Cytoreductive Surgery in Combination with HIPEC in the Treatment of Peritoneal Sarcomatosis

Abstract

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective treatment for peritoneal carcinomatosis, but it has been debated for peritoneal sarcomatosis. The purpose of the study is the presentation of perioperative and long-term results of CRS and hyperthermic intraoperative intraperitoneal chemotherapy in patients with peritoneal sarcomatosis. Retrospective study in a prospectively maintained database of 20 patients that underwent 29 CRS + HIPEC for peritoneal sarcomatosis. Clinical and histopathologic variables were correlated to survival. Complete cytoreduction was possible in 86.2% of the cases. The hospital mortality and morbidity rate were 0 and 20.7%, respectively. The median follow-up was 26 months, and recurrence was recorded in 20 cases (69%). The median and 5-year survival was 55 ± 13 (34–58) months and 43%, respectively. Prior surgical score (PSS) was the single variable related to survival (p = 0.018). The histologic subtype of the tumor was related to recurrence (p < 0.001). CRS and HIPEC in peritoneal sarcomatosis may offer a survival benefit in selected patients with low hospital mortality. The variety of histologic types of sarcomatosis has not made possible the identification of subgroups of patients that may be offered significant benefit by CRS and HIPEC. Further studies are required.

https://ift.tt/2KDqJ0V

Different Presentations of Five Rare Cases of Sclerosing Stromal Tumor of the Ovary

Abstract

A rare subtype of preceding neoplasm of ovary is sclerosing stromal cell tumor with few presented cases in the literature. In these case series, we describe five cases of ovarian sclerosing stromal cell tumor with different presentations in our department. Interestingly, one of our cases had elevated alfa-fetoprotein.

https://ift.tt/2IymFCE

Budding and tumor infiltrating lymphocytes – combination of both parameters predicts survival in colorectal cancer and leads to new prognostic subgroups

Tumor budding is an independent prognostic factor in colorectal cancer (CRC) and has recently been well defined by the International Concensus Conference on Tumor Budding (ITBCC). Tumor infiltrating lymphocytes (TILs) are also an issue in different human cancers and correlate with prognosis in CRC.Here we evaluate the combination of budding and TILs in CRC with regard to prognosis.Hematoxylin and Eosin (H&E) stained slides of 501 CRC patients, diagnosed between 2005 and 2010 were reevaluated for tumor budding according to the ITBCC-criteria.

https://ift.tt/2rUYzH6

Clinicopathological characteristics of thyroid transcription factor 1-negative small cell lung cancers

Limitations in obtaining surgically resected or biopsy samples of small cell lung cancer (SCLC) tumors make comprehensive biological analyses difficult. The loss of thyroid transcription factor 1 (TTF-1) has been associated with the aggressive behavior of non-small cell lung cancer (NSCLC); however, clinicopathological features of TTF-1-negative SCLC remain unclear. This study aimed to elucidate the characteristics of TTF-1-negative SCLC. We studied the associations between the expression of TTF-1 and the clinicopathological factors associated with SCLC, including survival and expression of neuroendocrine markers (synaptophysin, chromogranin A, and CD56), neuroendocrine cell-specific transcription factors (achaete-scute homolog like 1 (ASCL1), BRN2), a proliferation marker (Ki-67 labeling index), and an oncogene (Nuclear Factor 1B (NF1B)).

https://ift.tt/2k9YDPF

Pathological significance and prognostic roles of densities of CD57+ cells, CD68+ cells, and mast cells, and their ratios in clear cell renal cell carcinoma

The immune system is closely associated with malignant behavior in renal cell carcinoma (RCC). Therefore, understanding the pathological roles of immune cells in tumor stroma is essential to discuss the pathological characteristics of RCC. In this study, the clinical significance of densities of CD57+ cells, CD68+ cells, and mast cells, and their ratios were investigated in patients with clear cell RCC. The densities of CD57+, CD68+, and mast cells were evaluated by immunohistochemical techniques in 179 patients.

https://ift.tt/2rUE3GE

Re-irradiation in gynecological cancers, present experiences and future hopes

Abstract

Objective

Treatment of recurrent diseases in patients with cervical or endometrial cancers after primary treatment by radiotherapy is challenging due to limitations of treatment options and success rates. Results are variable with contrasting outcomes and toxicities.

Methods

The authors reviewed all recent evidences and summarized the recent series of studies along with recent advancements and future possibilities.

Results

Surgical options were traditionally limited to extensive resections such as pelvic exenteration with or without intraoperative radiotherapy (IORT) or radical radiotherapy. IORT can be used as an adjunct to surgery in recurrent malignancies with positive margins. Recent interstitial brachytherapy (ISBT) studies for central recurrences have demonstrated a moderate 2 to 3 years local control of ~ 50%. Stereotactic body radiotherapy (SBRT) has also emerged as an attractive and apparently viable alternative, especially in treating relapsed nodes and pelvic sidewall disease, achieving 1- and 2-year local control rates of about 80 and 50%, respectively.

Conclusion

The results of salvage re irradiation are reasonable. More upcoming evidences and ongoing technological innovations will guide us in more effective retreatment and addition to life in this group of patients.

https://ift.tt/2Gz27UO

Response to “The combination therapy with cytapheresis plus vedolizumab in a corticosteroid-dependent patient with ulcerative colitis and previous Anti-TNF alfa failure” by Sáez-González and coworkers MariamAguas, José M.Huguet, PilarNos, Belén Beltrán

https://ift.tt/2KGAwTV

Rearing and Long-Term Maintenance of Eristalis tenax Hoverflies for Research Studies

The overall goal of these procedures is to establish, maintain and refresh a captive population of Eristalis tenax in a research setting.

https://ift.tt/2KCws7d

Collection and Processing of Lymph Nodes from Large Animals for RNA Analysis: Preparing for Lymph Node Transcriptomic Studies of Large Animal Species

This protocol provides an overview of procedures for the isolation of RNA for the transcriptomic profiling of lymph node tissues from large animals, including steps in the identification and excision of lymph nodes from livestock and wildlife, sampling approaches to provide consistency across multiple animals, and considerations plus representative results for the post-collection preservation and processing for RNA analysis.

https://ift.tt/2Gys32M

Production of Elastin-like Protein Hydrogels for Encapsulation and Immunostaining of Cells in 3D

Recombinant protein-engineered hydrogels are advantageous for 3D cell culture as they allow for complete tunability of the polymer backbone and therefore, the cell microenvironment. Here, we describe the process of recombinant elastin-like protein purification and its application in 3D hydrogel cell encapsulation.

https://ift.tt/2IuhljL

LncRNA MALAT-1 competitively regulates miR-124 to promote EMT and development of non-small-cell lung cancer

This study was carried out to explore the mechanism of LncRNA MALAT-1 as a competing endogenous RNA to regulate miR-124 in epithelial–mesenchymal transition and development of non-small-cell lung cancer (NSCLC). NSCLC and adjacent tissues were collected for RT-qPCR. The correlation of MALAT-1 and miR-124 was analyzed by Pearson. MALAT-1 expression was measured in NSCLC A549, NCI-H460, NCI-H529, SK-MES-1 cells, and 16HBE cells. A549 cells were selected for cell transfection experiments after the creation of six groups. Luciferase reporter assay and RNA immunoprecipitation were used to verify the relationship between MALAT-1 and miR-124. Expressions of E-cadherin and vimentin were determined by western blot. Cell variability, apoptosis, invasion, and migration were measured by MTT, FCM, transwell assay, and scratch test. LncRNA MALAT-1 expression was higher in NSCLC tissues than that in adjacent tissues, but a lower expression of miR-124 was detected in the former tissues than in the latter tissues. Compared with 16HBE cells, MALAT-1 was highly expressed in NSCLC tissues. Compared with the blank group, E-cadherin and cell apoptosis were increased, but vimentin, cell variability, cell invasion, and migration ability in the si-MALAT-1 and miR-124 mimics groups were reduced. Compared with the blank group, decreased E-cadherin and cell apoptosis and increased vimentin, cell variability, cell invasion, and migration ability were detected in the oe-MALAT-1 group. The oe-MALAT-1+miR-124 mimics group had increased E-cadherin and cell apoptosis, but decreased vimentin, cell variability, cell invasion, and migration ability in comparison with the oe-MALAT-1 group. By competitively regulating miR-124, MALAT-1 can promote epithelial–mesenchymal transition, thus accelerating the development of NSCLC. Correspondence to Lin Cai, MM, The School of Public Health, Fujian Medical University, Jiaotong Road, No. 88, Fuzhou 350001, People's Republic of China Tel/fax: +86 591 2286 2539; e-mail: cailin01010@163.com Received October 10, 2017 Accepted March 2, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Effect of pyruvate kinase M2-regulating aerobic glycolysis on chemotherapy resistance of estrogen receptor-positive breast cancer

This study aims to explore the effect and mechanism of pyruvate kinase M2 (PKM2) on chemotherapy resistance of estrogen receptor-positive breast cancer (ER+ BC) by regulating aerobic glycolysis. The expression of PKM2 in ER+ BC MCF-7 cells, T47D cells and MCF-7/ADR cells (which are subject to adriamycin/ADR induction) were determined by quantitative real-time PCR and western blot. MCF-7/ADR (M/A) cells were grouped into blank group (M/A), negative group (M/A+NC), low expression of PKM2 group (M/A+si-PKM2 group), overexpression of PKM2 group (M/A+PKM2 group) and glycolysis inhibition group (M/A+PKM2+2-DG group). Quantitative real-time PCR and western blot were applied to measure the expressions of PKM2, multidrug resistance, and glutathione-S-transferase π. Glucose and lactic acid kit was used to detect the amount of glucose uptake and lactic production. Cell variability, clone formation ability, and cell apoptosis were respectively measured by MTT, clone formation assay, and flow cytometry. Transwell assay and scratch assay were applied for cell invasion and migration ability. By overexpressing PKM2 in MCF-7 and T47D cells and using 2-DG, the effect on sensitivity of adriamycin amycin was explored. MCF-7/ADR cells have both elevated mRNA and protein expressions of PKM2 when compared with MCF-7 cells (both P

https://ift.tt/2IxqFU4

Renal Ewing sarcoma treated with apatinib

Renal Ewing sarcoma (RES) is an extremely rare disease. The standard treatment for this disease is lacking, and clinical experience needs to be accumulated. Here, we report a case of RES that rapidly developed to metastatic disease and was refractory to radiotherapy and chemotherapy; however, the case obtained a partial response based on Choi criteria by orally taking antiangiogenic drug apatinib. Our case suggests that apatinib may be a therapeutic option for RES. Correspondence to Ji-Yan Liu, MD, PhD, The State Key Laboratory of Biotherapy, Department of Medical Oncology, West China Medical School, Cancer Center, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu 610041, Sichuan Province, China Tel: +86 288 542 3262; fax: +86 288 542 3609; e-mail: liujiyan1972@163.com Received December 7, 2017 Accepted March 15, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2wVeQBP

Role of LKB1 in migration and invasion of Cr(VI)-transformed human bronchial epithelial Beas-2B cells

Hexavalent chromium [Cr(VI)] is a common human carcinogen associated with lung cancer and other pulmonary diseases as exposure to excessive Cr(VI) induces malignant transformation in human lung epithelial cells. The mechanism underlying its carcinogenicity is unclear in terms of how it facilitates metastases. Cr(VI) compounds are reported to briefly promote cell migration in a concentration-dependent manner and oncogene liver kinase B1 (LKB1) was reduced in Cr(VI)-transformed cells. Overexpression of LKB1 in Beas-2B-Cr [Cr(VI) malignantly transformed Beas-2B cells] suppressed cell migration and invasion and inactivated FAK, Src, MMP-2, GSK3β, β-catenin, and HEF1, which contribute to cell migration and invasion. Silencing LKB1 with siRNA promoted migration and invasion, and activated these downstream proteins. Long-term exposure to Cr(VI) enhanced the migration and invasiveness of Beas-2B cells and reduced the expression of LKB1, while activating these proteins as mentioned above. Data suggest that LKB1 may regulate downstream proteins such as FAK, Src, MMP-2, GSK3β, β-catenin, and HEF1, and affect the migration and invasiveness of Beas-2B-Cr cells. * Jian Lu and Zhongping Zhou contributed equally to the writing of this article. Correspondence to Jian Lu, PhD, Jiangsu University, No.301, Xuefu Road, Jingkou District, Zhenjiang, Jiangsu 212013, China Tel: +86 511 8878 8776; fax: +86 511 8879 1923; e-mail: lujian@ujs.edu.cn Correspondence to Zhanao Wu, MS, No. 359 Hospital, No.8, Zhongshan East Road, Zhenjiang, Jiangsu 212050, China Tel/fax: +86 511 8333 5901; e-mail: wza_007@qq.com Received November 10, 2017 Accepted April 9, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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An update on the management of pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PNETs) are a rare and heterogeneous group of neoplasia and differ in their clinical presentation, behavior, and prognosis based on both histological features and cancer stage at the time of diagnosis. Although small-sized tumors can be surgically resected, locally advanced and metastatic tumors confer a poor prognosis. In addition, only limited treatment options are available to the latter group of patients with PNETs, such as hormonal analogs, cytotoxic agents, and targeted therapy. In selected patients, liver-directed therapies are also used. As expected, clinicians taking care of these patients are challenged to develop an effective and comprehensive treatment strategy for their patients amid a wide variety of treatment modalities. Targeted therapy for PNETs is limited to sunitinib and everolimus. Presently, a number of clinical studies are ongoing to assess the efficacy of newer targeted agents alone and in combination with previous agents for the treatment of advanced PNETs. The authors reviewed the current treatment and also discussed the emerging agents and emphasized the need to identify biomarkers. Correspondence to Muhammad W. Saif, MBBS, MD, Department of Medicine and Cancer Center, Tufts Medical Center, 800 Washington Street Box 245, Boston, MA 02111, USA Tel: +1 617 636 5627; fax: +1 617 636 8535; e-mail: wsaif@tuftsmedicalcenter.org Received January 23, 2018 Accepted March 23, 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Specificity of action selection modulates the perceived temporal order of action and sensory events

Abstract

The perceived temporal order of actions and changes in the environment is crucial for our inferences of causality. Sensory events presented shortly after an action are more likely considered as self-generated compared to the same events occurring before action execution. However, the estimation of when an action or a sensory change occurred is a challenge for the human brain. This estimation is formed from available sensory information combined with internal representations. Researchers suggested that internal signals associated with action preparation drive our awareness of initiating an action. This study aimed to directly investigate this hypothesis. Participants performed a speeded action (left or right key-press) in response to a go-signal (left or right arrow). A flash was presented at different time points around the time of the action, and participants judged whether it was simultaneous with the action or not. To investigate the role of action preparation in time perception, we compared trials where a cue indicated which action to perform in response to a later go signal presentation, and trials with a neutral cue where participants did not know until the time of the go signal which action to perform. We observed that a flash presented before the action was reported as simultaneous with the action more frequently when actions were cued than when they were uncued. This difference was not observed when the action was replaced by a tactile stimulation. These results indicate that precued actions are experienced earlier in time compared to unprepared actions. Further, this difference is not due to mere non-motor expectation of an event. The experience of initiating an action is driven by action preparation process: when we know what to do, actions are perceived ahead of time.

https://ift.tt/2Is8oay

Prevalence of self-reported symptoms of sexually transmitted infections, knowledge and sexual behaviour among youth in semi-rural Tanzania in the period of adolescent friendly health services strategy implementation

Global evidence shows that sexually transmitted infections (STIs) prevalence and sexual risk behaviours are high among youth, and knowledge about STIs is low. In Tanzania, there is limited recent evidence rega...

https://ift.tt/2IwQIdQ

Primary bacterial ventriculitis in adults, an emergent diagnosis challenge: report of a meningoccal case and review of the literature

Defined by an infection of the ventricular system of the brain, ventriculitis is usually known as a health-care associated infection. In contrast, primary pyogenic ventriculitis complicating community-acquired...

https://ift.tt/2wWM1oj

Linking young men who have sex with men (YMSM) to STI physicians: a nationwide cross-sectional survey in China

Many young men who have sex with men (YMSM) are reluctant to seek health services and trust local physicians. Online information seeking may encourage YMSM to identify and see trustworthy physicians, obtain se...

https://ift.tt/2IwLwXF

Molecular identification of tick-borne pathogens in asymptomatic individuals with human immunodeficiency virus type 1 (HIV-1) infection: a retrospective study

The studies on the occurrence and diversity of tick-borne infections in HIV-infected individuals have been few, and the subject has been relatively neglected when compared with other common infections associat...

https://ift.tt/2wS9mru

Frozen in Time: A History of the Synthesis of Nitrous Oxide and How the Process Remained Unchanged for Over 2 Centuries

Three major factors have contributed to the unrivaled popularity of nitrous oxide (N2O) among anesthetists in the 20th century and beyond: its impressive safety profile, its affordability, and its rapid induction and emergence times. These 3 characteristics of N2O have been discussed and written about extensively throughout the medical literature. Nonetheless, the characteristic that contributed most to N2O's initial discovery—the elegance and simplicity of its synthesis—has received substantially less attention. Although N2O was first used as an anesthetic in Hartford, CT, in 1844, it had been identified and synthesized as a distinct gas in the late 18th century. In this article, we track the developments in the recognition and early synthesis of N2O, highlight the major players credited with its discovery, and examine its evolution from the late 1700s to today. The discovery and assimilation of N2O into common medical practice, alongside ether and chloroform, heralded a new paradigm in surgical medicine—one that no longer viewed pain as a fundamental component of surgical medicine. Its continued usage in modern medicine speaks to the brilliance and skill of the chemists and scientists involved in its initial discovery. Accepted for publication March 30, 2018. Funding: Intramural. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Manisha S. Desai, MD, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655. Address e-mail to manisha.desai@umassmemorial.org. © 2018 International Anesthesia Research Society

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In Response

No abstract available

https://ift.tt/2GxtPRG

Is Neuraxial Anesthesia Appropriate for Cesarean Delivery in All Cases of Morbidly Adherent Placenta?

No abstract available

https://ift.tt/2ItKU4N

Understanding Conflict Management Styles in Anesthesiology Residents

BACKGROUND: Successful conflict resolution is vital for effective teamwork and is critical for safe patient care in the operating room. Being able to appreciate the differences in training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing various clinical and professional scenarios. The goal of this study was to assess conflict styles in anesthesiology residents via self- and counterpart assessment during participation in simulated conflict scenarios. METHODS: Twenty-two first-year anesthesiology residents (first postgraduate year) participated in this study, which aimed to assess and summarize conflict management styles by 3 separate metrics. One metric was self-assessment with the Thomas-Kilmann Conflict Mode Instrument (TKI), summarized as percentile scores (0%–99%) for 5 conflict styles: collaborating, competing, accommodating, avoiding, and compromising. Participants also completed self- and counterpart ratings after interactions in a simulated conflict scenario using the Dutch Test for Conflict Handling (DUTCH), with scores ranging from 5 to 25 points for each of 5 conflict styles: yielding, compromising, forcing, problem solving, and avoiding. Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. Sign tests were used to compare self- and counterpart ratings on the DUTCH scores, and Spearman correlations were used to assess associations between TKI and DUTCH scores. RESULTS: On the TKI, the anesthesiology residents had the highest median percentile scores (with first quartile [Q1] and third quartile [Q3]) in compromising (67th, Q1–Q3 = 27–87) and accommodating (69th, Q1–Q3 = 30–94) styles, and the lowest scores for competing (32nd, Q1–Q3 = 10–57). After each conflict scenario, residents and their counterparts on the DUTCH reported higher median scores for compromising (self: 16, Q1–Q3 = 14–16; counterpart: 16, Q1–Q3 = 15–16) and problem solving (self: 17, Q1–Q3 = 16–18; counterpart: 16, Q1–Q3 = 16–17), and lower scores for forcing (self: 13, Q1–Q3 = 10–15; counterpart: 13, Q1–Q3 = 13–15) and avoiding (self: 14, Q1–Q3 = 10–16; counterpart: 14.5, Q1–Q3 = 11–16). There were no significant differences (P > .05) between self- and counterpart ratings on the DUTCH. Overall, the correlations between TKI and DUTCH scores were not statistically significant (P > .05). CONCLUSIONS: Findings from our study demonstrate that our cohort of first postgraduate year anesthesiology residents predominantly take a more cooperative and problem-solving approach to handling conflict. By understanding one's dominant conflict management style through this type of analysis and appreciating the value of other styles, one may become better equipped to manage different conflicts as needed depending on the situations. Accepted for publication April 4, 2018. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Brenda G. Fahy, MD, MCCM, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100254, Gainesville, FL 32610. Address e-mail to bfahy@anest.ufl.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2wVuZqS

Hagberg and Benumof’s Airway Management, 4th ed

No abstract available

https://ift.tt/2IzL9f2

Surveying the Literature: Synopsis of Recent Key Publications

No abstract available

https://ift.tt/2wVuQDQ

Perioperative Management in Robotic Surgery, 1st ed

No abstract available

https://ift.tt/2ItKGdX

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public–private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses. Accepted for publication March 5, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). The views expressed in this article are those of the authors, none of whom has financial conflicts of interest specifically related to the issues discussed. At the time of the meeting (November 17–19, 2016) on which this article is based, several authors were employed by a pharmaceutical company or had received consulting fees or honoraria from 1 or more pharmaceutical or device companies. The authors of this article who were not employed by industry at the time of the meeting received (or their universities received) travel stipends, hotel accommodations, and meals during the meeting from the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public–private partnership. No official endorsement by the US Food and Drug Administration or the pharmaceutical and device companies that have provided unrestricted grants to support the activities of ACTTION should be inferred. Financial support for this project was provided by ACTTION, which has received research contracts, grants, or other revenue from the US Food and Drug Administration, multiple pharmaceutical and device companies, philanthropy, and other sources. Reprints will not be available from the authors. Address correspondence to Denham S. Ward, MD, PhD, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 604, Rochester, NY 14642. Address e-mail to Denham_Ward@URMC.Rochester.edu. © 2018 International Anesthesia Research Society

https://ift.tt/2wTKVK5

The Impact of Anesthesia-Influenced Process Measure Compliance on Length of Stay: Results From an Enhanced Recovery After Surgery for Colorectal Surgery Cohort

BACKGROUND: Process measure compliance has been associated with improved outcomes in enhanced recovery after surgery (ERAS) programs. Herein, we sought to assess the impact of compliance with measures directly influenced by anesthesiology in an ERAS for colorectal surgery cohort. METHODS: From January 2013 to April 2015, data from 1140 consecutive patients were collected for all patients before (pre-ERAS) and after (ERAS) implementation of an ERAS program. Compliance with 9 specific process measures directly influenced by the anesthesiologist or acute pain service was analyzed to determine the impact on hospital length of stay (LOS). RESULTS: Process measure compliance was associated with a stepwise reduction in LOS. Patients who received >4 process measures (high compliance) had a significantly shorter LOS (incident rate ratio [IRR], 0.77; 95% CI, 0.70–0.85); P

https://ift.tt/2ItKtrb

Population Pharmacokinetics and Pharmacodynamics of Dexmedetomidine in Children Undergoing Ambulatory Surgery

BACKGROUND: Dexmedetomidine (DEX) is an α-2 adrenergic agonist with sedative and analgesic properties. Although not approved for pediatric use by the Food and Drug Administration, DEX is increasingly used in pediatric anesthesia and critical care. However, very limited information is available regarding the pharmacokinetics of DEX in children. The aim of this study was to investigate DEX pharmacokinetics and pharmacodynamics (PK–PD) in Mexican children 2–18 years of age who were undergoing outpatient surgical procedures. METHODS: Thirty children 2–18 years of age with American Society of Anesthesiologists physical status score of I/II were enrolled in this study. DEX (0.7 µg/kg) was administered as a single-dose intravenous infusion. Venous blood samples were collected, and plasma DEX concentrations were analyzed with a combination of high-performance liquid chromatography and electrospray ionization-tandem mass spectrometry. Population PK–PD models were constructed using the Monolix program. RESULTS: A 2-compartment model adequately described the concentration–time relationship. The parameters were standardized for a body weight of 70 kg by using an allometric model. Population parameters estimates were as follows: mean (between-subject variability): clearance (Cl) (L/h × 70 kg) = 20.8 (27%); central volume of distribution (V1) (L × 70 kg) = 21.9 (20%); peripheral volume of distribution (V2) (L × 70 kg) = 81.2 (21%); and intercompartmental clearance (Q) (L/h × 70 kg) = 75.8 (25%). The PK–PD model predicted a maximum mean arterial blood pressure reduction of 45% with an IC50 of 0.501 ng/ml, and a maximum heart rate reduction of 28.9% with an IC50 of 0.552 ng/ml. CONCLUSIONS: Our results suggest that in Mexican children 2–18 years of age with American Society of Anesthesiologists score of I/II, the DEX dose should be adjusted in accordance with lower DEX clearance. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication March 27, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Gustavo Lugo-Goytia, PhD, Departamento de Anestesiología y Medicina Crítica, Instituto Nacional de Ciencias Médicas y Nutrición, México; and Respiratory Intensive Care Unit, Instituto Nacional de Enfermedades Respiratorias, México. Address e-mail to lugogoy@yahoo.com.mx. © 2018 International Anesthesia Research Society

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Benefit and Harm of Adding Epinephrine to a Local Anesthetic for Neuraxial and Locoregional Anesthesia: A Meta-analysis of Randomized Controlled Trials With Trial Sequential Analyses

BACKGROUND: This systematic review examines the benefit and harm of adding epinephrine to local anesthetics for epidural, intrathecal, or locoregional anesthesia. METHODS: We searched electronic databases to October 2017 for randomized trials comparing any local anesthetic regimen combined with epinephrine, with the same local anesthetic regimen without epinephrine, reporting on duration of analgesia, time to 2 segments regression, or any adverse effects. Trial quality was assessed using the Cochrane risk of bias tool and a random-effects model was used. Trial sequential analyses (TSA) were applied to identify the information size (IS; number of patients needed to reach a definite conclusion) and were set to detect an increase or decrease of effect of 30%–50%, depending on the end point considered. Alpha levels were adjusted (1%) for multiple outcome testing. RESULTS: We identified 70 trials (3644 patients, 17 countries, from 1970 to 2017). Median number of patients per trial was 44 (range, 9–174). Thirty-seven trials (1781 patients) tested epinephrine for epidural, 27 (1660) for intrathecal, and 6 (203) for locoregional anesthesia (sciatic, femoral, popliteal, axillary blocks). TSA enabled us to conclude that adding epinephrine to epidural local anesthetics could not decrease postoperative pain intensity by 30%, and did not impact the risk of intraoperative arterial hypotension. IS was insufficient to conclude on the impact of epinephrine on the risk of motor block (IS, 4%), arterial hypotension (20%), urinary retention (23%), or pain intensity at rest (27%) during labor. TSA confirmed that adding epinephrine to intrathecal local anesthetics increased the duration of motor block (weighted mean difference [WMD] 64 minutes; 99% CI, 37–91), analgesia (WMD 34 minutes; 99% CI, 6–62), and the time to 2 segments regression (WMD 20 minutes; 99% CI, 11–28). IS was insufficient to conclude on its impact on arterial hypotension (IS, 15%), or when administrated in a combined spinal-epidural, on motor block (IS, 11%) or arterial hypotension (IS, 11%). Adding epinephrine to local anesthetics for a locoregional block increased the duration of analgesia (WMD 66 minutes; 98% CI, 32–100]). CONCLUSIONS: Adding epinephrine to intrathecal or locoregional local anesthetics prolongs analgesia and motor block by no more than 60 minutes. The impact of adding epinephrine to epidural local anesthetics or to a combined spinal-epidural remains uncertain. Accepted for publication March 27, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Protocol registration: International prospective register of systematic reviews (PROSPERO) (CRD: 42015026148). Reprints will not be available from the authors. Address correspondence to Clément Tschopp, MD, MSc, Division of Anesthesiology, University Hospital of Zürich, Rämistrasse 100, Zürich CH-8091, Switzerland. Address e-mail to clement.tschopp@usz.ch. © 2018 International Anesthesia Research Society

https://ift.tt/2KDZseY

Surgical Labyrinthectomy of the Rat to Study the Vestibular System

This protocol describes the surgical labyrinthectomy of a rat, which is a useful method for studying the vestibular system.

https://ift.tt/2KEt3ES

Using Human Induced Pluripotent Stem Cell-derived Hepatocyte-like Cells for Drug Discovery

The protocol presented here describes a platform for identifying small molecules for the treatment of liver disease. A step-by-step description is presented detailing how to differentiate iPSCs into cells with hepatocyte characteristics in 96-well plates, and to use the cells to screen for small molecules with potential therapeutic activity.

https://ift.tt/2LgDShM

GLP-I secretion in healthy and diabetic Wistar rats in response to aqueous extract of Momordica charantia

Diabetes mellitus is one of the major global health disorders increasing at an alarming rate in both developed and developing countries. The objective of this study was to assess the effect of aqueous extract of

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Neoadjuvant Interdigitated Chemoradiotherapy Using Mesna, Doxorubicin, and Ifosfamide for Large, High-grade, Soft Tissue Sarcomas of the Extremity: Improved Efficacy and Reduced Toxicity

Objectives: Patients with large, high-grade extremity soft tissue sarcoma (STS) are at high risk for both local and distant recurrence. RTOG 95-14, using a regimen of neoadjuvant interdigitated chemoradiotherapy with mesna, doxorubicin, ifosfamide, and dacarbazine followed by surgery and 3 cycles of adjuvant mesna, doxorubicin, ifosfamide, and dacarbazine, demonstrated high rates of disease control at the cost of significant toxicity (83% grade 4, 5% grade 5). As such, this regimen has not been widely adopted. Herein, we report our institutional outcomes utilizing a modified interdigitated chemoradiotherapy regimen, without dacarbazine, and current radiotherapy planning and delivery techniques for high-risk STS. Materials and Methods: Adults with large (≥5 cm; median, 12.9 cm), grade 3 extremity STS who were prospectively treated as part of our institutional standard of care from 2008 to 2016 are included. Neoadjuvant chemoradiotherapy consisted of 3 cycles of mesna, doxorubicin, and ifosfamide (MAI) and 44 Gy (22 Gy in 11 fractions between cycles of MAI) after which patients underwent surgical resection and received 3 additional cycles of MAI. Results: Twenty-six patients received the MAI treatment protocol. At a median follow-up of 47.3 months, 23 (88.5%) patients are still alive. Three year locoregional recurrence-free survival, disease-free survival, and overall survival are 95.0%, 64.0%, and 95.0%, respectively. There have been no therapy-related deaths or secondary malignancies. The nonhematologic grade 4 toxicity rate was 7.7%. Conclusions: Neoadjuvant interdigitated MAI radiotherapy followed by resection and 3 cycles of adjuvant MAI has resulted in acceptable and manageable toxicity and highly favorable survival in patients at greatest risk for treatment failure. M.C. and N.S. contributed equally. Portions of this work were presented as an oral presentation at the American Society for Radiation Oncology (ASTRO) 2016 Annual Meeting in Boston, MA. The authors declare no conflicts of interest. Reprints: Mudit Chowdhary, MD, Rush University Medical Center, Department of Radiation Oncology, 500 South Paulina, Chicago, IL 60612. E-mail: mchowdharymd@gmail.com. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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BRCA1 Mutations Associated With Increased Risk of Brain Metastases in Breast Cancer: A 12 Matched-pair Analysis

Background: Brain metastases (BM) occur in ∼5% of breast cancer patients. BRCA1-associated cancers are often basal-like and basal-like cancers are known to have a predilection for central nervous system metastases. We performed a matched-pair analysis of breast cancer patients with and without BRCA mutations and compared the frequency of BM in both groups. Materials and Methods: From a database of 1935 patients treated for localized breast cancer at our institution from 2009 to 2014 we identified 20 patients with BRCA1 or BRCA2 mutations and manually matched 40 patients without BRCA mutations accounting for age, stage, estrogen receptor expression, and human epidermal growth factor receptor 2 (HER2) expression. Comparisons of freedom from brain metastasis, brain metastasis-free survival, and overall survival were made using the log rank test. Testing for a basal-type phenotype using the immunohistochemistry definition (ER−/PR−/HER2− and either CK 5/6+ or EGFR+) was performed for BRCA+ patients who developed BM and their matched controls. Results: We analyzed 60 patients: 20 BRCA+ and 40 were matched controls. Median follow-up was 37 and 49 months, respectively. Three years freedom from brain metastasis was 84% for BRCA+ patients and 97% for BRCA− controls (P=0.049). Three years brain metastasis-free survival was 84% and 97% for the BRCA+ and controls, respectively (P=0.176). Mean time to brain failure was 11 months from diagnosis for the BRCA+ patients. All 3 BRCA1+ patients who developed BM were of a basal-type triple negative phenotype. Conclusions: Breast cancer patients with germline BRCA1 mutations appear to have a shorter interval to brain progression while accounting for confounding factors. The authors declare no conflicts of interest. Reprints: Peter J. Zavitsanos, MD, Department of Radiation Oncology, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. E-mail: peter.zavitsanos@lifespan.org. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

https://ift.tt/2KCVyTr

A Phase II Study of Celecoxib With Irinotecan, 5-Fluorouracil, and Leucovorin in Patients With Previously Untreated Advanced or Metastatic Colorectal Cancer

Objective: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Cyclooxygenase-2 (COX-2) overexpression is associated with increased tumor invasiveness and proliferation in CRC, and COX-2 inhibition has demonstrated chemopreventive activity. This study investigated the addition of celecoxib, a selective COX-2 inhibitor, to the irinotecan, 5-fluorouracil, and leucovorin (IFL) regimen for patients with previously untreated metastatic CRC. Patients and Methods: Forty-seven patients enrolled in this single-arm phase II study received celecoxib at 400 mg orally twice daily in combination with weekly irinotecan (125 mg/m2), 5-fluorouracil (500 mg/m2), and leucovorin (20 mg/m2) for 4 weeks every 6 weeks. The primary endpoint was response rate (RR) as measured by Response Evaluation Criteria in Solid Tumors. The protocol was amended midway to additionally exclude patients with Eastern Cooperative Oncology Group performance status 2 and require all patients with specific cardiovascular risk factors to take daily aspirin (81 mg). Results: The objective RR was 31.9% (95% confidence interval [CI], 19%-47%). Median progression-free survival was 8.7 months (95% CI, 5.8-10.6), and the median overall survival was 19.7 months (95% CI, 15.4-22.8). All cardiac events were observed before protocol modification. The median overall survival before and after protocol modification was 11.4 versus 24.2 months, respectively (P

https://ift.tt/2Lck2nI

The Significance of Para-Aortic Nodal Size and the Role of Adjuvant Systemic Chemotherapy in Cervical Cancer: An Institutional Experience

Objective: Cervical cancer metastatic to the para-aortic lymph nodes (PALNs) carries a poor prognosis. Despite extended-field radiation therapy (EFRT), only 30% to 50% of patients will survive 3 years. We sought to examine the treatment regimens used, associated toxicities, and treatment outcomes in patients with cervical cancer metastatic to PALN. Methods: A retrospective review was performed of all patients with cervical cancer treated at a single institution between January 1, 2007 and November 1, 2014. Included patients had PALN metastases as the most distant site of disease, and all treatment plans were designated as curative. Excluded patients had other distant disease or treatment plans considered palliative. Standard treatment consisted of EFRT with concurrent platinum-based chemotherapy. Results: Fifty-one of 344 patients (14.8%) fulfilled the inclusion criteria. The median age was 48.4 years. Forty-four patients received standard EFRT; 7 also received adjuvant platinum/taxane chemotherapy. Thirty-nine of 51 (76%) of patients achieved a complete response to primary treatment. Twelve of 51 (24%) had persistent disease or progression at the completion of treatment. Of responders, 15 of 39 (38%) recurred for an overall treatment failure rate of 27 of 51 (53%). Nineteen of 27 (70%) of treatment failures occurred outside the radiated field. Adjuvant chemotherapy following EFRT was not predictive of progression-free survival or overall survival. PALN diameter ≥1 cm was a significant negative prognostic indicator for overall survival. Conclusions: Over half of patients with cervical cancer metastatic to the PALN failed extended-field chemoradiation. Most failures occurred outside the radiated field suggesting PALN involvement is a surrogate marker of systemic disease. These findings underscore the need for effective systemic therapy, especially in patients with PALN ≥1 cm in size. The authors declare no conflicts of interest. Reprints: Travis T. Sims, MD, 5323 Harry Hines Blvd., Dallas, TX 75390-9032. E-mail: travis.sims@phhs.org. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Breast-conservation Therapy After Neoadjuvant Chemotherapy Does Not Compromise 10-Year Breast Cancer–specific Mortality

Objectives: Neoadjuvant chemotherapy can increase the rate of breast-conserving surgery by downstaging disease in patients with breast cancer. The aim of this study was to determine whether patients who received neoadjuvant chemotherapy have equal survival after breast-conservation therapy compared with mastectomy. Material and Methods: Using the New Jersey State Cancer Registry (NJSCR) patients with a primary breast cancer diagnosed between 1998 and 2003 who underwent neoadjuvant chemotherapy were selected (n=1,468). Of those, only patients who received lumpectomy plus radiation (n=276) or mastectomy without radiation (n=442) were included in the analysis. The main outcome measured included 10-year breast cancer–specific mortality, with 90% of patients with known vital status through the end of 2011. Results: Baseline characteristics did not differ significantly between the breast-conservation and mastectomy without radiation groups except with respect to summary stage and lymph node involvement. After propensity score matching these differences were no longer statistically significant; however, both estrogen and progesterone status achieved statistical significance. The Kaplan-Meier survival curve showed that the breast-conservation group had significantly higher breast cancer–specific survival than the mastectomy group (P=0.0046). After adjusting for the propensity score in the regression model, the breast-conservation group continued to show significantly better survival than the mastectomy group (hazard ratios, 0.46; 95% confidence interval, 0.27-0.78). Conclusions: This study is consistent with previous research showing that breast-conserving surgery after neoadjuvant chemotherapy does not reduce breast cancer–specific survival. In fact, patients undergoing breast-conservation after neoadjuvant therapy appeared to have better survival than patients undergoing mastectomy without radiation. Cancer data used in this study were provided by the New Jersey State Cancer Registry, Cancer Epidemiology Services, New Jersey Department of Health, which is funded by the Surveillance, Epidemiology and End Results (SEER) Program of the National Cancer Institute under contract HHSN261201300021I, the National Program of Cancer Registries (NPCR), Centers for Disease Control and Prevention under grant 5U58DP003931-02 as well as the State of New Jersey and the Rutgers Cancer Institute of New Jersey. The authors declare no conflicts of interest. Reprints: Renee L. Arlow, MD, Department of Surgery, Rutgers Robert Wood Johnson Medical School, 51 French Street, MEB 596, P.O. Box 19, New Brunswick, NJ 08901. E-mails: renee.arlow@gmail.com; renee.arlow@uphs.upenn.edu. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Regional Lymph Node Metastases in Groin Sarcomas: A Diagnostic and Therapeutic Challenge

Introduction: The evaluation of lymph nodes and the role of groin dissection for groin sarcomas has been controversial where there have not been previous studies or guidelines published. In this study, we aim to first formulate a clinical approach in the evaluation of regional lymph nodal metastases. Second, we aim to also evaluate the role of regional lymphadenectomy in the setting of pathologically involved regional lymph nodes for groin sarcomas. Materials and Methods: In total, 43 consecutive patients with groin sarcomas underwent treatment at the National Cancer Centre Singapore between 2002 and 2015. Univariate comparisons were performed using the log-rank test. A Cox multivariate analysis was performed for disease-specific survival to identify independent prognostic factors. Results: The median disease-free survival was 18 months (range, 1 to 180 mo). The median overall survival (OS) was 28 months (range, 3 to 180 mo). In total, 28 patients underwent a groin dissection. Of the 28 patients who underwent groin dissections, 15 had negative lymph node involvement, 7 had positive lymph node involvement and 6 had lymphovascular invasion. On univariate analysis, grade (P=0.047) and clinical and/or radiological involvement (P=0.039) were significant for regional lymph nodal metastases. The 5-year OS for patients with positive lymph nodes was 31%. Conclusions: Our study suggests that the evaluation of lymph nodes via groin dissections in groin sarcomas in the Asian population should be based primarily on clinical and radiologic evidence. Regional lymph node dissection seems to confer OS benefit in patients with these high-risk tumors and can improve local control of disease. The authors declare no conflicts of interest. Reprints: Melissa Ching Ching Teo, MBBS, FRCS, Division of Surgical Oncology, National Cancer Centre, 11 Hospital Drive, Singapore 169610, Singapore. E-mail: melissa.teo.c.c@singhealth.com.sg. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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The Utility of Diagnostic Laparoscopy in Patients Being Evaluated for Cytoreductive Surgery and Hyperthermic Peritoneal Chemotherapy

Background: To assess the role of diagnostic laparoscopy (DL) to evaluate candidates for optimal cytoreduction surgery of peritoneal carcinomatosis (PC) combined with hyperthermic intraperitoneal chemotherapy in a consecutive series. Methods: The characteristics of 31 patients undergoing DL between August 2012 and October 2016 for a diagnosis of PC secondary to digestive neoplasms were retrospectively reviewed. Results: Laparoscopic evaluation was successful and well-tolerated in 100% patients (N=31). In 17 patients (54.8%) the PC was deemed unresectable. A cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy was performed in 10 of 12 patients with PC considered resectable at laparoscopy wity a positive predictive value of 83.3%. One patient was diagnosed with more extensive disease than that as assessed by the DL at the time of laparotomy and 1 patient elected not to have further surgery. There were no port-site recurrences and morbidity at mean follow-up of 19.3 months. Conclusions: Laparoscopic assessment of PC is a useful tool to assess the complete resectability of peritoneal surface disease in patients for whom there is inadequate information concerning disease extent. DL also helps selected patients to avoid an unnecessary laparotomy. The authors declare no conflicts of interest. Reprints: Alessio Pigazzi, MD, PhD, 333 City Blvd West, Suite 850, Orange, CA 92868. E-mail: apigazzi@uci.edu. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Utilization of an Alternative Docetaxel-based Intraperitoneal Chemotherapy Regimen in Patients With Ovarian, Fallopian Tube or Primary Peritoneal Carcinoma: A Continued Need for Ovarian Cancer Patients

Objective: The objective of this study was to report the tolerability and toxicity of a regimen consisting of intravenous (IV) docetaxel and intraperitoneal (IP) cisplatin and paclitaxel with granulocyte colony-stimulating factor support. Materials and Methods: We conducted a retrospective cohort study of patients with surgical stage II-IV epithelial ovarian, fallopian tube or primary peritoneal carcinoma treated with an outpatient IP chemotherapy regimen consisting of docetaxel 75 mg/m2 IV and cisplatin 75 mg/m2 IP day 1 followed by paclitaxel 60 mg/m2 IP day 8 every 21 days. Grade 3 and 4 toxicity, dose delays and reductions, port complications, and tolerability are reported. Outcomes, including response rate, progression-free survival (PFS), overall survival (OS) are also reported. Results: A total of 60 patients received this IP regimen. Most common toxicities included neutropenia (47%), gastrointestinal (28%), and anemia (25%). Most patients (85%) experienced no IP port complications. Dose delay or reduction was required in 30% of patients. Two-thirds completed all prescribed cycles, with 80% of total planned cycles completed. Complete response was achieved for 88%, and 43% are currently without evidence of disease. Median PFS for all patients was 25.5 months (95% confidence interval [CI], 20.4-30.5 mo) while OS for all patients was 56.8 months (95% CI, 47.7-65.9 mo). For the 44 patients with stage III disease, median PFS was 22.1 months (95% CI, 16.3-28.0 mo), while median OS was 56.8 months (95% CI, 47.3-66.3 mo). Conclusions: This docetaxel-based IP chemotherapy regimen demonstrates an improved tolerability profile compared with GOG172. Additional evaluations on alternative IP regimens remain warranted. Short follow-up time limits survival assessment, but results are encouraging. Presented as a poster presentation at the Society of Gynecologic Oncology Annual Meeting on Women's Cancer, 2015, Chicago, IL. Supported in part by NIH 3P30CA013148-43S3 and 5K12HD0012580-15 to C.A.L. and K.S.B. The authors declare no conflicts of interest. Reprints: Charles A. Leath III, MD, MSPH, Division of Gynecologic Oncology, University of Alabama at Birmingham, 1700 6th Avenue South, Room 10250, Birmingham, AL 35233. E-mail: cleath@uabmc.edu. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Single-agent Bevacizumab in Recurrent Glioblastoma After Second-line Chemotherapy With Fotemustine: The Experience of the Italian Association of Neuro-Oncology

Objectives: Bevacizumab is an anti-vascular endothelial growth factor antibody used in the treatment of recurrent glioblastoma (GBM). Despite the large number of studies carried out in patients with recurrent GBM, little is known about the administration of this angiogenesis inhibitor after the failure of the second-line chemotherapy. Materials and Methods: In this retrospective multicenter study, on behalf of the Italian Association of Neuro-Oncology, we reported the results obtained in 51 patients with recurrent GBM treated with single-agent bevacizumab after the failure of second-line chemotherapy with fotemustine. Results: In March 2016, at the time of data analysis, 3 patients (14.4%) were still alive with stable disease, whereas 48 died due to disease progression. Kaplan-Meier estimated median survival from the diagnosis of GBM was 28 months (95% confidence interval [CI], 22.1-33.9 mo). Median survival measured from the beginning of fotemustine and bevacizumab therapy were 11.3 (95% CI, 8.4-13.6 mo) and 6 months (95% CI, 3.8-8.1 mo), respectively. The 6- and 12-month progression free survival rates from the beginning of bevacizumab treatment were 18% and 13%, respectively. Conclusions: On the basis of our data, in patients with recurrent GBM, the failure of a second-line chemotherapy with cytotoxic agents might not exclude the administration of bevacizumab as third-line chemotherapy. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed consent for treatments was obtained from all individual participants included in the study. The authors declare no conflicts of interest. Reprints: Francesco Pasqualetti, MD, PhD, Department of Oncology, Division of Radiation Oncology, Azienda Ospedaliero Universitaria Pisana, Via Roma 67, Pisa 56123, Italy. E-mails: francep24@hotmail.com, f.pasqualetti@ao-pisa.toscana.it. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis

We thank Jacques and colleagues for their critical appraisal of our manuscript.1 2 Although recurrence is a shortcoming of wide-field endoscopic mucosal resection (WF-EMR), it is typically unifocal, diminutive and its management does not add substantial cost beyond that of the surveillance colonoscopy. Our base case rate of 14.4% was determined from our large prospective WF-EMR cohort and is consistent with a recent meta-analysis (13.8%).3 We modelled recurrence rates following endoscopic submucosal dissection (ESD) that were six- to sevenfold lower and in line with the rates quoted by the French group. Our modelled assumptions reflect contemporary evidence and favour ESD given adjunctive thermal ablation of the post-EMR margin4 has been shown to reduce recurrence following WF-EMR to 5%–6% including for larger lesions.

ESD is a revolutionary procedure and likely to become more efficient, but is currently far more time and resource consuming than WF-EMR....

https://ift.tt/2KEkcDk

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

Objectives: To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral. Data Sources: Medline and Embase databases from January 2006 to September 2017. Study Selection: All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations. Data Extraction: Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers. Data Synthesis: One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported. Conclusions: Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation. This work was performed at The Ottawa Hospital Research Institute in Ottawa, ON, Canada. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). This study is part of the Canadian National Transplant Research Program and is supported, in part, by the Canadian Institutes of Health Research (Grant Number Transplantation Research - Full Application 127880). Drs. Squires', Coughlin's, Linklater's, Grimshaw's, and Knoll's institutions received funding from the Canadian Institutes of Health Research. Dr. Grimshaw received funding from Abbott Diagnostics Canada, Campbell Collaboration, Biomed Central, Canadian Patient Safety Institute, and National Health Service Education in Scotland. Dr. Shemie disclosed being the Medical Advisor, Deceased Donation for Canadian Blood Services. Dr. Dhanani disclosed being the research lead for Trillium Gift of Life Network. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: janet.squires@uottawa.ca Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

https://ift.tt/2wXEpSw

Inhibition of Vascular Endothelial Cell Leak Following Escherichia coli Attachment in an Experimental Model of Sepsis

Objectives: The vascular endothelium is a major target of sepsis-induced events, and endothelial activation accounts for much of the pathology of sepsis. Urinary tract infections and pneumonia caused by Escherichia coli are among of the most common infections causing sepsis in both community and hospital settings. Currently, there are no approved drugs on the market to treat the underlying pathophysiology of sepsis. The aim of this study is to elucidate the molecular mechanism by which E. coli induces endothelial injury as a result of attachment. Design: Laboratory research using a hemodynamic perfusion ex vivo model. Setting: Research Laboratories of Royal College of Surgeons in Ireland and Beaumont Hospital. Patients: Ex vivo human vascular endothelial cells. Interventions: Addition of αVβ3 antagonist, cilengitide. Measurements and Main Results: Clinical strains of E. coli isolated from patients with sepsis bound to sheared human endothelial cells under static and hemodynamic shear conditions. Binding was dependent on E. coli cell membrane protein outer membrane protein A attaching directly to endothelial cell integrin αVβ3. Attachment resulted in disturbances in endothelial barrier integrity, as determined by loss of tight junction protein staining, permeability changes, and ultimately cell death by apoptosis. Using a low concentration of the αVβ3 antagonist cilengitide or using a strain deficient in outer membrane protein A resulted in a significant reduction in endothelial dysfunction following infection. Conclusions: Inhibition of E. coli binding to endothelial cell αVβ3 by cilengitide prevents endothelial dysfunction and may, therefore, present as a novel early therapeutic for the treatment of sepsis. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by Science Foundation Ireland Grant Number 13/CDA/2119 (to Dr. Kerrigan) and Health Research Board Grant Number HRA-POR-2010–33 (to Dr. Smith). Drs. Fagan's and Smith's institutions received funding from Health Research Board Ireland (a PhD studentship awarded to Dr. Smith who supported the start-up costs and PhD stipend and consumables for Dr. Fagan). Dr. Fagan received support for article research from the Health Research Board Ireland. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: skerrigan@rcsi.ie Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

https://ift.tt/2IWGP93

Acute Neurologic Complications During Extracorporeal Membrane Oxygenation—A Systematic Review

Objectives: We determine the frequency, risk factors, and mortality of neurologic complications in adults on extracorporeal membrane oxygenation and propose an algorithm for preventive strategies. Data Sources: PubMed, Embase, and Cochrane databases. Study Selection: Screening was performed using predefined search terms to identify cohort studies reporting neurologic complications in adults during extracorporeal membrane oxygenation from 1990 to 2017. Data Extraction: The final reference list was generated on the basis of relevance to the discussed topics. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation classification of evidence scheme. Data Synthesis: In 44 studies, the median frequency of acute neurologic complications is 13% (1–78%; 5% intracranial hemorrhages, 5% ischemic strokes, 2% seizures). Neurologic complications are reported more frequently with venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation (14 vs eight studies) with a median proportion of complications of 15% (6–33%; 95% CI, 8–19) for venoarterial extracorporeal membrane oxygenation. Median in-hospital mortality is higher with neurologic complications (83%; interquartile range, 54–100% vs 42%; interquartile range, 24–55% without neurologic complications; p

https://ift.tt/2IuCDxQ

Reversible Microvascular Hyporeactivity to Acetylcholine During Diabetic Ketoacidosis

Objectives: Metabolic acidosis is commonly observed in critically ill patients. Experimental studies suggested that acidosis by itself could impair vascular function, but this has been poorly investigated in human. Design: Prospective observational study. Setting: Medical ICU in a tertiary teaching hospital. Patients: To assess the relationship between metabolic acidosis severity and microvascular reactivity, we included adult diabetic patients admitted in ICU for ketoacidosis. Microvascular response to acetylcholine iontophoresis was measured at admission (baseline) and after correction of metabolic acidosis (24 hr). Interventions: None. Measurements and Main Results: Thirty-nine patients with diabetic ketoacidosis were included (68% male), with a median age of 43 (31–57) years. At admission, microvascular reactivity negatively correlated with acidosis severity (R = –0.53; p 7.20; p

https://ift.tt/2wWBvNR

What is the agronomic potential of biofertilizers for maize? A meta-analysis

Abstract

Biofertilizers are promoted as a strategy for sustainable intensification of agriculture, but their efficacy varies widely among published studies and it is unclear whether they deliver the promised benefits. Studies are commonly conducted under controlled conditions prior to deployment in the field, yet the predictive value of such studies for field-scale productivity has not been critically examined. A meta-analysis was conducted using a novel host crop-specific approach to evaluate the agronomic potential of bacterial biofertilizers for maize. Yield increases tended to be slightly higher and more variable in greenhouse studies using field soil than in the field, and greenhouse studies poorly predicted the influence of moderating climate, soil, and taxonomic variables. We found greater efficacy of Azospirillum spp. and lower efficacy of Bacillus spp. and Enterobacter spp. under field conditions. Surprisingly, biofertilizer strains with confirmed plant-growth-promoting traits such as phosphorus solubilization, nitrogen fixation, and phytohormone production in vitro were associated with lower yields in the field than strains not confirmed to possess these traits; only 1-aminocyclopropane-1-carboxylate deaminase synthesis increased yields. These results indicate the need for a novel biofertilizer development framework that integrates information from native soil microbial communities and prioritizes field validation of results.

https://ift.tt/2LfC5t9

Role of quorum sensing and chemical communication in fungal biotechnology and pathogenesis

Abstract

Microbial cells do not live in isolation in their environment, but rather they communicate with each other using chemical signals. This sophisticated mode of cell-to-cell signalling, known as quorum sensing, was first discovered in bacteria, and coordinates the behaviour of microbial population behaviour in a cell-density dependent manner. More recently, these mechanisms have been described in eukaryotes, particularly in fungi, where they regulate processes such as pathogenesis, morphological differentiation, secondary metabolite production and biofilm formation.In this manuscript, we review the information available to date on these processes in yeast, dimorphic fungi and filamentous fungi. We analyse the diverse chemical 'languages' used by different groups of fungi, their possible cross-talk and interkingdom interactions with other organisms. We discuss the existence of these mechanisms in multicellular organisms, the ecophysiological role of QS in fungal colonisation, and the potential applications of these mechanisms in biotechnology and pathogenesis.

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360-degree suture trabeculotomy ab interno to treat open-angle glaucoma: 2-year outcomes

https://ift.tt/2k9ilen

Brachytherapy for patients with uveal melanoma: historical perspectives and future treatment directions

https://ift.tt/2rSjGK0

Neuropsychiatric expression and catatonia in 22q11.2 deletion syndrome: An overview and case series

American Journal of Medical Genetics Part A, EarlyView.


https://ift.tt/2ITwjiB

Current clinical evidence does not support a link between TBL1XR1 and Rett syndrome: Description of one patient with Rett features and a novel mutation in TBL1XR1, and a review of TBL1XR1 phenotypes

American Journal of Medical Genetics Part A, EarlyView.


https://ift.tt/2wV3jlH

8th International conference on Tumor Microenvironment, Lisbon, Portugal June 10-14, 2018

https://ift.tt/2rTDkX7

Evaluation of femtosecond laser in flap and cap creation in corneal refractive surgery for myopia: a 3-year follow-up

https://ift.tt/2k7w5Gw

Recurrent Retroperitoneal Liposarcoma: a Case Report and Literature Review

Abstract

This is a case report of a 61-year-old male patient, presented with fifth recurrence of retroperitoneal liposarcoma and operated for six times. Literature review on retroperitoneal liposarcoma biology, recurrence pattern, role of surgery in primary tumor, and recurrent tumor, adjuvant therapy, role of multivisceral resection, and palliative surgery.

https://ift.tt/2GxtXk5

Feasibility, Safety, and Surgical Outcome of Robotic Hemithyroidectomy Via Transaxillary and Retroauricular Approach: an Institutional Experience

Abstract

The aim of this observational prospective study was to determine the technical feasibility, safety, and adequacy of robotic hemithyroidectomy. From April 2015 to May 2016, 16 patients with solitary thyroid lesion underwent robotic hemithyroidectomy using the Da Vinci® Si Surgical system. Patients were observed and data were recorded on surgical time, blood loss, complications, and functional outcome of the patients. A total of 16 patients (3 males and 13 females; mean age 39.9 years) underwent robotic hemithyroidectomy after evaluation for solitary thyroid nodule with a mean nodule size of 2.2 ± 0.3 cm. Fiber-optic laryngoscopy (FOL) was normal in all cases pre-operatively. Five patients were operated by transaxillary approach, the rest by retroauricular (facelift) approach. Mean pocket dissection time was 42 min for transaxillary and 40 min for retroauricular approach. Mean operative console time was 59.4 min for transaxillary and 52.6 min for retroauricular approach. Average blood loss was 45 ml. Mean hospital stay was 1.5 days. None of the patients had any post-operative complication on follow-up. One patient had restricted left vocal cord mobility which improved in 3 months. Mean pain score was 0.25 ± 0.4 and average speech score was 0.5 ± 0.2 at 3 months. Post-operatively, all patients had adequate swallowing with no episode of aspiration. Robotic hemithyroidectomy is a safe, feasible, and oncologically safe procedure. It has benefits in terms of better scar cosmesis than open surgery.

https://ift.tt/2rSYtjY

Tumour stage and gender predict recurrence and second primary malignancies in head and neck cancer: a multicentre study within the INHANCE consortium

Abstract

Recurrence and second primary cancer (SPC) continue to represent major obstacles to long-term survival in head and neck cancer (HNC). Our aim was to evaluate whether established demographics, lifestyle-related risk factors for HNC and clinical data are associated with recurrence and SPC in HNC. We conducted a multicentre study by using data from five studies members of the International Head and Neck Cancer Epidemiology consortium—Milan, Rome, Western Europe, Sao Paulo, and Japan, totalling 4005 HNC cases with a median age of 59 (interquartile range 52–67). Multivariate hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for recurrence and SPC. During follow-up, 1161 (29%) patients had recurrence and 343 (8.6%) developed SPC. Advanced tumour stage was associated with increased risk of recurrence in HNC overall (HR = 1.76, 95% CI 1.41–2.19). Women with laryngeal cancer had a reduced risk of recurrence compared to men (HR = 0.39, 95% CI: 0.24–0.74). Concerning predictors of SPC, advanced age (HR = 1.02; 95% CI: 1.00–1.04) and alcohol consumption (> 1 drink per day, HR = 2.11; 95% CI: 1.13–3.94) increased the risk of SPC among patients with laryngeal cancer. Additionally, women were at higher risk of SPC, in HNC overall group (HR = 1.68; 95% CI: 1.13–2.51) and oropharyngeal cancer group (HR = 1.74; 95% CI: 1.02–2.98). Tumour stage and male gender (larynx only) were positive predictors of cancer recurrence in HNC patients. Predictors of SPC were advanced age and alcohol use among laryngeal cancer cases, and female gender for oropharyngeal and HNC overall.

https://ift.tt/2IXCu58

Subjective social status and mortality: the English Longitudinal Study of Ageing

Abstract

Self-perceptions of own social position are potentially a key aspect of socioeconomic inequalities in health, but their association with mortality remains poorly understood. We examined whether subjective social status (SSS), a measure of the self-perceived element of social position, was associated with mortality and its role in the associations between objective socioeconomic position (SEP) measures and mortality. We used Cox regression to model the associations between SSS, objective SEP measures and mortality in a sample of 9972 people aged ≥ 50 years from the English Longitudinal Study of Ageing over a 10-year follow-up (2002–2013). Our findings indicate that SSS was associated with all-cause, cardiovascular, cancer and other mortality. A unit decrease in the 10-point continuous SSS measure increased by 24 and 8% the mortality risk of people aged 50–64 and ≥ 65 years, respectively, after adjustment for age, sex and marital status. The respective estimates for cardiovascular mortality were 36 and 11%. Adjustment for all covariates fully explained the association between SSS and cancer mortality, and partially the remaining associations. In people aged 50–64 years, SSS mediated to a varying extent the associations between objective SEP measures and all-cause mortality. In people aged ≥ 65 years, SSS mediated to a lesser extent these associations, and to some extent was associated with mortality independent of objective SEP measures. Nevertheless, in both age groups, wealth partially explained the association between SSS and mortality. In conclusion, SSS is a strong predictor of mortality at older ages, but its role in socioeconomic inequalities in mortality appears to be complex.

https://ift.tt/2GyKGnd

Hypertensive disorders of pregnancy and subsequent maternal cardiovascular health

Abstract

To examine associations between hypertensive pregnancy disorders and maternal cardiovascular disease (CVD) in later life. We examined the associations between blood pressure (BP) in pregnancy, gestational hypertension (GH) and preeclampsia (PE) with cardiovascular measurements 6 years after index pregnancy among 4912 women participating in the Generation R Study, the Netherlands. BP, left ventricular mass (LV mass), aortic root diameter (AOD), left atrial diameter, fractional shortening, and carotid-femoral pulse wave velocity (PWV). Early pregnancy systolic and diastolic BP were associated with more adverse maternal cardiovascular measurements and a higher incidence of chronic hypertension 6 years after pregnancy. GH was associated with a higher BP, a higher PWV, a larger AOD and an increased LV mass 6 years after index pregnancy. Compared to previous normotensive pregnancies these women had a sixfold increased risk to develop chronic hypertension after pregnancy (OR 6.6, 95% CI 4.6–9.5). Compared to women with a normotensive pregnancy, women with PE had a higher BP and a higher risk of chronic hypertension (OR 4.5, 95% CI 2.6–7.8) at follow-up. After adjustment for BMI at follow-up in all the analyses on GH, PE and cardiovascular measurements, effect estimates attenuated up to 65%, but remained significant. Both GH and PE are associated with markers of adverse maternal cardiovascular health after pregnancy with an increased risk of chronic hypertension. Women with GH and PE may be offered long-term cardiovascular follow-up incorporated in CVD risk management guidelines.

https://ift.tt/2IvsGjB

Intervention planning for the REDUCE maintenance intervention: a digital intervention to reduce reulceration risk among patients with a history of diabetic foot ulcers

Objectives

To develop a comprehensive intervention plan for the REDUCE maintenance intervention to support people who have had diabetic foot ulcers (DFUs) to sustain behaviours that reduce reulceration risk.

Methods

Theory-based, evidence-based and person-based approaches to intervention development were used. In phase I of intervention planning, evidence was collated from a scoping review of the literature and qualitative interviews with patients who have had DFUs (n=20). This was used to identify the psychosocial needs and challenges of this population and barriers and facilitators to the intervention's target behaviours: regular foot checking, rapid self-referral in the event of changes in foot health, graded and regular physical activity and emotional management. In phase II, this evidence was combined with expert consultation to develop the intervention plan. Brief 'guiding principles' for shaping intervention development were created. 'Behavioural analysis' and 'logic modelling' were used to map intervention content onto behaviour change theory to comprehensively describe the intervention and its hypothesised mechanisms.

Results

Key challenges to the intervention's target behaviours included patients' uncertainty regarding when to self-refer, physical limitations affecting foot checking and physical activity and, for some, difficulties managing negative emotions. Important considerations for the intervention design included a need to increase patients' confidence in making a self-referral and in using the maintenance intervention and a need to acknowledge that some intervention content might be relevant to only some patients (emotional management, physical activity). The behavioural analysis identified the following processes hypothesised to facilitate long-term behaviour maintenance including increasing patients' skills, self-efficacy, knowledge, positive outcome expectancies, sense of personal control, social support and physical opportunity.

Conclusions

This research provides a transparent description of the intervention planning for the REDUCE maintenance intervention. It provides insights into potential barriers and facilitators to the target behaviours and potentially useful behaviour change techniques to use in clinical practice.

https://ift.tt/2k7Lwyx

Impact of extracorporeal cardiopulmonary resuscitation on outcomes of elderly patients who had out-of-hospital cardiac arrests: a single-centre retrospective analysis

Objectives

Little is known about the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for elderly patients who had out-of-hospital cardiac arrest (OHCA). The aim of this study was to examine the impact of age on outcomes among patients who had OHCA treated with ECPR.

Design

Single-centre retrospective cohort study.

Setting

A critical care centre that covers a population of approximately 1 million residents.

Participants

Patients who had consecutive OHCA aged ≥18 years who underwent ECPR from 2005 to 2013.

Primary and secondary outcome measures

Primary outcomes were 1 month neurologically favourable outcomes and survival. To determine the association between advanced age and each outcome, we fitted multivariable logistic regression models using: (1) age as a continuous variable and (2) age as a categorical variable (<50 years, 50–59 years, 60–69 years and ≥70 years).

Results

Overall, 144 patients who had OHCA who underwent ECPR were eligible for our analyses. The proportion of neurologically favourable outcomes was 7%, while survival was 19% in patients who had OHCA. After the adjustment for potential confounders, while advanced age was non-significantly associated with neurologically favourable outcomes (adjusted OR 0.96 (95% CI 0.91 to 1.01), p=0.08), the association between advanced age and the poor survival rate was significant (adjusted OR 0.96 (95% CI 0.93 to 0.99), p=0.04). Additionally, compared with age <50 years, age ≥70 years was non-significantly associated with poor neurological outcomes (adjusted OR 0.08 (95% CI 0.01 to 1.00), p=0.051), whereas age ≥70 years was significantly associated with worse survival in the adjusted model (adjusted OR 0.14 (95% CI 0.03 to 0.80), p=0.03).

Conclusions

In our analysis of consecutive OHCA data from a critical care hospital in an urban area of Japan, we found that advanced age was associated with the lower rate of 1-month survival in patients who had OHCA who underwent ECPR. Although larger studies are required to confirm these results, our findings suggest that ECPR may not be beneficial for patients who had OHCA aged ≥70 years.

https://ift.tt/2rTkoa4

Splenic myoid angioendothelioma mimicking metastatic disease in an 8-year-old with Stage IV Wilms tumour

Myoid angioendothelioma are rare and benign vascular tumours of the spleen. Radiographic evaluation and diagnosis is often challenging and subjecting tissue samples to immuhistochemical analysis is often required to make a definitive diagnosis. Myoidangioendotheliomas can be managed with open or laparoscopic splenectomy with minimal risk of recurrent disease. Herein, we present a case of a myoid angioendothelioma in a patient with stage IV Wilms' tumour.

https://ift.tt/2IwQD5T

Coexisting squamous cell carcinoma and high-grade neuroendocrine carcinoma, small cell type: a rare collision in cervix

Collision tumours of the uterine cervix are extremely uncommon with exact incidence not known. Unlike squamous cell carcinoma (SCC) and adenocarcinoma that are known to coexist, small cell neuroendocrine carcinoma (SCNEC) is rarely documented with other histological types in the cervix. We report such rare case of a collision tumour in cervix displaying dual histological component of SCNEC and SCC in a 36-year-old woman. The case is being presented because of its rarity and represents a unique and hitherto seldom-reported combination of two malignant tumours with distinct and often contrasting epidemiology, histology and prognosis coexisting in the same patient.

https://ift.tt/2LfbQDq

Case of unilateral leg swelling: a DVT mimic

A 68-year-old woman with known metastatic renal cell carcinoma presented with an acutely swollen right leg. In between the two sessions of palliative radiotherapy to the right hip, she also had right hip modified Harrington procedure for tumour resection with hip replacement. Initial clinical evaluation raised the suspicion of right leg deep vein thrombosis (DVT). However, DVT was excluded and further investigations revealed stenosis of the right external and common iliac veins, likely secondary to radiotherapy.

https://ift.tt/2KEKTrF

Idiopathic nodular glomerulosclerosis (ING) in an African American (AA) man with hepatitis C

Idiopathic nodular glomerulosclerosis (ING) in a non-diabetic patient is uncommon. Nodular glomerulosclerosis is hallmark sign of diabetic nephropathy. ING is a very rare clinicopathological disease associated with smoking, obesity and hypertension, chronic obstructive pulmonary disease and metabolic syndrome. A 68-year-old non-obese African American man with hypertension, smoking and history of hepatitis C presented to the clinic with progressive worsening of lower extremity oedema and declining renal function over few months. Renal biopsy demonstrated nodular glomerulosclerosis. In this case, ING is hypothesised to be associated with hepatitis C along with smoking and hypertension (HTN). We present this case to speculate the existence of yet unknown aetiologies of ING.

https://ift.tt/2La2Pv7

Everyone is valuable

This case highlights the therapeutic value of valuing our patients as people. It starts with a common challenge we can all face as doctors both in primary and in secondary care. It is the challenge of facing a situation where both patient and doctor are 'stuck' where no progress is being made in patient care. A different approach was made to the situation and both patient and doctor could move on. It highlights an issue that is relevant for 'stuck' patients and all of our patients.

https://ift.tt/2IvvIA5

Texture analysis of paraspinal musculature in MRI of the lumbar spine: analysis of the lumbar stenosis outcome study (LSOS) data

Abstract

Objective

To evaluate association of fatty infiltration in paraspinal musculature with clinical outcomes in patients suffering from lumbar spinal stenosis (LSS) using qualitative and quantitative grading in magnetic resonance imaging (MRI).

Materials and methods

In this retrospective study, texture analysis (TA) was performed on postprocessed axial T2 weighted (w) MR images at level L3/4 using dedicated software (MaZda) in 62 patients with LSS. Associations in fatty infiltration between qualitative Goutallier and quantitative TA findings with two clinical outcome measures, Spinal stenosis measure (SSM) score and walking distance, at baseline and regarding change over time were assessed using machine learning algorithms and multiple logistic regression models.

Results

Quantitative assessment of fatty infiltration using the histogram TA feature "mean" showed higher interreader reliability (ICC 0.83–0.97) compared to the Goutallier staging (κ = 0.69–0.93). No correlation between Goutallier staging and clinical outcome measures was observed. Among 151 TA features, only TA feature "mean" of the spinotransverse group showed a significant but weak correlation with worsened SSM (p = 0.046). TA feature "S(3,3) entropy" showed a significant but weak association with worsened WD over 12 months (p = 0.046).

Conclusion

MR TA is a reproducible tool to quantitatively assess paraspinal fatty infiltration, but there is no clear association with the clinical outcome in asymptomatic LSS patients.

https://ift.tt/2IuzWfJ

Abnormal alignment of the left lower extremity and irregular gait

https://ift.tt/2KDv5Fs

Browser’s Notes

https://ift.tt/2IU3brB

Multimodality imaging of subacromial impingement syndrome

Abstract

Subacromial impingement syndrome results from irritation of the tendons of the rotator cuff muscles in the subacromial space and may manifest as a range of pathologies. However, subacromial impingement is a dynamic condition for which imaging reveals predisposing factors but no pathognomonic indicators. Also, the usual imaging features of subacromial impingement may be seen in symptomatic and asymptomatic patients. Therefore, imaging is able to detect tears and describe the risk factors of impingement but cannot confirm subacromial impingement. Radiographs allow assessment of the morphology of the acromion and its lateral extension by means of the acromial index and the critical shoulder angle, which may increase in cases of subacromial impingement. Ultrasound is necessary to evaluate a tendon tear and is the only tool that provides dynamic information, which is essential to assessing dynamic conditions. Magnetic resonance imaging (MRI) allows the assessment of associated intraarticular abnormalities, joint effusion, and bone marrow edema. The objective of this article is to provide an overview of the pathophysiology and clinical manifestations of subacromial impingement and discuss recent advances in the imaging of subacromial impingement and the role of radiography, ultrasound, and MRI in differentiating normal from pathologic findings.

https://ift.tt/2x3SQ7V

Anaplastic plasmacytoma: a rare tumor presenting as a pathological fracture in a younger adult

Abstract

Solitary plasmacytoma is the rarest type of plasma cell neoplasm, and the anaplastic form is even more uncommon. Plasmacytoma most commonly originates in bone and predominantly affects older patients. We describe the case of a 35-year-old woman with solitary osseous anaplastic plasmacytoma that presented initially with a pathological fracture following minor trauma. The patient was immunocompetent and had no predisposing conditions for a plasma cell tumor. Left lower extremity radiographs revealed an oblique fracture of the distal femur, and CT imaging indicated a primary osseous lesion at the fracture site. MRI confirmed the diagnosis of pathological fracture. Initial surgical pathology of the lesion was concerning because it could have been an osteosarcoma. Further immunostaining demonstrated CD138 positivity and kappa light chain restriction, confirming the diagnosis of plasmacytoma. In addition, the presence of marked anaplastic cellular changes confirmed the anaplastic variant. Further workup showed no evidence of multiple myeloma. This case is unusual given the age and gender of the patient. Awareness of the anaplastic variant of plasmacytoma is important to avoid erroneous diagnoses.

https://ift.tt/2IuzQVp

Prevalence of vitamin D insufficiency in radiologists: a cross-sectional study

Abstract

Objective

To compare the prevalence of vitamin D insufficiency between radiologists and a control group of non-radiologists.

Materials and methods

This prospective cross-sectional study was conducted at the Swiss Congress of Radiology in May of 2016. Attendees (radiologists and non-radiologists) were asked to give a venous blood sample to measure vitamin D (25-hydroxyvitamin D) blood serum level. Vitamin D insufficiency was defined as < 50 nmol/l (30 ng/ml). We collected information on profession, age, gender, vitamin D supplements, recent sunny vacation, and eating fish. We compared vitamin D between radiologists and non-radiologists.

Results

A total of 137 radiologists (mean age, 38 ± 10 years) and 164 non-radiologists (mean age, 40 ± 12 years) participated in the study. Prevalence of vitamin D insufficiency in both groups was similar (58.4% (80/137) vs. 53.7% (88/164); p = 0.240). Forty-three participants were under vitamin D supplementation. In those without supplementation, we found no difference in vitamin D between groups (44.0 ± 16.2 nmol/l (17.6 ± 6.5 ng/ml) vs. 44.4 ± 16.9 nmol/l (17.8 ± 6.8 ng/ml); p = 0.757). Average vitamin D levels for radiologists were slightly lower (−0.98 nmol/l (0.39 ng/ml), 95% confidence interval − 5.96 to 4.00 (− 2.38 to 1.6 ng/ml); p = 0.699), when adjusting for the potential confounders, but not statistically significant. The odds ratio of vitamin D insufficiency for radiologists versus non-radiologists was 1.7 (95% CI = 0.94–3.06; p = 0.078) after adjusting for the other independent variables.

Conclusions

The prevalence of vitamin D insufficiency in radiologists was high (58.4%), but not substantially higher than in non-radiologists.

https://ift.tt/2x3SOgj

Bladder cancer presenting with acrometastases: a different cause of foot pain

Abstract

Acrometastasis means tumor seeding distally to the elbow or the knee and is an uncommon event. Foot acrometastases occur in 0.58% of patients with skeletal metastases overall, and only about 10% of these are caused by bladder cancer. We present a case of bladder cancer manifesting with insidious foot pain, caused by multiple lytic lesions located solely at the left foot. It was suspected after whole-body CT and later confirmed by biopsy result. We enumerate the differential diagnosis of distal extremity lytic lesions for educational purposes and review the literature listing similar published cases.

https://ift.tt/2IVh8FS

Epiphyseal hyperplasia caused by an ectopic ossification center of the distal tibia: presentation of a pediatric case with 13 years of radiological surveillance

Abstract

Herein, we report the case of a 4-year-old boy, who presented with a cortical lytic lesion of his distal tibia. It was located eccentrically, measured 2 cm in its craniocaudal diameter, and was associated with a lamella-like soft-tissue mineralization that resembled a periosteal reaction. Thus, the lesion's radiographic features were initially suggestive of an aggressive disease. However, further imaging revealed the lesion to be of cartilaginous origin and to extend into the metaphysis, thus creating the aspect of hyperplastic epiphyseal cartilage. This cartilaginous hyperplasia was likely caused by an ectopic ossification center, although no similar cases have yet been reported. As radiology and clinics no longer indicated the imminent threat of a high-grade malignancy, we decided against a biopsy to avoid interfering with epiphyseal growth. However, because of the unprecedented nature of the given constellation, we closely monitored the lesion radiologically to rule out an untypical manifestation of a benign but potentially expanding lesion, in addition to a growth disturbance resulting from the lesion itself. However, further imaging indicated that mineralization and ossifications, which were already present at the lesion's initial presentation, increased over time, until the lesion fully disappeared after 13 years of clinical and radiological surveillance. This case is outstanding because of its singular morphology and the long-term follow-up that illustrates its self-limiting natural course. This report provides support in differential diagnosis to help discriminate potentially self-limiting conditions from other diseases that may require invasive diagnosis and/or therapy.

https://ift.tt/2KEV8fr

Incorporation of musculoskeletal ultrasound training into the radiology core curriculum

https://ift.tt/2wT87YR

Abnormal alignment of the left lower extremity and irregular gait

https://ift.tt/2Itgjo9

Superficial acral fibromyxoma: a case report with radiological review

Abstract

Superficial acral fibromyxoma is a benign, slow-growing soft-tissue neoplasm that has a predilection for the peripheries. Although considered benign, its risk of recurrence warrants consideration in the radiological differential diagnoses of acral tumors. To our knowledge, there has been minimal literature studying the radiological features of this entity. We present a case report with a discussion focusing on its clinical and radiological findings.

https://ift.tt/2wVPe7B

MRI sport-specific pulley imaging

Abstract

Objective

We aim to create a novel MRI methodology that employs sport-specific stress views for imaging finger pulley injuries in the evaluation of post-operative healing effectiveness. The goal is to measure the bone to tendon distance (BTD), which is the current standard for determining pulley injuries.

Materials and methods

The athlete was imaged in a crimp-grip stressed position to emulate sport-specific biomechanics. A Gradient Echo technique was modified to maximize the signal to noise ratio and minimize distortion near the bone and tendon, simplifying the determination of the BTD.

Results

A stress-crimped hand position is imaged in less than one half-minute to enable diagnostic visualization of a normal proximal phalanx' bone and tendon via measurement of their BTD.

Conclusion

This novel stress methodology allows for sport-specific imaging, which is ideal for determining functional compromise of the hand's pulley mechanism. Surgical outcomes may be more sensitively compared when using stress views, and these comparisons may then direct optimal repair technique. Future studies will utilize this technique to attempt early-stage detection of pulley injuries prior to complete rupture.

https://ift.tt/2ISCVh3

Is a single-level measurement of paraspinal muscle fat infiltration and cross-sectional area representative of the entire lumbar spine?

Abstract

Purpose

Lumbar paraspinal muscle morphology has recently been evaluated in several studies with conflicting results. Several studies have performed single-slice evaluations of paraspinal muscle morphology, whereas other studies have done a multi-level assessment; this methodological difference might explain the observed different results. Our study evaluated if a single-slice axial measurement is representative of the entire lumbar musculature.

Methods

We included 80 adult patients who were consecutively evaluated with magnetic resonance imaging (MRI) for spinal symptoms. Using T2-weighted axial images, we measured the fat signal fractions (FSF) and cross-sectional area (CSA) of the erector spinae and multifidus at the five levels of the lumbar spine (from L1-L2 to L5-S1). We used the ANOVA test for repeated measurements (with Bonferroni correction) to compare the FSF and CSA among the levels.

Results

Erector spinae showed an increasing FSF from L1-L2 to L5-S1; all erector spinae FSF comparisons among the different levels were significantly different. Multifidus FSF also increased caudally below L2-L3, although significant differences were observed only with two or more levels of distance. The CSA of the erector spinae showed a caudal decrease (L4-L5 and L5-S1 being significantly smaller than all the levels above). The CSA of the multifidus showed that all levels exhibited a significantly different area compared to their adjacent level (except L5-S1 compared to L4-L5).

Conclusions

No single-level FSF or CSA is representative of the whole lumbar spine. A standardized multi-level evaluation of the paraspinal musculature should be used in future research.

https://ift.tt/2wRTwwI

Interposition of the transverse ligament of the knee into a fracture of the tibial plateau: a case report

Abstract

Interposition of the transverse ligament of the knee between fragments of an intercondylar eminence fracture was diagnosed using magnetic resonance imaging (MRI) in a 11-year-old boy after a sports injury. The interposition was confirmed and corrected during arthroscopy. We report what we believe to be the first published case of isolated interposition of the transverse ligament in a minimally displaced fracture of the tibial eminence.

https://ift.tt/2ITjiFL

Post-operative extra-spinal etiologies of sciatic nerve impingement

Abstract

Sciatica is a highly prevalent cause of morbidity, commonly resulting from intra-spinal pathological processes. Many cases can have extra-spinal etiologies and can be clinically challenging. Certain scenarios should suggest an extra-spinal etiology, particularly total and revision hip arthroplasty, surgical hip dislocation, hip arthroscopy, and surgery in the lithotomy position. We review the post-operative clinical scenarios where sciatic neuropathy may occur, along with the pertinent imaging findings.

https://ift.tt/2wUMBCZ

Multicentric carpotarsal osteolysis syndrome: long-term follow-up of three patients

Abstract

Multicentric carpotarsal osteolysis (MCTO) is a rare skeletal disorder characterized by progressive carpal and tarsal destruction. The upper and lower limbs may be involved, leading to deformities and joint limitation. These anatomic features may be associated with progressive renal failure. The radiographs obtained during childhood showed a carpal and tarsal osteolysis and an asymmetrical involvement. Here, we report on the long-term clinical and radiological findings of three patients with skeletal manifestations of MCTO.

https://ift.tt/2IUpnle

Feasibility of using an inversion-recovery ultrashort echo time (UTE) sequence for quantification of glenoid bone loss

Abstract

Objective

To utilize the 3D inversion recovery prepared ultrashort echo time with cones readout (IR-UTE-Cones) MRI technique for direct imaging of lamellar bone with comparison to the gold standard of computed tomography (CT).

Materials and methods

CT and MRI was performed on 11 shoulder specimens and three patients. Five specimens had imaging performed before and after glenoid fracture (osteotomy). 2D and 3D volume-rendered CT images were reconstructed and conventional T1-weighted and 3D IR-UTE-Cones MRI techniques were performed. Glenoid widths and defects were independently measured by two readers using the circle method. Measurements were compared with those made from 3D CT datasets. Paired-sample Student's t tests and intraclass correlation coefficients were performed. In addition, 2D CT and 3D IR-UTE-Cones MRI datasets were linearly registered, digitally overlaid, and compared in consensus by these two readers.

Results

Compared with the reference standard (3D CT), glenoid bone diameter measurements made on 2D CT and 3D IR-UTE-Cones were not significantly different for either reader, whereas T1-weighted images underestimated the diameter (mean difference of 0.18 cm, p = 0.003 and 0.16 cm, p = 0.022 for readers 1 and 2, respectively). However, mean margin of error for measuring glenoid bone loss was small for all modalities (range, 1.46–3.92%). All measured ICCs were near perfect. Digitally registered 2D CT and 3D IR-UTE-Cones MRI datasets yielded essentially perfect congruity between the two modalities.

Conclusions

The 3D IR-UTE-Cones MRI technique selectively visualizes lamellar bone, produces similar contrast to 2D CT imaging, and compares favorably to measurements made using 2D and 3D CT.

https://ift.tt/2wUIpDm

Hand MRI and the Greulich-Pyle atlas in skeletal age estimation in adolescents

Abstract

Objective

To evaluate the feasibility of hand MRI in age assessment in adolescents using the Greulich-Pyle (GP) atlas criteria.

Materials and methods

Two radiologists, who were blinded to the study subjects' chronologic ages, semi-objectively evaluated 1.5-T MRIs of the left hands of ten patients (13.5 ± 2.6 years) who had left-hand radiographs and 50 healthy volunteers (15 ± 2 years).

Results

A coronal T1-weighted, volumetric, interpolated, breath-hold examination with water excitation (T1 VIBE-3D-WE) achieved the best image quality. The correlation between estimated patients' ages on radiographs and MRI was high. The average estimated age difference between the MRIs and radiographs was −0.05 years for reader 1 and −0.175 years for reader 2. The interclass coefficients (ICCs) showed high interobserver agreement (radiographs: ICC = 0.95, MRI: ICC = 0.97). The ICC, calculated separately for the male and female volunteers' estimated ages by MRI, also showed a high agreement between the two readers (male: ICC = 0.97, female: ICC = 0.95). Reader 1 estimated 94% of volunteers within 2 standard deviations (SD) and 62% within 1 SD. The results for reader 2 were 92% and 54%, respectively. Thirty-nine percent of girls and 27% of boys were estimated to be older using 1 SD.

Conclusion

MRI of the left hand is a feasible alternative to hand radiographs for skeletal age estimation in adolescents using the GP criteria with 2 SD. Using 1 SD, the age of healthy volunteers tended to be estimated as higher than the chronologic age. Future studies should evaluate the results in a larger number of participants.

https://ift.tt/2IVhaO0