Risk factors for corneal graft rejection after penetrating keratoplasty for keratoconus.

PURPOSE: To evaluate the association between donor-related factors and the risk of rejection in patients undergoing penetrating keratoplasty (PKP) for keratoconus. METHODS: A retrospective review was performed of keratoconus patients with no corneal neovascularization who underwent PKP from November 2014 to December 2016 and completed at least two years of follow-up. Preoperative, donor, operative, and postoperative data were collected and analyzed to identify factors leading to corneal graft rejection. RESULTS: A total of 201 eyes (of 201 patients) that underwent PKP for keratoconus were included. Of these, 22.9% (95% CI 17.6-29.2%) had an episode of graft rejection. The overall graft survival rate was 98.5%. Receipts with a history of corneal transplant in the fellow eye (IRR 1.69, 95% CI 1.01, 2.80; p = 0.044) and those with postoperative stromal neovascularization (IRR 2.51, 95% CI 1.49, 4.21; p = 0.001) had a significantly higher incidence of rejection than those without these features. In univariate analysis, death-to-surgery time and death-to-excision time (DET) showed a weak association with graft rejection (p 0.05 and 0.08 respectively); However, in the multivariable analysis, this significance was lost. Grafts with a death-to-excision time (DET) greater than 8 h had a 0.53X lower risk of rejection compared with grafts with DET within 8 h or less (p = 0.05). Rejection was higher in patients receiving grafts with a preservation time within 7 days or less compared with preservation time greater than 7 days (30.6% vs. 21.2%, respectively, p = 0.291). CONCLUSION: In the multivariable analysis, none of the donor-related factors were significantly associated with graft rejection; however, short death-to-surgery time may be associated with rejection after PKP. Recipients with a history of PKP in the fellow eye and those who developed corneal neovascularization were also at increased risk of developing rejection after keratoplasty.

Immediate Dialysis After Simultaneous Laparoscopic Peritoneal Dialysis Catheter Placement and Laparoscopic Inguinal Hernia Repair.

Background and Objectives: Peritoneal dialysis (PD) is an accepted renal replacement therapy for end-stage renal disease (ESRD). Managing inguinal hernia in patients with PD is not standardized. Thus, this study reported the outcomes of simultaneous laparoscopic peritoneal dialysis catheter (PDC) placement and transabdominal preperitoneal (TAPP) repair of inguinal hernia. Methods: Thirteen patients with chronic renal disease and inguinal hernia attending a tertiary hospital between May 1, 2016 and June 30, 2021 were evaluated for laparoscopic PDC placement. Concurrent laparoscopic inguinal herniorrhaphy and laparoscopic PDC placement were performed. Dialysate fluid was measured intraoperatively to the level below the incised peritoneum by 1 inch. The inflow and outflow was smooth without leakage. The amount was increased gradually in the two weeks after regular PD was obtained. Results: Laparoscopic PDC was inserted for 13 patients. Ten patients had unilateral hernia and two had bilateral inguinal hernia. Associated paraumbilical hernia was discovered in two patients. The median follow-up was 30 months. The measured safe amount of dialysate fluid intraoperatively was 400 - 600 mL. There was no death, intraoperative complication, or dialysate leakage. Three PDCs were removed owing to noncompliance. No hernia recurrence was observed. Conclusion: Simultaneous laparoscopic PDC placement and laparoscopic repair of inguinal hernia with immediate dialysis is a safe and feasible surgical technique. Utilizing minimally invasive surgery affords PDC placement and inguinal hernia repair simultaneously.

FAMILIAL EXUDATIVE VITREOTINOPATHY-LIKE FEATURES IN STICKLER TYPE IV ASSOCIATED WITH NOVEL VARIANTS IN COL9A1.

BACKGROUND/PURPOSE: To report a case of Stickler Type IV with familial exudative vitreoretinopathy phenotype. METHODS: Retrospective case report. RESULTS: A 24-year-old woman presented with right eye exotropia and decreased vision. She had no facial or typical retinal features of Stickler syndrome but complained of right-sided hearing loss and right-sided neck pain. Examination of the right eye showed a chronic combined exudative and traction retinal detachment with temporal retinal dragging associated with far temporal retinal exudations and fibrovascular proliferations. The left eye had an attached retina with large areas of peripheral temporal retinal nonperfusion on fluorescein angiography, sharply demarcated by end circulation vascular pruning and mild peripheral vascular leakage, consistent with familial exudative vitreoretinopathy phenotype. Genetic analysis identified two heterozygous c.1052C>A and c.1349A>G variants in COL9A1, but did not disclose any mutation in genes classically associated with familial exudative vitreoretinopathy. CONCLUSION: Familial exudative vitreoretinopathy-like retinal vascular features can be the presenting sign in patients with Stickler syndrome Type IV.

Blood Group and Response to Bariatric Surgery in Morbidly Obese Patients: A Retrospective Study in Saudi Arabia.

OBJECTIVES: To explore the relationship between the blood group of patients and their response to bariatric surgery and to identify predictors of better outcomes. METHODS: This was a retrospective cross-sectional analysis of patients who underwent laparoscopic sleeve gastrectomy for morbid obesity between 2014 and 2020 at King Saud University Medical City in Riyadh, Saudi Arabia. RESULTS: This study included 1434 individuals. The mean change in BMI (pre- versus post-BMI) differed statistically significantly between blood groups (p ≤ 0.01). The greatest drop in body weight was seen in individuals with the AB-negative blood type (56.0 (21.4) kg), which corresponds to the greatest percentage of reduction from baseline (47.7% (14.8)). The mean BMI of the patients decreased by 34.7% (9.2) from a mean pre-operation BMI of 45.5 (8.4) kg/m2 to 29.7 (6.1) kg/m2 (p ≤ 0.001). After laparoscopic sleeve gastrectomy, male patients and those with the B-negative blood type are more likely to see a greater BMI reduction (pre-operation compared to post-operation) (p ≤ 0.05). CONCLUSIONS: For morbidly obese patients, laparoscopic sleeve gastrectomy demonstrated promising weight loss outcomes. Blood groups may be able to predict the success rate of bariatric surgery in morbidly obese patients.

Central Serous Chorioretinopathy Associated with Tadalafil.

We report a case of central serous chorioretinopathy (CSCR) associated with tadalafil, a phosphodiesterase 5 inhibitor medication. In this report, we describe a case of a 59-year-old male who presented with blurred vision in the right eye. On examination, he was noted to have serous macular, pigment epithelial detachments, and increased choroidal thickness. The diagnosis of CSCR was made, and the patient was asked to stop the offending agent. Three months after stopping tadalafil, the patient's visual symptoms and subretinal fluid resolved. In conclusion, prescribing physicians should be aware of tadalafil's ability to decrease vision and cause CSCR. The addition of CSCR to the list of tadalafil's side effects should also be considered.

Secondary Hyperparathyroidism in Obese Patients Post Sleeve Gastrectomy.

INTRODUCTION: Bariatric surgery provides an effective option for the management of morbid obesity. Several studies have investigated the association between bariatric surgery and secondary hyperparathyroidism (SHPT). This study aims to compare the levels of blood biomarkers, specifically, calcium (Ca), vitamin D, and phosphate (PO4), and their association with parathyroid hormone (PTH) levels pre- and post-bariatric surgery. In addition, it aims to assess the prevalence of hyperparathyroidism post-bariatric surgery in a tertiary care hospital in Saudi Arabia. MATERIAL AND METHODS: A prospective cohort study was conducted at a large tertiary care hospital between May 2017 and April 2019. The study included adult obese patients who underwent laparoscopic sleeve gastrectomy (LSG). Patients were excluded if they were known to have any comorbidities, receiving vitamin supplements, and those who had undergone bariatric procedures previously. Routine blood tests, including PTH, vitamin D, Ca, and PO4, were collected at baseline, and post-surgery. RESULTS: A total of 143 patients who underwent LSG were included in the study. Hyperparathyroidism was observed in 15.4% of patients at baseline and in 36.4% of patients' post-surgery (p < 0.001). Low vitamin D levels, which were highly prevalent before surgery, decreased sustainably (66.4% pre-operative and 28% at follow-up after surgery, P=0.032). Baseline hypocalcemia was observed in 20.3% of patients compared to 8.4% post-surgery (P=0.546). Hypophosphatemia was present in 60.8% of subjects at baseline, while the percentage dropped to 21.7% post-surgery. There was a significant association between PO4 and PTH levels at baseline. Post-operatively, there was a significant correlation between PTH and both vitamin D and calcium levels. CONCLUSION: Our study showed that the higher levels of PTH post LSG can be related to vitamin D deficiency and lower calcium levels, despite patients following the provided recommendations for supplementation. This study also emphasizes the importance of routine testing for hyperparathyroidism both before and after bariatric surgery.

Quantifying recall bias in surgical safety: a need for a modern approach to morbidity and mortality reviews

Background: Despite recent investments into reducing errors and adverse events in health care, methods for quality improvement in surgery are outdated and ineffective. Most current efforts in this field are centred around morbidity and mortality conferences (MMCs), which have remained unchanged for over 100 years. The present study aimed to quantify the recall bias associated with details from surgical cases. Methods: We gathered immediate postoperative questionnaires from 1 surgeon, 1 fellow and 11 trainees following 25 routine surgical cases. Information elicited included their perceived level of concentration, mental preparedness and assessment of whether the procedure deviated from its expected course, including any intraoperative adverse events. We readministered the questionnaire 7−9 days later to assess participants' ability to recall important aspects of the procedure. Results: After 1 week, members of the surgical team were universally inaccurate in their recollection of even major details from the operating room. Although most participants felt mentally prepared and perceived no issues with concentration during the case, all participants misclassified operations as having been performed with or without adverse events in almost every included case. Conclusion: Our findings show that recall bias regarding surgical safety events is exceedingly common. This likely has a major impact on the integrity of data presented at MMCs.

Contexte: Malgré les récents investissements visant à réduire les erreurs et les effets indésirables en santé, les méthodes d'amélioration de la qualité en chirurgie sont dépassées et inefficaces. Les efforts les plus récents dans ce domaine sont axés sur les conférences portant sur la morbidité et la mortalité (CMM), qui sont les mêmes depuis une centaine d'années. La présente étude souhaitait quantifier les biais de rappel relatifs aux détails des cas de chirurgie. Méthodes: Nous avons recueilli les questionnaires postopératoires immédiats d'un chirurgien, d'un moniteur clinique et de 11 stagiaires après 25 chirurgies de routine. L'information recueillie incluait leur degré perçu de concentration, leur état de préparation mentale et leur évaluation du déroulement de l'intervention par rapport au plan prévu, y compris tout effet indésirable peropératoire. Nous avons réadministré le questionnaire 7 à 9 jours plus tard pour évaluer la capacité des participants à se rappeler les aspects importants des interventions. Résultats: Après 1 semaine, les souvenirs des membres de l'équipe chirurgicale étaient tous imprécis en ce qui concerne même certains éléments majeurs des interventions. Même si la plupart des participants se sentaient mentalement prêts et qu'ils n'ont perçu aucun problème de concentration au cours des interventions, ils ont tous commis des erreurs de classification des opérations effectuées, avec ou sans effets indésirables, dans près de la totalité des cas inclus. Conclusion: Nos observations montrent que les biais de rappel au sujet des enjeux de sécurité en cours d'intervention sont extrêmement fréquents. Cela exerce sûrement un impact de taille sur l'intégrité des données présentées lors des CMM.

Diagnosis of VTE postdischarge for major abdominal and pelvic oncologic surgery: implications for a change in practice.

BACKGROUND: Extended thromboprophylaxis after hospital discharge following cancer surgery has been shown to reduce the incidence of venous thromboembolism (VTE); however, this practice has not been universally adopted. We conducted a population-based analysis to determine the proportion of patients with symptomatic VTE diagnosed within 90 days after initial discharge following major abdominopelvic cancer surgery who might have benefited from extended thromboprophylaxis. METHODS: We used the Manitoba Cancer Registry to identify patients who underwent major abdominopelvic cancer surgery between 2004 and 2009. The proportion in whom VTE was diagnosed during the initial hospital stay was determined by accessing the Hospital Separations Abstracts. The proportion in whom VTE was diagnosed after discharge was determined by examining repeat admissions within 90 days and by accessing Drug Programs Information Network records for newly prescribed anticoagulants. Detailed tumour and treatment-specific data allowed calculation of VTE predictors. RESULTS: Of 6612 patients identified, 106 (1.60%) had VTE diagnosed during the initial stay and 96 (1.45%) presented with VTE after discharge. Among patients in whom VTE developed after discharge, 33.3% had a pulmonary embolus, 24% had deep vein thrombosis, and 6.3% had both. Predictors of presenting with VTE after discharge within 90 days of surgery included advanced disease, presence of other complications, increased hospital resource utilization, primary tumours of noncolorectal gastrointestinal origin and age younger than 45 years. The development of VTE was an independent predictor of decreased 5-year overall survival. CONCLUSION: The cumulative incidence of VTE within 90 days of major abdominopelvic oncologic surgery was 3.01%, with about half (1.45%) having been diagnosed within 90 days after discharge.

CONTEXTE: La thromboprophylaxie prolongée après le congé hospitalier suite à une chirurgie pour cancer a permis de réduire l'incidence de la thrombo-embolie veineuse (TEV); or, cette pratique n'a pas été universellement adoptée. Nous avons procédé à une analyse de population afin de déterminer la proportion de patients qui ont reçu un diagnostic de TEV symptomatique dans les 90 jours suivant leur congé à la suite d'une chirurgie majeure pour cancer abdomino-pelvien et qui auraient pu bénéficier d'une thromboprophylaxie prolongée. MÉTHODES: Nous avons utilisé le registre du cancer du Manitoba pour recenser les patients ayant subi une chirurgie majeure pour cancer abdomino-pelvien entre 2004 et 2009. La proportion de patients chez qui une TEV a été diagnostiquée au cours du séjour hospitalier initial a été calculée à partir des sommaires d'hospitalisation préparés au congé du patient. La proportion de patients chez qui la TEV a été diagnostiquée après le congé provient de l'examen des dossiers de réadmission dans les 90 jours et du réseau provincial d'information sur les programmes de médicaments pour les anticoagulants nouvellement prescrits. L'analyse des données détaillées sur les tumeurs et les traitements a permis d'établir les prédicteurs de la TEV. RÉSULTANTS: Sur 6612 patients recensés, 106 (1,60 %) ont reçu un diagnostic de TEV durant leur séjour initial et 96 (1,45 %), après leur congé. Parmi les patients chez qui la TEV est survenue après le congé, 33,3 % ont souffert d'une embolie pulmonaire, 24 %, d'une thrombose veineuse profonde et 6,3 %, des deux. Les prédicteurs de la TEV consécutive au congé hospitalier dans les 90 jours suivant une chirurgie incluaient : maladie avancée, présence d'autres complications, utilisation accrue des ressources hospitalières, tumeur primitive d'origine gastro-intestinale non colorectale et âge < 45 ans. La TEV s'est révélée être un prédicteur indépendant d'une plus brève survie globale à 5 ans. CONCLUSION: L'incidence cumulative des TEV dans les 90 jours suivant une chirurgie majeure pour cancer abdomino-pelvien a été de 3,01 %, environ la moitié des cas (1,45 %) ayant été diagnostiqués dans les 90 jours suivant le congé.