bluuebunny/crossref_metadata_2025 huggingface dataset:
Small-cell lung cancer transformation from EGFR-mutant adenocarcinoma after EGFR-TKIs resistance
Authors: Jiang Yiqian , Shou Leyi , Guo Qingmin , Bao Yanhong , Xu Xiaoping , An Suhong , Lu Jianfeng
Published: August 2021

Rationale:

With the recent advancements in molecular biology research, epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) have emerged as excellent therapies for patients with EGFR-mutant cancers. However, these patients inevitably develop cross-acquired resistance to EGFR-TKIs. Transformation to small-cell lung cancer (SCLC) is considered a rare resistance mechanism against EGFR-TKI therapy. Here, we report a case of TKI resistance due to SCLC transformation and demonstrate its mechanisms and clinical features.

Patient concerns:

A 54-year-old Chinese man with a history of smoking for 40 years complained of an intermittent cough in March 2019.

Diagnosis:

Transbronchial lung biopsy was performed on the basal segment of the left lower lobe, which confirmed lung adenocarcinoma. In January 2020, repeat biopsy was performed, and the results of immunohistochemistry (IHC) staining showed TTF-1 (+), CK7 (+), napsin A (+), syn (+), and CD56 (+), with a Ki-67 (+) index 80% of small cell carcinomas. Infiltrating adenocarcinomas and small cell carcinomas were observed.

Interventions:

Icotinib (125 mg thrice daily) was administered as a first-line treatment from June 2019. We subsequently administered a chemotherapy regimen consisting of etoposide (180 mg, days 1–3) plus cisplatin (45 mg, days 1–3) every 3 weeks for 1 cycle after recurrence. As the patient could not tolerate further chemotherapy, he continued taking icotinib orally and received whole-brain radiotherapy 10 times to a total dose of 30 Gy after brain metastases.

Outcomes:

The patient relapsed after successful treatment with icotinib for 9 months. A partial response was achieved after 4 cycles of chemotherapy, and despite the brief success of chemotherapy, our patient exhibited brain metastasis and metastases of the eleventh thoracic spine and the second lumbar vertebra with pathological fracture. The patient eventually died of aggressive cancer progression.

Lessons:

Our case highlights the possibility of SCLC transformation from EGFR-mutant adenocarcinoma and the importance of repeat biopsy for drug resistance. Serum neuron-specific enolase levels may also be useful for detecting early SCLC transformation.
The potential value of microRNA-145 for predicting prognosis in patients with ovarian cancer
Authors: Chen Zhen , Xiao Zelan , Zeng Siheng , Yan Zhiqiang
Published: August 2021

Background:

As an anticancer gene, microRNA-145 (miRNA-145) inhibits the growth, migration, and invasion of cancer cells, and inhibits tumorigenesis by targeting various genes that are abnormally expressed in tumors. However, whether miRNA-145 can be applied as a biomarker for potential prognosis of ovarian cancer still remains controversial. Therefore, this study further explored the prognostic value and mechanism of miRNA-145 in ovarian cancer through meta-analysis and bioinformatics analysis.

Methods:

Eligible studies were identified by searching the China National Knowledge Infrastructure, Chinese Biomedical literature Database, Chinese Scientific and Journal Database, Wan Fang database, PubMed, EMBASE, and Web of Science up to July 2021. Pooled hazard ratios with 95% confidence intervals for patient survival were calculated to investigate the effects of miRNA-145 on the prognosis of ovarian cancer. Survival curves of differential expression of miRNA-145 were analyzed by Oncomir. The target genes of miRNA-145 were predicted by miRTARbase and Diana-Tarbase V7.0 database. Enrichr database was applied to analyze the target genes by gene ontology and Kyoto Encyclopedia of Genes and Genomes pathways. Protein–protein interaction network of target genes was constructed from STRING database. Cytoscape software was used to screen the hub genes to meet the requirements. The Gene Expression Profiling Interactive Analysis database was applied to analyze the survival outcomes of hub genes.

Results:

The results of this meta-analysis would be submitted to peer-reviewed journals for publication.

Conclusion:

This study provides high-quality evidence to support the relationship between miRNA-145 expression and ovarian cancer prognosis. Through bioinformatics analysis, we further explored the mechanism of miRNA-145 in ovarian cancer and related pathways.
The value of Angipoietin-2 as a biomarker for the prognosis of osteosarcoma
Authors: Liu Lizhu , Zhang Xinbo , Li Chaoyi , Qu Ye
Published: August 2021

Background:

The function of Angipoietin-2 (Agn2) in osteosarcoma has not been fully explored and exists controversial. Therefore, we conducted a meta-analysis to investigate the role of Agn2 in the prognosis of osteosarcoma. In addition, bioinformatics analysis was carried out to reveal the mechanism and related pathways of Agn2 in osteosarcoma.

Methods:

Literature search was operated on databases up to July 2021, including PubMed, Web of Science, China National Knowledge Infrastructure, China Biology Medicine disc, and Wan Fang Data. The relation between Agn2 expression and survival outcome was estimated by hazard ratio and 95% confidence interval. Meta-analysis was performed on the Stata 16.0. Being obtained from The Cancer Genome Atlas, the original data were used to further verify the prognostic role of Agn2 in osteosarcoma. Gene set enrichment analysis was applied to predict the potential mechanism of Agn2. The correlation between Agn2 and osteosarcoma immune infiltration was analyzed by TIMER database.

Results:

The results of this meta-analysis would be submitted to peer-reviewed journals for publication.

Conclusion:

This study will provide evidence for the exploration of the relationship between Agn2 and the prognosis of osteosarcoma and its mechanism.

Ethics and dissemination:

The private information from individuals will not be published. This systematic review also should not damage participants’ rights. Ethical approval is not available. The results will be published in a peer-reviewed journal or disseminated in relevant conferences.

OSF registration number:

DOI 10.17605/OSF.IO/GWQ53.
Effectiveness and safety of massage for athletic injuries
Authors: Guo Guangxin , Xie Shengji , Cai Feihong , Zhou Xu , Xu Jianghan , Wu Boyi , Wu Guanghui , Xiao Ran , Xu Xiruo , Lu Ping , Fang Min
Published: August 2021

Background:

Athletic injuries have been a major area of interest in the field of sports and clinical medicine. Implemented on people's skin, muscles, and joints as an important part of complementary and alternative medicine (CAM), massage therapy has a positive effect on athletic injuries. This protocol is to provide the methods used to evaluate the effectiveness and safety of massage therapy for patients with athletic injuries.

Methods:

A systematic search will be performed in the following electronic databases for randomized controlled trials (RCTs) to evaluate the effectiveness and safety of massage therapy in treating athletic injuries: PubMed, the Cochrane Library, EMBASE and four Chinese databases (CNKI, Wan Fang, CBMdisc and VIP). Each database will be searched from inception to July 2021. The entire process will include study selection, data extraction, risk of bias assessment and meta-analysis.

Results:

A high-quality synthesis of current evidence of massage therapy for patients with athletic injuries will be provided.

Conclusions:

This systematic review will provide evidence for assessing the credibility of massage therapy for patients with athletic injuries.

Dissemination and ethics:

The results of this review will be disseminated through peer-reviewed publication. This review does not require ethical approval because all the data used in this systematic review and meta-analysis have already been published. Furthermore, all of these data will be analyzed anonymously during the review process.

INPLASY registration number:

INPLASY202170066.
A meta-analysis of the utility of transabdominal ultrasound for evaluation of gastric cancer
Authors: Zhang Yuqin , Zhang Jianzhong , Yang Liu , Huang Songxiong
Published: August 2021

Background:

Clinical discovery/staging of gastric cancer (GC) is crucial in designing the treatment strategies and largely decides GC patients’ survival. Endoscopic ultrasonography (EUS) and computed tomography (CT) are 2 useful GC diagnosis tools. High doses of radiation associated with CT make its use limited, while the process of EUS is stressful, time-consuming, and challenging. Transabdominal ultrasound (TAUS) is a promising candidate to address these shortcomings. This study aimed to meta-analyze the diagnostic accuracy and sensitivity of TAUS in discriminating between advanced and early GCs, as well as compare its utility with other imaging techniques.

Methods: Literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library databases up to 2019. Data were analyzed using RevMan software (Cochrane Collaboration, Oxford, UK), and pooled estimates of accuracy, sensitivity, and other features were acquired. Seven papers were eventually selected for meta-analysis.

Results:

TAUS had distinct diagnostic efficacies for early and advanced GC patients. The accuracy and sensitivity were significantly higher in the advanced group. A high color Doppler vascularity index and a lesion larger than 1 cm were 2 features of advanced GC. Moreover, TAUS had a comparable (but slightly higher) accuracy than CT and EUS.

Conclusions:

TAUS is more accurate and sensitive in diagnosing advanced GC compared to early GC. More features of advanced GC are required to improve the recognition ability. At least, TAUS can be considered as a complementary imaging diagnostic tool to CT and EUS.
Total vascular resistance, augmentation index, and augmentation pressure increase in patients with peripheral artery disease
Authors: Takemoto Rika , Uchida Haruhito A. , Toda Hironobu , Okada Ken , Otsuka Fumio , Ito Hiroshi , Wada Jun
Published: August 2021

Peripheral arterial disease (PAD) is one of major vascular diseases which frequently coexists with coronary arterial disease and cerebrovascular disease. The patients with PAD have a poor prognosis when it progresses. A new blood pressure testing device enables to simultaneously measure brachial blood pressure (BP), central BP, and several vascular parameters, with easy and non-invasive, in a short time. Here, we aimed to evaluate these arterial stiffness parameters in patients with PAD.

In this study, 243 consecutive patients who were suspected of having PAD and referred to our hospital from September 2016 to June 2019, were registered. Several parameters, such as brachial BP, central BP, aortic pulse wave velocity (aPWV), total vascular resistance (TVR), augmentation index (AI) and augmentation pressure (AP), were determined by Mobil-O-Graph. Ankle-brachial pressure index (ABI) was used to define PAD (ABI ≤ 0.9 as PAD). The relationship between PAD and central BP, aPWV, TVR, AI, or AP were investigated.

One hundred sixty-two patients (67%) were categorized as the PAD group and 81 patients (33%) as the non-PAD group. In the PAD group, the systolic brachial BP and central systolic BP were significantly higher than those in the non-PAD group (138 ± 24 mmHg vs 131 ± 19 mmHg, P < .05, 125 ± 22 mmHg vs 119 ± 18 mmHg, P < .05, respectively). TVR, AI, and AP were significantly higher in the PAD group (1785 ± 379 dyn s/cm5 vs 1661 ± 317 dyn s/cm5, P < .05, 26.2 ± 13.0% vs 22.2 ± 13.3%, P < .05, 13.5 ± 9.4 mmHg vs 10.7 ± 7.2 mmHg, P < .05, respectively). No significant differences in diastolic BP, central diastolic BP, and aPWV were found between the groups. Multivariate logistic regression analysis revealed that PAD was significantly associated with TVR, AI, and AP (P < .05, respectively).

TVR/AP/AI were significantly higher in the PAD group than in the non-PAD group.
Intestinal flora differences between patients with ulcerative colitis of different ethnic groups in China
Authors: Liu Huan , Liu Weidong , Huang Xiaoling , Feng Yan , Lu Jiajie , Gao Feng
Published: August 2021

To determine the differences in intestinal flora between Uygur and Han patients with ulcerative colitis (UC).

Microbial diversity and structural composition of fecal bacteria from patients with UC and their matched healthy spouses or first-degree relatives were analyzed using high-throughput sequencing technology.

The fecal microbial diversity and abundance index of Uygur patients with UC (UUC) were significantly lower compared with the Uygur normal control group, while there was no significant difference between the Han UC patients (HUC) and the Han normal control group (HN). Compared with their respective control groups, Uygur UC patients and Han UC patients had a different main composition of human intestinal flora (P < .05). The abundance of Burkholderia, Caballeronia, Paraburkholderia in the UUC group were higher compared with the HUC group, while Faecalibacterium, Bifidobacterium, and Blautia in the HUC group were higher than those in the UUC group (P < .05). Veillonella in the UUC group was higher than that in the Uygur normal control group group, while Subdoligranulum and Ruminococcaceae_UCG-002 were significantly lower (P < .05). Prevotella_9 in the HUC group was significantly higher than that in HN group, while Blautia, Anaerostipes, and [Eubacterium]_hallii_group were significantly lower. Moreover, the top 6 species in order of importance were Christensenellaceae_R_7_group, Ruminococcae_ucg_005, Ruminococcae_ucg_010, Ruminococcae_ucg_013, Haemophilus, and Ezakiella.

The difference in intestinal microflora structure may be one of the reasons for the clinical heterogeneity between Uygur and Han patients with UC. Christensenellaceae_R_7_group, Ruminococcae_ucg_005, Ruminococcae_ucg_010, Ruminococcae_ucg_013, Haemophilus, and Ezakiella could be used as potential biomarkers for predicting UC.
Application of mentorship program for another aspect of surgical residency training
Authors: Chan Kun-Ming , Hsu Jun-Te , Yeh Chun-Nan , Yeh Ta-Sen , Lee Wei-Chen , Lien Hsin-Yi
Published: August 2021

Traditionally, surgical residency training is more focused on obtaining surgical skills through a well-established coaching system worldwide. However, constant advances in medical science require surgeons to learn not only surgical skills but also the ability of scientific research to improve clinical practice and future professional development. The study aims to emphasize that professional education in terms of scientific research is also significant for surgical residency training.

All residents who had been recruited in a medical center for the surgery residency program between years 2006 and 2015 were evaluated in the study. Generally, every resident is assigned to a mentor since the first year of residency. Then, the mentor would help the resident qualify a 2-step evaluation in terms of scientific research during the residency training program.

A total of 193 residents were evaluated in the study. All of them had completed the first step regarding oral presentation of their designated research, and the majority of residents obtained 80 to 90 points that were rated by referees. Overall, 102 residents (52.8%) had completed the second step with the publication of a research manuscript. The percentage of residents who had fulfilled the criteria of this 2-step assessment ranged from 35.3% to 81.8% by year.

The continuing education for surgical residents should not be limited in coaching clinical practice. Scientific research is also essential for current surgical residency training, and a formal mentorship program may be beneficial for the future professional development of surgical residents. However, the success of the 2-step evaluation could possibly depend on the career choices of the residents instead of the mentorship program.
Nalbuphine and dexmedetomidine as adjuvants to ropivacaine in ultrasound-guided erector spinae plane block for video-assisted thoracoscopic lobectomy surgery
Authors: Rao Jin , Gao Zhixin , Qiu Gaolin , Gao Pei , Wang Qing , Zhong Weiwei , Wang Yiqiao , Li Yuanhai
Published: August 2021

Background:

Adjuvants to local anesthetics, such as nalbuphine and dexmedetomidine, can be used to improve the quality and duration of peripheral nerve block effects. Dexmedetomidine has been successfully used as an adjuvant of erector spinae plane block (ESPB) with ropivacaine in video-assisted thoracoscopic lobectomy surgeries (VATLS). This study aimed to compare the effects of nalbuphine and dexmedetomidine used as adjuvants to ropivacaine for ESPB in VATLS.

Methods:

A total of 102 patients undergoing VATLS with ESPB were enrolled and randomized into 3 groups, each of which received a different adjuvant to ropivacaine. The visual analogue scale score, onset and duration of sensory block, use of patient-controlled analgesia (PCA), rate of rescue analgesia, duration of postoperative hospitalization, incidence of postoperative nausea and vomiting, and chronic pain were measured and observed.

Results:

The visual analogue scale score, total PCA use, rate of rescue analgesia, and postoperative chronic pain in the ropivacaine with dexmedetomidine (RD), and ropivacaine with nalbuphine (RN) groups were lower than those in the ropivacaine (RC) group (P < .05). The duration of sensory block was longer and the first use of PCA occurred later in the RD and RN groups than they did in the RC group (P < .05).

Conclusions:

As an adjuvant to ropivacaine in ESPB, nalbuphine and dexmedetomidine are comparable in terms of the associated analgesia, sensory block duration, need for rescue analgesia, and incidence of chronic pain in patients after VATLS.
The iterative lipid impact on inflammation in atherosclerosis
Authors: Kraaijenhof Jordan M. , Hovingh G. Kees , Stroes Erik S.G. , Kroon Jeffrey
Published: August 2021

Purpose of review

Lipid-mediated atherogenesis is hallmarked by a chronic inflammatory state. Low-density lipoprotein cholesterol (LDL-C), triglyceride rich lipoproteins (TRLs), and lipoprotein(a) [Lp(a)] are causally related to atherosclerosis. Within the paradigm of endothelial activation and subendothelial lipid deposition, these lipoproteins induce numerous pro-inflammatory pathways. In this review, we will outline the effects of lipoproteins on systemic inflammatory pathways in atherosclerosis.

Recent findings

Apolipoprotein B-containing lipoproteins exert a variety of pro-inflammatory effects, ranging from the local artery to systemic immune cell activation. LDL-C, TRLs, and Lp(a) induce endothelial dysfunction with concomitant activation of circulating monocytes through enhanced lipid accumulation. The process of trained immunity of the innate immune system, predominantly induced by LDL-C particles, hallmarks the propagation of the low-grade inflammatory response. In concert, bone marrow activation induces myeloid skewing, further contributing to immune cell mobilization and plaque progression.

Lipoproteins and inflammation are intertwined in atherogenesis. Elucidating the inflammatory pathways will provide new opportunities for therapeutic agents.
Rapid Progression After 177Lu-DOTATATE in Patients With Neuroendocrine Tumors
Authors: Assi Hussein A. , Hornbacker Kathleen , Shaheen Shagufta , Wittenberg Theresa , Silberman Robyn , Kunz Pamela L.
Published: August 2021

Peptide receptor radionuclide therapy (PRRT) is a treatment option for somatostatin receptor–positive, unresectable or metastatic neuroendocrine tumors (NETs). Despite high disease control rates seen with PRRT, a subset of the NET population seems to have a short progression-free interval. We hypothesize that patients with NETs with rapid progression post-PRRT may have mixed low- and high-grade cell populations, and PRRT treats the lower-grade component, allowing the more aggressive high-grade component to progress.

We report 7 patients with biopsy-proven NET who received PRRT with 177Lu-DOTATATE at the Stanford Cancer Center who had evidence of progressive disease (PD) on or within 6 months of therapy.

All patients had primary pancreatic, metastatic, well-differentiated NET on diagnosis and were heavily pretreated before receiving PRRT. Two patients had PD while on PRRT; 5 had PD within 6 months of completing PRRT. The median time from the last cycle to PD was 3.2 months (range, 1.1–4.6 months). The median progression-free survival was 7.7 months (95% confidence interval, 5.7–9.8 months). Three patients had a repeat biopsy post-PRRT, 2 of which demonstrated higher disease grade compared with their initial pathology. Further evaluation in larger patient cohorts is warranted to elucidate predictive factors of PRRT response/nonresponse to enable better patient selection.
The Social Determinants of Mental Health
Authors: Fink-Samnick Ellen
Published: August 2021

Purpose:

The social determinants of mental health (SDoMH) continue to exert their fierce presence around the globe. The factors known to influence health outcomes equally impact mental health. A global mental health chasm has widened courtesy of COVID-19's intersection with every psychosocial aspect of functioning, inclusive of how people are born, live, learn, work, socialize, worship, and die. Racial, ethnic, and cultural inequities across the diversity, equity, and inclusion space have led to rising morbidity and mortality across every population. Part 2 of this article series is dedicated to assessment and intervention tools for the workforce. A key fifth or Quintile Aim of wholistic health equity is also presented to advance the industry's seminal quality compass, the Triple Aim, for the future.

Learning Outcomes:

After reading this article, learners will be able to:

Finding/Conclusion:

Access to quality wholistic health care encompasses pathophysiology, psychopathology, and psychosocial circumstances and remains a challenge across populations. Mental health, along with health disparities, has been fueled by systematic racism that has facilitated inadequate funding, poor reimbursement, decreased treatment options, and pervasive stigma across the cultural divide (e.g., race, ethnicity, gender, sexual orientation, familial status, disability, socioeconomic status). The SDoMH mandate a fresh lens by health and behavioral health professionals, and particularly case management, to ensure a more proactive and comprehensive approach to care. To achieve the successful outcomes mandated by this approach, the industry's quality compass, the Triple/Quadruple Aim, must be expanded to include a Quintile Aim of wholistic health equity.

Implications for Case Management Practice:

Case management's unique transdisciplinary composition has the workforce well positioned to effect grand change in population health perspectives. Wider attention to clinical and fiscal outcomes for health and mental health inequities mandates innovative approaches to patient care, which encompasses a wholistic health triad of pathophysiology, psychopathology, and psychosocial circumstances.
Mothers' Experiences with Antenatal Milk Expression
Authors: Juntereal Nina A. , Spatz Diane L.
Published: August 2021

Background:

Antenatal milk expression is a milk expression intervention beginning at either 36 or 37 weeks of gestation for the purpose of potential colostrum collection and storage prior to birth for postnatal infant feeding. Research on antenatal milk expression is limited and originates outside the United States.

Methods:

Women who used antenatal milk expression were interviewed about their experiences. A conventional, inductive approach to qualitative content analysis was used to analyze participants' responses.

Results:

Three women participated in interviews. They reported learning and performing antenatal milk expression for various postpartum needs including avoidance of formula, milk available for potential infant hypoglycemia, and to support human milk feeding during surrogate mother–infant separation. These mothers obtained education and information on antenatal milk expression primarily on their own.

Clinical Implications:

Greater awareness and understanding of antenatal milk expression is needed in the professional community caring for childbearing women. Perinatal nurses need to be aware of all breastfeeding practices including antenatal milk expression. Knowledge of the practice and advocacy for more research on antenatal milk expression will improve lactation support and ensure expectant mothers reach their personal breastfeeding goals.
Complex Regional Pain Syndrome
Authors: Nirenberg Michael
Published: August 2021

Complex regional pain syndrome (CRPS) is a potentially life-altering, neuropathic pain condition that often affects an extremity in response to surgery or even minor trauma. The pain is often disproportionate to the injury sustained or the surgical procedure performed—and it has been described as excruciating and unbearable. CRPS can result in irreversible, disabling changes in the affected limb. In some cases it has resulted in amputation or severe psychological issues. However, CRPS outcomes are generally more successful with early detection and treatment. This article presents an overview of CRPS and discusses the critical role nurses can play in recognizing the condition early, assisting with treatment, and providing psychological support.
Understanding the Experience of Osteoporosis Risk in Bariatric Surgical Patients
Authors: Mori Candace , Sheehan Denice , Graor Christine Heifner , Petrinec Amy
Published: August 2021

Despite what is known about risk factors, preventive treatment, and increased prevalence of fragility fractures in post-bariatric surgical patients, little is known about how patient perspectives of osteoporosis risk inform their commitment to bone health. The purpose of this study was to examine the lived experience of osteoporosis risk in people who have had bariatric surgery. Interpretive phenomenology was used to explore osteoporosis from the perspectives of patients who have had bariatric surgery. Eligibility criteria included female, age older than 18 years, and able to understand and speak English.

This research provided an understanding of the risk of osteoporosis from the constructed realities and experiences of those who have had bariatric surgery. Participants in this study incorrectly felt they had little to no risk for osteoporosis after bariatric surgery.

Patients need to be aware of an increased risk for osteoporosis leading to the potential for fragility fractures after bariatric surgery; nurses are well positioned to enhance osteoporosis prevention efforts in this population through pre- and postoperative education.
Application of the Convergence Insufficiency Symptom Survey in Oculomotor Dysfunction and Accommodative Insufficiency
Authors: Pang Yi , Tan Qing-Qing , Gabriel Helen , Block Sandra S. , Wang Jingyun
Published: August 2021

SIGNIFICANCE

This study confirmed the application of the Convergence Insufficiency Symptom Survey (CISS) in distinguishing children with oculomotor dysfunction (OMD) from those with normal binocular vision (NBV) but not in distinguishing children with accommodative insufficiency (AI).

PURPOSE

The purpose of this study was to determine the application of the CISS for quantifying symptoms in children aged 9 to 18 years with AI or OMD.

METHODS

All participants (aged 9 to 18 years) underwent comprehensive binocular vision tests including visual acuity, cover test, near point of convergence, fusional vergence, accommodative amplitude, and the Developmental Eye Movement test to ascertain the presence of any vision conditions. According to the examination outcomes, participants were divided into four groups: NBV group, AI group, OMD group, and a group with both AI and OMD (AI-OMD). The CISS was individually administered to each participant. An ANOVA and a receiver operating characteristic curve were performed to evaluate the ability of the CISS to quantify symptoms in AI and OMD.

RESULTS

A total of 82 participants were qualified for this study, with 18 in the NBV group, 21 in AI, 16 in OMD, and 27 in AI-OMD group. The mean CISS score was significantly different among the four groups (F = 4.19, P = .008). Post hoc tests showed significantly higher CISS scores in the OMD group than the NBV (P = .01) and the AI (P = .03) groups, but no differences were detected among other groups. Receiver operating characteristics curve showed a significant effect of the CISS score on predicting an OMD (area under curve = 0.78, P = .006). Using a CISS score of ≥15, good discrimination of OMD was obtained.

CONCLUSIONS

Children with OMD (Developmental Eye Movement type II or IV) had higher CISS scores than ones with NBV. Using the CISS, children with AI did not report worse symptoms than children with NBV.
Pharmacologic Management of Acute Agitation in Youth in the Emergency Department
Authors: Hoffmann Jennifer A. , Pergjika Alba , Konicek Claire E. , Reynolds Sally L.
Published: August 2021

When youth in the emergency department become acutely agitated, it can be dangerous and distressing to patients, families, and clinicians. Timely, effective, and patient-centered management is key to reducing the potential for patient and staff injury while preserving patient dignity. We review the definition of agitation and pharmacologic management for youth with acute agitation, including common classes of medications, indications for use, and adverse effects. We also discuss the need to integrate the use of medications into a comprehensive strategy for agitation management that begins with proactive prevention of aggressive behavior, creation of a therapeutic treatment environment, and verbal de-escalation strategies.
Is There a Role for Cellular Therapy in Chronic Lymphocytic Leukemia?
Authors: Dreger Peter
Published: August 2021

Despite multiple advances in the treatment landscape of chronic lymphocytic leukemia (CLL) during recent years, cellular therapies, such as allogeneic hematopoietic cell transplantation and chimeric antigen-engineered T cells, represent valuable therapeutic options for patients with multiply relapsed or poor-risk disease. This brief overview will summarize current results of cellular therapies in CLL including Richter transformation, suggest an indication algorithm and strategies for performing cellular therapies in these conditions, and discuss the impact of COVID-19 (coronavirus disease 2019) on allogeneic hematopoietic cell transplantation and chimeric antigen-engineered T cells in CLL.
Management of Chronic Lymphocytic Leukemia in Less-Resourced Countries
Authors: Chiattone Carlos S. , Gabus Raul , Pavlovsky Miguel A. , Akinola Norah O. , Varghese Abraham M. , Arrais-Rodrigues Celso
Published: August 2021

Despite the practice-changing advances achieved in the prognostic stratification and treatment of chronic lymphocytic leukemia (CLL), a large fraction of the world population resides in countries where access to many of these advances remains unavailable or subject to severe constraints. Although some of these countries display incidence rates of CLL that are lower than those of developed Western countries, a large number of patients are expected to be diagnosed with CLL in these regions every year. In this article, we review issues regarding management of CLL in some less-resourced countries, with a focus on the evidence basis for epidemiological and clinical information on this disease, the availability of diagnostic and therapeutic resources, and participation in clinical trials. Going forward, challenges that still need to be addressed include the development of unified countrywide registries, guidelines for management applicable to each country, wider availability of prognostic tools, access to new drugs, and policies that ensure these drugs are affordable to all patients worldwide.
Autoimmune Cytopenia in CLL
Authors: Albiol Nil , Moreno Carol
Published: August 2021

Chronic lymphocytic leukemia (CLL) is frequently associated with autoimmune hemolytic anemia and immune thrombocytopenia and, less frequently, with pure red cell aplasia and immune neutropenia. The emergence of these complications is related to an intertwined and complex relationship between patient, disease, and treatment characteristics. The prognostic repercussion of autoimmune cytopenia (AIC) in patients with CLL mainly depends on its response to therapy. For patients with AIC and nonactive CLL, treatment is as in primary, uncomplicated AIC, keeping in mind that no response is an indication for CLL therapy. The success of treating active CLL-related AIC widely relies on a flexible strategy that should include initial therapy with corticosteroids and a rapid shift to effective CLL therapy in nonresponding patients. Targeted therapies (e.g., ibrutinib) that have already demonstrated to be effective in CLL-related AIC will likely offer a unique possibility of treating both AIC and CLL as a single target.
Can Breast Implants Induce Breast Cancer Immunosurveillance? An Analysis of Antibody Response to Breast Cancer Antigen following Implant Placement
Authors: Fracol Megan , Shah Nikita , Dolivo David , Hong Seok , Giragosian Lexa , Galiano Robert , Mustoe Thomas , Kim John Y. S.
Published: August 2021

Background:

Women with cosmetic breast implants have significantly lower rates of subsequent breast cancer than the general population (relative risk, 0.63; 95 percent CI, 0.56 to 0.71). The authors hypothesize that breast implant-induced local inflammation stimulates immunosurveillance recognition of breast tumor antigen.

Methods:

Sera were collected from two cohorts of healthy women: women with long-term breast implants (i.e., breast implants for >6 months) and breast implant-naive women. Antibody responses to breast tumor antigens were tested by enzyme-linked immunosorbent assay and compared between cohorts by unpaired t test. Of the implant-naive cohort, nine women underwent breast augmentation, and antibody responses before and after implant placement were compared by paired t test.

Results:

Sera were collected from 104 women: 36 (34.6 percent) long-term breast implants and 68 (65.4 percent) implant-naive women. Women with long-term breast implants had higher antibody responses than implant-naive women to mammaglobin-A (optical density at 450 nm, 0.33 versus 0.22; p = 0.003) and mucin-1 (optical density at 450 nm, 0.42 versus 0.34; p = 0.02). There was no difference in antibody responses to breast cancer susceptibility gene 2, carcinoembryonic antigen, human epidermal growth factor receptor-2, or tetanus. Nine women with longitudinal samples preoperatively and 1 month postoperatively demonstrated significantly elevated antibody responses following implant placement to mammaglobin-A (mean difference, 0.13; p = 0.0002) and mucin-1 (mean difference 0.08; p = 0.02). There was no difference in postimplant responses to other breast tumor antigens, or tetanus.

Conclusions:

Women with long-term breast implants have higher antibody recognition of mammaglobin-A and mucin-1. This study provides the first evidence of implant-related immune responses to breast cancer antigens.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Maximizing the Flap Inflow in a Foot Reconstruction: Ultrasonographic Evaluation of Artery Flow in Accordance with the Angle of the Ankle
Authors: Suh Young Chul , Kim Hyung Bae , Brown Erin , Hong Joon Pio , Suh Hyunsuk Peter
Published: August 2021

Adequate arterial inflow is mandatory for a successful free tissue transfer. Maximizing this inflow appears to be especially important during distal lower extremity reconstruction, where perfusion pressures can be significantly lower than in the trunk or head and neck. In the current study, the authors used color and pulsed-wave Doppler ultrasonography to analyze blood flow volumes in the foot in accordance with the ankle position. Twenty feet of 10 healthy subjects were included in the analyses. All subjects were examined by Doppler ultrasonography at three different ankle angles (dorsiflexion at 90 degrees, relaxed position, and complete plantar flexion). The average flow volumes of the dorsalis pedis artery varied dramatically at the different ankle positions, as follows: dorsiflexion, 19.81 ± 3.88 ml/minute; relaxed position, 11.71 ± 4.72 ml/minute; and plantar flexion, 3.47 ± 1.41 ml/minute. The average flow volume of the posterior tibial artery also varied dramatically at these different ankle positions: dorsiflexion, 9.08 ± 8.25 ml/minute; relaxed position, 14.78 ± 2.45 ml/minute; and plantar flexion, 19.03 ± 5.03 ml/minute. The ankle position dramatically affects the flow velocity in the anterior and posterior tibial vessels, which is an important consideration when performing free tissue transfer reconstruction of the foot. Ankle dorsiflexion would be recommended when using the anterior tibial artery as a recipient vessel, whereas plantar flexion of the ankle would be advised when the posterior tibial artery is used as a recipient vessel.
Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations
Authors: Rochlin Danielle H. , Sheckter Clifford C. , Khosla Rohit K. , Lorenz H. Peter
Published: August 2021

Background:

The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States.

Methods:

A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision.

Results:

A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type.

Conclusions:

In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
The Role of the Buccal Fat Pad in Facial Aesthetic Surgery
Authors: Rohrich Rod J. , Stuzin James M. , Savetsky Ira L. , Avashia Yash J. , Agrawal Nikhil A. , Prada Margarita
Published: August 2021

Social media have triggered a buccal fat pad excision frenzy. Not surprisingly, there is tremendous appeal of having a slimmer lower face and more defined jawline after undergoing a small intraoral procedure under local anesthesia. Although this procedure is great for social media and seemingly beneficial for jawline aesthetics, the evidence remains limited as to whether or not this is an effective long-term solution. How much the buccal fat pad persists or diminishes as we age is an area of debate. However, the possibility of causing premature aging and midface distortion in the long run is disconcerting.
MR Perfusion in the Evaluation of Mechanical Thrombectomy Candidacy
Authors: Muddasani Varsha , de Havenon Adam , McNally J. Scott , Baradaran Hediyeh , Alexander Matthew D.
Published: August 2021

Stroke is a leading cause of disability and mortality, and the incidence of ischemic stroke is projected to continue to rise in coming decades. These projections emphasize the need for improved imaging techniques for accurate diagnosis allowing effective treatments for ischemic stroke. Ischemic stroke is commonly evaluated with computed tomography (CT) or magnetic resonance imaging (MRI). Noncontrast CT is typically used within 4.5 hours of symptom onset to identify candidates for thrombolysis. Beyond this time window, thrombolytic therapy may lead to poor outcomes if patients are not optimally selected using appropriate imaging. MRI provides an accurate method for the earliest identification of core infarct, and MR perfusion can identify salvageable hypoperfused penumbra. The prognostic value for a better outcome in these patients lies in the ability to distinguish between core infarct and salvageable brain at risk—the ischemic penumbra—which is a function of the degree of ischemia and time. Many centers underutilize MRI for acute evaluation of ischemic stroke. This review will illustrate how perfusion-diffusion mismatch calculated from diffusion-weighted MRI and MR perfusion is a reliable approach for patient selection for stroke therapy and can be performed in timeframes that are comparable to CT-based algorithms while providing potentially superior diagnostic information.
Endovascular Thrombectomy Treatment
Authors: Lavie Jayson , Vellimana Ananth K. , Chatterjee Arindam Rano
Published: August 2021

Tremendous advancements in the treatment of acute ischemic stroke in the last 25 years have been based on the principle of reperfusion in early time windows and identification of small core infarct for intravenous thrombolysis and mechanical thrombectomy. Advances in neuroimaging have made possible the safe treatment of patients with acute ischemic stroke in longer time windows and with more specific selection of patients with salvageable brain tissue. In this review, we discuss the history of endovascular stroke thrombectomy trials and highlight the neuroimaging-based trials that validated mechanical thrombectomy techniques in the extended time window with assessment of penumbral tissue. We conclude with a survey of currently open trials that seek to safely expand eligibility for this highly efficacious treatment.
Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction
Authors: Song Dajiang , Li Juanjuan , Pafitanis Georgios , Li Zan
Published: August 2021

Background

Extensive reconstruction of complex full-thickness chest wall oncological defects is challenging. Bilateral free anterolateral thigh (ALT) myocutaneous flap transfer for the complex reconstruction of a large area of the chest wall is discussed.

Materials and Methods

We reported a single unit's experience in 1-staged multilayered reconstruction of large full-thickness chest wall defects in 22 patients (16 primary chest wall tumor cases, 5 locally advanced breast cancer cases, and 1 osteoradionecrosis case) treated between 2011 and 2018. Bilateral ALT myocutaneous flaps together with traditional cement implant or unmovable/movable joint conformable titanium struts were used for chest wall reconstruction. The anatomical characteristics of pedicle origin and pattern of the venae comitantes of the ALT myocutaneous flap, recipient vessels, and anastomosis patterns were described.

Results

Bilateral ALT myocutaneous flaps were used for soft tissue reconstruction in 22 cases. Different methods of flap harvesting and vascular anastomosis were selected as needed. No vein grafts or arteriovenous loops were required. We observed 3 vascular patterns of the flap pedicle, including 1 oblique branch and descending branch (59.1%, n = 26), 2 single descending branch (9.1%, n = 4), and 3 double branches of the descending branch (31.8%, n = 14). The flap was harvested pedicled with solely the oblique branch in 7 (15.9%) cases, solely the descending branch in 28 (63.6%) cases to minimize the donor site morbidity, and pedicled with the oblique and descending branch in 9 (20.5%) cases to achieve multiple vascular anastomosis choices. Stable skeletal reconstructions were achieved using traditional cement implant (13.6%, n = 3) or conformable titanium struts (86.4%, n = 19), with good fixation strength. Complication risk was low. An algorithmic approach to management is presented and recommended.

Conclusion

Various forms of bilateral ALT myocutaneous flap transfer with different skeletal reconstruction presents as a reliable treatment for patients with large full-thickness chest wall defects. Anatomical variations in the pedicle and pattern of venae comitantes of the ALT myocutaneous flap are reported. In some challenging cases, finding the vessels in the recipient area is difficult. The clinical significance of each vascular pattern is delineated, and surgical technical considerations are discussed on the basis of the recipient area requirements and types of a flap's vascular anatomy.
Patient reported outcomes 6 to 12 months after interpersonal violence: A multicenter cohort study
Authors: Castillo-Angeles Manuel , Herrera-Escobar Juan P. , Toppo Alexander , Sanchez Sabrina E. , Kaafarani Haytham M. , Salim Ali , Haider Adil H. , Nehra Deepika
Published: August 2021

PURPOSE

Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes.

METHODS

We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes.

RESULTS

A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59–4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes.

CONCLUSION

The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.