bluuebunny/crossref_metadata_2025 huggingface dataset:
Association Between Pembrolizumab-related Adverse Events and Treatment Outcome in Advanced Melanoma: Results From the Dutch Expanded Access Program
Authors: Bisschop Cornelis , Wind Thijs T. , Blank Christian U. , Koornstra Rutger H.T. , Kapiteijn Ellen , Van den Eertwegh Alfonsus J.M. , De Groot Jan Willem B. , Jalving Mathilde , Hospers Geke A.P.
Published: May 2019

Toxicity of immune checkpoint inhibitors such as ipilimumab and nivolumab is likely associated with clinical efficacy. In this study, we aim to evaluate this association for pembrolizumab. To this end, data of 147 patients included in the Dutch cohort of the Pembrolizumab Expanded Access Program were collected. All data were collected prospectively. Patients with adverse events (AEs) at any time during therapy showed a higher chance of achieving disease control compared with patients without AEs (low-grade AEs vs. no AEs: odds ratio=12.8, P=0.0002, high-grade AEs vs. no AEs: odds ratio=38.5, P=0.0001) according to a multivariate logistic regression analysis. In addition, Cox regression analysis showed a lower risk of death (hazard ratio: 0.51, 95% confidence interval: 0.28–0.97) and disease progression (hazard ratio: 0.54, 95% confidence interval: 0.30–0.98) over time for patients with high-grade AEs at any time during therapy compared with patients without AEs during therapy. To correct for time dependency of occurrence of AEs, a pseudolandmark analysis at 6 months of therapy was performed. Although significance was lost (Wald test P>0.05), prolonged survival in 3 patients who stopped therapy within 6 months due to the occurrence of AEs was observed, suggesting the potential treatment benefit despite the premature ending of therapy. The occurrence of high-grade toxicity at any time during treatment was associated with higher objective response rates, progression-free survival, and overall survival. There remains a need to assess the predictive value of early occurring AEs on patient survival.
Daily Electrocardiogram Electrode Change and the Effect on Frequency of Nuisance Alarms
Authors: Shue McGuffin Katherine , Ortiz Sheri
Published: May 2019

Background

In 2018, The Joint Commission identified false telemetry alarms as a significant technology hazard placing patients at risk of injury. Reasons include poor skin preparation when applying electrodes and improper placement of electrodes.

Objectives

The purpose of this quality improvement project was to determine if changing electrocardiogram electrodes daily would decrease the frequency of nuisance alarms.

Methods

Study design was quantitative/comparative on all patients receiving telemetry monitoring on a 36-bed adult inpatient cardiac telemetry unit. Data collection occurred for 14 days before the intervention and 14 days during the intervention of daily electrode change. Comparison analysis determined if frequency of alarms decreased after the intervention with daily electrode change.

Results

Postintervention data showed a 74.15% reduction in telemetry alarms following implementation of a daily electrode change.

Discussion

Daily electrocardiogram electrode changes may be an effective strategy for reducing nuisance alarms on telemetry units. Outcomes can be used in conjunction with existing evidence to drive current practice.
Nipple Reconstruction: A Novel Triple Flap Design
Authors: Krogsgaard Sofie H.H. , Carstensen Lena F. , Thomsen Jørn B. , Rose Michael
Published: May 2019

Background:

Restoring the nipple–areola complex completes the breast reconstructive process. Local flaps are often used for the nipple reconstruction; however, the number of techniques indicates the lack of a superior design. The aims of this study were to test the feasibility of a new triple flap design for nipple reconstruction and to evaluate complication rate and nipple projection.

Methods:

From November 2015 to November 2018, we performed the triple flap nipple reconstruction guided by a template for preoperative mark-up. Patients were followed up postoperatively to evaluate healing and signs of complications including wound dehiscence, infection, and flap necrosis, and nipple projection. The areola was tattooed 3 months postoperatively.

Results:

Twenty-six nipple reconstructions were successfully performed in 22 women. Four nipple reconstructions (15%) were performed in irradiated tissue. One reconstruction had a superficial infection, while there were no cases of wound dehiscence or flap necrosis. Three nipple reconstructions (12%) experienced prolonged healing that did not require intervention. None of these reconstructions had received radiation therapy. The nipple projection was 7.3 mm (range 6–9 mm) at the time of surgery and 3.1 mm (range 0–6 mm), 2.5 mm (range 2–3 mm), and 1.6 mm (range 0–3 mm) at follow-up of 3, 6, and 12 months, respectively.

Conclusions:

We present the new triple flap design for nipple reconstruction guided by a template for mark-up. The preliminary results indicate a low complication rate in both irradiated and nonirradiated patients while sustaining the projection over time remains to be a challenge.
Use of Acellular Dermal Matrix Following Fasciectomy for the Treatment of Dupuytren’s Disease
Authors: Hoang Don , Steven Patrick , Chen Vivi W. , Stasiak Ashley , Cohen Myles , Kulber David A.
Published: May 2019

Background:

Recurrence rates following surgical intervention for Dupuytren's disease (DD) remains high. In this study, we investigate the use of acellular dermal matrix (ADM) to reduce recurrence and improve long-term clinical outcome.

Methods:

We examined 132 patients undergoing open fasciectomy for DD from 2007 to 2017. The experimental group had a sheet of ADM (FlexHD) sutured into the surgical bed controls were not closed with ADM. Patient characteristics, range of motion, and complications were examined.

Results:

Twenty-eight (21.2%) patients were treated with acellular dermal matrix, whereas 104 (78.8%) patients were not. The median age was 67.0 years (range 34–91 years). with no differences between group regarding age, comorbidities, and laterality. The mean preoperative interphalangeal joint flexion contracture in the ADM group of 66.5 ± 29.9 degrees was corrected to 9.7 ± 12.4 degrees, whereas the mean metacarpophalangeal joint preoperative flexion contracture of 51.4 ± 23.9 degrees was corrected to 7.8 ± 14.1 degrees at postoperative examination (P < 0.05). The median follow-up was 18.7 months, during which the recurrence of contracture was observed in 1 of 28 patients in the group receiving ADM compared with 9 of 104 in the control group (P = 0.37). There were no differences in the incidence of minor wound complications observed.

Conclusion:

The adjunct placement of acellular dermal matrix into the wound bed following fasciectomy for DD may be an important surgical strategy to reduce recurrence rates as well as augment coverage of exposed vital structures in cases of severe flexion contracture.
Hyperspasticity After Partial Neurectomy for Treatment of Myospasms Following Subpectoral Breast Reconstruction
Authors: Mamsen Frederik P. , Carstensen Lena F.
Published: May 2019

Breast reconstruction using tissue expander is a frequently used method of reconstruction after mastectomy. We describe a rare complication of myospasms after subpectoral tissue expander reconstruction with acellular dermal matrix. The patient gradually developed disturbing pectoral muscle spasms lasting almost a year. Botulinum toxin A was undesired due to its transient effect. Selective denervation of the medial pectoral nerve branches was performed and resulted in worse spasms where the breast bounced at a rapid speed. Complete denervation of the pectoral nerves led to immediate liberation. We recommend a cranial denervation of both medial and lateral pectoral nerves to secure complete denervation leading to permanent relief of involuntary spasms where selective denervation may lead to hyperspasticity.
Safety Bundles in Gynecology
Authors: ENGLISH EMILY M. , MORGAN DANIEL M.
Published: May 2019

Patient safety bundles and checklists have been shown to improve outcomes in medicine, surgery, and obstetrics. Until recently, there has been less study into their use in the gynecology setting. Here, we review the available evidence and examples of successful checklist and bundle implementation in gynecology and encourage more robust implementation and standardization in our field going forward.
High-dose prescribed opioids are associated with increased risk of heroin use among United States military veterans
Authors: Banerjee Geetanjoli , Edelman E. Jennifer , Barry Declan T. , Crystal Stephen , Gordon Kirsha S. , Gordon Adam J. , Gaither Julie R. , Green Traci C. , Kerns Robert D. , Manhapra Ajay , Moore Brent A. , Fiellin David A. , Marshall Brandon D.L.
Published: May 2019

Despite evidence linking increased risk of opioid use disorder with specific opioid-prescribing patterns, the relationship between these patterns and heroin use is less understood. This study aimed to determine whether dose and duration of opioid prescriptions predict subsequent heroin use in United States veterans. We analyzed data from 2002 to 2012 from the Veterans Aging Cohort Study, a prospective cohort study. We used inverse probability of censoring weighted Cox regression to examine the relationship between self-reported past year heroin use and 2 primary predictors: (1) prior receipt of a high-dose opioid prescription (≥90 mg morphine equivalent daily dose), and (2) prior receipt of a long-term opioid prescription (≥90 days). Heroin use was ascertained using most recent value of time-updated self-reported past year heroin use. Models were adjusted for HIV and hepatitis C virus infection status, sociodemographics, pain interference, posttraumatic stress disorder, depression, and use of marijuana, cocaine, methamphetamines, and unhealthy alcohol use. In the final model, prior receipt of a high-dose opioid prescription was associated with past year heroin use (adjusted hazard ratio use = 2.54, 95% confidence interval: 1.26-5.10), whereas long-term opioid receipt was not (adjusted hazard ratio = 1.09, 95% confidence interval: 0.75-1.57). Patients receiving high-dose opioid prescriptions should be monitored for heroin use. These findings support current national guidelines recommending against prescribing high-dose opioids for treating pain.
DNA methylation profiles are associated with complex regional pain syndrome after traumatic injury
Authors: Bruehl Stephen , Gamazon Eric R. , Van de Ven Thomas , Buchheit Thomas , Walsh Colin G. , Mishra Puneet , Ramanujan Krishnan , Shaw Andrew
Published: May 2019

Factors contributing to development of complex regional pain syndrome (CRPS) are not fully understood. This study examined possible epigenetic mechanisms that may contribute to CRPS after traumatic injury. DNA methylation profiles were compared between individuals developing CRPS (n = 9) and those developing non-CRPS neuropathic pain (n = 38) after undergoing amputation following military trauma. Linear Models for Microarray (LIMMA) analyses revealed 48 differentially methylated cytosine-phosphate-guanine dinucleotide (CpG) sites between groups (unadjusted P's < 0.005), with the top gene COL11A1 meeting Bonferroni-adjusted P < 0.05. The second largest differential methylation was observed for the HLA-DRB6 gene, an immune-related gene linked previously to CRPS in a small gene expression study. For all but 7 of the significant CpG sites, the CRPS group was hypomethylated. Numerous functional Gene Ontology-Biological Process categories were significantly enriched (false discovery rate-adjusted q value <0.15), including multiple immune-related categories (eg, activation of immune response, immune system development, regulation of immune system processes, and antigen processing and presentation). Differentially methylated genes were more highly connected in human protein–protein networks than expected by chance (P < 0.05), supporting the biological relevance of the findings. Results were validated in an independent sample linking a DNA biobank with electronic health records (n = 126 CRPS phenotype, n = 19,768 non-CRPS chronic pain phenotype). Analyses using PrediXcan methodology indicated differences in the genetically determined component of gene expression in 7 of 48 genes identified in methylation analyses (P's < 0.02). Results suggest that immune- and inflammatory-related factors might confer risk of developing CRPS after traumatic injury. Validation findings demonstrate the potential of using electronic health records linked to DNA for genomic studies of CRPS.
Persistent opioid use is associated with worse survival after lobectomy for stage I non-small cell lung cancer
Authors: Nelson David B. , Cata Juan P. , Niu Jiangong , Mitchell Kyle G. , Vaporciyan Ara A. , Antonoff Mara B. , Hofstetter Wayne L. , Giordano Sharon H. , Sepesi Boris , Mehran Reza J. , Rice David C.
Published: May 2019

The incidence of persistent opioid use after lung surgery is high. Although adverse effects by opioids have been well described, it is unknown whether persistent opioid use is associated with worse survival. Patients who received a lobectomy for stage I NSCLC from 2007 to 2013 were identified from the Surveillance, Epidemiology and End Results-Medicare database. Opioid use was ascertained through records of prescriptions filled through part D. Patients were matched 2:1 according to their likelihood of persistent opioid use, which was defined as any opioid prescription filled 3 to 6 months after surgery. Two thousand eight hundred eighty-four patients were identified. The incidence of persistent opioid use 3 to 6 months after surgery was 27.0%. After matching, persistent opioid use was associated with worse overall survival (P < 0.001) and cancer-specific survival (P < 0.001). Those who used the lowest quartile of opioids, which was often manifested as a single opioid prescription, showed similar overall survival as no opioid use (HR 1.27, 95% confidence interval [CI] 0.93-1.72). However, the second and third quartiles of opioid use were associated with decreased overall survival (HR 1.53, 95% CI 1.14-2.03 and HR 1.39, 95% CI 1.04-1.86, respectively) that was nonetheless less severe than the highest quartile of opioid use (HR 2.50, 95% CI 1.95-3.21). Age, sex, marital status, comorbidity, tumor size, tumor grade, and radiation were also associated with worse overall survival, with chemotherapy use and video-assisted thoracoscopic surgery being associated with improved overall survival. Persistent opioid use 3 to 6 months after lobectomy is independently associated with worse overall survival and worse cancer-specific survival.
Effect of topical application of adrenaline on Schlemm canal, trabecular meshwork and intraocular pressure
Authors: Ye Meng , Chen Zhiqi , Li Mu , Chen Wei , Zhang Hong , Wang Junming
Published: May 2019

Aim:

To measure changes in the sizes of Schlemm canal (SC) and trabecular meshwork (TM) in healthy individuals before and after topical application of 1% adrenaline at 15, 45, and 90 minutes using anterior segment optical coherence tomography (ASOCT).

Methods:

Anterior chamber angle imaging of the nasal and temporal regions of the right eyes was performed with anterior segment optical coherence tomography (ASOCT) before and after topical application of 1% adrenaline at 15, 45, and 90 minutes. The diameter and area of SC, width and thickness of TM, anterior chamber depth (ACD) and pupil diameter (PD) were measured with ASOCT images. Intraocular pressure (IOP) was also recorded simultaneously.

Results:

A total of 15 healthy individuals were enrolled and included 7 male subjects and 8 female subjects; Compared with the parameters before intervention, both the SC diameter and area in the 2 quadrants increased after the application of adrenaline at the 3 time points (P < .05). The TM width increased after medication (P < .05). IOP decreased significantly after application (P < .05). There were no statistically significant changes in TM thickness, ACD, and PD at any point of time (P > .05).

Conclusion:

Topical application of 1% adrenaline in eye led to decrease in IOP with the SC diameter and area as well as the TM width increased after medication. While the TM thickness, ACD, PD seemed to remain constant.
The effect of air pollution on hospitalization of individuals with respiratory and cardiovascular diseases in Jinan, China
Authors: Chen Cai , Wang Xianfeng , Lv Chenguang , Li Wei , Ma Dedong , Zhang Qi , Dong Leilei
Published: May 2019

To analyze the short-term effects of air pollution on the hospitalization rates of individuals with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), stroke, and myocardial infarction (MI) after adjusting for confounding factors including weather, day of the week, holidays, and long-term trends in Jinan, China.

Hospitalization information was extracted based on data from the primary class 3-A hospitals in Jinan from 2013 to 2015. The concentrations of PM2.5, PM10, SO2, NO2, and O3 were obtained from Jinan Environment Monitoring Center. The relative risk and 95% confidence intervals of AECOPD, stroke, and MI were estimated using generalized additive models with quasi-Poisson distribution in the mgcv package, using R software, version 1.0.136.

The incremental increased concentrations of particulate pollutants including PM2.5 and PM10 were significantly associated with increased risk of hospitalization of AECOPD, stroke, and MI, and the adverse influences of PM2.5 on these diseases were generally stronger than that of PM10. The incremental increased concentrations of gaseous pollutants including SO2, NO2, and O3 were significantly associated with increased risk of hospitalization of stroke and MI in this population.

Air pollution has significant adverse effects on hospitalization rates of individuals with AECOPD, stroke, and MI in Jinan, China.
Effectiveness and safety of Danshen injection on heart failure
Authors: Yuan Tianhui , Chen Yi , Zhou Xiaoqi , Lin Xueying , Zhang Qingsong
Published: May 2019

Background:

Danshen injection (DSI) is a traditional Chinese medicine preparation extracted from Danshen (Salvia miltiorrhiza), which has the functions of promoting blood circulation and removing blood stasis. Heart failure (HF) is a complex cardiovascular disease, always leading to frequent onset and hospitalization, decreased quality of life, increased mortality, etc. Many clinical studies demonstrate that DSI has a good treatment on HF. We will provide a protocol to evaluate the effectiveness and safety of DSI for HF.

Methods:

We will systematically search 3 English databases (PubMed, Excerpta Medica database [EMBASE], the Cochrane Central Register of Controlled Trials [Cochrane Library]) and 4 Chinese databases (Chinese National Knowledge Infrastructure [CNKI], Chinese VIP Information, Wanfang Database, and Chinese Biomedical Literature Database [CBM]) for randomised controlled trials (RCT) of DSI for HF. Left ventricular ejection fraction (LVEF), ejection fraction, left ventricular end diastolic dimension (LVEDD), and six-minute walk distance (SWD) will be set as the primary outcome measures. The secondary outcome measures will include NT-pro BNP, quality of life and adverse reaction. All data will be analysed by using Stata 14.0 software and TSA v0.9 software. We will use I
2 test statistics to assess the heterogeneity of included studies, and Begg's funnel plots and Egger's test to assess publication bias. Methodological quality will be assessed through a Cochrane risk of bias tool for randomized controlled trials (RCTs).

Result:

This study will provide a high quality evidence for DSI on HF.

Conclusion:

This protocol will provide a reliable evidence to evaluate the effectiveness and safety of DSI on HF.

Registration:

PROS-PERO CRD42019125274.
A diagnostic challenge of seromucinous borderline tumor
Authors: Liu Tingting , Sumida Daichi , Wada Takuya , Maehana Tomoka , Yamawaki Aika , Sugimoto Sumire , Kawahara Naoki , Yoshimoto Chiharu , Kobayashi Hiroshi
Published: May 2019

Introduction:

Magnetic resonance (MR) relaxometry provides a noninvasive predictive tool to discriminate between benign ovarian endometrioma (OE) and endometriosis-associated ovarian cancer (EAOC). Transverse relaxation rate R2 value was determined using a single-voxel, multi-echo MR sequence (HISTO) by a 3T-MR system. R2 with cutoff value of 12.1 s−1 was established to discriminate between benign and malignant tumors.

Patient concerns:

We present a case of a 39-year-old woman who was initially thought to be malignant transformation of endometriosis by diagnostic MR imaging of the vascularized solid components.

Diagnosis:

A R2 value of 42.62 s−1 on MR relaxometry demonstrated that this case is non-malignant.

Interventions:

To confirm the diagnose, left salpingo-oophorectomy by laparoscopic surgery was performed.

Outcomes:

Histopathological results revealed seromucinous borderline tumor (SMBT). Our experience suggests that preoperative MR relaxometry may be useful for discriminating “borderline (SMBT)” from “malignancy (EAOC).” Furthermore, immunohistochemical studies of this case demonstrated ovarian SMBT cells were positive for estrogen receptor, progesterone receptor, and hepatocyte nuclear factor-1beta. A similar expression pattern was also observed in patients with benign OE.

Lessons:

In many respects, SMBT characteristics differ from those of EAOC but resemble those of benign OE. MR relaxometry unveils a new clinical approach as an adjunctive modality for discriminating SMBT from EAOC.
Persistent cholestasis resulting from duodenal papillary carcinoma in an adolescent male
Authors: Fu Haiyan , Li Yingchao , Bai Gelan , Yin Runkai , Yin Chunlan , Shi Weina , Zhang Lili , Li Rongpin , Zhao Ruiqin
Published: May 2019

Rationale:

Cholestasis in pediatric patients has diverse etiologies and can be broadly classified as intrahepatic or extrahepatic. The common causes of extrahepatic cholestasis are bile duct calculus, inflammation, or pancreatitis. Malignant tumor is a rare cause of bile ducts obstruction in adolescent. Here we report a 14-year-old male patient with cholestasis due to poorly differentiated adenocarcinoma.

Patient concerns:

A 14-year-old male patient with cholestasis was admitted because of jaundice, weakness, weight loss, and stomach pain for 2 months. The patient had been diagnosed with epilepsy 4 years previously and was being treated with sodium valproate and oxcarbazepine. On admission, laboratory studies showed elevated levels of aspartate aminotransferase (271 IU/L), alanine aminotransferase (224 IU/l), γ-glutamyltransferase (1668.9 IU/L), total bilirubin (66.4 μmol/L), and direct bilirubin (52.6 μmol/L). Additional laboratory tests eliminated common causes of cholestasis such as bacterial/viral infection, autoimmune liver disease, Wilson disease, Alagille syndrome, or progressive familial intrahepatic cholestasis type 3. The results of laboratory investigations showed no improvement after 10 days of treatment with ursodeoxycholic acid and vitamins A, D, and K1. Enhanced magnetic resonance imaging demonstrated a tumor of 22 mm diameter in the duodenal lumen and dilatation of the common bile duct. Endoscopic retrograde cholangiopancreatography detected a tumor in the duodenal lumen.

Diagnosis:

Considering the clinical features, imaging manifestation, endoscopic findings, and pathologic characteristic, the patient was diagnosed with poorly differentiated adenocarcinoma.

Interventions:

The patient underwent pancreaticoduodenectomy and chemotherapy.

Outcome:

The patient recovered well. Elevated levels of tumor biomarkers or abnormal liver function tests have not occurred during the 2-year follow-up.

Conclusion:

Cholestasis resulting from primary duodenal papillary carcinoma is rare in pediatric patients but should be considered in the differential diagnosis.
Prevalence of back pain and the knowledge of preventive measures in a cohort of 11619 Polish school-age children and youth—an epidemiological study
Authors: Kędra Agnieszka , Kolwicz-Gańko Aleksandra , Sitarski Dominik , Kędra Przemysław , Czaprowski Dariusz
Published: May 2019

The study sought to characterize back pain (BP) (in the period of 12 months) in children and youth aged 10 to 19 from eastern Poland.

The study included 11619 children and youth (6254 girls and 5365 boys) aged 10 to 19 from eastern Poland. An original questionnaire was applied as a research tool. Before the study, the reliability of the questionnaire had been assessed. The Kappa coefficient value for all the analyzed variables was equal to or higher than 0.91.

Over 74.4% of the respondents admitted that within the last 12 months, they had experienced BP which was usually located in the lumbar spine (55.8%). The percentage of individuals reporting BP increased with age of participants. Girls reported BP more often than boys (82.8% vs 64.3%). The main circumstances in which BP occurred included lifting heavy objects, carrying school backpack and maintaining a sedentary position (70.7% vs 67.4% vs 67.8%). Over 67% of the respondents declared they did not know ergonomic principles.

High prevalence of BP was noted. The declared BP was mainly located in the lumbar spine. Girls reported BP more often than boys. The students presented a very low level of knowledge about ergonomics. Therefore, the appropriate education should be included at school.
Depression may not be a risk factor for mortality in stroke patients with nonsurgical treatment
Authors: Li Hsing-Jung , Kuo Chao-Chan , Li Ying-Chun , Tsai Kuan-Yi , Wu Hung-Chi
Published: May 2019

Patients with depression have more comorbidities than those without depression. The cost of depression-associated comorbidities accounts for the largest portion of the growing cost of depression treatment. Patients with depression have a higher risk of stroke with poor prognoses than those without depression; however, previous studies evaluating the relationship between depression and stroke prognosis have not accounted for surgical treatment or other risk factors. Therefore, we investigated whether depression is a risk factor for mortality in stroke patients with nonsurgical treatment after adjusting for other risk factors.

We retrospectively analyzed the data of patients with major depressive disorder (MDD) and age and sex-matched controls without MDD during 1999 to 2005. We then identified patients who developed stroke in both groups and analyzed risk factors for death in these stroke patients who received nonsurgical treatments during a follow-up period from 2006 to 2012.

Patients with MDD had higher Charlson Comorbidity Index Scores (CCISs) and exhibited higher frequencies of comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, and coronary heart disease than controls without MDD, and most of MDD patients had very low or high socioeconomic status (SES) and lived in urban settings. Most stroke patients with MDD who received nonsurgical treatment were female, had very low or high SES, and lived in urban settings; in addition, stroke patients with MDD who received nonsurgical treatment had higher CCISs and frequencies of hyperlipidemia and coronary heart disease than those without MDD who received nonsurgical treatment. However, depression was not a risk factor for death in stroke patients with nonsurgical treatment.

Hemorrhagic stroke, age, sex, and CCISs were risk factors for death in stroke patients with nonsurgical treatment, but depression did not affect the mortality rate in these patients.
Complete remission of giant malignant phyllodes tumor with lung metastasis
Authors: Moon So Hyang , Jung Jin Hyang , Lee Jeeyeon , Kim Wan Wook , Park Ho Yong , Lee Jeong Woo , Lee Soo Jung
Published: May 2019

Rationale:

Malignant phyllodes tumors are rare breast neoplasms that are associated with a 6.2% to 25% incidence rate of distant metastasis; the lung is the most common metastatic site. To date, there is no consensus regarding the treatment of metastatic malignant phyllodes breast tumors.

Patient concern:

A 48-year-old woman was admitted into the breast clinic for a rapidly growing right breast tumor that was first noticed 1 month prior.

Diagnosis:

Core needle biopsy revealed a malignant phyllodes tumor. A chest computed tomography and positron emission tomography/CT showed metastatic lymph nodes that appeared to have spread to the right axilla, as well as multiple solitary pulmonary nodules in the right lung. Fine needle aspiration on the axillary lymph node confirmed metastasis.

Interventions:

A right mastectomy with axillary lymph node dissection was conducted and a thoracoabdominal flap and a split thickness skin graft were performed for the skin defect. Palliative chemotherapy with doxorubicin plus ifosfamide was performed.

Outcomes:

An examination conducted 3 years postsurgery showed no signs of recurrence, and the patient's overall health status was satisfactory.

Lessons:

As standard treatment guidelines for metastatic malignant phyllodes tumors are lacking, we opted for the aforementioned aggressive treatments that resulted in complete remission of the lung metastasis. Therefore, aggressive treatment, whenever possible, is warranted.
The concentration of tumor necrosis factor in the blood serum and in the urine and selected early organ damages in patients with primary systemic arterial hypertension
Authors: Puszkarska Anna , Niklas Arkadiusz , Głuszek Jerzy , Lipski Dawid , Niklas Karolina
Published: May 2019

Arterial hypertension is considered to be an inflammatory condition with low intensity. Therefore, an elevated concentration of inflammatory cytokines can be expected in patients with systemic arterial hypertension, including tumor necrosis factor (TNF).

The study included a group of 96 persons aged 18 to 65 years: 76 patients with primary arterial hypertension and 20 healthy individuals (control group). Blood pressure was measured in all individuals using the office and ambulatory blood pressure monitoring (ABPM) measurement, blood was collected for laboratory tests [tumor necrosis factor (TNF), tumor necrosis factor receptor 1 (TNFR1)], and 24-hour urine collection was performed in which albuminuria and TNF concentration were assessed. Moreover, assessment of the intima-media thickness (IMT) in ultrasonography and left ventricular mass index (LVMI) in echocardiography were carried out.

Statistically elevated TNF concentration in the blood serum (P = .0001) and in the 24-hour urine collection (P = .0087) was determined in patients with hypertension in comparison with the control group. The TNF and TNFR1 concentration in the serum and TNF in the 24-hour urine in the group of patients with arterial hypertension and organ damages and without such complications did not differ statistically significantly.

We observed a positive and statistically significant correlation between TNFR1 concentration in the serum and TNF urine excretion in patients with hypertension (r = 0.369, P < .05)

Patients with arterial hypertension are characterized by higher TNF concentrations in blood serum and higher TNF excretion in 24-hour urine than healthy persons.

TNF and TNFR1 concentration in blood serum and TNF excretion in 24-hour urine in patients with early organ damages due to arterial hypertension do not differ significantly from those parameters in patients with arterial hypertension without organ complications.

There is a positive correlation between TNFR1 concentration in the serum and TNF urine excretion in patients with hypertension.
Diagnosis of hereditary diffuse leukoencephalopathy with neuroaxonal spheroids based on next-generation sequencing in a family
Authors: Shi Tianji , Li Jia , Tan Cheng , Chen Jiajun
Published: May 2019

Rationale:

Hereditary diffuse leukoencephalopathy with neuroaxonal spheroids (HDLS) is a rare disease with white matter lesions of the central nervous system, and it usually has autosomal dominant inheritance. Its pathogenesis and causes are complex, and it has obvious clinical and genetic heterogeneities; also, it is classed as a neurodegenerative disease.

Patient concerns:

In preliminary clinical work, we identified a family with rapid progressive dementia.

Diagnosis:

Within this family, all patients had a CSF1R gene c.2696delA mutation (a deletion mutation), and head magnetic resonance imaging showed extensive white matter lesions. We diagnosed these patients with HDLS.

Interventions:

The proband was given hormonal treatments and immunoglobulin therapy, and his dementia symptoms have been relieved to a certain extent.

Outcomes:

After treatment, the symptoms of dementia were still progressively aggravated. However, the mutation site has not previously been reported.

Lessons:

This newly discovered mutation site may provide a new basis for the genetic diagnosis of HDLS disease in clinical work.
Gamma knife radiosurgery as an alternative treatment of Barrow type B carotid cavernous fistulas
Authors: Park Kang-Hoon , Park Jung-Soo , Koh Eun-Jeong , Lee Jong-Myong
Published: May 2019

Rationale:

Barrow type B carotid-cavernous fistulas are dural shunts between the meningeal branches of the internal carotid artery and the cavernous sinus; these types of dural fistulas can produce specific patterns of symptoms based on the pattern of venous drainage.

Patient concerns and diagnoses:

A 67-year-old man came to our hospital presenting with acute left orbital pain and double vision in the left eye. The diagnosis was carotid-cavernous fistula fed by the meningohypophyseal trunk and drained to the left superior ophthalmic vein.

Interventions and outcomes:

We planned gamma knife radiosurgery for the left cavernous sinus including fistula point as an alternative treatment. The orbital pain disappeared in 2 weeks, and all signs and symptoms in the left eye completely improved within 2 months.

Lessons:

Gamma knife radiosurgery may be an alternative treatment for carotid cavernous fistula. Furthermore, in patients with poor vascular access and no fatal presentation, this may be a reasonable first-line treatment option.
Effect of strabismus surgery on ocular axial length, anterior chamber depth, and intraocular pressure
Authors: Lee Donghun , Kim Myung Mi , Kim Won Jae
Published: May 2019

We evaluated changes in ocular axial length (AL), anterior chamber depth (ACD), and intraocular pressure (IOP) after strabismus surgery by comparing the operated and fellow eyes in patients undergoing unilateral strabismus surgery.

This was a prospective study including patients who underwent unilateral strabismus surgery for exotropia alone or exotropia with unilateral superior oblique palsy. The AL and ACD using IOLMaster biometer and the IOP using non-contact tonometry were measured 1 day prior to surgery and 1 week, 1 month, and 3 months postoperatively.

Fourteen female and 22 male patients (mean age: 8.2 years) were included in the study. In the operated eye, the mean AL increased significantly from 23.99 mm preoperatively to 24.08 mm 1 week postoperatively (P < .001), and although the mean ACD decreased in this time, the decrease was not statistically significant. The mean IOP of the operated eye increased from 17.08 mmHg preoperatively to 20.31 mmHg at 1 week postoperatively (P = .01), as did the IOP of the fellow eye (P = .03). However, the AL and IOP of the operated eyes decreased by 1 month postoperatively. There were no significant differences in the AL, ACD, and IOP between operated and fellow eyes by 3 months postoperatively.

Strabismus surgery caused significant AL elongation in the operated eye and IOP elevation in both the operated and fellow eyes immediately after surgery. However, both ocular changes were transient. The AL, ACD, and IOP did not exhibit any significant differences between operated and fellow eyes 3 months postoperatively.
Safety of aripiprazole for tics in children and adolescents
Authors: Yang Chunsong , Yi Qiusha , Zhang Lingli , Cui Hao , Mao Jianping
Published: May 2019

Background:

Aripiprazole is widely used in the management of tic disorders (TDs), we aimed to assess the safety of aripiprazole for TDs in children and adolescents.

Methods:

A systematic literature review was performed in the databases of MEDLINE, Embase, the Cochrane Library and 4 Chinese databases, from inception to February 2019. All types of studies evaluating the safety of aripiprazole for TDs were included. The quality of studies was assessed using the Cochrane Risk of Bias tool, the Newcastle–Ottawa Scale tool, the National Institute of Clinical Excellence, the CARE (Case Report) guidelines according to types of studies. Risk ratio (RR) and incidence rate with a 95% confidence interval (CI) were used to summarize the results.

Results:

A total 50 studies involving 2604 children met the inclusion criteria. The result of meta-analysis of randomized controlled trials showed that there was a significant difference between aripiprazole and haloperidol with respect to rate of somnolence (RR = 0.596, 95% CI: 0.394, 0.901), extrapyramidal symptoms (RR = 0.236, 95% CI: 0.111, 0.505), tremor (RR = 0.255, 95% CI: 0.114, 0.571), constipation (RR = 0.148, 95% CI: 0.040, 0.553), and dry mouth (RR = 0.141, 95% CI: 0.046, 0.425). There was a significant difference between aripiprazole and placebo in the incidence rate of adverse events (AEs) for somnolence (RR = 6.565, 95% CI: 1.270, 33.945). The meta-analysis of incidence of AEs related to aripiprazole for case series studies revealed that the incidence of sedation was 26.9% (95% CI: 16.3%, 44.4%), irritability 25% (95% CI: 9.4%, 66.6%), restlessness 31.3% (95% CI: 13%, 75.1%), nausea and vomiting 28.9% (95% CI: 21.1%, 39.5%), and weight gain 31.3% (95% CI: 10.7%, 91.3%).

Conclusion:

Aripiprazole was generally well tolerated in children and adolescents. Common AEs were somnolence, headache, sedation, nausea, and vomiting. Further high-quality studies are needed to confirm the safety of aripiprazole for children and adolescents with TDs.
Transient Budd-Chiari syndrome as an unpredictable complication of supradiaphragmatic inferior vena cava reconstruction after blunt thoracic trauma
Authors: Kim Jung Hee , Baek Jong Hyun
Published: May 2019

Rationale:

Supradiaphragmatic inferior vena cava (IVC) injury due to blunt thoracic trauma is extremely rare. Budd-Chiari syndrome (BCS) is also rare and presents with ascites, abdominal pain, hepatomegaly, leg swelling, and jaundice. Its etiology is diverse, and it is rarely caused by trauma.

Patient concerns:

A 36-year-old man with blunt trauma from a traffic accident presented with chest pain. Chest computed (CT) and emergency surgery with CPB revealed completely transected supradiaphragmatic inferior vena cava (IVC), which reconstruction was essential.

Diagnoses:

BCS caused by impaired hepatic venous drainage through a reconstructed neo-IVC after severe blunt trauma injury to the supradiaphragmatic IVC was diagnosed.

Intervention:

Hepatic failure, ascites, leg swelling, and jaundice were resolved post-insertion of a veno-venous extracorporeal membrane oxygenator (V-V ECMO) for hepatic venous drainage, but these clinical symptoms reappeared after ECMO removal.

Outcome:

The patient died from rapidly progressing sepsis, pneumonia, and acute renal failure during repeated insertion of ECMO and weaning off ECMO.

Lessons:

Reconstructing and improving the patency of the supradiaphragmatic IVC is essential for successful hepatic venous drainage. Additionally, a surgical strategy focused on graft selection can prevent kinking stenosis, and possibly BCS, especially in emergency surgeries. A ring-supported synthetic graft should be considered an alternative to improve long-term patency and survival rate.
Combined transoral and endoscopic approach for cervical spine tumor resection
Authors: Zhou Jun , Lu Yong-Tian , Lu Fei-Yan
Published: May 2019

This study aimed to explore the feasibility and clinical effectiveness of a combined transoral and endoscopic approach for the removal of benign cervical spine tumors.

First, we obtained detailed anatomical measurements of the atlantoaxial joint from 20 fresh cadaveric specimens and performed simulated surgeries with the combined transoral and endoscopic approach on 10 cadaveric specimens. Then, we applied the combined approach for the resection of benign cervical spine tumors in 8 patients at our hospital from October 2013 to October 2015. All patients underwent enhanced axial, coronal, and sagittal computed tomography (CT) examination before and after surgery. Preoperative 3-dimensional (3D) reconstruction and printing models were used in 5 cases.

On the basis of CT measurements of fresh cadaveric atlantoaxial anatomy and practical experiences from simulated surgeries on the cadaveric specimens with latex perfusion, cervical tumors were completely removed from 8 patients without complications. The average surgery time was 73 minutes, and the average intraoperative bleeding volume was 34 mL. The average hospital stay was 6.5 days. The average NRS score of patients was 2.25 points at 3 days postoperation. At the 12-month postoperative follow-up, the atlantoaxial vertebral bone had been largely repaired, and no recurrence was observed by cervical CT examination.

The combined transoral and endoscopic approach could be used safely and effectively to excise cervical spine tumors with substantial advantages, including direct surgical access, relatively simple operation, short operative time, quick postoperative recovery, a reliable curative effect, and few complications.
Protocol of a clinical trial study involving educational intervention in patients treated with warfarin
Authors: Costa Josiane Moreira da , Marcolino Milena Soriano , Torres Heloisa Carvalho , Resende Raissa Eda de , Souza Renan Pedra de , Barbosa Hannah Cardoso , Ribeiro Daniel Dias , Martins Maria Auxiliadora Parreiras
Published: May 2019

Background:

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. Oral anticoagulation is an effective strategy for primary and secondary prevention of stroke in patients with AF. Warfarin is an oral anticoagulant widely prescribed and, despite its benefits, the achievement of the goals of drug therapy depends on patient involvement, among other factors. Educational interventions can contribute for effectiveness and safety of oral anticoagulation therapy. We sought to describe the protocol of a clinical trial designed to evaluate the effect of a patient-centered educational strategy focused on low-income patients with AF and poor anticoagulation control.

Methods:

Patients ≥18 years with AF, on warfarin for at least 6 months and time in therapeutic range (TTR) <60% will be recruited at 2 anticoagulation clinics (ACs) in Brazil. Patients from 1 AC will be allocated to the intervention group and patients from the other AC will be allocated to the control group. Intervention group will attend educational sessions based on a patient-centered care approach, and the control group will receive usual care. The intervention will be based on Paulo Freire's theory and tailored according to practices involving health empowerment and techniques applied to individuals with limited socioeconomic status. The intervention is estimated to last 5 months. We will consider TTR as the primary outcome and knowledge and self-reported non-adherence to warfarin therapy as secondary outcomes. TTR values and non-adherence will be measured before intervention (T0) and at times immediately after (T1), and 3 (T2), 6 (T3), 9 (T4), and 12 (T5) months after intervention. Knowledge will be measured at times T0, T1 e T5. The calculated sample size indicated 85 patients in each group.

Discussion:

The proposed study aims to investigate whether an innovative educational approach to deliver care to a low-income population on warfarin improves anticoagulation control. Once our hypothesis is confirmed, our findings are expected to help improving anticoagulation control, knowledge on warfarin therapy and adherence to drug therapy. Thus, we believe our results may contribute to improve oral anticoagulation effectiveness in a low-income population.

Trial registration: Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR- 9cy6py and UTN: U1111-1217-0151 (March, 2019).
The alteration of ferritin and transferrin saturation under body mass index and blood pressure in first-time and regular male blood donors in Taiwan
Authors: Wang Hsuan-Hui , Liao Li-Na , Chang Ci-Wen , Chang Yu-Chang , Wu Kang-Hsi , Ko Jiunn-Liang
Published: May 2019

Iron status, body mass index (BMI) and blood pressure (BP) are all important health indicators. In this study, ferritin and transferrin saturation levels and their correlations with BMI and BP were investigated in first-time and regular male blood donors in Taiwan. Serum ferritin and transferrin saturation values represented iron status of blood donors. Serum ferritin, serum iron, and total iron binding capacity (TIBC) were determined by chemiluminescent immunoassay sandwich method, timed-endpoint method, and turbidimetric method, respectively. Transferrin saturation was calculated as 100× serum iron/TIBC. Statistical analyses included 2-sample t test, chi-square test, Pearson correlation coefficient, and multiple linear regression. Comparisons of ferritin and transferrin saturation mean values with BMI, age, systolic blood pressure (SBP), diastolic blood pressure (DBP), and occupation were conducted. A total of 111 first-time donors and 1249 regular blood donors participated in this study. The ferritin and transferrin saturation mean values of regular male blood donors were lower than those of first-time male blood donors, but remained within the safe range. BMI was positively correlated with serum log ferritin, but not with transferrin saturation value in first-time and regular blood donors. First-time donors with BMI ≥24 kg/m2 and aged more than 40 years demonstrated 1.37-fold higher serum ferritin on average. Among regular donors, significant effects of BMI ≥24 kg/m2 and age >40 years were observed with 1.25- and 1.18-fold higher serum ferritin levels, respectively. First-time donors with SBP ≥120/DBP ≥80, ≥120/<80, and <120/≥80 mm Hg had on average 1.65-, 1.54-, and 2.59-fold higher serum ferritin levels than those with normal BP. Ferritin level was higher in BMI ≥24 kg/m2 subgroup than in BMI <24 kg/m2 subgroup among first time and regular male donors, but no difference was found in transferrin saturation values.

Abnormal SBP/DBP was associated with increased ferritin level only in first-time male blood donors.
Torsional and burst mode phacoemulsification for patients with hard nuclear cataract
Authors: Yang Wan-Ju , Wang Xing-Hua , Zhao Fang , Mei Zhong-Ming , Li Shuang , Xiang Yi
Published: May 2019

This article aims to evaluate the outcomes of torsional and burst mode phacoemulsification in hard nuclear cataracts.

Eighty eyes with grade IV or V nuclear opalescence were treated with phacoemulsification and intraocular lens implantation using conventional mode (Group A, n = 40) or torsional and burst mode phacoemulsification (Group B, n = 40). For good visualization of anterior capsule, trypan blue was injected to the anterior chamber before continuous circular capsulorhexis. The mean cumulative dissipated energy and ultrasound time were recorded. The best-corrected visual acuity, endothelial cell density, and central corneal thickness were measured before and at 1 month after surgery.

The cumulative dissipated energy and ultrasound time of Group B were significantly less than that of Group A. The postoperative best-corrected visual acuities of the 2 groups were comparable. At 1 month after surgery, the changes in the endothelial cell density were significantly greater in Group A than in Group B, and the changes in the central corneal thickness were not significantly different between the 2 groups.

Torsional and burst mode is a safe and effective surgical method for treating hard cataracts.