The Effect of Age on Corneal Topographic Indices, Keratometry and Visual Acuity After Combined Intrastromal Corneal Ring Segment (ICRS) Implantation and Corneal Crosslinking

We aimed to assess age-related changes in corneal topographic indices, keratometry and visual acuity after sequential intracorneal ring segment implantation (ICRS) and crosslinking (CXL). This was a retrospective matched case-control series including 26 eyes of patients ≤18 years as the cases and 26 eyes of adult patients as control. All eyes received ICRS+CXL for progressive keratoconus. Eyes were matched regarding the keratoconus parameters and the treatment (type, number and thickness of ICRS). Data was analyzed for refractive and topographic values [uncorrected and corrected distance visual acuity (UDVA; CDVA) sphere; cylinder; spherical equivalent; maximum keratometry (Kmax); flat keratometry (Kflat); steep keratometry (Ksteep); all 7 pentacam topographic indices] preoperatively and one year postoperatively. Preoperatively, there was no significant difference for any refractive, clinical or topographic parameters between the groups except for vertical asymmetry. After one year, children had a significantly higher improvement in Ksteep (3.05D) than adults (2.10D; P=0.036) and a trend to significance for Kflat (2.7D compared to 1.78D, respectively; P=0.081). UDVA improved by 4.3 ETDRS lines in children compared to 3.3 ETDRS lines in adults and CDVA improved by 1.7 ETDRS lines in children compared to 1.2 ETDRS lines in adults, but with no statistical significance. The effects on keratometry indicated that corneal response after ICRS and CXL for keratoconus is more pronounced in young patients than adults. This assumption is also supported by functional improvement and by the fact that a few eyes (5) of some very young patients (<13years) showed highly remarkable improvements after surgery (higher than any adult eye)

Portal Vein Thrombosis and Thrombocytopenia in Eosinophilic Granulomatosis with Polyangiitis: A Paradox?

A 36-year-old woman with eosinophilic granulomatosis with polyangiitis (EGPA) presented with necrotic skin lesions and pulmonary infiltrates. There was eosinophilic vasculitis on skin biopsy, and substantial tissue eosinophilia in her bone marrow. She had unexplained worsening thrombocytopenia, which prompted a thrombophilia work-up. However, abnormalities in liver enzymes led to the extraordinary finding of portal vein thrombosis. Thrombocytopenia resolved with treatment with low molecular weight heparin. This case highlights the risk of hypercoagulability in eosinophilia specifically, and in EGPA. We suggest that thrombosis should be ruled out in all cases of EGPA

Chronic ocular GVHD: limbal and conjunctival stem cell allografts from the same hematopoietic stem cell donor

Letter to the edito

Culprit-Vessel Percutaneous Coronary Intervention Followed by Contralateral Angiography Versus Complete Angiography in Patients With St-Elevation Myocardial Infarction

In patients with ST-elevation myocardial infarction, delay in door-to-balloon time strongly increases mortality rates. To our knowledge, no randomized studies to date have focused on reducing delays within the catheterization laboratory. We performed a retrospective analysis of all patients who presented with ST-elevation myocardial infarction at our institution from July 2006 through June 2010, looking primarily at time differences between percutaneous coronary intervention in the culprit vessel on the basis of ECG criteria, followed by contralateral angiography (Group 1), versus complete coronary angiography followed by culprit-vessel percutaneous intervention (Group 2). There were 49 patients in Group 1 and 57 patients in Group 2. No major differences in baseline characteristics were observed between the groups, except a higher prevalence of diabetes mellitus in Group 2. There was a statistically significant difference between Groups 1 and 2 in door-to-balloon time (median and interquartile range, 75 min [61–89] vs 87 min [70–115], P=0.03, respectively) and access-to-balloon time (12 min [9–18] vs 21 min [11–33], P=0.0006, respectively). Five Group 1 patients (10%) with inferior myocardial infarction had a contralateral culprit vessel. There were no differences in mortality rate or ejection fraction at the median 1-year follow-up. Four patients in Group 1 and 3 patients in Group 2 were referred for coronary artery bypass grafting after percutaneous intervention. This study suggests that performing culprit-vessel percutaneous intervention on the basis of electrocardiographic criteria, followed by angiography in patients with anterior ST-elevation myocardial infarction, might be the preferred approach, given the door-to-balloon time that is saved

Aquablation for benign prostatic obstruction: Single center technique evolution and experience

Purpose: Aquablation is a new technology that relies on real-time ultrasound guidance to ablate prostatic tissues using high ve-locity pressurized water. We hereby present our data and experience in this technique by exploring the perioperative surgical and functional outcomes. Materials and Methods: This is a prospectively filled study including consecutive patients who underwent aquablation at our Middle Eastern tertiary care center. Patient demographics, voiding parameters, and prostate disease specific variables were col-lected. We reported on the surgical and functional outcomes as well as the 3-month adverse events. We also explored the trend in hemoglobin drop and hemostasis method by dividing the consecutive cases into four temporal periods. Results: Fifty-nine patients underwent aquablation between March 2018 and March 2020. Mean time from transrectal ultrasound to Foley insertion was 48.5±2.5 minutes. Cautery was performed in 35 patients (59.3%) and a catheter-tensioning device was mounted in 50 patients (84.7%). On average, the hemoglobin dropped by-1.7±0.2 ng/dL (p<0.0001). The average length of cath-eterization and hospital stay were 2.1±0.3 days and 2.2±0.1 days, respectively. Only three patients (5.1%) were re-hospitalized. At three months, the average drop in serum prostate-specific antigen was-36.6±6.0% (p<0.0001) and functional outcomes consider-ably improved. We also recorded 14 adverse events in 13 patients (overall rate of 22.0%), with grade 1 and grade 2 complications comprising 71.4% of all adverse events. Conclusions: Our study results confirm the safety and efficacy of the aquablation procedure in the adoption phase. © The Korean Urological Association

Risk factors for wound dehiscence following radical cystectomy: a prediction model

Objectives: Radical cystectomy (RC) is a complex urologic procedure performed for the treatment of bladder cancer and causes significant morbidity. Wound dehiscence (WD) is a major complication associated with RC and is associated with multiple risk factors. The objectives of this study are to identify clinical risk factors for incidence of WD and develop a risk-prediction model to aid in patient risk-stratification and improvement of perioperative care. Materials and Methods: The American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database was used to derive the study cohort. A univariate analysis provided nine variables eligible for multivariate model entry. A stepwise logistic regression analysis was conducted and refined considering clinical relevance of the variables, and then bootstrapped with 1000 samples, resulting in a five-factor model. Model performance and calibration were assessed by a receiver operated curve (ROC) analysis and the Hosmer–Lemeshow test for goodness of fit, respectively. Results: A cohort of 11,703 patients was identified from years 2005 to 2017, with 342 (2.8%) incidences of WD within 30 days of operation. The final five-factor model included male gender [odds ratio (OR) = 2.5, p < 0.001], surgical site infection (OR = 6.3, p < 0.001), smoking (OR = 1.8, p < 0.001), chronic obstructive pulmonary disease (COPD) (OR = 1.9, p < 0.001), and weight class; morbidly obese patients had triple the odds of WD (OR = 2.9, p < 0.001). The ROC analysis provided a C-statistic of 0.76 and calibration R2 was 0.99. Conclusion: The study yields a statistically robust and clinically beneficial five-factor model for estimation of WD incidence risk following RC, with good performance and excellent calibration. These factors may assist in identifying high-risk patients, providing preoperative counseling and thus leading to improvement in perioperative care. © The Author(s), 2021

An evaluation of an array of viruses and fungi in adult Lebanese patients presenting with various dental infections: A cross-sectional study

Introduction: The role of bacteria in the pathogenesis of periodontitis, pericoronitis, and periapical infections has been well-established. However, the variation in the severity and prognosis of these lesions could suggest a potential role of other microorganisms, such as viruses and fungi. This study aims to evaluate the presence of adenovirus, human papillomavirus-16, Epstein-Barr virus, Candida, and non-Candida fungi in these infections. Methodology: A cross-sectional study including 120 healthy adult patients presenting with dental infections requiring dental extractions were conducted to assess the prevalence and the relative quantity of viruses and fungi in saliva, infected, and healthy tissues using quantitative polymerase chain reaction tests. Samples were collected, and a categorical scale was used for the prevalence and a continuous scale for the relative quantification. Statistical analyses were performed using Chi-square for the prevalence and Wilcoxon rank test for the relative quantification. Results: Except for the Epstein-Barr virus and Candida, the presence of viruses and fungi was significantly associated with dental infections. Adenovirus showed an association with pericoronitis, while human papilloma virus-16 exhibited an association with periapical infections. Non-Candida fungi, on the other hand, showed a positive association with all infected tissues and saliva as compared to healthy control lesions except for periapical infections. Conclusions: According to this study, viruses and fungi were found to be prevalent in dental infections. However, their associations with those infections vary depending on the types of viruses or fungi involved and the category of dental infections. Copyright © 2022 Khalil et al

Major adverse cardiovascular events following partial nephrectomy: a procedure-specific risk index

Introduction: Partial nephrectomy (PN) is associated with a non-negligible risk of postoperative cardiovascular morbidity and mortality. Identification of high-risk patients may enable optimization of perioperative management and consideration of alternative approaches. The authors aim to develop a procedure-specific cardiovascular risk index for PN patients and compare its performance to the widely used revised cardiac risk index (RCRI) and AUB-HAS2 cardiovascular risk index. Methods: The cohort was derived from the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database. The primary outcome was the incidence of major adverse cardiovascular events (MACE), defined as 30-day postoperative incidence of myocardial infarction, stroke, or mortality. A multivariate logistic regression model was constructed; performance and calibration were evaluated using an ROC analysis and the Hosmer–Lemeshow test and compared to the RCRI and the AUB-HAS2 index. Results: In a cohort of 4795 patients, MACE occurred in 52 (1.1%) patients. A univariate analysis yielded 13 eligible variables for entry into the multivariate model. The final PN-A4CH model utilized six variables: Age ⩾75 years, ASA class >2, Anemia, surgical Approach, Creatinine >1.5, and history of Heart disease. Index ROC analysis provided a C-statistic of 0.81, calibration R2 was 0.99, and sensitivity was 85%. In comparison, the RCRI and AUB-HAS2 C-statistics were 0.59 and 0.68, respectively. Conclusion: This study proposes a novel procedure-specific cardiovascular risk index. The PN-A4CH index demonstrated good predictive ability and excellent calibration using a large national database and may enable further individualization of patient care and optimization of patient selection. © The Author(s), 2022

Degenerated hair follicle cells and partial loss of sebaceous and eccrine glands in a familial case of axenfeld-rieger syndrome: An emerging role for the FOXC1/NFATC1 genetic axis

Background: Cutaneous malformations are at times associated with some forms of congenital heart defects. Many a times subtle cutaneous phenotypes maybe overlooked as their significance on the lives of individuals is minimal. Lebanon represents an area of high consanguinity, where the rates can go beyond 70% in some districts. For the past 6 years, we have been studying several genodermatoses in Lebanon including those with cardiac malformations. Objectives: The main aim of this study is to document the genetic basis of a familial case of Axenfeld-Rieger Syndrome (ARS) with a mild cutaneous phenotype represented histologically with degeneration/ absence of hair follicles and incomplete formation of sebaceous and eccrine glands, in addition to the cardiac and ocular phenotypes. Methods: Whole exome sequencing was performed on two identical-twins with ARS along with their affected father and non-affected mother. Sanger sequencing was used to confirm the mutation, and the effects of the mutations on protein function was assessed in vitro using transient transfections. Results: A novel mutation inFOXC1 designated p.L240Rfs*75 was found in both twins and their father. The affected individuals share also a rare documented variant in NFATC1 designated p.V197 M. Both were absent from 200 Lebanese exomes. Our in vitro results suggested a gain of function activity of the FOXC1/NFATC1 complex, confirming its documented role in controlling murine hair follicle stem cells quiescence and regeneration. Conclusion: This is the first documented human case with a mutation inFOXC1 regulating multi-organ developmental pathways that reflect a conserved mechanism in cell differentiation and proliferation. © 2018 Japanese Society for Investigative Dermatolog

A Novel Role for CSRP1 in a Lebanese Family with Congenital Cardiac Defects

Despite an obvious role for consanguinity in congenital heart disease (CHD), most studies fail to document a monogenic model of inheritance except for few cases. We hereby describe a first-degree cousins consanguineous Lebanese family with 7 conceived children: 2 died in utero of unknown causes, 3 have CHD, and 4 have polydactyly. The aim of the study is to unveil the genetic variant(s) causing these phenotypes using next generation sequencing (NGS) technology. Targeted exome sequencing identified a heterozygous duplication in CSRP1 which leads to a potential frameshift mutation at position 154 of the protein. This mutation is inherited from the father, and segregates only with the CHD phenotype. The in vitro characterization demonstrates that the mutation dramatically abrogates its transcriptional activity over cardiac promoters like NPPA. In addition, it differentially inhibits the physical association of CSRP1 with SRF, GATA4, and with the newly described partner herein TBX5. Whole exome sequencing failed to show any potential variant linked to polydactyly, but revealed a novel missense mutation in TRPS1. This mutation is inherited from the healthy mother, and segregating only with the cardiac phenotype. Both TRPS1 and CSRP1 physically interact, and the mutations in each abrogate their partnership. Our findings add fundamental knowledge into the molecular basis of CHD, and propose the di-genic model of inheritance as responsible for such malformations