Evolving frontiers: endovascular strategies for the treatment of delayed cerebral ischemia.

Cerebral vasospasm and delayed cerebral ischemia represent a very challenging aspect of cerebrovascular pathophysiology, most commonly subarachnoid hemorrhage, with significantly high mortality if left untreated. Considerable advances have been made in medical treatment and prompt diagnosis, while newer endovascular modalities have recently been proposed for cases of resistant cerebral vasospasm. However, there is still paucity of data regarding which and whether a single endovascular technique is non inferior to the pharmacological standard of care. In this review, we aim to summarize the current funds of knowledge concerning cerebral vasospasm and the emerging role of the endovascular techniques for its treatment.

Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data.

BACKGROUND: The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. METHODS: PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model. RESULTS: Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001). CONCLUSIONS: Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up. CLINICAL IMPACT: Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.

The Use of Empagliflozin Post Myocardial Infarction.

Empagliflozin is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that is mainly used for the treatment of type 2 diabetes mellitus. The study's objective was to assess empagliflozin's effects and impacts on post-myocardial patients to highlight its worth in comparison to alternative therapies. Only studies evaluating the effects of empagliflozin on individuals who have undergone a myocardial infarction (MI) are included in this review of the literature, which employed PubMed, Google Scholar, and Embase. To compare the advantages of empagliflozin for individuals who have recently experienced a myocardial infarction, abstracts from pertinent articles were retrieved, and complete publications were reviewed. A total of four articles were reviewed, which showed that in patients who suffered from a recent MI, empagliflozin caused a significant decrease in N-terminal pro-brain natriuretic peptide (NT-proBNP). Additionally, it was shown that these individuals had better echocardiographic results for both structural and functional metrics. With studies showing a significantly larger median NT-proBNP decrease with empagliflozin compared to placebo among patients hospitalised with an acute big MI when empagliflozin was started early and administered in addition to the post-MI care suggested by guidelines, it is safe to say that the benefits outweigh the risks. There are currently larger double-blind trials in progress to prove the hypothesis of the benefits of empagliflozin for post-MI patients.

A Review of Robotic Surgery in Colorectal Surgery.

Colorectal surgery is a treatment for colorectal lesions. Technological advancements have given the rise to robotic colorectal surgery, a procedure that limits excessive blood loss via 3D pin-point precision capabilities during surgeries. The aim of this study is to review robotic surgery in colorectal treatment procedures in order to dictate its ultimate merits. This is a literature review utilising PubMed and Google Scholar; it only includes case studies and case reviews related to robotic colorectal surgeries. Literature reviews are excluded. We incorporated abstracts from all articles and full publications were examined to compare the benefits of robotic surgery in colorectal treatments. The number of articles reviewed was 41 literature spanning from 2003 to 2022. We found that robotic surgeries yielded finer marginal resections, greater amounts of lymph node resections and earlier recovery of bowel functions. The patients also spent less time in hospital after surgery. The obstacles on the other hand are it costs longer operative hours and further training, which is expensive. Studies show robotic approach is a choice for treating rectal cancer. However further studies would be needed to conclude the best approach. This is especially true with patients treated for anterior colorectal resections. Based on the evidence it's safe to say that the upsides outweigh the downsides, but advancements and further research in robotic colorectal surgeries are still necessary to reduce operative hours and cost. Surgical societies should also take the initiative and set up effective training programmes for colorectal robotic surgeries, as trained physicians result in better treatment outcomes.

Robotic Sympathectomy for Hyperhidrosis.

In hyperhidrosis, the body's sweat glands overact. Excessive sweating results from this overactivity, and for many hyperhidrosis patients, managing symptoms can be difficult in day-to-day life. Both surgical and non-surgical types of treatment are available for hyperhidrosis. Surgical treatments include microwave sympathectomy (video-assisted thoracic surgery and robotic). Da Vinci Si and Xi robotic systems are used. This review summarizes the outcomes, complications, advantages, and disadvantages of robotic sympathectomy. We conducted a literature search using PubMed, Cochrane, and Scopus. After analyzing nine articles, we found that robotic sympathectomy decreased compensatory hyperhidrosis with similar outcomes to other procedures. Robotic sympathectomy also reduced complications of Horner syndrome and has changed minimally invasive surgery significantly due to the reduction in tremors by a surgeon's hands to three-dimensional magnified views. It can potentially address the limitations of human video-assisted sympathectomy. However, the higher cost of robotic surgery, longer perioperative time due to the setting up of the machine, and higher training requirements are some of the disadvantages. The advantages of robotic sympathectomy are a reduction in compensatory sweating, better dexterity, loss of tremors, better visualization, and better accuracy. Although the overall success rates seem to be similar between robotic and video-assisted approaches, more studies are needed.

Anastomotic Leak and Perioperative Outcomes of Esophagectomy for Esophageal Cancer during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

Background and Objectives: The coronavirus disease-2019 (COVID-19) pandemic influenced the healthcare system tremendously, as well as the number of elective surgical procedures worldwide. The aim of this study is to investigate the COVID-19 pandemic's impact on esophagectomies. Materials and Methods: The MEDLINE (via PubMed), Cochrane Library, and Google Scholar bibliographical databases were systematically searched. Original clinical studies investigating the outcomes of esophageal cancer surgery during the COVID-19 pandemic were deemed eligible. After exclusion criteria were applied, eight studies were considered eligible for inclusion. Results: Eight studies with non-overlapping populations, reporting on patients undergoing esophagectomy for resectable esophageal cancer during the COVID-19 pandemic, were included in our analysis, with a total of 18548 patients. Background characteristics for age, lung disease, smoking history as well as Body Mass Index and age were equal among the groups. The background of diabetes presented a statistically significant difference among the groups. Perioperative outcomes like reoperation rates, the length of intensive care unit stay, or readmission rates were not significantly increased during the pandemic. The 30-day readmission, and 30- and 90-day mortality were not affected either. The length of hospital stay was significantly lower in the non-pandemic period. Conclusions: The results of our study support the evidence that in the context of the COVID-19 pandemic, esophageal cancer operations took place safely and effectively, similarly to the standards of the non-COVID-19 era.

Is There an Association Between Chronic Obstructive Pulmonary Disease and Chronic Renal Failure?

Chronic obstructive pulmonary disease (COPD) is one of the most common diseases worldwide with its prevalence increasing with age. It is commonly comorbid with other diseases and managing patients could be difficult and expensive. Chronic kidney disease (CKD) is often present in COPD patients and may be underdiagnosed, especially if it is mild. This study intended to summarize recent findings showing the correlation between the two diseases. Studies were gathered that were published in the last 11 years, from 2010 to 2021. PubMed was used as the main source of data, but papers from the references of the included other sources were added for thoroughness. Observational studies on examining the prevalence and prognosis of comorbid COPD and CKD published in the English language were included. A higher prevalence of CKD in COPD patients was found in most studies; it was found that a higher risk of mortality is present if these diseases coexist. Further research is required and more extensive prospective studies are needed with matched control groups to support the correlation.

Pneumomediastinum in the COVID-19 era: to drain or not to drain?

Pneumomediastinum (PNM) is a rare clinical finding, usually with a benign course, which is managed conservatively in the majority of cases. However, during the COVID-19 pandemic, an increased incidence of PNM has been observed. Several reports of PNM cases in COVID-19 have been reported in the literature and were managed either conservatively or surgically. In this study, we present our institutional experience of COVID-19 associated PNM, propose a management algorithm, and review the current literature. In total, 43 Case Series were identified, including a total of 747 patients, of whom 374/747 (50.1%) were intubated at the time of diagnosis, 168/747 (22.5%) underwent surgical drain insertion at admission, 562/747 (75.2%) received conservative treatment (observation or mechanical ventilation. Inpatient mortality was 51.8% (387/747), while 45.1% of the population recovered and/or was discharged (337/747). In conclusion, with increased incidence of PNM in COVID-19 patients reported in the literature, it is still difficult to assign a true causal relationship between PNM and mortality. We can, however, see that PMN plays an important role in disease prognosis.  Due to increased complexity, high mortality, and associated complications, conservative management may not be sufficient, and a surgical approach is needed.

Hemophagocytic Lymphohistiocytosis and Infection: A Literature Review.

Hemophagocytic lymphocytosis (HLH) is a life-threatening, underdiagnosed syndrome caused by the excessive release of inflammatory mediators. Primary lymphocytosis is usually seen in young children and is associated with genetic defects, while secondary lymphocytosis is presented in adults due to malignancy, rheumatic disease, or infection. The aim of this study is to describe the infectious agents that trigger HLH in the adult population and provide diagnostic and treatment guidelines for this life-threatening syndrome. We conducted a literature review using PubMed as our basic database. We collected papers from the past six years that studied infectious agents that triggered HLH and described the most recommended treatment options for this serious condition. A total of 32 studies were included for this literature review.HLH is considered a syndrome with variable symptoms, and clinicians should be familiar with its complexity and the pathologies that could contribute to its presentation. Collaboration between physicians and awareness are basic steps for the management of patients with HLH.

Headache - A Window to Dementia: An Unexpected Twist.

Migraine and other types of headaches have several symptoms associated with them. The association between migraine and dementia has been considered. It is a topic of discussion and appears to be multifactorial. Dementia is a cluster of symptoms, with memory loss and cognitive dysfunction being the prominent symptoms. In this review, we discussed the association of headache and cognitive dysfunction in a broader context and how the practiced treatment of headaches may silently lead to dementia. We conducted a thorough literature search using PubMed as our main database. The articles exploring the association between headache (both migraine and non-migraine) and dementia were included. Some risk factors like migraine-induced stroke and inherent vascular diseases in migraine patients channeling to stroke and dementia were not considered. A total of 28 studies were included for review. All the reviewed studies put together showed an association between headache and cognitive dysfunction of any form. They showed that the frequency and duration of headache is a determinant for dementia. Few studies also focused on how treating headaches with certain drugs can lead to dementia. The reviewed published literature showed that headaches of any sort and their treatment are potentially linked to dementia. Not all headache patients will require medical treatment, as the benefit might outweigh the risk sometimes. It is interim to understand these facts and formulate a better protocol for treating headache patients. However, due to some discordant results, further studies are needed.

A Comprehensive Review on Vitamin D as a Novel Therapeutic Agent in Chronic Obstructive Pulmonary Disease.

Vitamin D has been playing an important role in the treatment of lung diseases. The non-calcemic effects of this vitamin and its role in chronic obstructive pulmonary disease (COPD) has drawn significant attention recently. Many studies have been conducted to explore the relationship between the two. We tested the hypothesis that vitamin D can act as an effective therapeutic agent for COPD by reviewing the correlation between the two and effectiveness along with the safety of supplemental vitamin D when used to treat chronic bronchitis and emphysema through clinical trials. An electronic search was conducted using combinations of keywords "vitamin D" and "COPD" from PubMed and Google scholar. Only relevant, human studies of all types were included from the last decade. A total of 36 articles were selected for review. Observational studies indicate a correlation between low serum 25(OH)D levels and obstructive lung disease pathology as well as clinical outcomes. Moreover, clinical trials were aimed to understand the impact of the use of vitamin D in improving disease indexes. These clinical trials used different drug regimes, mode of administration, and intervention duration with contrasting outcomes. Hypovitaminosis D is a common and harmful variant of this group of obstructive lung diseases, and correcting this deficiency can improve exacerbations, inflammation, lung functions, symptoms, and quality of life. These benefits are more prevalent in patients with low baseline serum 25 hydroxyvitamin D(25(OH)D) levels. Peroral is the most frequently used route of drug administration, however, further work is required to explore the pharmacological properties of vitamin D. There was not enough literature available about the safety of the drug of intervention.

Non-rodent animal models of osteosarcoma: A review.

Osteosarcoma is extremely malignant, and the most common cancer that affects bone. Current treatments involve surgical resection of the affected area and multi-agent chemotherapy, though survival rate is generally poor for those affected by metastases. As treatment for osteosarcoma has remained unchanged for the past few decades, there is a need for further advancements in the understanding of osteosarcoma biology and therapeutics. Thus, reliable animal models that can accurately recapitulate the disease are required. Though rodents represent the most popular animal model of osteosarcoma, they may not model the disease best. This review analyzes emerging alternative non-rodent animal models of osteosarcoma, such as the chick chorioallantoic membrane (CAM) assay, pigs, and canines. Each of these alternatives offer advantages over classic rodent models for pre-clinical research. Research of these cross-species platforms imparts knowledge of metastases biology and potential new treatments for osteosarcoma.