bluuebunny/crossref_metadata_2025 huggingface dataset:
Investigation of the relationship between non-ketotic hyperglycemia and hemichorea-hemiballism
Authors: Hsiao Po-Jen , Kuo Chih-Chun , Kuo Tai-You , Kao Yung-Hsi , Chan Jenq-Shyong , Lin Yen-Yue , Chen Ming-Hua , Chen Jin-Shuen , Chuu Chih-Pin
Published: July 2019

Rationale:

Hemichorea-hemiballism, a rare manifestation of non-ketotic hyperglycemia, characterized by involuntary arrhythmic motions involving one side of the body, results from focal lesions in the contralateral caudate nucleus and putamen. Hyperkinetic disorders can be complications of uncontrolled diabetes mellitus and should not be ignored.

Patient concerns:

We present the case of a 39-year-old woman who presented to the emergency department with a 3-day history of left-sided hemichorea-hemiballism. She had type 2 diabetes mellitus with poor control and maintenance of regular hemodialysis.

Diagnoses:

The patient was diagnosed as hyperglycemia, normal ketone body and hemichorea-hemiballism based on laboratory examination, computed tomography (CT) scan, and brain magnetic resonance image (MRI).

Interventions:

Intensive glycemic control via insulin injection was prescribed for correction of hyperglycemia.

Outcomes:

The unilateral involuntary movements subsided progressively over four weeks. The patient's hemichorea had completely resolved at the three-month follow-up.

Lessons:

This unusual clinical presentation is often accompanied by severe hyperglycemia. Appropriate blood glycemic control is important. If physicians recognize and provide early treatment for this disease, it is usually treatable and has a good prognosis.
Uterine hypertonus and fetal bradycardia occurred after combined spinal-epidural analgesia during induction of labor with oxytocin infusion
Authors: Yang Lingyun , Wan Li , Huang Han , Qi Xiaorong
Published: July 2019

Rationale:

Pain management is an essential part of good obstetrical care. The rapid onset of pain relief after combined spinal-epidural (CSE) analgesia may cause a transient imbalance in maternal catecholamine level, leading to uterine hyperactivity and fetal heart rate (FHR) abnormalities. How to manage the uterine basal tone and FHR abnormalities after labor analgesia still remains controversial.

Patient concerns:

A 33-year-old nulliparous woman at 40+5 weeks’ gestation underwent induction of labor after premature rupture of membranes. CSE analgesia was provided when the patient described her pain as the top on a scale of 10 during induction of labor with oxytocin infusion.

Diagnoses:

Uterine hypertonus and fetal bradycardia were diagnosed within 10 minutes after CSE analgesia.

Interventions:

Oxytocin infusion and CSE analgesia were immediately suspended, and measures of staying in left lateral decubitus position and giving supplemental oxygen were attempted to resuscitating the baby. Because of suspicious fetal distress, the baby was rapidly delivered by emergency cesarean section.

Outcomes:

The Apgar score of the baby was 8 and 10 at 1 and 5 minutes after birth. Subsequent follow-up confirmed that both mother and baby were in good condition.

Lessons:

The loss of the tocolytic effect of epinephrine after CSE analgesia and continuous oxytocin infusion may work together to form a totally synergistic function, finally leading to inevitable uterine hypertonus and fetal bradycardia. Both the obstetrical provider and anesthesiologist should carefully monitor all patients in the first 15 minutes after CES analgesia induction. Oxytocin administration in this critical period deserves attention. Additionally, intraprofessional collaboration is also necessary to ensure high quality and safe delivery for all childbearing women.
Medical expenditures and its determinants depending on receipt of public pension in South Korea
Authors: Choi Ryoung , Kang Hyun Goo
Published: July 2019

Background:

The objective of this study was to analyze the expenditures on medical expenses and its determinants using the Korean Retirement and Income Data conducted by the National Pension Research Institute.

Methods:

This study utilized data from the Korean Retirement and Income Study from 2005 to 2013, which were compiled by the National Pension Research Institute. The t test and ANOVA were used to analyze the general characteristics and medical expenditures of subjects depending on the receipt of public pension, and logistic regression was used to identify the determinants of medical expenditures.

Results:

The results of this study indicated that households not receiving public pension are likely to spend more on medical expenses than those receiving public pension. The analysis results showed that gross household expenditures quintiles affected medical expenditures up to 4 times. Moreover, poor physical health was a stronger influence factor of medical expenditures than good physical health.

Conclusion:

It is necessary to prepare a pension policy that can guarantee a reasonable amount of a retirement pension to the retiree, provide health policy and financial support programs to medical services.
Sentinel lymph node mapping procedure in T1 colorectal cancer
Authors: Di Berardino Stefano , Capolupo Gabriella Teresa , Caricato Chiara , Caricato Marco
Published: July 2019

Objective:

to investigate the role of sentinel lymph node mapping procedure in T1 Colorectal cancer.

Background:

The incidence of T1 Colorectal cancer is increasing thanks to screening and awareness campaigns. The issue concerning T1 is when to consider a local treatment curative or when it is necessary a radical resection. The histopathological features of resected polyps are able to predict the nodal spread but the value of specificity is increasingly a problem of these predictors. The sentinel lymph node procedure could be a solution.

Methods:

A systematic review was performed following PRISMA guidelines and using “sentinel node”, “lymph nodes”, and “colorectal cancer” as search terms in PubMed and Embase databases. References from included studies, review articles, and editorials were cross-checked. The risk of bias and quality of the included studies were assessed using the QUADAS-2 tool. The primary outcome was sentinel lymph node accuracy rate and the secondary outcome was sentinel lymph node detection rate for T1 Colorectal cancer.

Results:

A total of 12 studies (108 patients) met inclusion and exclusion criteria, 8 were monocentric cohort studies and 4 were multicentric cohort studies. The rate of sentinel lymph node accuracy in T1 colorectal cancer varies from 89% to 100%. Only 1 false negative was found. In 7 of these 12 studies (71 patients) the detection rate of T1 colorectal cancer was reported and showed a variation from 92% to 100%. Even in this case, only 1 case of failed procedure was found.

Discussion:

The literature on this topic agrees on that sentinel lymph node mapping, differently from breast cancer and melanomas should not be used for therapeutic purposes in colorectal cancer, but mainly to refine staging. The reason is the low sensitivity of this procedure with an accompanying high false negative rate. However, the data refers mainly to advanced stages of the disease because there are few data available on the earlier stages and in particular related to T1. Isolating the data related only to T1, the false negative rate seems to be very low. Additional studies are necessary, but a decisional role of sentinel lymph node mapping on the treatment of T1 Colorectal cancer is possible in the future.
Acute pulmonary thromboembolism caused by factor V Leiden mutation in South Korea
Authors: Choe Hun Jee , Suh Koung Jin , Lee Ji Yun , Kim Minyoung , Kim Man Jin , Park Sung Sup , Kim Ji-Won , Kim Se Hyun , Kim Jin Won , Lee Jeong-Ok , Kim Yu Jung , Lee Keun-Wook , Kim Jee Hyun , Bang Soo-Mee , Lee Jong Seok
Published: July 2019

Rationale:

Although Factor V Leiden (FVL) mutation is a major cause of inherited thrombophilia in Western populations; the mutation is extremely rare in Asia.

Patient concerns:

Here we report a case of a 28-year old Korean woman admitted to our hospital with extensive pulmonary embolism.

Diagnosis:

She was heterozygous for FVL mutation up on evaluation, and screening for asymptomatic family members also revealed heterozygous FVL mutation for her mother.

Interventions:

Enoxaparin 1 mg/kg was initiated, followed by rivaroxaban 15 mg every 12 hours.

Outcomes:

The patient showed improvement in both subjective dyspnea and right ventricular dysfunction and was successfully discharged after five hospital days.

Lessons:

FVL mutation screening may be considered in Asian patients with thrombophilia of uncertain etiology in the future.
Metabolic tumor volume and conformal radiotherapy based on prognostic PET/CT for treatment of nasopharyngeal carcinoma
Authors: Fei Zhaodong , Chen Chuanben , Huang Yingying , Qiu Xiufang , Li Yi , Li Li , Chen Taojun
Published: July 2019

For patients with nasopharyngeal carcinoma (NPC), prognostic indicators to customize subsequent biologically conformal radiation therapy may be obtained via 2-(fluorine-18)-fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT). This retrospective study assessed the prognostic significance and feasibility of conformal radiotherapy for NPC, based on 18F-FDG PET/CT. Eighty-two patients with NPC underwent 18F-FDG PET/CT prior to intensity-modulated radiation therapy (IMRT). The maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) of the primary tumor were measured, with MTV
x
based on absolute SUV
x
values ≥ specific threshold x on each axial image. The cut-off SUVmax and MTV values for predicting 3-year progression-free survival (PFS) were calculated according to a receiver operating characteristic curve. Assessed were correlations between SUVmax and MTV and between threshold x and MTV
x
, and the MTV percentage of the primary tumor volume at threshold x. The SUVmax and MTV were positively associated, as were MTV and primary tumor volume. Primary tumor volume, SUVmax, and MTV were significant predictors of survival. The 3-year PFS rates for SUVmax ≤8.20 and >8.20 were 91.1% and 73.0%, respectively (P = .027). With furthermore analysis, patients having tumor with smaller MTV had higher 3-year PFS than patients having tumor with larger MTV. The 3-year PFS rate was inversely related to MTV. SUVmax and MTV, derived by PET/CT, are important for assessing prognosis and planning radiotherapy for patients with NPC. Small MTV indicated better 3-year PFS compared with large MTV. For the best therapeutic effect, MTV4.0 was the best subvolume to determine radiotherapy boost.
Real-world treatment patterns and clinical outcomes among patients with advanced melanoma
Authors: Cowey C. Lance , Liu Frank Xiaoqing , Boyd Marley , Aguilar Kathleen M. , Krepler Clemens
Published: July 2019

Recently, the effectiveness of novel immune checkpoint inhibitors and BRAF-directed therapies has been demonstrated in advanced melanoma trial populations. Limited research, however, has evaluated the impact of these therapies in a real-world setting. The aim of this study was to evaluate treatment patterns and clinical outcomes among advanced melanoma patients treated with modern therapies within community oncology clinics. Adult patients with advanced melanoma who initiated treatment within the US Oncology Network between 1/1/14 and 12/31/16 were included. Data were sourced from electronic healthcare records. Patients were followed through 12/31/17. Descriptive analyses were performed to assess patient and treatment characteristics and Kaplan–Meier methods were used for time-to-event outcomes. In total, 484 patients met eligibility criteria (32.0% with brain metastasis, 12.6% with Eastern Cooperative Oncology Group performance status ≥2). In the first-line (1L) setting during the study period, 37.0% received anti-PD1 monotherapies, 26.4% ipilimumab monotherapy, 19.8% BRAF/MEK combination therapy, 6.4% BRAF or MEK monotherapy, 4.1% ipilimumab/nivolumab combination therapy and 6.2% other regimens. Differences in baseline demographic and clinical characteristics were observed across treatment groups. For the overall study population, the median (95% confidence interval) estimates for overall survival, time to next treatment and progression-free survival were 20.7 (16.0, 26.8), 5.8 (5.3, 6.5), and 4.9 (4.2, 5.7) months, respectively. The results of this study provide real-world insight into advanced melanoma treatment trends and clinical outcomes, including high utilization of immunotherapies and BRAF/MEK combination therapy. Future research can explore underlying differences in patient subpopulations and the sequence of therapies across lines of therapy.
Effects of continuous positive airway pressure (CPAP) therapy on neurological and functional rehabilitation in Basal Ganglia Stroke patients with obstructive sleep apnea
Authors: Ren Lei , Wang Kai , Shen Honghua , Xu Yiming , Wang Jing , Chen Rui
Published: July 2019

Obstructive sleep apnea (OSA) adversely affects neurological recovery. This study aimed to determine the impact of continuous positive airway pressure (CPAP) and/or rehabilitation in basal ganglia stroke patients with OSA.

A prospective controlled trial was conducted in 2015–2018. The subjects received routine rehabilitation training for up to 2 years and were assigned to the intervention and control groups treated with CPAP or without, respectively. Then, treatment effects on sleep parameters, motor function, stroke severity, daily life activities, cognitive function, and psychological states were assessed at different time points.

At 6 months, the CPAP group showed significantly lower mean apnea-hypopnea index (AHI), percentage of time with SpO2 at <90% (TS90%), micro-arousal index, and percentages of time in non-rapid eye movement (non-REM) stages 1–2 and REM stage in total sleeping time compared with the control group, and significantly higher mean minimum of peripheral oxygen saturation (L-SaO2%) and percentage of time in stage 3 (P < .001) sleep. The CPAP group showed significant improvements in average the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment scale (FMA), Barthel index (BI), Minimental state examination (MMSE), Hamilton anxiety scale (HAMA) and Hamilton depression rating scale for depression (HRSD) scores at different times versus the control group, respectively (P < .05). However, no difference in body mass index (BMI) management was observed (P > .05). Repeated-measures ANOVA revealed significant interactions between the two groups for change in FMA, MMSE, BI, HAMA, and HRSD scores from admission to 24 months (P < .001), but no significant was found for BMI (P = .582).

Basal ganglia stroke patients with OSA tend to have significantly greater sleeping, neurological and functional recovery after CPAP, and rehabilitation over 2 years.
Automatic current selection with iterative reconstruction reduces effective dose to less than 1 mSv in low-dose chest computed tomography in persons with normal BMI
Authors: Chen Li-Guo , Wu Ping-An , Sheu Min-Huei , Tu Hsing-Yang , Huang Li-Chuan
Published: July 2019

Most of the recent studies have used fixed tube current while few investigators use automatic current selection (ACS) with iterative reconstruction (IR) techniques to reduce effective dose (ED) to < 1 mSv in low-dose chest computed tomography (LDCCT). We investigated whether image quality of lungs as produced by a fixed tube current (FTC) of 35 mAs can be maintained with ED < 1 mSv produced by ACS with IR techniques in LDCCT. A total of 32 participants were included. The LDCCT was performed by a FTC 35 mAs (with a kilovoltage peak of 120 kVp) in 16 participants (Group A), and by a DoseRight ACS in 16 participants (Group B). Their images were improved by IR technique. The ED was estimated by multiplying the individual dose length product (DLP) by the dose conversion factor. The image quality was assessed by the CT number, noise levels, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) of the regions of interest in the apex, upper lobe, and lower lobe of lung regions in the CT images. A t-test was used to evaluate the LDCCT image quality between the groups. The ED was significantly 49.2% lower in Group B than in Group A (0.71 ± 0.05 mSv vs 1.40 ± 0.02 mSv, P < .001). However, noise level, SNR, and CNR were not significantly different between Groups A and B, indicating the image quality was similar between two groups, or our setting parameters for DoseRight ACS with IR technique can achieve the image quality as good as obtained on the FTC 35 mAs with IR techniques. Our results suggest that the DoseRight ACS with IR technique reduces ED to lower than 1 mSv (averagely 0.71 mSv) yet maintains an image quality as good as produced by FTC 35 mAs with IR technique in normal BMI persons. The ACS setup thus is more preferable than the FTC to achieve the ALARA (as low as reasonably achievable) principle.
Is there a standard treatment for displaced pediatric diametaphyseal forearm fractures?
Authors: Kubiak Rainer , Aksakal Devrim , Weiss Christel , Wessel Lucas M. , Lange Bettina
Published: July 2019

To review our institutional results and assess different surgical and non-surgical techniques for the treatment of displaced diametaphyseal forearm fractures in children and adolescents.

Thirty-four children (25M, 9F) with a total of 36 diametaphyseal forearm fractures who underwent treatment under general anesthesia between July 2010 and February 2016 were recruited to this retrospective study. From October 2016 until March 2018 patients and/or parents were contacted by telephone and interviewed using a modified Pediatric Outcomes Data Collection Instrument (PODCI).

Median age at the time of injury was 9.1 years (range, 1.9–14.6 years). Initial treatment included manipulation under anesthesia (MUA) and application of plaster of Paris (POP) (n = 9), elastic stable intramedullary nailing (ESIN) (n = 10), percutaneous insertion of at least one Kirschner wire (K-wire) (n = 16), and application of external fixation (n = 1). Eleven children (32%) experienced a total of 22 complications. Seven complications were considered as major, including delayed union (n = 1) and extensor pollicis longus (EPL) tendon injury (n = 1) following ESIN, as well as loss of reduction (n = 2) and refractures (n = 3) after MUA/POP. The median follow-up time was 28.8 months (range, 5.3–85.8 months). In 32 out of 34 cases (94%) patients and/or parents were contacted by telephone and a PODCI score was obtained. Patients who experienced complications in the course of treatment had a significantly lower score compared with those whose fracture healed without any sequelae (P = .001). There was a trend towards an unfavorable outcome following ESIN compared with K-wire fixation (P = .063), but not compared with POP (P = .553). No statistical significance was observed between children who were treated initially with a POP and those who had K-wire fixation (P = .216).

There is no standard treatment for displaced pediatric diametaphyseal forearm fractures. Management with MUA/POP only is associated with an increased refracture rate. Based on our experience K-wire fixation including intramedullar positioning of at least one pin seems to be favorable compared with ESIN.
Cryptococcal pleuritis with pleural effusion as the only clinical presentation in a patient with hepatic cirrhosis
Authors: Wang Jie , Hong Jin-Jing , Zhang Piao-Piao , Yang Mei-Fang , Yang Qing , Qu Ting-Ting
Published: July 2019

Rationale:

Cryptococcosis is a significant life-threatening fungal infection in worldwide, mainly reported in immunocompromised patients. Pleural effusion presentation of cryptococcal infection as the only clinical presentation is rarely seen in pulmonary cryptococcosis, which may lead to be misdiagnosed, and the study on this subject will provide further insights.

Patient concerns:

A 64-year-old man was hospitalized in our department and diagnosed as hepatic B cirrhosis. A computed tomography (CT) of the thorax showed a massive right pleural effusion without pulmonary parenchymal abnormalities. He was started on empirical treatment for pleural tuberculosis (TB). However, during his hospitalization, a right pleural effusion developed and fever was not controlled.

Diagnoses:

On day 14 admission, pleural fluid cultured positive for Cryptococcus neoformans. The C neoformans isolate belonged to ST5 and molecular type VNI (var. grubii).

Interventions:

The patient was diagnosed with cryptococcal pleuritis, then amphotericin B and fluconazole were administrated.

Outcomes:

Finally, the patient was improved and discharged from our hospital.

Lessons:

Similar cases in cryptococcal pleuritis patients with pleural effusion as the only clinical presentation in the literature are also reviewed. Through literature review, we recommend that pleural effusion cryptococcal antigen test should be used to diagnose cryptococcal pleuritis to reduce misdiagnosis. The early administration of antifungal drug with activity to Cryptococcus seemed beneficial in preventing dissemination of cryptococcosis.
The prognostic values of neutrophil to lymphocyte ratio for outcomes in chronic obstructive pulmonary disease
Authors: Ye Zengpanpan , Ai Xiaolin , Liao Zenglin , You Chao , Cheng Yongzhong
Published: July 2019

Objective:

Neutrophil to lymphocyte ratio (NLR) is considered as an inflammatory biomarker for clinical outcomes in patients with chronic obstructive pulmonary disease (COPD). We aimed to conduct a meta-analysis to evaluate the prognostic values of NLR for the exacerbation and mortality in patients with COPD.

Methods:

We searched the database of Cochrane Central Register of Controlled Trials, EMBASE, and PubMed, before September 2017. The eligible studies were retrieved by 2 authors independently following the criteria. The pooled odds ratios (ORs) of included studies were used to evaluate the prognostic values of NLR. Subgroup analyses were conducted to make the results more accurate.

Results:

Nine studies with 5140 patients were enrolled in this analysis. The high NLR was associated with higher risk of exacerbation (OR: 3.81, 95% confidence interval [CI]: 1.20–12.13, P = .02) and mortality (OR: 2.60, 95% CI: 1.48–4.57, P < .01). By subgroup analysis, high NLR could predict the mortality in patients >70 years (OR: 2.16, 95% CI: 1.17–3.98, P = .01) but not in patients <70 years (OR: 4.08, 95% CI: 0.91–18.24, P = .07), and had a higher predictive ability in Asian group (OR: 3.64, 95% CI: 1.87–7.08, P < .01) than Eurasia group (OR: 1.82, 95% CI: 1.43–2.32, P < .01). In addition, high NLR could predict the short-term mortality (OR: 2.70, 95% CI: 1.10–6.63, P = .03) and the long-term mortality (OR: 2.61, 95% CI: 1.20–5.65, P = .02).

Conclusions:

The NLR may be an independent predictor for incidence of exacerbation in patients with COPD. In addition, high NLR may be associated with higher mortality in patients with COPD, especially for Asian and the patients with higher mean NLR.
Umbilical cord blood-based gene signatures related to prenatal major depressive disorder: Retracted
Authors: Liu Wenhua , Zhang Lan , Zheng Donglin , Zhang Yijie
Published: July 2019

Background:

Prenatal exposure to depression has been considered as a risk factor for adverse childhood, while it is accompanied by unknown molecular mechanisms. The aim of this study was to identify differentially expressed genes (DEGs) and associated biological processes between cord blood samples from neonates born to mothers who exposed to major depressive disorder (MDD) and healthy mothers.

Methods:

The microarray data GSE114852 were downloaded to analyze the mRNA expression profiles of umbilical cord blood with 31 samples exposed to prenatal MDD and 62 samples with healthy mothers. Kyoto Encyclopedia of Genes and Genomes pathway and Gene ontology enrichment analyses were conducted to identify associated biochemical pathways and functional categories of the DEGs. The protein–protein interaction network was constructed and the top 10 hub genes in the network were predicted.

Results:

The results showed several immunity related processes, such as “phagosome”, “Epstein-Barr virus infection”, “proteasome”, “positive regulation of I-kappaB kinase/NF-kappaB signaling”, “interferon-gamma-mediated signaling pathway”, and “tumor necrosis factor” presented significant differences between two groups. Most of the hub genes (for example PSMD2, PSMD6, PSMB8, PSMB9) were also associated with immune pathways.

Conclusion:

This bioinformatic analysis demonstrated immune-mediated mechanisms might play a fatal role in abnormalities in fetal gene expression profiles caused by prenatal MDD.
Asymptomatic left posterior mediastinal functional paraganglioma
Authors: Yue Yang , Xin Hua , Li Fu-Qiang , Wu Jun-Duo , Liu Jun-Zhi , Zhang Le-Ning
Published: July 2019

Rationale:

Paraganglioma refers to a set of neuroendocrine tumors derived from the chromaffin cells of the adrenal diplomatic ganglion. Paragangliomas can be classified as functional or nonfunctional based on the ability to synthesize and release catecholamines.

Patient concerns:

We report a 47-year-old man with a functional paraganglioma in the left posterior mediastinum and highlight the key elements of management of mediastinal paragangliomas.

Diagnoses:

A left posterior mediastinal mass was found by computed tomography (CT) scan and Chest-enhanced CT. Preoperative ultrasound-guided biopsy suggested the possibility of a paraganglioma. A diagnosis of paraganglioma was established by immunohistochemistry.

Interventions:

The patient underwent single-stage resection of the lesion via left thoracotomy after preoperative oral α-adrenoceptor (phenoxybenzamine) therapy and intravenous fluid resuscitation for two weeks.

Outcomes:

The postoperative period was uneventful. The patient exhibited no abnormal blood pressure or recurrence during the 12-month follow-up period.

Lessons subsections as per style:

Pathological examination alone cannot determine whether it was a benign or malignant paraganglioma, which can be determined by pathological examination combined with distant metastasis. Long-term follow-up is required to assess the treatment effect.
The clinical significance of PYCR1 expression in renal cell carcinoma
Authors: Weijin Fu , Zhibin Xie , Shengfeng Zheng , Xiaoli Yang , Qijian Ding , Jiayi Liu , Qiumei Liang , Yilong Chen , Hua Mi , Deyun Liu , Jiwen Cheng
Published: July 2019

Pyrroline-5-carboxylate reductase 1 (PYCR1) is an enzyme involved in cell metabolism and is upregulated in cancer. However, the correlations of PYCR1 expression with the clinicopathological features and prognosis of renal cell carcinoma (RCC) remain unclear. The purpose of this study was to identify the expression of PYCR1 and its clinical relevance in RCC patients.

PYCR1 mRNA expression differences between RCC and the adjacent normal renal tissues were assessed using the Cancer Genome Atlas database (TCGA). Subsequently, the expression of PYCR1 mRNA and protein were evaluated by quantitative real-time polymerase chain reaction, Western blot, and immunochemistry using 30 paired frozen samples of RCC and the adjacent normal renal tissues. The protein expression of PYCR1 was evaluated by immunostaining formalin-fixed, paraffin-embedded sections of RCC samples from 96 patients who underwent radical nephrectomy, and its relationship with clinical features were analyzed. Nonpaired t tests were used to statistically analyze the differences between the 2 groups. Cox univariable and multivariable analyses of overall survival (OS) among RCC patients were performed.

The expression of PYCR1 mRNA was significantly upregulated in RCC tissues compared to adjacent normal renal tissues in the TCGA database (P < .01). The area under the receiver operating characteristic curve value was 0.748. The expression of PYCR1 mRNA and protein was significantly upregulated in RCC compared with that in paired normal renal tissues (P < .01). Higher PYCR1 levels were associated with metastasis (P < .01). Kaplan–Meier survival curves indicated that higher PYCR1 expression was correlated with poorer OS. Therefore, PYCR1 may act as a novel prognostic marker and therapeutic target in the diagnosis and treatment of RCC.
Fenestration deformity of the basilar artery trunk with an aneurysm
Authors: Zhang Donghuan , Wang Honglei , Feng Yingli , Xu Ning
Published: July 2019

Rationale:

Fenestration of the basilar artery is most common in the proximal portion near the vertebrobasilar artery junction. Conversely, fenestration of the middle and distal portions of the basilar artery is not common, and fenestration of the basilar artery with an aneurysm is even less common.

Patient concerns:

This study reports the case of a 37-year-old woman with basilar artery fenestration malformation and an aneurysm at the mid-distal junction; her symptoms included sudden headaches with nausea and vomiting.

Diagnoses:

Head digital subtraction angiography showed fenestration at the junction of the middle and upper portions of the basilar artery associated with an aneurysm, and spontaneous pseudoaneurysm formation could not be excluded.

Interventions:

The patient underwent stent-assisted fenestration and channel occlusion.

Outcomes:

Five months later, no abnormalities were found by head magnetic resonance imaging. The stents were well positioned, and no occluded branches or aneurysms were present.

Lessons:

For mid-distal basilar artery fenestration malformation with an aneurysm, occlusion of the lesion channel is relatively safe when there are no perforating vessels in the fenestration channel and the lesion channel is a nondominant channel. Overall, more attention should be paid to the possibility of pseudoaneurysm formation in the diagnosis and treatment of this type of aneurysm.
Scalp melanoma with rectus abdominis metastasis
Authors: Hsu Kuo-Feng , Chen Chun-Yu , Chu Tzi-Shiang , Liu Hung-Hui , Chang Chun-Kai , Wu Chien-Ju , Lin Chin-Ta , Wang Chih-Hsin , Tzeng Yuan-Sheng , Dai Niann-Tzyy , Chen Shyi-Gen
Published: July 2019

Rationale:

The main cause of death in melanoma patients is widespread metastases as it can metastasize to almost every organ. However, melanoma skeletal muscle metastases (MSMM) are exceptional, and only a few cases of MSMM to the rectus abdominis muscles have been previously described. And our case maybe the first reported case in Asia region.

Patient concerns:

A 45-year-old man with history of right scalp melanoma, pT3aN0M0, stage IIA status post wide excision with 2 cm safe margin and right neck lymph node dissection at 5 years before. He had an almost 5 years disease-free period but presented to our clinic due to intermittent abdominal sharp pain for 1 to 2 months, with a palpable soft tissue mass over his right abdomen. Metastatic melanoma to rectus abdominis muscles was highly suspected.

Interventions:

The patient subsequently underwent radical en-block extraperitoneal 15 cm segmental resection of the right rectus abdominis muscle including tumor mass. The resected tumor was a black-gray colored solid mass, and the final histologic study showed a metastasis of melanoma.

Outcomes:

Postoperative course of the patient was uneventful, and the right abdominal pain was improved. The patient was referred for further target therapy, but passed away half a year later due to multiple metastasis.

Lessons:

Scalp melanoma with isolated rectus muscle metastasis is extremely rare especially for a young aged patient who had an almost 5-year disease-free period. Surgery is a potentially curative therapy for patients with isolated metastatic melanoma. The goal is negative resection margins, in order to avoid local recurrences. Radical compartmental surgery should be considered for selected stage IV melanoma patients with sole rectus abdominis MSMM, whose disease could be amenable to complete resection, in preliminary procedure to prolong disease-free survival time. For oligometastatic disease, surgical resection is sometimes useful in carefully selected patients after systemic therapy; also, it could be performed as symptomatic treatment.
Fentanyl-based intravenous patient-controlled analgesia with low dose of ketamine is not inferior to thoracic epidural analgesia for acute post-thoracotomy pain following video-assisted thoracic surgery
Authors: Tseng Wei-Cheng , Lin Wei-Lin , Lai Hou-Chuan , Huang Tsai-Wang , Chen Pin-Hsuan , Wu Zhi-Fu
Published: July 2019

Background:

Thoracic epidural analgesia is the preferred method for postoperative analgesia following thoracic surgery. However, intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. This study was conducted because few scientific reports exist comparing fentanyl-based IVPCA including a low dose of ketamine (fk-IVPCA) with thoracic patient-controlled epidural analgesia (t-PCEA) for the treatment of postoperative pain after video-assisted thoracic surgery (VATS).

Methods:

This prospective, and randomized study included 70 patients randomized into fk-IVPCA and t-PCEA groups. Pain at rest and during movement, successful and unsuccessful triggers after pressing the PCA device button, the need for rescue analgesia, drug-related adverse events, and patient satisfaction were recorded for 48 hours postoperatively.

Results:

No significant differences in the intensity of pain at rest or during movement were observed between the 2 groups within 48 hours postoperatively. The number of unsuccessful PCA triggers in the t-PCEA group 0 to 4 hours after surgery was significantly higher than that in the fk-IVPCA group. However, the numbers of successful PCA triggers in the fk-IVPCA group at 4 to 12 and 0 to 24 hours after surgery were significantly higher than those in the t-PCEA group. The incidence of analgesic-related side effects and patient satisfaction were similar in both groups.

Conclusions:

Compared with t-PCEA, the addition of a subanesthetic dose of ketamine to fentanyl-based IVPCA resulted in similar pain control after VATS with no increase in the incidence of drug-related adverse effects. The results confirm that both multimodal intravenous analgesia and epidural analgesia can provide sufficient pain control and are safe strategies for treating acute post-thoracotomy pain.
“Left at right” liver transplantation with heterotopic implantation of left liver graft in the right subphrenic space
Authors: Chan Kun-Ming , Cheng Chih-Hsien , Wu Tsung-Han , Lee Chen-Fang , Wu Ting-Jung , Chou Hong-Shiue , Lee Wei-Chen
Published: July 2019

Conventional orthotopic implantation of left liver grafts is technically demanding and requires consideration of limited space and vascular complications. The study proposed a modified approach termed “left at right” liver transplantation (LAR-LT), wherein left liver grafts were rotated and implanted in right subphrenic spaces. The selection of recipients for this approach is based on the measurement of the right subphrenic space width and left liver graft length, in which a rotated left liver graft could be comfortably placed in the right subphrenic space. A total of 36 recipients who had undergone LAR-LT between July 2006 and December 2017 were retrospectively reviewed. None of recipients died of complications related to this approach immediately after operation. All grafts showed remarkable increment in liver volume and bi-directional regeneration to fit well within the right abdominal cavity. Meanwhile, the alignment of the biliary tree in LAR-LT is quite straight, making no difficulty in both anastomosis during operation and dealing with biliary stenosis afterward. As such, long-term outcome of LAR-LT is satisfactory. Keeping in mind certain technical concerns, a heterotopic LAR-LT might be safely applied as an alternative with an easier reconstruction procedure for select patients.
Impacts of the surgical safety checklist on postoperative clinical outcomes in gastrointestinal tumor patients
Authors: Wang Hao , Zheng Taohua , Chen Dong , Niu Zhaojian , Zhou Xiaobin , Li Shikuan , Zhou Yanbing , Cao Shougen
Published: July 2019

A 19-item surgical safety checklist (SSC) was published by the World Health Organization in 2008 and was proved to reduce postoperative complications. To date, however, the impacts of SSC implementation in China have not been evaluated clearly. The study was performed to evaluate the impacts of the SSC on postoperative clinical outcomes in gastrointestinal tumor patients.

Between April 2007 and March 2013, 7209 patients with gastrointestinal tumor who underwent elective surgery at the Affiliated Hospital of Qingdao University were studied. Data on the clinical records and outcomes of 3238 consecutive surgeries prior to SSC implementation were retrospectively collected; data on another 3971 consecutive surgeries performed after SSC implementation were prospectively collected. The clinical outcomes (including mortality, morbidity, readmission, reoperation, unplanned intervention and postoperative hospital stay) within postoperative 30 days were compared between the two groups. Univariate and multivariate logistic regression analysis were performed to identify independent factors for postoperative complications.

The rates of morbidity and in-hospital mortality before and after SSC implementation were 16.43% vs 14.33% (P = .018), 0.46% vs 0.18% (P = .028), respectively. Median of postoperative hospital stay in post-implementation group was shorter than that in pre-implementation group (8 vs 9 days, P < .001). Multivariable analysis demonstrated that the SSC was an independent factor influencing postoperative complications (odds ratio = 0.860; 95% CI, 0.750–0.988).

Implementation of the SSC could improve the clinical outcomes in gastrointestinal tumor patients undergoing elective surgery in China.
The risk of end-stage renal disease in systemic lupus erythematosus
Authors: Choi Hong Sang , Han Kyung-Do , Jung Jin-Hyung , Kim Chang Seong , Bae Eun Hui , Ma Seong Kwon , Kim Soo Wan
Published: July 2019

Systemic lupus erythematosus (SLE) is known to be one of the leading causes of end-stage renal disease (ESRD). The aim of this study was to estimate the incidence rate of ESRD and the risk for progression to ESRD in SLE patients compared to the general population.

A total of 21,253 SLE patients were extracted from the Korean National Health Insurance Service database between 2008 and 2013. Age-and sex-matched controls (n = 106,265) were randomly sampled in a 5:1 ratio from non-SLE individuals. Both cohorts were followed up for development of ESRD until 2015.

During the median 7.53 years of follow-up, 533 (2.51%) cases of ESRD were newly developed in SLE patients and 145 (0.14%) cases in matched controls (incidence rate: 4.075 and 0.219 per 1000 person-year, respectively). SLE patients were at higher risk for ESRD development compared to matched controls (hazard ratio [HR], 9.84; 95% confidence interval [CI] 8.10–11.96) after multivariate adjustment. In subgroup analysis, the risk for ESRD was higher in male (HR, 7.76; 95% CI 5.07–11.90) and female patients with SLE (HR, 10.48; 95% CI 8.41–13.07) than in matched controls. When analyzed by age group, the younger the age, the higher the risk of ESRD versus non-SLE matched controls; this result was also significant after adjustment. In subgroup analysis according to comorbidities, the SLE group had a significantly higher risk of ESRD than the non-SLE group in almost all subgroups.

SLE was associated with an increased incidence of ESRD.
A simple algorithm for non-invasive diagnosis of significant liver histological changes in patients with CHB and normal or mildly elevated alanine transaminase levels
Authors: Li Qiang , Huang Chenlu , Xu Wei , Hu Qiankun , Chen Liang
Published: July 2019

Significant liver histological changes (SLHC) were defined as moderate to severe liver inflammation (A2 or higher) and/or fibrosis (F2 or higher) using the METAVIR scoring system. This study aimed to develop an algorithm for the non-invasive detection of SLHC in patients with chronic hepatitis B (CHB) and normal or mildly elevated alanine transaminase (ALT) levels.

Using liver histology as gold standard, we developed a simple algorithm for the diagnosis of SLHC in a training set (504 patients), and then validated the diagnostic accuracy in a validation set (166 patients).

A new algorithm (AAG) attributed to age, ALT, and gamma-glutamyl transpeptidase (GGT) was developed. In the training set, the area under ROC curve (AUROC) of AAG was significantly higher than that of ALT, aspartate transaminase (AST), GPR, and APRI for the diagnosis of SLHC (0.74, 0.68, 0.65, 0.56, and 0.53, respectively; all P < .05). In the validation set, the AUROC of AAG was also higher than that of ALT, AST, GPR, and APRI (0.73, 0.65, 0.62, 0.62, and 0.61, respectively; all P < .05). Using AAG ≥ 2, the sensitivity and negative predictive value was 84% to 98% and 75% to 94%, respectively, for the diagnosis of SLHC. Using AAG ≥ 6, the specificity and positive predictive value was 93% to 97% and 67% to 79%, respectively, for the diagnosis of SLHC.

The AAG algorithm represents a novel noninvasive method for the diagnosis of SLHC in CHB patients with normal or mildly elevated ALT levels.
A pancreatic mucinous cystic neoplasm undergoing intriguing morphological changes over time and associated with recurrent pancreatitis
Authors: Shioyama Erika , Mitoro Akira , Ogawa Hiroyuki , Kubo Takuya , Ozutsumi Takahiro , Kitagawa Koh , Yoshikawa Masaaki , Ueda Shigehiko , Akahori Takahiro , Marugami Naga-aki , Hatakeyama Kinta , Yamao Junichi , Sho Masayuki , Ohbayashi Chiho , Yoshiji Hitoshi
Published: July 2019

Rationale:

Mucinous cystic neoplasms (MCNs) are pancreatic mucin-producing cystic lesions with a distinctive ovarian-type stroma. The diagnosis is generally easy in typical cases; however, differential diagnosis is difficult in others such as in the case we report herein.

Patient concerns:

A 27-year-old woman with sudden onset of epigastric pain was referred to our hospital for suspected acute pancreatitis. Contrast-enhanced computed tomography revealed a 25-mm cystic lesion in the pancreas and a low density area with delayed enhancement at the right upper side of the cystic lesion.

Diagnoses:

During its clinical course, the cystic lesion underwent various morphological changes. Eventually, it presented typical findings of MCNs, and could be accurately diagnosed.

Interventions:

Laparoscopic distal pancreatectomy was performed on the patient by preserving the spleen.

Outcomes:

The patient revealed no symptoms till 1 year after the operation.

Lessons:

This case of MCN with intriguing short-term morphological changes was associated with recurrent pancreatitis. A combination of imaging modalities is essential for accurate diagnosis of MCNs, and follow-up with serial imaging might be useful for certain unusual lesions.
Grade-lymph node ratio predicts the survival of breast cancer in different molecular types
Authors: Liu Chaoqun , Li Huiyao , Zhuo Ran , Wang Lijun , He Lihua , Ruan Qiqi , Luan Xiaoyi , Mo Xiujuan , Sun Yi
Published: July 2019

The prognostic value and conflicting results of metastatic lymph node ratio (mLNR) on breast cancer have aroused an increasing concern. We aimed to evaluate the imperative of mLNR classification and prognostic factors in breast cancer with molecular subtypes.

This study uses the database of surveillance, epidemiology, and end results (SEER) to investigate the imperative for reliable mLNR classification and critical prognostic factors in breast cancer with different molecular subtypes.

The prognostic characteristics for disease-specific survival (DSS) of breast cancer were investigated in the SEER cohort (n = 3651). mLNR (P = .017) and histology grade (P < .001) were independent factors. A novel grade-lymph node ratio (G-R) staging system was proposed for breast cancer prognosis. The receiver operating characteristic curves revealed that the G-R staging system had an accurate 1-, 3-, and 5-year DSS prediction. Further stratification analysis with molecular subtypes of breast cancer (Luminal and TNBC) first proved robust prognostic values of the G-R staging system among molecular subtypes.

The current population-based cohort demonstrated the capacity of mLNR serving as a critical prognostic factor. Also, G-R staging system has the potential to be regarded as reliable classification for breast cancer patients with different molecular subtypes.
Spontaneous remission of West syndrome following a human herpesvirus 7 infection in a Chinese infant
Authors: Li Honghua , Wang Bing , Shan Ling , Du Lin , Jia Feiyong
Published: July 2019

Rationale:

West syndrome (WS) is an age-dependent epileptic encephalopathy that is characterized by intractable epileptic seizures, hypsarrhythmia, and observed through electroencephalogram (EEG) and significant neurodevelopmental regression. The spontaneous remission of epileptic seizure is clinically rare and has not previously been reported in a Chinese infant. Herein, we reported a Chinese infant with WS whose seizures disappeared following a human herpesvirus 7 (HHV-7) infection.

Patient concerns:

The male Chinese infant was born at the gestational age of 36 weeks with a birth weight of 1.65 kg and an Apgar score of 7 at the first minute. At the age of 6 months, the infant developed seizures that manifested as flexor spasms with trunk involvement and mental regression.

Diagnosis:

Brain magnetic resonance imaging revealed leukomalacia of the posterior horn and a reduction in the size of the periventricular of the bilateral ventricle and the corpus callosum. An EEG revealed hypsarrhythmia and typical spasm seizures. Therefore, the infant was diagnosed with symptomatic WS.

Interventions:

The infant was treated with adequate vitamin B6 intravenous drip and oral treatment with topiramate and levetiracetam.

Outcomes:

The observed seizures disappeared spontaneously 40 days after onset, without any changes in the anti-epileptic drug treatment, following a febrile rash due to a HHV-7 infection.

Lessons:

Spontaneous remission of epileptic seizures can occur following viral infection of HHV-7 in children with WS. The mechanism behind this spontaneous remission warrants further research.
Superior mesenteric artery branch pseudoaneurysm rupture mimicking acute pancreatitis in a patient with acute type B aortic dissection
Authors: Wang Jing , Cao Dianbo , Tong Qian
Published: July 2019

Rationale:

Visceral arterial pseudoaneurysms are rare but important vascular entities because of their inclination to cause life-threatening hemorrhage. They were commonly reported to be associated with trauma, infection, inflammatory disease, or occurred as postoperative complication. To date, there has been no published report of a superior mesenteric artery (SMA) branch pseudoaneurysm rupture mimicking acute pancreatitis in a patient with acute type B aortic dissection.

Patient concerns:

The patient's medical history, clinical information, imaging findings including follow-up computed tomography angiography (CTA), and treatment are reported. A 51-year-old male presenting with epigastric pain and fever was found to have an enlarged pancreatic head and obscure fatty space around it on abdominal nonenhanced CT. He has medical history of anaphylactoid purpura and uncontrolled hypertension. His serum lipase and amylase were both within normal limits. Thoracoabdominal CTA following a sudden blood pressure drop attributed to the accurate diagnosis.

Diagnoses:

He was diagnosed with acute type B aortic dissection involving SMA and retroperitoneal hemorrhage secondary to SMA branch pseudoaneurysm rupture.

Interventions:

The patient was successfully treated by thoracic endovascular aortic repair without additional branch intervention.

Outcomes:

Follow-up CTA at 3 months later demonstrated that the endoprothesis is well positioned with no endoleaks, and SMA branch pseudoaneurysm disappeared.

Lessons:

We report a rare and complicated case presenting with SMA branch pseudoaneurysm rupture and acute type B aortic dissection. CTA is vital in the diagnosis of such vessel pathology. We must inspect carefully to ensure that no small lesions are missed.