Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations.

BACKGROUND: Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS: A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION: Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.

A case-matched validation study of anatomic severity grade score in predicting reinterventions after endovascular aortic aneurysm repair.

BACKGROUND: In 2002, the Society for Vascular Surgery created the anatomic severity grading (ASG) score to classify abdominal aortic aneurysms (AAAs). Our objective was to identify the predictive capability and cutoff value of preoperative ASG score for reintervention after endovascular aneurysm repair (EVAR). METHODS: We completed a retrospective review of AAA patients treated with elective EVAR from 2007 through 2011. Patients who had reinterventions as well as preoperative M2S (M2S Inc, West Lebanon, NH) three-dimensional reconstructions were identified and compared with a case-matched control group of patients without reintervention. ASG component scores (neck, aortic, and iliac) and total ASG scores were calculated using M2S software. RESULTS: Of the 623 patients treated with EVAR, 79 (13%) had reinterventions of which 45 had preoperative M2S three-dimensional reconstructions available for ASG score calculation. The reintervention group (mean age, 74 ± 8; 80% male) had a mean ASG score of 18 ± 5 (range, 8-30) compared with a cohort of 45 EVAR patients (mean age, 74 ± 7; 80% male) who had a mean ASG score of 13 ± 4 (range, 6-21; P < .0001). The mean AAA diameter for all patients was 52 mm ± 14 and was not significantly different between the groups. After area under the receiver-operating curve analysis, an ASG score of 17 was highly predictive for reintervention (area = 0.8; sensitivity = 60%; specificity = 78%; positive predictive value = 73%; negative predictive value = 66%). An ASG score of 13 was highly predictive for freedom from reintervention (sensitivity = 93%; specificity = 47%; positive predictive value = 64%; negative predictive value = 88%). The lowest ASG score that yielded a 100% reintervention rate was 22. The majority of reinterventions fell into three categories: proximal extension cuff (n = 18; 40%), distal extension limb (n = 7; 16%), and type II endoleak embolization (n = 13; 29%). Those that received proximal extensions had significantly higher mean total ASG score (19 vs 15; P = .0005), mean neck score (3.28 vs 2.36; P = .047), and mean aorta score (7.39 vs 2.36; P = .004). Those that received distal extensions had a significantly higher mean iliac score (9.00 vs 6.86; P = .013), and those that required an embolization had a significantly higher mean aorta branch score (1.92 vs 1.19; P = .017). CONCLUSIONS: Preoperative total ASG score strongly predicts reintervention after EVAR. Use of a cutoff ASG value predictive of prohibitive reintervention rates could help guide the decision between endovascular vs open AAA repair.

Electrically enhanced percutaneous delivery of delta-aminolevulinic acid using electric pulses and a DC potential.

Selectivity of photodynamic therapy can be improved with localized photosensitizer delivery, but topical administration is restricted by poor diffusion across the stratum corneum. We used electric pulses to increase transdermal transport of delta-aminolevulinic acid (ALA), a precursor to the photosensitizer protoporphyrin IX (PpIX). ALA-filled electrodes were attached to the surface of excised porcine skin or the dorsal surface of mice. Pulses were administered and, in some in vivo cases, a continuous DC potential (6 V) was concomitantly applied. For in vitro 14C ALA penetration, 10 microm layers parallel to the stratum corneum were assayed by liquid scintillation analysis, and 10 microm cross sections were examined autoradiographically. As the electrical dose (voltage x frequency x pulse width x treatment duration) increased, there was an increase in penetration depth. In vivo delivery was assayed by measuring the fluorescence of PpIX in skin samples. A greater than two-fold enhancement of PpIX production with electroporative delivery was seen versus that obtained with passive delivery. Superimposition of a DC potential resulted in a nearly three-fold enhancement of PpIX production versus passive delivery. Levels were higher than the sum of PpIX detected after pulse-alone and DC-alone delivery. Electroporation and electrophoresis are likely factors in electrically enhanced delivery.