Risk factors for endocrine complications in transfusion-dependent thalassemia patients on chelation therapy with deferasirox: a risk assessment study from a multicentre nation-wide cohort

Transfusion-dependent patients typically develop iron-induced cardiomyopathy, liver disease, and endocrine complications. We aimed to estimate the incidence of endocrine disorders in transfusion-dependent thalassemia (TDT) patients during long-term iron-chelation therapy with deferasirox (DFX).We developed a multicentre follow-up study of 426 TDT patients treated with once-daily DFX for a median duration of 8 years, up to 18.5 years. At baseline, 118, 121, and 187 patients had 0, 1, or ≥2 endocrine diseases respectively. 104 additional endocrine diseases were developed during the follow-up. The overall risk of developing a new endocrine complication within 5 years was 9.7% (95%CI=6.3-13.1). Multiple Cox regression analysis identified 3 key predictors: age showed a positive log-linear effect (adjusted HR for 50% increase=1.2, 95%CI=1.1-1.3, P=0.005), the serum concentration of thyrotropin (TSH) showed a positive linear effect (adjusted HR for 1 mIU/L increase=1.3, 95%CI=1.1-1.4, P

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Surgical Research, Staging-Guided Technical Procedures and Long-Term Clinical Outcomes for the Treatment of Peripheral Lymphedema: the Genoa Protocol

The Author ’s vast surgical experience in the treatment of primary and secondary peripheral lymphedema is reported. The objective is to describe the techniques and the long-lasting clinical outcomes based on more than 45 years research and clinical applications, with particular reference to staging-guided derivative and reconstructive lymphatic microsurgery at a single site, and to complementary, sequential, minimally invasive procedures of selective liposuction.5.046 cases of patients (demographic characteristics are at length described) affected by upper and/or lower limb lymphedema, between 1973 and 2020, underwent lymphatic microsurgery and, between 2012 and 2020, Fibro-Lipo-Lymph-Aspiration according to Lymph Vessel Sparing Procedure (FLLA-LVSP), for latest stages of Lymphedema previously treated by Lymphatic Microsurgery with partial improvement of the disease. Derivative Multiple Lymphatic-Venous Anastomoses (MLVA) or, in selected cases of Phlebolymphedema absolutely contraindicating derivative procedures, lymphatic pathway reconstruction, using interpositioned vein grafted shunts (Multiple-Lymphatic-Venous-Lymphatic Anastomose - MLVLA), above all at lower limbs, were performed at a single site, either the brachial-axillary or inguinal-crural region.Adopted surgical techniques are described in detail. As far as exposition of results is concerned, patients were followed up for a minimum of 5 years to over 20 years. Clinical outcomes included excess limb volume (ELV), frequency of dermatolymphangioadenitis (DLA) attacks, lymphoscintigraphy, and use of conservative therapies.Compared with preoperative conditions, patients obtained significant reduction in ELV of over 90%, with an average follow-up of 10 years or more. Over 96% of patients with earlier stages of disease (stage IB or IIA) progressively stopped using conservative therapies and over 80% of patients with later stages (stages IIB and III) significantly decreased the frequency of physical therapies and discontinued compressive garments or stockings. DLA attacks considerably reduced by over 95%.MLVA or MLVLA techniques when performed at a single site produce excellent outcomes in the treatment of both primary and secondary lymphedemas, giving the possibility of a complete restoration of lymphatic flow in early stages of disease, when tissue changes are minimal. For late stages of lymphedema only partially responding to MLVA or MLVLA, FLLA-LVSP sequential procedures can significantly improve the long-term clinical outcomes.&nbsp;Staging-guided treatment of peripheral lymphedema, according to Authors’ Genoa Protocol, carries out contextual target of primary, secondary and tertiary prevention in the potential worsening of the disease.</p