bluuebunny/crossref_metadata_2025 huggingface dataset:
Two-stage Reconstruction of the Large and Ptotic Breasts: Skin Reduction Mastectomy with Prepectoral Device Placement
Authors: Rammos Charalambos K. , Mammolito Denise , King Victor A. , Yoo Aran
Published: July 2018

Wise pattern skin reduction mastectomy with prepectoral placement of the device is a recent technique for reconstruction in patients with large and ptotic breasts. Expanders in the first stage, followed by implant exchange in the second stage are placed above the pectoralis major muscle, totally covered by acellular dermal matrix and an inferior dermal flap. This technique was performed on 6 breasts in 4 obese patients with macromastia and grade 2 and 3 ptosis. Two patients experienced complications at the T-junction. One patient experienced superficial skin sloughing managed conservatively. The second patient developed full-thickness necrosis treated with excision and primary closure. No implant loss occurred. All patients were exchanged in a second stage to an implant, and 2 of them had symmetry procedures, with good cosmetic results. Larger, long-term studies are required to further characterize results and define the limitations of this newer surgical technique.
A NOVEL CASE SERIES OF NMNAT1-ASSOCIATED EARLY-ONSET RETINAL DYSTROPHY: EXTENDING THE PHENOTYPIC SPECTRUM
Authors: Kumaran Neruban , Robson Anthony G. , Michaelides Michel
Published: July 2018

Purpose:

To report two siblings with NMNAT1-associated retinopathy presenting with a later onset and milder phenotype than previously described.

Methods:

Retrospective case series of two siblings. The authors describe two cases of early-onset retinal dystrophy caused by disease-causing NMNAT1 variants. Visual acuity, clinical examination, and retinal imaging including color fundus photography, spectral domain optical coherence tomography, and fundus autofluorescence were performed. Both cases underwent full-field and pattern electroretinography incorporating the International standards.

Results:

Two siblings were found to harbor the variants c.53A>G, p.(Asn18Ser) and c.769G>A, p.(Glu257Lys) in NMNAT1 after retinal dystrophy panel gene testing. Both had good visual acuity until the ages of 6 and 11 years, respectively, with subsequent gradual worsening into their twenties. At the ages of 10 and 16 years, respectively, electroretinograms indicated generalized rod and cone system dysfunction of moderate severity, with pattern electroretinography evidence of severe macular involvement. Repeat testing at the ages of 26 and 33 years revealed only mild worsening of rod photoreceptor function in both.

Conclusion:

NMNAT1-associated retinopathy has previously only been described as a typical form of Leber congenital amaurosis, with poor visual acuity from birth associated with nystagmus, characteristic macular atrophy, and intraretinal pigmentation from birth. Here, we present two siblings with a novel, later onset, and far milder phenotype. We suggest that this may be due to the two missense NMNAT1 variants resulting in milder reduction of NMNAT1 enzymatic activity. These cases extend the phenotypic spectrum associated with NMNAT1 and further highlight the clinical heterogeneity associated with inherited retinal diseases.
BILATERAL INTRAVITREAL 0.19-MG FLUOCINOLONE ACETONIDE IMPLANT FOR PERSISTENT NONDIABETIC CYSTOID MACULAR EDEMA AFTER VITRECTOMY
Authors: Ong Sally S. , Walter Scott D. , Chen Xi , Thomas Akshay S. , Finn Avni P. , Fekrat Sharon
Published: July 2018

Background/Purpose:

Iluvien (Alimera Science, Alpharetta, GA) is an injectable, nonbiodegradable, sustained-release 0.19-mg fluocinolone acetonide intravitreal implant. Although currently approved by the Food and Drug Administration only for diabetic macular edema previously treated with a course of corticosteroids without a clinically significant intraocular pressure response, the 0.19-mg fluocinolone acetonide implant could theoretically be used to treat other noninfectious inflammatory conditions including persistent cystoid macular edema because of nondiabetic etiologies.

Methods:

Interventional case report. A 79-year-old man had persistent cystoid macular edema after pars plana vitrectomy in both eyes that was refractory to topical treatments and intravitreal anti–vascular endothelial growth factor. His cystoid macular edema was responsive to preservative-free intravitreal triamcinolone acetonide after which he developed noninfectious endophthalmitis or pseudoendophthalmitis in both eyes precluding further intravitreal triamcinolone acetonide injections. He was subsequently treated with bilateral intravitreal 0.19-mg fluocinolone acetonide implants.

Results:

At the most recent post-treatment follow-up (11 months for the right eye and 13 months for the left eye), the patient demonstrated an improvement in visual acuity, 20/126 to 20/50 in the right eye and 20/80 to 20/40 in the left eye, and in central subfield thickness, 592 μm to 288 μm in the right eye and 565 μm to 287 μm in the left eye, without intraocular pressure elevation.

Conclusion:

The intravitreal 0.19-mg fluocinolone acetonide implant is an effective and potentially safe off-label therapeutic option for persistent nondiabetic cystoid macular edema after vitrectomy.
Fuchs Endothelial Corneal Dystrophy: Update on Pathogenesis and Future Directions
Authors: Sarnicola Caterina , Farooq Asim V. , Colby Kathryn
Published: July 2018

Fuchs endothelial corneal dystrophy (FECD) is the most common indication for corneal transplantation in the United States, accounting 36% of the almost 47,000 transplants performed in 2016. Although the surgical management of FECD has undergone a revolution over the past 20 years, its pathogenesis remains elusive, with multiple putative disease pathways and an ever increasing number of candidate genes thought to play a role. This review will summarize the recent advancements in our understanding of the biology of FECD, including potential parallels with neurodegenerative disease like amyotrophic lateral sclerosis and will highlight prospects for future treatment advances.
Corneal Higher-Order Aberrations in Eyes With Corneal Scar After Traumatic Perforation
Authors: Shimizu Eisuke , Yamaguchi Takefumi , Tsubota Kazuo , Shimazaki Jun
Published: July 2018

Objectives:

To evaluate corneal higher-order aberrations (HOAs) in eyes with corneal scar after traumatic perforation and their correlation with visual acuity.

Methods:

This retrospective consecutive case study included 40 eyes of 40 consecutive patients (mean age, 39.2±21.6 years), treated for traumatic corneal perforation at Tokyo Dental College, and 18 normal control eyes. Higher-order aberrations of anterior and posterior corneal surfaces and total cornea were analyzed by swept-source optical coherence tomography. Correlations between corneal HOAs and visual acuity were analyzed.

Results:

Higher-order aberrations within 4-mm diameter were significantly larger in eyes with corneal perforation (anterior surface, 0.51±0.54 μm; posterior surface, 0.20±0.14; and total cornea, 0.52±0.50) as compared to normal controls (0.10±0.02, 0.02±0.01, and 0.09±0.02, respectively; all P<0.001). Higher-order aberrations within 6-mm diameter were significantly larger in eyes with corneal perforation (anterior surface, 1.15±1.31; posterior surface, 0.31±0.23; and total cornea, 1.09±1.28) as compared to normal controls (0.21±0.06, 0.06±0.01, and 0.19±0.06, respectively; all P<0.001). The most common topography pattern observed was the minimal change pattern (37.5%), followed by asymmetric pattern (30.0%). Visual acuity significantly correlated with corneal HOAs (anterior surface: R=0.646, P<0.001; posterior surface: R=0.400, P=0.033; and total cornea: R=0.614, P<0.001).

Conclusions:

Corneal scar after traumatic perforations not only induces corneal opacity, but also increases corneal HOAs, which indicates a direct effect on visual acuity.
A Study of Corneal Biomechanics in Delayed-Onset Mustard Gas Keratopathy Compared to Cases With Corneal Scarring and Normal Corneas
Authors: Jadidi Khosrow , Mohazzab-Torabi Saman , Pirhadi Shiva , Naderi Mostafa , Yekta Abbasali , Sardari Sara , Khabazkhoob Mehdi
Published: July 2018

Purpose:

This study compares the corneal biomechanical properties, as measured with Corvis ST, in three groups of cases with delayed-onset mustard gas keratopathy (DMGK), chronic corneal scarring (CCS), and those with normal corneas.

Methods:

Forty-five eyes were enrolled in the DMGK, CCS, and normal groups (15 eyes each). All patients were examined with the slitlamp and Corvis ST. Extracted corneal biomechanical parameters included first and second applanation time (AT1, AT2), first and second applanation length (AL1, AL2), first and second applanation velocity (AV1, AV2), deformation amplitude (DA), highest concavity time, peak distance, highest concavity radius (HCR), central corneal thickness, corrected intraocular pressure (IOP), and noncorrected IOP.

Results:

The mean age of the participants in the DMGK, CCS, and normal groups was 49.20±5.16, 60.40±22.92, and 44.60±8.32 years, respectively. Comparison between DMGK and CCS groups showed significant differences in AT1, AT2, corrected IOP, and noncorrected IOP. There were also significant differences in AT1, AT2, HCR, DA, and noncorrected IOP between the DMGK and normal groups. None of the parameters were significantly different between the CCS and normal groups.

Conclusion:

There seems to be reduced corneal rigidity and stiffness in cases exposed to mustard gas, which causes the cornea in the DMGK group to become applanated more easily and take longer to rebound compared with the other two groups. Also, IOP was lower than normal in the DMGK group, and thus, misdiagnosis of glaucoma is likely for these patients.
Effect of Cataract Surgery on the Refractive Index of the Cornea Estimated by Optical Pachymetry
Authors: Tutchenko Larysa , Patel Sudi , Horak Olha , Sanin Volodymyr , Kosuba Serhii
Published: July 2018

Purpose:

To noninvasively estimate the refractive index (RI) of the central cornea along the antero–posterior direction before and after routine phacoemulsification.

Methods:

Using 2 setups for a standard optical pachymeter, the ratio of observed optical section widths (OSWs) is a function of the RI. Thus, the corneal RI could be estimated using a calibration equating OSW ratios with known RI values. The OSW was measured by 2 observers for 1) normal subjects for estimating interoperator errors and effects of sex and age on the RI and 2) before and after patients underwent routine phacoemulsification.

Results:

First, the average interoperator difference (ΔRI) was +0.0005 (SD = ±0.0044, 95% confidence limit, −0.0002 to +0.0012). The root mean square difference between measurements obtained by the observers was 0.0032. There was a significant correlation between the ΔRI and the mean of each pair of measured values (r = −0.172, n = 153, P = 0.003). The mean RI (±SD) was 1.435 (±0.005, n = 82) for females and 1.429 (±0.005, n = 71) for males. There was no significant between-sex difference or association between the RI and age (mean age, ±SD, and range, 44.31, 20.38, and 19–88 years, respectively). Second, the difference (y) between the preoperative (x) and postoperative RI was, y = 0.844x − 1.203 (r = 0.694, n = 31, P ≤ 0.001) according to observer 1 and according to observer 2, y = 0.755x − 1.108 (r = 0.681, n = 31, P ≤ 0.001).

Conclusions:

The RI of the human cornea along the antero–posterior axis can be estimated using a modified application of traditional optical pachymetry. The average values for the corneal RI were higher compared with those reported in previous reports. The change in the RI after phacoemulsification could be predicted from the preoperative value.
Effect of the Meibomian Gland Squeezer for Treatment of Meibomian Gland Dysfunction
Authors: Wang Da-Hu , Liu Xin-Quan , Hao Xiao-Jun , Zhang Yin-Jian , Zhu Hua-Ying , Dong Zhi-Guo
Published: July 2018

Purpose:

To investigate the effect of the meibomian gland squeezer for treatment of meibomian gland dysfunction (MGD).

Methods:

Seventy patients (140 eyes) with MGD were randomly divided into 2 groups: 36 patients who were treated by the meibomian gland squeezer as the treatment group and 34 patients were selected as the control group. Patients were evaluated at baseline, and 2-week and 1-month visits for subjective symptoms, objective signs and pain assessments, including ocular symptom scores, Ocular Surface Disease Index, tear breakup time, corneal fluorescein staining, Schirmer scores with no anesthetic (Schirmer I test), meibum quality, meibum expressibility, and Numeric Rating Scale-11.

Results:

Sixty-five patients were followed in the study, and mean (±SD) age was 57.0 (±12.6) years. Compared with baseline, the 2 groups had varying degrees of improvement in ocular symptom scores and Ocular Surface Disease Index at the 2-week and 1-month visits; there was a statistically significant difference between groups (P < 0.001). At the 1-month visit, the treatment group showed a greater improvement in the breakup time (3.8 ± 1.6 vs. 1.8 ± 1.0 seconds, P < 0.001), corneal fluorescein staining (−2.1 ± 2.13 vs. −0.9 ± 1.3, P = 0.03), Schirmer I test (5.3 ± 2.9 vs. 2.3 ± 2.8 mm, P < 0.001), meibum quality (−7.5 ± 2.9 vs. −5.3 ± 2.4, P = 0.004), and meibum expressibility (−1.2 ± 0.8 vs. −0.7 ± 0.4, P = 0.007). In the treatment group, the mean (±SD) of total pain scores was 2.4 ± 1.0, which indicated that mild pain was still predominant under topical anesthesia.

Conclusions:

The meibomian gland squeezer may be safe, effective, and helpful for treatment of MGD and may offer an attractive treatment option for some patients with MGD, although it can cause mild pain or discomfort.
Multicenter Study of Intense Pulsed Light Therapy for Patients With Refractory Meibomian Gland Dysfunction
Authors: Arita Reiko , Mizoguchi Takanori , Fukuoka Shima , Morishige Naoyuki
Published: July 2018

Purpose:

To evaluate the efficacy of intense pulsed light (IPL) therapy combined with meibomian gland expression (MGX) for refractory meibomian gland dysfunction (MGD) in a prospective study conducted at 3 sites in Japan.

Methods:

Patients with refractory obstructive MGD were enrolled and underwent 4 to 8 IPL-MGX treatment sessions at 3-week intervals. Clinical assessment included the Standard Patient Evaluation of Eye Dryness questionnaire; noninvasive breakup time of the tear film and interferometric fringe pattern as determined by tear interferometry; lid margin abnormalities, fluorescein breakup time of the tear film, corneal and conjunctival fluorescein staining (CFS), and meibum grade as evaluated with a slit-lamp microscope; meibomian gland morphology (meiboscore); and tear production as measured by the Schirmer test without anesthesia.

Results:

Sixty-two eyes of 31 patients (17 women, 14 men; mean age ± SD, 47.6 ± 16.8 years) were enrolled. The Standard Patient Evaluation of Eye Dryness score (P < 0.001), noninvasive breakup time (P < 0.001), and interferometric fringe pattern (P < 0.001) were significantly improved after therapy, with 74% of eyes showing a change in the interferometric fringe pattern from 1 characteristic of lipid deficiency to the normal condition. Meibum grade, lid margin abnormality scores, fluorescein breakup time, and CFS were also significantly improved (P < 0.001, P < 0.001, P < 0.001, and P = 0.002, respectively) after treatment, whereas the meiboscore and Schirmer test value remained unchanged.

Conclusions:

IPL-MGX ameliorated symptoms and improved the condition of the tear film in patients with refractory MGD and is therefore a promising treatment option for this disorder.
Infectious Keratitis After Ocular Surface Stem Cell Transplantation
Authors: Cheung Albert Y. , Sarnicola Enrica , Eslani Medi , Kurji Khaliq H. , Genereux Brad M. , Govil Amit , Holland Edward J.
Published: July 2018

Purpose:

To describe the rate, clinical/microbiological characteristics, and outcomes of infectious keratitis in eyes with limbal stem cell deficiency after ocular surface stem cell transplantation (OSST).

Methods:

In this retrospective chart review of 278 eyes that underwent OSST between January 2006 and December 2016, eyes treated for previous infectious keratitis (bacterial, fungal, or viral) were included. Demographics, risk factors, course, microbiological characteristics, and outcomes were assessed.

Results:

A total of 52 eyes (18.7%) of 48 patients (28 men and 20 women) developed 75 episodes (culture-proven or presumed) of infectious keratitis (range 1–4 episodes) with mean follow-up of 5.3 ± 3.6 years after OSST. The most common limbal stem cell deficiency etiologies included chemical/thermal (27 episodes), Stevens-Johnson syndrome (19 episodes), aniridia (8 episodes), and mucous membrane pemphigoid (8 episodes). There were 44 (58.7%) bacterial keratitis episodes, 24 (32%) fungal keratitis episodes, and 7 (9.3%) HSV keratitis episodes. Gram-positive bacteria (79%) and Candida species (73%) were the most common bacterial and fungal pathogens. Before infection, 33% had an epithelial defect, 69% had a bandage contact lens, 91% were on systemic immunosuppression, and 25% recently had undergone ocular surgery (<3 months). Although 75% resolved with antimicrobial treatment, 25% required a therapeutic keratoplasty (TPK; 2 cases needed multiple TPK).

Conclusions:

Despite successful OSST surgery, infectious keratitis is relatively common, and aggressive medical/surgical therapy is warranted. Prophylactic topical antibiotics and a cicatrizing conjunctivitis diagnosis may account for the high proportion of fungal keratitis in this population.
Short Axial Length and Iris Damage Are Associated With Iris Posterior Synechiae After Descemet Membrane Endothelial Keratoplasty in Asian Eyes
Authors: Shimizu Toshiki , Hayashi Takahiko , Yuda Kentaro , Takahashi Hidenori , Oyakawa Itaru , Yamazaki Kenichiro , Mizuki Nobuhisa , Kato Naoko
Published: July 2018

Purpose:

To evaluate the frequency and severity of iris posterior synechiae after Descemet membrane endothelial keratoplasty (DMEK) and to investigate possible causes of iris posterior synechiae.

Methods:

Twenty-three eyes were investigated in 20 Asian patients who underwent DMEK 1 month after phacoemulsification and intraocular lens implantation surgery. A preexisting iris damage score was defined by iris damage and classified into 5 grades. Six months after DMEK, the iris posterior synechiae severity score was evaluated based on the extent of posterior synechiae, according to every 45 degrees of the pupillary rim (posterior synechiae score, 0–8). Correlations were analyzed between the posterior synechiae score and preexisting factors (preexisting iris damage score, axial length [AXL], anterior chamber depth, and anterior chamber volume, both before and after cataract surgery).

Results:

Iris posterior synechiae appeared in 20 of 23 eyes (87.0%). Best spectacle-corrected visual acuity significantly improved at 6 months after DMEK (P < 0.001). Endothelial cell density was 1596 ± 530 cells/mm2 (P < 0.001); loss of cell density was 37.8 ± 19.9% at 6 months. Single regression analysis showed that the onset of iris posterior synechiae was correlated with the preexisting iris damage score (P = 0.006, r = 0.55), AXL (P < 0.001, r = −0.71), anterior chamber depth (P < 0.001, r = −0.70), and anterior chamber volume before cataract surgery (P < 0.001, r = −0.79).

Conclusions:

Iris posterior synechiae after DMEK frequently appeared in Asian eyes with shorter AXLs or a damaged iris.
Echo-Guided Insertion of a Dual-Lumen Cannula for Venovenous Extracorporeal Membrane Oxygenation
Authors: Cianchi Giovanni , Lazzeri Chiara , Bonizzoli Manuela , Batacchi Stefano , Peris Adriano
Published: July 2018

We provide a step-by-step description of the insertion of a dual-lumen cannula, for venovenous extracorporeal membrane oxygenation support and how a close monitoring by combined transthoracic and transesophageal techniques ensures a safe procedure and can promptly detect complications.
Nurse Practitioner Practice Environments in Primary Care and Quality of Care for Chronic Diseases
Authors: Poghosyan Lusine , Norful Allison A. , Liu Jianfang , Friedberg Mark W.
Published: July 2018

Background:

The chronic disease burden in the United States represents a significant challenge for the primary care system. The nurse practitioner (NP) workforce can help meet the demand for care; however, organizational barriers such as poor practice environments prevent NPs from delivering high quality care.

Objectives:

We investigated the relationship between NP practice environments and quality of care for chronic diseases.

Research Design:

We fit regression models to assess cross-sectional associations between claims-based quality measure performance and survey data on NP practice environments in Massachusetts.

Subjects:

We used survey data from 221 primary care NPs from 118 practices. We obtained quality of care data for patients with asthma, diabetes, and cardiovascular disease.

Measures:

The Nurse Practitioner Primary Care Organizational Climate Questionnaire was used to measure practice environments with its following 4 subscales: NP-Physician Relations, Independent Practice and Support, Professional Visibility, and NP-Administration Relations. Three Healthcare Effectiveness Data and Information Set measures were used to evaluate the quality of care.

Results:

A 1-SD increase in the organizational-level NP-Administration Relations subscale score was associated with a near doubling of the odds of receiving medication management for asthma. A 1-SD increase in the organizational-level Independent Practice and Support subscale score was associated with a 60% increase in the odds of receiving recommended screening for cardiovascular disease. There was no impact on diabetes care measure.

Conclusions:

NP practice environment affected the quality of care for 2 chronic conditions. Efforts should be implemented to improve NP practice environment to potentially improve care quality.
Does Providing Positive Airway Pressure for Sleep Apnea Change Health Care Utilization?
Authors: Derose Stephen F. , Zhou Hui , Huang Brian Z. , Manthena Prasanth , Hwang Dennis , Shi Jiaxiao M.
Published: July 2018

Background:

Sleep apnea is underdiagnosed and thus undertreated. If therapy for sleep apnea results in reduced health care utilization in an entire treated population, then decision-makers will have key information for allocating limited health care resources.

Objectives:

To determine whether positive airway pressure (PAP) for sleep apnea was associated with reduced health care utilization in an entire treated population.

Research Design:

This was a retrospective cohort; propensity score-matched cases and noncases; pre-post analyses of individual subject utilization.

Subjects:

Electronic health records were used to identify adult subjects diagnosed with sleep apnea and dispensed PAP therapy (cases) and those without either diagnosed sleep apnea or dispensed PAP therapy (noncases).

Measures:

Acute care hospital days and dispensed medication days supply were compared in cases and noncases. Negative binomial regression was used to model utilization for up to 5 years before and 7 years after PAP dispensation (cases) or a random date (noncases). The association of PAP with changing annual utilization was estimated.

Results:

There were 13,271 cases and 13,271 matched noncases from 2008 to 2012 for analyses. Trends in the annual rate of acute care utilization were no different between cases and noncases (rate ratio, 0.98, P=0.543). Trends in the annual rate of medication utilization were no different between cases and noncases (rate ratio, 1.008, P=0.112).

Conclusions:

PAP dispensation for sleep apnea did not appear to reduce the rate of acute care and medication utilization over several years of follow-up in a large integrated health care system.
Pathophysiology of immune thrombocytopenia
Authors: Li June , Sullivan Jade A. , Ni Heyu
Published: July 2018

Purpose of review

Immune thrombocytopenia (ITP) is a common autoimmune bleeding disorder with as of yet, no established clinical prognostic or diagnostic biomarkers. Patients frequently experience a markedly decreased quality of life and may be at risk for severe/fatal haemorrhage. Here, we address discoveries in the pathogenesis of ITP, and novel therapeutic strategies in mouse models and human patients. Consolidation of these findings should be important in providing insight to establish future prognostic protocols as well as cutting-edge therapeutics to target refractory ITP.

Recent findings

It is unknown why a significant portion of ITP patients are refractory to standard treatments. Recent findings suggest distinct heterogeneity in ITP including antibody-mediated platelet activation, Fc-independent desialylated platelet clearance, attenuation of platelet-mediated hepatic thrombopoietin generation, and decreased CD8+ T-suppressor generation. These mechanisms may partially explain clinical observations of increased refractoriness to standard therapies targeting classical Fc-dependent pathways. Moreover, these have initiated investigations into platelet desialylation as a diagnostic/prognostic marker and therapeutic target.

Recent evidence of distinct ITP pathophysiology has opened new exploratory avenues for disease management. We will discuss the utility of investigations into these mechanisms of ITP and its potential impact in our understanding of pathogenesis and future treatment strategies.
Adaptive Quizzing Improves End-of-Program Exit Examination Scores
Authors: Presti Carmen Rosa , Sanko Jill S.
Published: July 2018

Background

A third of nursing schools use a standardized, end-of-program exit examination requiring minimum passing scores for student progression. Student failures on high-stakes tests have negative implications for students and schools of nursing. Adaptive quizzing has increased grades, graduation rates, and NCLEX-RN passing rates and reduced test anxiety in nursing students.

Purpose

To diminish the negative effects of high-stakes testing and increase standardized exit examination scores, an undergraduate nursing program incorporated customized adaptive quizzing for nursing students in their final nursing course before graduation.

Methods

End-of-program exit examination scores were compared in a preintervention cohort of students and postintervention cohort assigned individualized adaptive quizzing.

Results

Statistically significant increases in end-of-program exit examination scores were evident in groups of students completing the customized adaptive quizzing assignments.

Conclusion

The use of tailored adaptive quizzing increased exit examination scores, supporting the implementation of customized assignments for remediation.
ALK Is a Specific Diagnostic Marker for Inflammatory Myofibroblastic Tumor of the Uterus
Authors: Mohammad Nissreen , Haimes Josh D. , Mishkin Skyler , Kudlow Brian A. , Leong May Ying , Chew Sung Hock , Koay Eleanor , Whitehouse Ann , Cope Nichola , Ali Rola H. , Köbel Martin , Stewart Colin J.R. , McCluggage W. Glenn , Lee Cheng-Han
Published: July 2018

Inflammatory myofibroblastic tumor (IMT) is a myofibroblastic/fibroblastic neoplasm of intermediate malignant potential. It is frequently characterized by genetic fusion of ALK with a variety of partner genes, which results in the activated ALK signaling pathway that can be targeted with kinase inhibitors. IMTs can occur in the gynecologic tract, with the uterus (corpus and cervix) being the most frequent site. Recent studies suggest that IMTs in the gynecologic tract are underrecognized, and a low-threshold for performing ALK immunohistochemistry has been proposed. The aim of this study was to evaluate the specificity of ALK immunohistochemistry for IMTs among uterine mesenchymal and mixed epithelial/mesenchymal tumors. We performed ALK immunohistochemistry on 14 molecularly confirmed uterine IMTs and 260 other uterine pure mesenchymal and mixed epithelial/mesenchymal tumors. Cases showing any positive cytoplasmic and/or membranous staining of the tumor cells were considered to be ALK positive. All 14 IMTs were confirmed to harbor ALK genetic fusion by RNA sequencing, and ALK immunostaining in the form of granular cytoplasmic positivity with paranuclear accentuation was observed in all 14 cases. ALK was negative (complete absence of staining) in all the other pure mesenchymal tumors and in all mixed epithelial/mesenchymal tumors examined. Our findings show that ALK is a highly specific diagnostic immunohistochemical marker for ALK fusion in uterine mesenchymal tumors. In the work-up of uterine mesenchymal tumors, particularly smooth muscle tumors showing myxoid stromal changes, a diagnosis of IMT should be strongly considered if ALK positivity is observed.
Evaluation of Clinical Plus Imaging Features and Multidetector Computed Tomography Texture Analysis in Preoperative Risk Grade Prediction of Small Bowel Gastrointestinal Stromal Tumors
Authors: Yan Jiayi , Zhao Xuesong , Han Shuai , Wang Ting , Miao Fei
Published: July 2018

Objective

This study aimed to evaluate the prediction roles of clinical plus imaging features and multidetector computed tomography (MDCT) texture analysis in preoperative risk grade classification of small bowel (SB) gastrointestinal stromal tumors (GISTs).

Methods

This study included 213 SB GIST patients. Clinical features and MDCT imaging findings were reviewed. Tumor risk stratifications were determined according to modified National Institutes of Health criteria. Random forest models were performed to evaluate the correlation of risk stratification.

Results

The model of clinical plus imaging findings showed an area under receiver operating characteristic curve (AUC) of 92.0%. The AUC of texture analysis based on MDCT portal phase was 93.3%, without statistical difference from that of clinical plus imaging model (P = 0.378). The AUC of the model combined clinical plus imaging features and MDCT texture analysis was 94.3%, which was significantly higher than the AUC of clinical imaging model (P = 0.042).

Conclusion

Texture analysis may become an important comprehensive tool for preoperative risk stratification of SB GISTs.
Diagnosis of Multiple Primary Intestinal-Type Adenocarcinoma in the Lung by 18F-FDG PET/CT
Authors: Hu Yujing , Wu Dayong , Tian Congna , Wei Qiang , Bian Yanzhu
Published: July 2018

A 74-year-old man with multiple soft tissue lesions in the lung, which were suspected to be metastatic neoplasms, underwent 18F-FDG PET/CT scan to detect primary malignancy. The images demonstrated that the lung and 2 retroperitoneal lymph nodes were the only affected organ or tissues with suspected primary lung neoplasms. Multiple intestinal-type adenocarcinoma was eventually diagnosed by CT-guided transthoracic needle aspiration biopsy.
18F-PBR06 Versus 11C-PBR28 PET for Assessing White Matter Translocator Protein Binding in Multiple Sclerosis
Authors: Singhal Tarun , O'Connor Kelsey , Dubey Shipra , Belanger Anthony P. , Hurwitz Shelley , Chu Renxin , Tauhid Shahamat , Kijewski Marie F. , DiCarli Marcelo F. , Weiner Howard L. , Bakshi Rohit
Published: July 2018

Background and Purpose

18F-PBR06 and 11C-PBR28 are second-generation PET radioligands targeting the 18-kd translocator protein to assess microglial activation. We directly compared 18F-PBR06 and 11C-PBR28 for detecting brain translocator protein binding in multiple sclerosis (MS).

Methods

Six patients with MS (4 women; mean age ± SD, 32.1 ± 4.9 [range, 23.5–37.4 years]; Expanded Disability Status Scale score 2.3 ± 1.2 [range, 1.0–4.0]) underwent brain PET with both ligands, along with 3-T MRI. MRI was coregistered to the summed 60- to 90-minute PET images. SUV ratios (SUVRs), derived by normalization to global brain radioactivity, were obtained for whole-brain white matter (WM), supratentorial WM, normal-appearing WM (NAWM), and T2 (fluid-attenuated inversion recovery) hyperintense and T1 hypointense MS WM lesions. The highest mean SUVR for the fluid-attenuated inversion-recovery lesional slices was defined as SUVRmax.

Results

18F-PBR06 and 11C-PBR28 were moderately intercorrelated for whole-brain WM SUVR (r = 0.83, P = 0.04) and supratentorial WM SUVR (r = 0.81, P = 0.05) but not for SUVRs of NAWM, T1 lesions, T2 lesions, or SUVRmax. Both tracers demonstrated that SUVR was higher in NAWM than in T1 and T2 lesions (all P < 0.05). 18F-PBR06 (but not 11C-PBR28) demonstrated a higher SUVR in T1 versus T2 lesions (0.85 ± 0.07 vs 0.78 ± 0.03, P = 0.03). 18F-PBR06-derived (but not 11C-PBR28) SUVRmax correlated with both Expanded Disability Status Scale score (r = 0.82, P = 0.04) and timed 25-ft walking speed (r = 0.89, P = 0.01).

Conclusions

Our preliminary results suggest an association between microglial activation and physical disability in MS. Microglial detection in lesions was not interchangeable between the tracers, with a higher clinical relevance suggested for 18F-PBR06.
68Ga-Labeled Prostate-Specific Membrane Antigen Uptake in Pheochromocytoma
Authors: Singh Deepa , Kumar Rajender , Mittal Bhagwant Rai , Singh Harmandeep , Bhattacharya Anish
Published: July 2018

We report a case of adenocarcinoma prostate treated previously with radical prostatectomy and hormonal therapy who underwent 68Ga-labeled prostate-specific membrane antigen PET/CT for recurrence evaluation. In addition to radiotracer uptake in the prostate bed, unusual intense prostate-specific membrane antigen uptake was also noted in the left adrenal gland. With a clinical suspicion of pheochromocytoma, 68Ga-DOTANOC PET/CT was done, which revealed tracer-avid left adrenal lesion.
Quadratus Lumborum Block Versus Perioperative Intravenous Lidocaine for Postoperative Pain Control in Patients Undergoing Laparoscopic Colorectal Surgery
Authors: Dewinter Geertrui , Coppens Steve , Van de Velde Marc , D’Hoore André , Wolthuis Albert , Cuypers Eva , Rex Steffen
Published: July 2018

Objective:

To investigate the comparative analgesic efficacy of systemic lidocaine and quadratus lumborum (QL) block in laparoscopic colorectal surgery.

Background:

Although epidural analgesia is the standard to control pain in patients undergoing open colorectal surgery, optimal analgesic management in laparoscopic surgery is less well-defined. There is need for effective and efficient alternatives to epidural analgesia for pain management in patients undergoing laparoscopic colorectal surgery.

Methods:

A total of 125 patients undergoing laparoscopic colorectal surgery were included in this randomized, double-blind controlled clinical trial. Patients randomly received an intravenous infusion with placebo plus a QL-block with placebo, a QL-block with ropivacaine 0.25% plus intravenous placebo, or intravenous lidocaine plus a QL-block with placebo. Postoperatively, all patients received patient-controlled intravenous anesthesia (PCIA) with morphine. Primary outcome parameter was the opioid consumption during the first 24 hours postoperatively. Secondary endpoints included severity of postoperative pain, time to return of intestinal function, incidence of postoperative nausea and vomiting, and length of hospital stay.

Results:

The QL-block was not superior to systemic lidocaine for the reduction of morphine requirements in the first 24 hours postoperatively {QL-group: 37.5 (28.4) mg [mean (standard deviation)] vs lidocaine group: 40.2 (25) mg, P = 0.15}. For the majority of secondary outcome parameters, no significant differences were found between the groups. Morphine consumption in the postanesthesia care unit, the number of PCIA-boli demanded by the patient, and the number of PCIA-boli delivered by the PCIA-pump during the first 24 hours postoperatively were lower in the placebo group.

Conclusions:

In our trial, the QL-block did not provide superior postoperative analgesia when compared to systemic lidocaine in laparoscopic colorectal surgery.

Trial registration:

Eudra CT: 2014-001499-73; 31/7/2014
Postoperative Acute Pancreatitis Following Pancreaticoduodenectomy
Authors: Bannone Elisa , Andrianello Stefano , Marchegiani Giovanni , Masini Gaia , Malleo Giuseppe , Bassi Claudio , Salvia Roberto
Published: July 2018

Objective:

The aim of the study is to characterize postoperative acute pancreatitis (POAP).

Summary Background Data:

A standardized definition of POAP after pancreaticoduodenectomy (PD) has been recently proposed, but specific studies are lacking.

Methods:

The patients were extracted from the prospective database of The Pancreas Institute of Verona. POAP was defined as an elevation of the serum pancreatic amylase levels above the upper limit of normal (52 U/L) on postoperative day (POD) 0 or 1. The endpoints included defining the incidence and predictors of POAP and investigating the association of POAP with postoperative pancreatic fistula (POPF).

Results:

The study population consisted of 292 patients who underwent PD. The POAP and POPF rates were 55.8% and 22.3%, respectively. POAP was an independent predictor of POPF (OR 3.8), with a 92% sensitivity and 53.7% specificity (AUC 0.79). Preoperative exocrine insufficiency (OR 0.39), neoadjuvant therapy (OR 0.29) additional resection of the pancreatic stump margin (OR 0.25), soft pancreatic texture (OR 4.38), and Main Pancreatic Duct (MPD) diameter ≤3 mm (OR 2.86) were independent predictors of POAP. In high-risk patients, an intraoperative fluid administration of ≤3 ml/kg/h was associated with an increased incidence of POAP (24.6 vs. 0%, P = 0.04) and POPF (27.6 vs. 11.4%, P = 0.05).

Conclusion:

This study represents the first clinical application of the only available definition of POAP as a specific complication of pancreatic surgery. POAP is associated with an increased occurrence of POPF and overall morbidity and could potentially be avoided through a specific intraoperative fluid regimen in high-risk pancreas.
Validity of the Novel Taiwan Lymphoscintigraphy Staging and Correlation of Cheng Lymphedema Grading for Unilateral Extremity Lymphedema
Authors: Cheng Ming-Huei , Pappalardo Marco , Lin Chieh , Kuo Chang-Fu , Lin Chia-Yu , Chung Kevin C.
Published: July 2018

Objective:

The aim was to validate the new Taiwan Lymphoscintigraphy Staging, correlate it with Cheng Lymphedema Grading (CLG) and evaluate the treatment outcomes of unilateral extremity lymphedema.

Background:

No consensus has been reached for diagnosis and staging for patients with lymphedema among medical specialties.

Methods:

We included 285 patients with unilateral extremity lymphedema using lymphoscintigraphy. Lymphoscintigraphy was correlated to clinical symptoms and signs, and classified into normal lymphatic drainage, partial obstruction, and total obstruction. Inter- and intraobserver reliability of Taiwan Lymphoscintigraphy Staging, correlation between Taiwan Lymphoscintigraphy Staging and clinical findings were conducted. Patients were categorized in “surgical” (n = 154) or “nonsurgical” (n = 131) groups for outcome evaluation.

Results:

Lymphoscintigraphy found 11 patients (3.9%) with normal lymphatic drainage, 128 (44.9%) with partial obstruction, and 146 (51.2%) with total obstruction. Taiwan Lymphoscintigraphy Staging showed high interobserver agreement [intraclass correlation coefficient: 0.89 (95% confidence interval, 0.82–0.94)], and significantly correlated to computed tomography volumetric difference (r = 0.66, P < 0.001) and CLG [intraclass correlation coefficient: 0.79 (95% confidence interval 0.72–0.84)]. At a mean follow-up of 31.2 ± 2.9 months, significant improvement in the circumferential difference (from 23.9% ± 17.6% to 14.6% ± 11.1%; P = 0.03) with a mean circumferential reduction rate of 40.4% ± 4.5% was found in surgical group. At a mean follow-up of 26.6 ± 8.7 months, the nonsurgical group had increase of mean circumferential difference from 24.0% ± 17.2% to 25.3% ± 19.0% (P = 0.09), with a mean circumferential reduction rate was −1.9% ± 13.0%.

Conclusions:

The Taiwan Lymphoscintigraphy Staging is a reliable diagnostic tool, correlated with clinical findings and CLG, aiding in the selection of the appropriate treatment to achieve favorable long-term outcomes in unilateral extremity lymphedema.
Results of a Prospective, Multicenter Initiative Aimed at Developing Opioid-prescribing Guidelines After Surgery
Authors: Thiels Cornelius A. , Ubl Daniel S. , Yost Kathleen J. , Dowdy Sean C. , Mabry Tad M. , Gazelka Halena M. , Cima Robert R. , Habermann Elizabeth B.
Published: July 2018

Objective:

The aim of this study was to conduct a prospective, multicenter survey of patients regarding postoperative opioid use to inform development of standardized, evidence-based, procedure-specific opioid prescribing guidelines.

Summary of Background Data:

Previous work has shown significant variation in the amount of opioids prescribed after elective procedures, calling for optimization of prescribing.

Methods:

Adults (n = 3412) undergoing 25 elective procedures were identified prospectively from 3 academic centers (March 2017 to January 2018) to complete a 29-question telephone interview survey 21 to 35 days post-discharge (n = 688 not contacted, n = 107 refused). Discharge opioids were converted into Morphine Milligram Equivalents (MMEs).

Results:

Of the 2486 patients who completed the survey, 91.2% received opioids at discharge [median 225 (interquartile range, IQR 125 to 381) MME]. A median of 43 (0 to 184) MMEs were consumed after discharge with 77.3% of patients having leftover opioids at the time of the survey. In total, 61.5% of prescribed opioids were unused; 31.4% of patients used no opioids, and 52.6% required <50 MME. Overall, 90.6% of patients were satisfied with their postdischarge pain control. While 28.3% reported being prescribed too many opioids, 9.0% felt they were not prescribed enough. Only 9.6% of patients disposed of remaining opioids. Of the 2068 opioid-naive respondents (83.2%), 33.6% consumed no opioids (range 5.2% to 80.0% by procedure) and 57.0% (65.7% nonorthopedic) consumed <50 MME. Utilization data and predictors of low/high opioid consumption informed development of postoperative prescribing guidelines.

Conclusion:

A large proportion of postoperative patients reported using no or few opioids following discharge. Guidelines were developed to minimize opioid prescribing and identify patients requiring low doses or additional multimodal pain control.
Global Surgery: Effective Involvement of US Academic Surgery
Authors: Mock Charles , Debas Haile , Balch Charles M. , Brennan Murray , Buyske Jo , Cusack James , DeMeester Steven , Herndon David , Le Holterman Ai-Xuan , Jaffe Bernard , Kandil Emad , Kauffman Gordon , Mazariegos George , sMerchant Nipun , Numann Patricia , Oleynikov Dmitry , Olutoye Oluyinka , O’Neill James , Shackford Steven , Stock Peter , Tarpley John L. , Tuttle Todd , Wolf Steven , Wren Sherry M. , Yang George P.
Published: July 2018

There is an unacceptably high burden of death and disability from conditions that are treatable by surgery, worldwide and especially in low- and middle-income countries (LMICs). The major actions to improve this situation need to be taken by the surgical communities, institutions, and governments of the LMICs. The US surgical community, including the US academic surgical community, has, however, important roles to play in addressing this problem. The American Surgical Association convened a Working Group to address how US academic surgery can most effectively decrease the burden from surgically treatable conditions in LMICs. The Working Group believes that the task will be most successful (1) if the epidemiologic pattern in a given country is taken into account by focusing on those surgically treatable conditions with the highest burdens; (2) if emphasis is placed on those surgical services that are most cost-effective and most feasible to scale up; and (3) if efforts are harmonized with local priorities and with existing global initiatives, such as the World Health Assembly with its 2015 resolution on essential surgery. This consensus statement gives recommendations on how to achieve those goals through the tools of academic surgery: clinical care, training and capacity building, research, and advocacy. Through all of these, the ethical principles of maximally and transparently engaging with and deferring to the interests and needs of local surgeons and their patients are of paramount importance. Notable benefits accrue to US surgeons, trainees, and institutions that engage in global surgical activities.
Impact of the Affordable Care Act (ACA) Medicaid Expansion on Cancer Admissions and Surgeries
Authors: Eguia Emanuel , Cobb Adrienne N. , Kothari Anai N. , Molefe Ayrin , Afshar Majid , Aranha Gerard V. , Kuo Paul C.
Published: July 2018

Objective:

This study aims to evaluate the trends in cancer (CA) admissions and surgeries after the Affordable Care Act (ACA) Medicaid expansion.

Methods:

This is a retrospective study using HCUP-SID analyzing inpatient CA (pancreas, esophagus, lung, bladder, breast, colorectal, prostate, and gastric) admissions and surgeries pre- (2010–2013) and post- (2014) Medicaid expansion. Surgery was defined as observed resection rate per 100 cancer admissions. Nonexpansion (FL) and expansion states (IA, MD, and NY) were compared. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID).

Results:

There were 317, 858 patients in our sample which included those with private insurance, Medicaid, or no insurance. Pancreas, breast, colorectal, prostate, and gastric CA admissions significantly increased in expansion states but decreased in nonexpansion states. (IRR 1.12, 1.14, 1.11, 1.34, 1.23; P < .05) Lung and colorectal CA surgeries (IRR 1.30, 1.25; P < .05) increased, while breast CA surgeries (IRR 1.25; P < .05) decreased less in expansion states. Government subsidized, or self-pay patients had greater odds of undergoing lung, bladder, and colorectal CA surgery (OR 0.45 vs 0.33; 0.60 vs 0.48; 0.47 vs 0.39; P < .05) in expansion states after reform.

Conclusions:

In states that expanded Medicaid coverage under the ACA, the rate of surgeries for colorectal and lung CA increased significantly, while breast CA surgeries decreased less. Parenthetically, these cancers are subject to population screening programs. We conclude that expanding insurance coverage results in enhanced access to cancer surgery.