PurposeStereotactic radiosurgery (SRS) in combination with immunotherapy (IMT) or targeted therapy is increasingly being used in the setting of melanoma brain metastases (MBMs). The synergistic properties of combination therapy are not well understood. We compared the distant intracranial failure rates of intact MBMs treated with SRS, SRS + IMT, and SRS + targeted therapy.Methods and materialsCombination therapy was defined as delivery of SRS within 3 months of IMT (anti-CTLA-4 /anti-PD-1 therapy) or targeted therapy (BRAF/MEK inhibitors). The primary endpoint was distant intracranial failure after SRS, which was defined as any new MBM identified on brain magnetic resonance imaging. Outcomes were evaluated using the Kaplan Meier method and Cox proportional hazards.ResultsA total of 72 patients with melanoma with 233 MBMs were treated between April 2006 and April 2016. The number of MBMs within each treatment group was as follows: SRS: 121; SRS + IMT: 48; and SRS + targeted therapy: 64. The median follow-up was 8.9 months. One-year distant intracranial control rates for SRS, SRS + IMT, and SRS + targeted therapy were 11.5%, 60%, and 10%, respectively (P < .001). On multivariate analysis, after adjusting for steroid use and number of MBMs, SRS + IMT remained associated with a significant reduction in distant intracranial failure compared with SRS (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.29-0.80; P = .003) and compared with SRS + targeted therapy (HR, 0.41; 95% CI, 0.25-0.68; P = .001).One-year local control for SRS, SRS + IMT, and SRS + targeted therapy was 66%, 85%, and 72%, respectively (P = .044). On multivariate analysis, after adjusting for dose, SRS + IMT remained associated with a significant reduction in local failure compared with SRS alone (HR, 0.37; 95% CI, 0.14-0.95; P = .04).ConclusionsSRS with immunotherapy is associated with decreased distant and local intracranial failure compared with SRS alone. Prospective studies are warranted to validate this result.

Atopic dermatitis is associated with cervical hrHPV infection in adult women.

OBJECTIVE The internal high-dose volume varies widely for a given prescribed dose during stereotactic radiosurgery (SRS) to treat brain metastases (BMs). This may be altered during treatment planning, and the authors have previously shown that this improves local control (LC) for non–small cell lung cancer BMs without increasing toxicity. Here, they seek to identify potentially actionable dosimetric predictors of LC after SRS for melanoma BM. METHODS The records of patients with unresected melanoma BM treated with single-fraction Gamma Knife RS between 2006 and 2017 were reviewed. LC was assessed on a per-lesion basis, defined as stability or a decrease in lesion size. Outcome-oriented approaches were utilized to determine optimal dichotomization for dosimetric variables relative to LC. Univariable and multivariable Cox regression analysis was implemented to evaluate the impact of collected parameters on LC. RESULTS Two hundred eighty-seven melanoma BMs in 79 patients were identified. The median age was 56 years (range 31–86 years). The median follow-up was 7.6 months (range 0.5–81.6 months), and the median survival was 9.3 months (range 1.3–81.6 months). Lesions were optimally stratified by volume receiving at least 30 Gy (V30) greater than or equal to versus less than 25%. V30 was ≥ and < 25% in 147 and 140 lesions, respectively. For all patients, 1-year LC was 83% versus 66% for V30 ≥ and < 25%, respectively (p = 0.001). Stratifying by volume, lesions 2 cm or less (n = 215) had 1-year LC of 82% versus 70% (p = 0.013) for V30 ≥ and < 25%, respectively. Lesions > 2 to 3 cm (n = 32) had 1-year LC of 100% versus 43% (p = 0.214) for V30 ≥ and < 25%, respectively. V30 was still predictive of LC even after controlling for the use of immunotherapy and targeted therapy. Radionecrosis occurred in 2.8% of lesions and was not significantly associated with V30. CONCLUSIONS For a given prescription dose, an increased internal high-dose volume, as indicated by measures such as V30 ≥ 25%, is associated with improved LC but not increased toxicity in single-fraction SRS for melanoma BM. Internal dose escalation is an independent predictor of improved LC even in patients receiving immunotherapy and/or targeted therapy. This represents a dosimetric parameter that is actionable at the time of treatment planning and warrants further evaluation.

In Iraq, in 2019, there were about 1.4 million Internally Displaced Persons (IDP); medical treatments were often interrupted. The feasibility of using Hibiscus sabdariffa (HS) decoction to curb hypertension was evaluated. A multicentric comparative pilot intervention for 121 participants with high blood pressure (BP) (≥140/90 mmHg) was conducted. Participants of the intervention group (with or without conventional medication) received HS decoction on a dose regimen starting from 10 grams per day. BP was measured five times over six weeks. The major active substances were chemically quantified. Results: After 6 weeks, 61.8% of participants from the intervention group (n = 76) reached the target BP < 140/90 mmHg, compared to 6.7% in the control group (n = 45). In the intervention group, a mean (±SD) reduction of 23.1 (±11.8) mmHg and 12.0 (±11.2) for systolic and diastolic BP, respectively, was observed, while in the control group the reduction was 4.4 (±10.2)/3.6 (±8.7). The chemical analysis of the starting dose indicated a content of 36 mg of total anthocyanins and 2.13 g of hibiscus acid. The study shows the feasibility of using HS decoction in IDP’s problematic framework, as hibiscus is a safe, local, affordable, and culturally accepted food product.

Purpose To compare and contrast the flow patterns in celiac artery (CA) and superior mesenteric artery (SMA) in normal children to those in normal adults with the use of duplex ultrasound techniques. Methods Thirty male subjects were entered prospectively to the study. Peak systolic velocities and diameter at the origin of CA and SMA were recorded while the subject was fasting for at least 4–6 hr. The Human Ethics Committee at the Faculty of Allied Health Sciences-Kuwait University approved the study. Informed consent form was obtained from all subjects. Results There were 15 healthy male adults. Their average age (yr ± SD) was 22.7 ± 4.7 and their average body mass index (kg/m2 ± SD) was 23.5 ± 2.1. There were 15 healthy male children. Their average age (yr ± SD) was 7.2 ± 2.92, and their average body mass index (kg/m2 ± SD) was 18.5 ± 4.8. The average diameters (cm ± SD) of CA and SMA in adults were 0.73 ± 0.8 and 0.76 ± 0.11, and the average peak systolic velocities (cm/s ± SD) were 113 ± 17.5 and 145 ± 25.8, respectively. However, the average diameter (cm ± SD) of CA and SMA in children was 0.52 ± 0.06 and 0.53 ± 0.06, and the average peak systolic velocities (±SD, cm/s) of CA and SMA were 179.5 ± 39.5 and 175 ± 31.7. respectively. Paired student's t-test showed no statistical significance between the two groups. Coefficient of variation for diameter calculation and velocity measurement was <10%. Conclusion The peak systolic velocities in normal children at the superior mesenteric artery and celiac artery are slightly greater than in normal adults but it did not exceed 200 cm/sec in CA and 275 cm/sec in SMA. The Doppler waveforms are still within normal range in both groups despite the caliber of the vessels being smaller in children. Most probably greater velocities in children are caused by the high pressure of the transducer in superficially located vessel inducing flow disturbances.

Recently, the Centers for Medicare & Medicaid Services announced its decision to review “potentially misvalued” Current Procedural Terminology (CPT) codes, including those for primary total knee arthroplasty (TKA). CPT 27447 is being reevaluated to determine contemporary relative value units for work value, with operative time considered a primary factor in this revaluation. Despite broader indications for TKA, including extension of the procedure to more complex patient populations, it is unknown whether operative times may remain stable in the future. Therefore, the purpose of this study was to specifically evaluate future trends in TKA operative times across a large sample from a national database. The American College of Surgeons National Surgical Quality Improvement Project database was queried from January 1, 2008 to December 31, 2017 to identify 286,816 TKAs using the CPT code 27447. Our final analysis included 140,890 TKAs. Autoregressive integrated moving average forecasting models were built to predict 2- and 10-year operative times. While operative times were significantly different between American Society of Anesthesiologists (ASA) classes 1 and 2 (p = 0.035), there were not enough patients in ASA class 1 to perform rigorous inference. Additionally, operative times were not significantly different between ASA classes 3 and the combined ASA classes 4 and 5 cohort (p = 0.95). Therefore, we were only able to perform forecasts for ASA classes 2 and 3. Operative time was found to be nonstationary for both ASA class 2 (p = 0.08269) and class 3 (p = 0.2385). As a whole, the projection models indicated that operative time will remain within 2 minutes of the present operative time, up to the year 2027. Our projections indicate that operative times will remain stable over the next decade. This suggests that there is a lack of evidence for reducing the valuation of CPT code 27477 based on intraservice time for TKA. Further study should examine operative time trends in the setting of evolving alternative payment models, increasing patient complexity, and governmental restrictions.

Case: We report a case of a 77-year-old man, with bilateral below-knee amputee, in whom the anterior approach (AA) for a left total hip arthroplasty was used successfully, with 3-year follow-up. This report also summarizes the key studies in the literature on this subject. Conclusions: The utility of AA surgery performed in the setting of bilateral below-knee amputation has not been previously described. We describe the surgical technique, including considerations and pearls in the amputee population, and particular technical tips related to the use of a fracture table and thin-wire femoral traction for optimum control of the residual limb.

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