteristics of CPSP. Non-pharmacological interventions, including physical therapy and psychological strategies, are pivotal in managing CPSP's chronic nature. For cases resistant to standard treatments, advanced interventions such as nerve blocks and surgical procedures like deep brain stimulation (DBS) or motor cortex stimulation (MCS) are considered. Additionally, innovative technologies such as neuromodulation techniques and personalized medicine are emerging as promising avenues to enhance therapeutic outcomes and improve quality of life for individuals grappling with CPSP. SUMMARY: Modern approaches in managing CPSP require an interdisciplinary and patient-centric approach. Customizing treatment plans to address the specific etiology and symptoms of CPSP is crucial. Pharmacotherapy remains fundamental, encompassing medications such as anticonvulsants and antidepressants tailored to manage neuropathic pain. Integrating non-pharmacological interventions is crucial for providing comprehensive care. Additionally, investigating innovative technologies and personalized medicine presents promising opportunities to enhance treatment results and elevate the quality of life for those suffering from CPSP. Ultimately, an integrated approach that acknowledges the multifaceted nature of CPSP is essential for effective management and patient well-being.

Plasminogen - safe for treatment of chronic tympanic membrane perforation: a phase 1 randomized, placebo-controlled study.

BACKGROUND: There is a need for a simpler and accessible intervention to heal tympanic membrane perforations than myringoplasty that is todaýs golden standard. Experimental studies have identified plasminogen as a promising agent for medical treatment of chronic tympanic membrane perforation. AIMS/OBJECTIVES: This was a phase 1, prospective, randomized, placebo-controlled study with the main objective to evaluate the safety of injecting plasminogen in the vicinity of the tympanic membrane in subjects with chronic tympanic membrane perforation. MATERIAL AND METHODS: Adults diagnosed with a dry chronic tympanic membrane perforation were recruited for an injection schedule with Human plasminogen 10. Adverse events, audiometry, VAS fluctuations and size of perforation, were monitored throughout the length of the study. RESULTS: It was possible to perform the injections according to schedule in all subjects. None of the subjects experienced any severe adverse events. Most common adverse event was ear pain. No signs of ototoxicity were reported. CONCLUSIONS AND SIGNIFICANCE: This pilot study suggests that plasminogen injections close to the tympanic membrane as treatment for chronic tympanic membrane injections are safe and feasible, encouraging further dose-escalating studies.

Clinical patterns and treatment outcomes of polycystic ovarian syndrome.

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common chronic endocrine disorder in women with complex and poorly understood etiologies. The present study aimed to describe the clinical features of PCOS in a sample of Syrian women as well as the risk factors, associated comorbid diseases, and patterns and efficacy of treatment. METHODS: The present study is cross-sectional observational study conducted on a sample of Syrian women diagnosed with PCOS, using self-administered questionnaire during the period between December 25, 2023 and January 18, 2024. Overall, 1666 women with PCOS were recruited through online platforms. RESULTS: Higher frequency of PCOS was observed in young women aged 15-25 years (63.1%) and in single ladies (76.5%). The main chief complaints experienced by patients with PCOS were hirsutism (71.25%), irregular menstrual cycle (70.95%), depressed mood (53.9%), acne (49.52%), abdominal obesity (43.88%), alopecia (38.12%), and weight gain (34.57%). The most common risk factors observed in patients with PCOS were lack of physical exercise (76.4%), unhealthy food habits (51.6%), family history (38.5%), and history of taking anabolic steroids (17.2%). Comorbid diseases were found in 11.5% of PCOS patients. These diseases were hypothyroidism (5.7%), hypertension (3.06%), dyslipidemia (1.68%), heart diseases (1.56%), and diabetes mellitus (0.78%). Most patients were treated with oral contraceptive pills (82.11%) or metformin (64.83%). The efficacy of treatment was observed as complete cure in 430 patients (25.8%) and partial response alleviating symptoms in 819 patients (49.2%), while and no benefit was found in 417 patients (25%). CONCLUSIONS: PCOS is associated with widespread dermatological and metabolic aberrations that pose psychological burden on women and increase their risk for having comorbid diseases. Most patients with PCOS do not receive adequate therapy. Understanding the risk factors and clinical features for each patient is essential to choose the proper treatment.

Trends in adverse effects of medical treatment in Paediatric populations in the United States: A global burden of disease study, 2000-2019.

BACKGROUND: Adverse effects of medical treatment (AEMT) pose significant risks to paediatric patients. However, the mortality trends associated with AEMT in this population have been unclear. OBJECTIVE: We aimed to clarify the trends in the incidence, disability-adjusted life years (DALYs) and mortality rates of AEMT for children in the US from 2000 to 2019. METHODS: Data were retrieved from the Global Burden of Disease study 2019. We estimated age-standardized incidence, DALYs and mortality rates of paediatric AEMT per 100,000 children in the US using a Bayesian meta-regression model. We also analysed incidence, DALYs and mortality in different age groups, and employed Joinpoint regression models to assess the age- and sex-specific trends. RESULTS: The number of deaths due to AEMT in children, the number of cases, and DALYs were 105.1, 551,076 and 145,555 in 2019, decreased by 37.5%, 6% and 28% from those in 2000, respectively. Age-standardized mortality rates decreased across all age groups, while the incidence increased across all age groups with an average annual percentage change (AAPC) of 2.2% in those children <1 year and 4.5% in 5-9 years of age. The increases in DALYs over time was higher in children aged 1-4 years (AAPC: 0.51, 95% CI: 0.47, 0.62) and 5-9 years (AAPC: 0.33, 95% CI: 0.15, 0.50), with the 1-4 year age group being the highest. CONCLUSION: The study reveals declining AEMT mortality but rising incidence and DALYs, emphasizing a disproportionate burden in <1, 1-4 and 5-9 years. To develop effective mitigation strategies, future research is warranted to identify the causes of increased AEMT in children, especially young males.

The efficacy of Aescin combined with MPFF for early control of bleeding from acute hemorrhoids, A randomized controlled trial.

BACKGROUND: Hemorrhoidal disease, affecting over 20 % of the population, presents management challenges due to its multifaceted nature. While treatments like Micronized Purified Flavonoid Fraction (MPFF) show promise, Aescin's efficacy remains uncertain. This study assesses the combined effectiveness of Aescin with MPFF against MPFF alone in treating Grades 1 and 2 hemorrhoids, focusing on halting bleeding and reducing mass effect. METHOD: This study recruited patients from the Division of Colorectal Surgery, Chiang Mai University. Patients were randomly assigned to receive MPFF alone or MPFF with Aescin. Outcomes included the duration until bleeding cessation and resolution of mass effect. RESULTS: Of 120 patients randomized to each group, the combination therapy demonstrated superiority in halting bleeding (two days VS four days) and resolving mass effect (four days VS five days) compared to MPFF alone with statistically significant differences. Treatment failure rates were lower in the combination therapy group, with high patient satisfaction. CONCLUSION: Combining Aescin with MPFF shows promise as a therapeutic approach for Grades 1 and 2 internal hemorrhoids, offering expedited relief from bleeding and mass effect. These findings suggest the need for further research to validate results in larger cohorts and optimize treatment strategies for hemorrhoidal disease.

BRAF and MEK inhibitor targeted therapy in papillary craniopharyngiomas: a cohort study.

OBJECTIVE: Targeted therapy (TT) with BRAF/MEK inhibitors has emerged as a potential treatment in papillary craniopharyngiomas (PCPs). However, standardized data on large cohorts are lacking. Our study aimed to assess real-life efficacy and safety of BRAF/MEK inhibition in patients with PCPs. DESIGN: Retrospective French multicenter study involving BRAF V600E-mutated PCP patients, treated with BRAF/MEK inhibitor combination dabrafenib and trametinib, from April 2019 to July 2023. METHODS: Objective response and clinical and safety outcomes were assessed after 3 months and at the last available follow-up during TT. RESULTS: Sixteen patients (8 females, mean age 50.5 ± 15.75 years), receiving either neoadjuvant therapy (NEO) for non-resectable tumors (n = 6), post-surgical adjuvant therapy (ADJ; n = 8), or palliative therapy (PAL) following failure of multimodal treatment (n = 2), were included.At the last follow-up (mean 7.6 ± 5.3 months), 12 patients showed subtotal response, 3 exhibited partial response, and 1 maintained stable disease. Mean volume reduction was 88.9 ± 4.4%, 73.3 ± 23.4%, and 91.8 ± 4.3% in the NEO, ADJ, and PAL groups, respectively.Targeted therapy resolved headaches in 5/5 patients and visual impairment in 6/9; 2/3 patients had improved neurological symptoms, 1/4 presented weight loss, and 2/14 recovered endocrine function.Targeted therapy was well-tolerated in 62.5% of cases; adverse events led to treatment discontinuation in 5 patients and definitive discontinuation in 3 cases. CONCLUSIONS: In this study, 94% of patients showed partial response or better to TT. Adverse events were acceptable. Further research is needed to establish standardized protocols; however, these results advocate for a NEO approach in invasive PCPs.

Cervical Tuberculous Lymphadenitis Associated With New-Onset Acanthosis Nigricans Following Antitubercular Therapy: A Case Report.

Cervical tuberculous lymphadenitis (CTL), also known as scrofula, is an extrapulmonary manifestation of tuberculosis, a disease that is endemic to many developing countries, particularly Sub-Saharan Africa and Asia, but may also be found worldwide in developed countries like the United States. CTL can be difficult to detect and may mimic other similar-appearing conditions, so a high index of suspicion is required to accurately diagnose the condition when a patient presents with one or more neck masses. Incision and drainage and excisional surgery are aggressive options available to treat CTL but are not preferred due to a high risk of serious adverse events like fistulization and hematological dissemination. Clinicians typically opt for traditional tubercular RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) therapy for its high efficacy in treating extrapulmonary tuberculosis. Despite this preference, RIPE therapy has been known to elicit a myriad of side effects that demand close monitoring by clinicians. One side effect of the RIPE regimen that has yet to be reported is acanthosis nigricans (AN), a dermatological sign that presents as thickening and darkening of the skin, often in intertriginous areas. AN frequently occurs in conjunction with insulin resistance, and interestingly, the RIPE drug isoniazid has been implicated in insulin derangements in patients, most notably diabetics. However, the incidence of AN secondary to isoniazid use has not been explicitly recorded in the literature to date. Herein we present a novel case of a young man from Nepal with CTL treated via RIPE therapy who developed AN likely secondary to isoniazid use.

A study of patients' choice of medical treatment based on rational choice theory: a cross-sectional survey from China.

OBJECTIVE: To describe how patients choose between primary care institutions (PCIs) and non-PCIs using rational choice theory from the perspective of survival rationality, economic rationality, and social rationality. METHODS: Multi-stage stratified sampling and convenience sampling were applied to select 1723 patients to conduct the questionnaire survey. Chi-square test and binary logistic regression were performed to analyze the factors associated with patients' choice of PCIs. RESULTS: In total 55.83% of 1723 patients would attend a PCIs for healthcare. The results of the univariate analysis revealed that patients who are female (58.46%, P = .015), suffering from chronic diseases (56.26%, P = .047), inpatients (67.58%, P < .001), Beijing (59.62%, P = .002), partial understanding of the family doctor contracting system (62.30%, P < .001), and not understanding of the medical alliance policy (58.04%, P = .031) had significantly higher probability of choosing PCIs. Logistic regression analysis showed that females were more unwilling to attend PCIs (odds ratio (OR) = 0.822, 95%CI: 0.676-0.999). Following survival rationality, patients without chronic diseases were more likely to attend PCIs (OR = 1.834, 95%CI: 1.029-3.268), and inpatients were more unlikely to attend PCIs (OR = 0.581, 95%CI: 0.437-0.774). From an economic rationality perspective, patients from the Fujian province were more likely to attend PCIs (OR = 1.424, 95%CI: 1.081-1.876). From a social rationality perspective, patients who partial understanding of the family doctor contracting system were more unlikely to attend PCIs (OR = 0.701, 95%CI: 0.551-0.892), and patients who partial and complete understanding of the medical alliance policy were more likely to attend PCIs (OR = 1.340, 95%CI: 1.064-1.687; OR = 1.485, 95%CI: 1.086-2.030). CONCLUSIONS: Survival, economic, and social rationality are involved in patients' choice to attend PCIs. Compared to survival rationality and social rationality, economic rationality showed a lower association with patients' choice to attend PCIs. Medical institutions are recommended to adopt a "patient health-centered" approach when providing medical services and further optimize the family doctor contracting system and construction of medical alliances.

Validating older adult patient's Medical Treatment Decision Maker's (MTDM). A retrospective observational study with follow-up phone interview transcript.

A Medical Treatment Decision Maker (MTDM), also referred to as surrogate decision maker, by law, is to be appointed to make medical treatment decisions on behalf of a person who cannot make such decisions for themselves. In the Emergency Department (ED) and acute healthcare services, the clinicians' (nurses and doctors) ability to contact MTDMs is essential for patient care, particularly in time-critical situations. Our primary objective was to review the verification process and assess the accuracy of MTDM contact numbers in the Health Information System (HIS) to assess compliance with legislation. We used a quantitative method with retrospective observational study design and follow-up phone interview transcript. One hundred and fifty-nine participants were randomly selected of whom 76 % had MTDM. Patient advancing age had statistically significant association with the number of call attempts made to reach the listed MTDM (P = 0.043; CI, -3.541 to -0.057) and the MTDM's consent to participate (p = 0.023).

Heart failure treatment in the last years of life: A nationwide study of 364 000 individuals.

AIMS: In patients with heart failure, treatment patterns in the last years of life have not been assessed at large scale. We aimed to assess whether heart failure treatment patterns up to 5 years prior to death changed over time. METHODS AND RESULTS: In a cohort study covering the whole Swedish population, we assessed all heart failure patients who died between 1 July 2007 and 31 December 2020 for evidence-based treatments. The proportion on the respective treatment at the time of death was examined by year of death using binomial regression. Looking back in time, treatment discontinuation rates were estimated using Poisson regression on time-split data. Combining these models, the proportion on each medication was estimated up to 5 years prior to death. A total of 364 480 patients died with heart failure during the study period. Half were women, and the median (interquartile range) age at death was 86 (79-90). The use of all heart failure treatments decreased gradually closer to death, but the discontinuation rate of beta blockers decreased over time, resulting in an increasing proportion of patients on treatment at the time of death. CONCLUSION: In patients with heart failure, a changing pattern of medical treatment during the last years of life was observed, most notably with an increasing use of beta blockers. This may in part be due to a changing pattern of comorbidities over time, with an increase in e.g. hypertension and atrial fibrillation, but a decline in ischaemic heart disease.

Medical treatments for abdominal aortic aneurysm: an overview of clinical trials.

INTRODUCTION: Abdominal aortic aneurysm is a progressive, segmental, abdominal aortic dilation associated with a high mortality rate. Abdominal aortic aneurysms with diameters larger than 55 mm are associated with a high risk of rupture, and the most effective treatment options are surgical repair. Close observation and lifestyle adjustments are recommended for smaller abdominal aortic aneurysms with lower rupture risk. The development of medical therapies that limit or prevent the progression, expansion, and eventual rupture of abdominal aortic aneurysms remains an unmet clinical need. AREAS COVERED: This review provides an overview of completed and ongoing clinical trials examining the efficacies of various drug classes, including antibiotics, antihypertensive drugs, hypolipidemic drugs, hypoglycemic drugs, and other potential therapies for abdominal aortic aneurysms. A search of PubMed, Web of Science, Clinical Trials, and another six clinical trial registries was conducted in January 2024. EXPERT OPINION: None of the drugs have enough evidence to indicate that they can effectively inhibit the dilation of abdominal aortic aneurysm. More clinical trial data is required to support the efficacy of propranolol. Future research should also explore different drug delivery mechanisms, such as nanoparticles, to elevate drug concentration at the aneurysm wall.

Understanding Superior Mesenteric Artery Syndrome: Etiology, Symptoms, Diagnosis, and Management.

Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, poses a diagnostic challenge due to its rarity and varied clinical manifestations. This review explores the syndrome's etiology, symptoms, diagnostic challenges, and management strategies. Symptoms range from early satiety to severe abdominal pain, often leading to malnutrition. Diagnosis involves a thorough gastrointestinal evaluation and various imaging modalities. Management includes medical interventions like nasogastric decompression and nutritional support, along with surgical interventions such as duodenojejunostomy. A thorough understanding of SMA syndrome's complexities is crucial for its timely diagnosis and effective management, especially considering its potential overlap with other gastrointestinal disorders or eating disorders. Further research is needed to enhance understanding and improve patient outcomes.

Informed Consent and the Duty to Warn: More than the Mere Provision of Information.

Before providing any form of medical treatment, medical practitioners are generally required to discharge their duty to warn. It is argued in this article that the duty to warn, at least as it relates to frail and elderly patients, requires the principles of shared decision-making to be adopted. Doing so will ensure a comprehensive biopsychosocial understanding of the patient and assist in identifying material risks that may not be readily apparent. Such risks include risks that threaten the patient's values, preferences, treatment aims and long-term outcomes. Once such risks are identified, in discharging the duty to warn, they should be contextualised in a manner that makes clear how that risk will manifest in that particular patient. These risks should then also be synthesised within the context of their other medical issues and longer-term interests. Finally, it is suggested that the traditional consent process may need restructuring.

Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection.

OBJECTIVE: Endovascular stent therapy (EST) for spontaneous isolated superior mesenteric artery dissection (SISMAD) is gaining popularity, yet the treatment strategy - BMT or EST - remains debatable. METHODS: A meta-analysis examined all randomized trials and observational studies exploring the relative merits and potential risks of EST vs. BMT in treating SISMAD patients. Key outcomes included early and long-term adverse effects, with odds ratios (ORs) and 95% confidence intervals (CI) calculated. A random- or fixed-effects model was selected according to a 50% heterogeneity threshold. RESULTS: 9 observational studies involving a total of 672 SISMAD patients (303 EST), met our selection criteria. We discovered no noteworthy distinctions between the EST group and the BMT group in terms of early symptoms' alleviation, reinterventions, or all-cause mortality. However, patients receiving EST management will be hospitalized longer than those receiving BMT (EST: 13.2 ± 5.1 months vs. BMT: 7.0 ± 2.2 months, P < 0.01). In the long run, EST was found to significantly contribute to a higher rate of complete remodeling (OR: 4.53, CI: 3.01 ~ 6.81, P < 0.01; heterogeneity, I2 = 50%) and a lower incidence of aneurysm formation (OR: 0.19, CI: 0.06 ~ 0.6, P < 0.01; heterogeneity, I2 = 0%) than BMT. However, there are no significant differences between ESTand BMTin terms of all-cause mortality, recurrent syndrome, reintervention, and SMA stenosis or occlusion. CONCLUSION: EST can effectively prevent the formation of aneurysmal dissection and improve SISMAD remodeling. Both EST and BMT are similar in reducing long-term mortality, recurrent symptoms, severe SMA stenosis or occlusion, and the need for reintervention in patients with SISMAD.

Follow up study of symptomatic human cystic echinococcosis treatment with albendazole and praziquantel, in Uruguay.

BACKGROUND: Cystic echinococcosis (CE) is a chronic disease considered a neglected one. Cystic echinococcosis is endemic in Uruguay and the region. Surgery, using various technical approaches, has the potential to safely remove the cyst(s) and lead to a complete cure in a high number of patients with simple forms of CE. However, surgery may be impractical in patients with multiple cysts in several organs, high surgical risk, or in patients with previous multiple surgeries. In these cases, the pharmacological treatment with the benzimidazolic drug Albendazole (ABZ) alone or combined with Praziquantel (PZQ), has been promising as the best choice to achieve improvement or cure. METHODS: In this study, we analyze the results obtained on the anti-parasitic treatment of 43 patients diagnosed with CE between the years 2003 and 2020. Patients were treated before and/or after surgery with ABZ or the combination ABZ/PZQ. The standardize protocol of the anti-parasitic drug treatment before surgery was 7 days, 15 days or 1 month depending on the urgency and availability of the surgical procedure. All cases that involved confirmed locations on lungs underwent immediate surgery with minimal pre-treatment when possible. After surgery, the standardize protocol of anti-parasitic drug treatment consisted of six cycles of 30 days each and resting intervals of 15 days in between. ABZ was used in all cases, administered orally, twice daily, at a total dosage of 15 mg/kg/day, with food high in fat content for improved absorption. The follow up was carried out according to WHO-IWGE guidelines for 5 years. RESULTS: Of the 43 patients fourteen were ≤ 15 years of age and had a differentiated pre-surgical treatment. From the ≥ 16 years of age, 36 completed the treatments and the 5 years follow up. Four patients changed geographical locations, without a forwarding contact, after the post-surgery treatment. No patient died during the study. Of the 36 patients that completed the study, 32 were treated only with ABZ; 93.75% achieved treatment success as determined by improvement or cure, and 6.25% treatment failure determined by no change or worsening. The last four patients received the ABZ/PZQ combination therapy and achieved 100% treatment success. CONCLUSION: The pharmacological treatment resulted in a good option not only as palliative but also as potentially curative. The main relevance of its use was in cases with previous multiple surgeries or surgeries with potential life-threatening complications due to the number and location of cysts and concurrent comorbidities. A follow-up of at least 5 years would be recommended to assure remission and control of the transmission. More randomized trials are needed to provide clear clinical evidence of different pharmacological treatments for CE.

Comparison of the treatment strategies for symptomatic chronic internal carotid artery occlusion.

OBJECTIVE: The best management of symptomatic chronic internal carotid artery occlusion (CICAO) has been controversial. This systematic review and meta-analysis were to compare the outcomes of different treatment strategies for symptomatic CICAO. METHODS: Two independent researchers conducted a search of articles on the treatment of CICAO published between January 2000 and October 2023 in PubMed, Web of Science, Embase, and The Cochrane Library. Twenty-two articles were eligible for meta-analysis using a random effects model to combine and analyze the data for the pooled rates of stroke and death, and the rates of procedural success and significant restenosis/occlusion. RESULTS: A total of 1193 patients from 22 publications were included in this study. Six of them had bilateral internal carotid artery occlusion. The 30-day stroke and death rates were 1.1% (95% confidence interval [CI], 0%-4.4%) in the best medical treatment (BMT) group, 4.1% (95% CI, 0.7%-9.3%; I2 = 71.4%) in the extracranial-intracranial (EC-IC) bypass group, 4.4% (95% CI, 2.4%-6.8%; I2 = 0%) in the carotid artery stenting (CAS) group, and 1.2% (95% CI, 0%-3.4%; I2 = 0%) in the combined carotid endarterectomy (CEA) and stenting (CEA + CAS) group. During follow-up of 16.5 (±16.3) months, the stroke and death rates were 19.5%, 1.2%, 6.6%, and 2.4% in the BMT, EC-IC, CAS, and CEA + CAS groups respectively. The surgical success rate was 99.7% (95% CI, 98.5%-100%; I2 = 0%) in the EC-IC group, 70.1% (95% CI, 62.3%-77.5%; I2 = 64%) in the CAS group, and 86.4% (95% CI, 78.8%-92.7%; I2 = 60%) in the CEA + CAS group. The rate of post-procedural significant restenosis or occlusion was 3.6% in the EC-IC group, 18.7% in the CAS group, and 5.7% in the CEA + CSA group. The surgical success rate was negatively associated by the length of internal carotid artery (ICA) occlusion. Surgical success rate was significantly higher in the patients with occlusive lesion within C1 to C4 segments, compared with those with occlusion distal to C4 segment (odds ratio, 11.3; 95% CI, 5.0-25.53; P < .001). A proximal stump of ICA is a favorable sign for CAS. The success rate of CAS was significantly higher in the patients with an ICA stump than that in the patients without (odds ratio, 11.36; 95% CI, 4.84-26.64; P < .01). However, the success rate of CEA + CAS was not affected by the proximal ICA stump. CONCLUSIONS: For the management of symptomatic CICAO, BMT alone is associated with the highest risk of mid- and long-term stroke and death. EC-IC bypass surgery and CEA + CAS should be considered as the choice of treatment based on operator's expertise and patient's anatomy. CAS may be employed as an alternative option in high surgical risk patients, especially when proximal ICA stump exists.

Timing of Switching to Steroid Implants in Cases of Recalcitrant Diabetic Macular Edema Not Responding to Anti-vascular Endothelial Growth Factor (VEGF) Therapy: A Real-World Study.

Purpose The purpose of this study is to examine the impact of the timing of the steroid switch on both visual and anatomical outcomes in diabetic macular edema (DME) eyes that have shown an inadequate response to multiple intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. In the treatment of DME, anti-VEGF injections are typically the initial course of action. However, in cases where DME persists despite anti-VEGF treatment, intravitreal dexamethasone implants (Ozurdex®, Allergan Inc., Irvine, CA) are often utilized. Despite this, there remains a lack of consensus regarding the optimal timing for transitioning to steroid treatment. This study aims to shed light on the potential benefits of adjusting the timing of the steroid switch in cases of recalcitrant DME.  Methods The eyes (n = 105) of 77 patients with recalcitrant DME were included in this retrospective, interventional, comparative study comprising three groups: participants switched to steroid implants after three anti-VEGF injections (Group I), four to six anti-VEGF injections (Group II), and more than six anti-VEGF injections (Group III). Anti-VEGF treatment failure was defined as a central retinal thickness (CRT) of ≥300 microns and/or a lack of visual improvement (≤1 line of visual gain according to Snellen acuity). The last follow-up took place after 10-12 weeks of Ozurdex® injections. Results Improvement was observed in 19 eyes (46%), 17 eyes (50%), and 10 eyes (33%) in Groups I, II, and III, respectively, after switching to dexamethasone implants. The best overall results (an improvement in vision and stabilization) were seen in Group II (32 eyes, 94%). The decrease in CRT was statistically significant in all three groups.  Conclusion Intravitreal dexamethasone implants improved functional and morphological outcomes in anti-VEGF-resistant DME eyes. After four to six anti-VEGF injections, switching to a steroid implant resulted in the best functional results.

Pituitary Apoplexy: Description of Medical and Surgical Treatment and Clinical, Visual, and Endocrinological Outcomes During the SARS-CoV-2 Pandemic and Over Three Years.

INTRODUCTION: Pituitary apoplexy (PA) is a rare neuroendocrinological emergency. The SARS-CoV-2 pandemic recommendations led to a shift in the management of patients with pituitary diseases, especially in the decision-making between conservative and surgical treatment of patients with PA. OBJECTIVE: This study aimed to describe the conservative and surgical treatment and the clinical, visual, and endocrinological outcomes in patients with PA at the Pituitary Center of Excellence (PTCEO) during the SARS-CoV-2 pandemic and within three years. METHODS: This is a cohort study. Patients with PA between April 2020 and September 2023 were followed up. Treatment decisions, clinical manifestations, hormonal profile, and tumor size with MRI were described at the onset, at three months, six months, one year, two years, and three years after diagnosis. RESULTS: A total of 27 patients with PA diagnosis were included in the study. Of these, 12 patients were conservatively treated, six (50%) had prolactinomas, five (41.6%) had non-functioning adenomas, and one (8.3%) had pituicytoma. Fifteen patients were surgically intervened during the first hospitalization, nine (60%) had non-functioning adenomas, four (26.6%) had prolactinomas, one (6.6%) had ACTH-producing adenoma, and one (6.6%) had gonadotropinoma. Two patients from the conservatively treated group (one non-functioning adenoma and one pituicytoma) were intervened surgically at years 2 and 3, respectively. During the initial assessment, there were no statistically significant differences between patients in visual acuity (9 [75%] vs 15 [100%]), visual field affection (8 [66.6%] vs 11 [73.3%]), and cranial nerve deficit (3 [25%] vs 6 [40%]). At six months follow-up, no statistically significant differences were found in the visual acuity improvement (8 [88%] vs 11 [100%]), visual field (8 [100%] vs 8 [72%]), and cranial nerve deficit between the two groups (3 [100%] vs 6 [100%]). Meanwhile, the average length of in-hospital stay was 1.5 vs 10 days (p = 0.019). The tumor size and largest diameter were smaller in the surgically treated group (6.2 vs. 0.5 cm3, p = 0.029 and 2.5 vs. 1.1 cm, p = 0.036, respectively). Visual acuity improved in nine (58.3%) patients at year 1: two (40%) conservative vs seven (100%) surgical (p = 0.039); six (85.7%) patients at year 2: two (66.6%) conservative vs. four (100%) surgical; and three (100%) patients on both groups at year 3. Fourteen patients needed hormonal substitution: 87.5% (eight [88.8%] conservative vs six [85.7%] surgical) at year 1, 85.7% (six patients in both groups) at year 2, and 80% (four conservative vs three [100%] surgical) at year 3. The thyrotropic axis was the most affected in both groups during the three years. During the first-year follow-up, six (85%) patients persisted with tumoral regression (2 [66.6%] conservative vs 4 [100%] surgical) and one (14.2%) patient from the medical group progressed. During the second and third years, 10 and three (100%) of the patients, respectively, showed the regression of the tumoral volume in both groups. CONCLUSIONS: The clinical, visual, and neuroendocrinological outcomes were similar in both groups of patients with PA during the SARS-CoV-2 pandemic. In cases where the Pituitary Apoplexy Score (PAS) score does not surpass three points without neurological deterioration, conservative management can be considered an adequate option for treatment.

Is a Carotid Doppler Scan Useful for Managing Patients with Suspected Ocular Ischemic Syndrome?

Purpose: This review aims to understand the value of a carotid Doppler scan (CDS) when managing patients with clinical/suspected ocular ischaemic syndrome (OIS); correlations between internal carotid artery (ICA) stenosis reports; subsequent patterns of referral to vascular experts; and subsequent decisions concerning surgical versus medical management. Methods: A retrospective review of 402 CDS requests by a single eye center over 4 years (2016-2019) for patients with a clinical suspicion of OIS was conducted. Data analysis included 344 patients who had reported CDS of both ICAs. We also studied referral patterns by ophthalmologists to other specialties. Results: CDS requests were related to the retina (53.2%), neuro/TIA problems (31.1%), glaucoma (10.5%) and other issues (5.2%). The majority of patients (209/344, 60.8%) had normal CDA results. Of the 688 ICAs reported, 469 (68.2%) were normal, 219 (31.8%) had atheroma present, and only 83 (12.1%) had significant stenosis. Of 83 ICAs with stenosis, 23 (27.7%) had ≥70% stenosis, 24 (28.9%) had 50-69% stenosis, and 25 (30.1%) had <50% stenosis. A total of 60/344 (17.4%) patients were referred to vascular/stroke teams: 15/60 (25%) referred had bilateral disease, and only 2/60 (3.3%) were offered carotid endarterectomy. All referred patients commenced statins and low-dose aspirin. Conclusion: Our cohort showed a low incidence of ICA stenosis according to CDS reports in patients with suspected OIS. There were very low rates of vascular and endarterectomy referral. Commencement of conservative treatment (mini aspirin+statin) by ophthalmologists could be beneficial even in the early stage of presenting clinical evidence of OIS.

Ocular ischemic syndrome (OIS) covers a wide spectrum of eye problems resulting from reduced blood flow to the eyes. OIS is commonly known to be a rapidly blinding disease due to late diagnosis. A high index of suspicion can lead to early investigation and perhaps prevent blindness with timely intervention. The fluorescein angiogram is a reliable eye test to confirm OIS disease affecting the retina. If reduced retina perfusion is confirmed, a carotid Doppler artery scan (CDS) is the next investigation to detect blood vessel lumen narrowing primarily affecting carotid arteries (neck arteries). The presence of carotid artery disease can indicate risk of stroke; hence, confirmed carotid artery disease merits a referral to vascular surgeons to consider carotid artery surgery aiming to unblock the artery and improve blood flow and hopefully reverse OIS. Our study aimed to investigate the prevalence of suspected OIS patients referred for carotid Doppler scans, correlations between carotid artery stenosis results and clinical OIS, and subsequent offers of carotid artery surgery versus conservative medical management. Our study showed that carotid artery disease severity defined by CDS has a poor correlation with clinical diagnosis of OIS. Conservative treatment is advised for all patients with carotid artery disease, whereas surgical options for carotid stenosis are rarely offered. Hence, this study questions the benefit of pursuing CDS tests in OIS patients, since the results do not change their management. Finally, we highlight the need for better guidance on carotid artery stenosis referral for carotid surgery.