bluuebunny/crossref_metadata_2025 huggingface dataset:
Pull-out of Upper Thoracic Pedicle Screws Can Cause Spinal Canal Encroachment in Growing Rod Treatment
Authors: Bekmez Senol , Kocyigit Aykut , Olgun Zeynep Deniz , Ayvaz Mehmet , Demirkiran Halil Gokhan , Karaagaoglu Ergun , Yazici Muharrem
Published: May 2018

Background:

Proximal foundation failure is a common complication of growing rod (GR) treatment for early-onset scoliosis. Spinal canal encroachment due to pull-out of pedicle screw used as proximal foundation has been anecdotally reported in GR patients. The aim of this study is to report the prevalence of spinal canal encroachment of pedicle screws in GR treatment and determine risk factors using a single-center cohort.

Methods:

Inclusion criteria were: (1) GR for early-onset scoliosis and (2) pull-out of at least 1 proximal anchor pedicle screw. Patients were divided into 2 groups according to the presence of medial screw migration. Medial migration of the screw was confirmed by computed tomography. The extracted data included demographic, clinical, and radiographic information.

Results:

A total of 21 patients (of 96) met inclusion criteria (21.8%). None of the screws appeared malpositioned on early postoperative x-ray. Average follow-up until screw failure was 50.4 months (64 to 85 mo) and average number of lengthenings 8.1 (4 to 13). Computed tomography revealed canal encroachment in 11 patients (group 1), and no encroachment in 10 (group 2). There was no significant difference between groups for age, follow-up or number of lengthenings. At the time of screw pull-out, coronal plane deformity was increased compared with early postoperative x-ray in all; however, this increase was significantly higher in group 1 (45.7 vs. 35 degrees, P=0.002). Proximal junctional angle (PJA) was increased in both groups at the time of pull-out. While not statistically significant, PJA increased linearly in group 1 but spiked in group 2 at the time of pull-out. There was no neurological event preoperatively, intraoperatively or postoperatively. Failed screws were safely revised in either planned/unplanned surgeries.

Conclusions:

In patients with proximal anchor failure of GR, especially if there is increase of coronal deformity and/or PJA, possible spinal encroachment should be kept in mind.

Level of Evidence:

Level IV—retrospective case series.
Novel Placement of Cortical Bone Trajectory Screws in the Lumbar Spine
Authors: Gao Hai , Zhang Renjie , Jia Chongyu , Xing Tao , Zhang Jianxiang , Dong Fulong , Ge Peng , Song Peiwen , Xu Peng , Zhang Huaqing , Li Huimin , Shen Cailiang
Published: May 2018

Study Design:

This is a radiographic and cadaveric study.

Objective:

The aim of this study was to conduct a detailed comparison about the parameters between the ideal cortical bone trajectory (CBT) and practical CBT screw.

Summary of Background Data:

CBT screws have recently become popular in spinal surgery, mainly because of their improved fixation while minimizing soft tissue dissection. However, to our knowledge, no previous study has provided a detailed comparison on the parameters between the ideal CBT and practical CBT screws.

Materials and Methods:

The 3-dimensional computed tomography scans of 126 spinal vertebrae separated from 40 lumbar spines were studied. After determining the CBT, the maximal screw length, maximal screw diameter, lateral angle (LA), and cephalad angle (CA) were calculated. Thereafter, CBT screws were inserted into these cadaveric lumbar spines. Subsequently, the lateral angle of screw (LAs) and cephalad angle of screw (CAs) of the screws were measured using 3-dimensional computed tomography.

Results:

As for the ideal CBT, the maximal screw length gradually increased from L1 (32.0 mm) to L4 (35.3 mm) and then decreased at L5 (34.8 mm). Moreover, the maximal screw diameter increased from L1 (4.5 mm) to L5 (7.5 mm). The LA from L1 to L5 were 9.2, 9.4, 9.9, 11.2, and 12.0 degrees, respectively. The CA from L1 to L5 were 25.8, 25.8, 26.3, 26.8, and 26.0 degrees, respectively. As for the actual CBT screw, the LAs from L1 to L5 were 12.7, 14.1, 13.2, 12.4, and 13.0 degrees, respectively. The CAs from L1 to L5 were 25.4, 27.5, 29.2, 30.1, and 30.5 degrees, respectively. Significant differences were observed between the angles of the ideal trajectory and the actual screw.

Conclusions:

Parameters of the actual CBT screw are slightly larger than the optimal trajectory measurements. The CAs and LAs are ∼25–30 and 10–16 degrees, respectively. L1 and L2 should be given considerable attention when using the CBT technique. And the trajectory measurements can only be used as a guide in clinical practice.
Minimally Invasive Proximal Interphalangeal Joint Arthrodesis Using Headless Screw: Surgical Technique
Authors: Newman Elizabeth A. , Orbay Maria C. , Nunez Fiesky A. , Nunez Fiesky
Published: May 2018

Proximal interphalangeal (PIP) joint arthritis causes debilitating hand pain and instability leading to significant functional impairment. Arthrodesis remains the gold standard for treatment of PIP arthritis. We present a minimally invasive PIP arthrodesis that provides rigid fixation with a headless compression screw. Seven patients who presented to the senior author with PIP joint arthritis underwent PIP arthrodesis by minimally invasive technique. A 1 cm transverse incision is made over the PIP joint, incising skin, central band, and articular capsule. PIP joint is flexed to expose the articular surface. Articular surfaces are prepared with a fine tipped rongeur, exposing subchondral bone until flat surfaces are obtained. Under fluoroscopy a guide wire for cannulated headless screw (3.0, 2.4, or 2.0 mm) is inserted in an antegrade manner. It progresses from the center of the proximal phalangeal articular surface until it exits through the dorsal cortex and the distal end lies within the subchondral bone. This is the most critical step of the procedure because the guide wire angle determines the degree of flexion of the fusion. A 5 mmincision is made over the guide wire and the wire is advanced through the center of the medullary canal of the middle phalanx. The wire is then overdrilled, length is measured, and a headless compression screws is inserted. Reevaluate alignment after insertion of the screws because malrotation may be induced by torque during compression. Six consecutive patients underwent the procedure by the senior author. All patients healed the arthrodesis without complications and hardware removal was not needed. Minimally invasive PIP joint arthrodesis is a safe and viable procedure. Critical portions of the procedure include placing the wire at the angle of the desired angle of fusion and avoiding malrotation during screw insertion.
Inhibition of Vascular Endothelial Cell Leak Following Escherichia coli Attachment in an Experimental Model of Sepsis
Authors: McHale Tony M. , Garciarena Carolina D. , Fagan Robert P. , Smith Stephen G. J. , Martin-Loches Ignacio , Curley Gerard F. , Fitzpatrick Fidelma , Kerrigan Steve W.
Published: May 2018

Objectives:

The vascular endothelium is a major target of sepsis-induced events, and endothelial activation accounts for much of the pathology of sepsis. Urinary tract infections and pneumonia caused by Escherichia coli are among of the most common infections causing sepsis in both community and hospital settings. Currently, there are no approved drugs on the market to treat the underlying pathophysiology of sepsis. The aim of this study is to elucidate the molecular mechanism by which E. coli induces endothelial injury as a result of attachment.

Design:

Laboratory research using a hemodynamic perfusion ex vivo model.

Setting:

Research Laboratories of Royal College of Surgeons in Ireland and Beaumont Hospital.

Patients:

Ex vivo human vascular endothelial cells.

Interventions:

Addition of αVβ3 antagonist, cilengitide.

Measurements and Main Results:

Clinical strains of E. coli isolated from patients with sepsis bound to sheared human endothelial cells under static and hemodynamic shear conditions. Binding was dependent on E. coli cell membrane protein outer membrane protein A attaching directly to endothelial cell integrin αVβ3. Attachment resulted in disturbances in endothelial barrier integrity, as determined by loss of tight junction protein staining, permeability changes, and ultimately cell death by apoptosis. Using a low concentration of the αVβ3 antagonist cilengitide or using a strain deficient in outer membrane protein A resulted in a significant reduction in endothelial dysfunction following infection.

Conclusions:

Inhibition of E. coli binding to endothelial cell αVβ3 by cilengitide prevents endothelial dysfunction and may, therefore, present as a novel early therapeutic for the treatment of sepsis.
Acute Neurologic Complications During Extracorporeal Membrane Oxygenation: A Systematic Review
Authors: Sutter Raoul , Tisljar Kai , Marsch Stephan
Published: May 2018

Objectives:

We determine the frequency, risk factors, and mortality of neurologic complications in adults on extracorporeal membrane oxygenation and propose an algorithm for preventive strategies.

Data Sources:

PubMed, Embase, and Cochrane databases.

Study Selection:

Screening was performed using predefined search terms to identify cohort studies reporting neurologic complications in adults during extracorporeal membrane oxygenation from 1990 to 2017.

Data Extraction:

The final reference list was generated on the basis of relevance to the discussed topics. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation classification of evidence scheme.

Data Synthesis:

In 44 studies, the median frequency of acute neurologic complications is 13% (1–78%; 5% intracranial hemorrhages, 5% ischemic strokes, 2% seizures). Neurologic complications are reported more frequently with venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation (14 vs eight studies) with a median proportion of complications of 15% (6–33%; 95% CI, 8–19) for venoarterial extracorporeal membrane oxygenation. Median in-hospital mortality is higher with neurologic complications (83%; interquartile range, 54–100% vs 42%; interquartile range, 24–55% without neurologic complications; p < 0.001). Median mortality is 96% for hemorrhages, 84% for ischemic strokes 84%, and 40% for seizures. Risk factors are age, preextracorporeal membrane oxygenation cardiac arrest, hypoglycemia, and administration of inotropes. Hemorrhages are associated with female gender, duration of ventilation and extracorporeal membrane oxygenation, decreased serum fibrinogen, heparin, serum creatinine greater than 2.6 mg/dL, hemodialysis, and thrombocytopenia. Increased odds for ischemic stroke is seen with a preextracorporeal membrane oxygenation serum lactate greater than 10 mmol/L. No studies report daily coagulation monitoring and neurologic assessments, and quality of evidence was low to very low.

Conclusions:

Neurologic complications are reported frequently and with high occurrence rate, especially with venoarterial extracorporeal membrane oxygenation, and associated with high mortality calling for daily weaning from sedation and neuromuscular blockers for neurologic assessment and coagulation monitoring. The low quality of evidence indicates the need for higher quality studies in this context.
Reversible Microvascular Hyporeactivity to Acetylcholine During Diabetic Ketoacidosis
Authors: Joffre Jérémie , Bourcier Simon , Hariri Geoffroy , Miailhe Arnaud-Felix , Bigé Naike , Dumas Guillaume , Dubée Vincent , Boelle Pierre-Yves , Abdallah Idriss , Baudel Jean-Luc , Guidet Bertrand , Maury Eric , Ait-Oufella Hafid
Published: May 2018

Objectives:

Metabolic acidosis is commonly observed in critically ill patients. Experimental studies suggested that acidosis by itself could impair vascular function, but this has been poorly investigated in human.

Design:

Prospective observational study.

Setting:

Medical ICU in a tertiary teaching hospital.

Patients:

To assess the relationship between metabolic acidosis severity and microvascular reactivity, we included adult diabetic patients admitted in ICU for ketoacidosis. Microvascular response to acetylcholine iontophoresis was measured at admission (baseline) and after correction of metabolic acidosis (24 hr).

Interventions:

None.

Measurements and Main Results:

Thirty-nine patients with diabetic ketoacidosis were included (68% male), with a median age of 43 (31–57) years. At admission, microvascular reactivity negatively correlated with acidosis severity (R = –0.53; p < 0.001). Microvascular response was strongly depressed at pH less than 7.20 (area under the curve, 1,779 [740–3,079] vs 12,944 [4,874–21,596] at pH > 7.20; p < 0.0001). In addition, acidosis severity was significantly correlated with capillary refill time (R = 0.50; p = 0.02). At H24, after rehydration and insulin infusion, clinical and biological disorders were fully corrected. After acidosis correction, microvascular reactivity increased more in patients with severe baseline acidosis (pH < 7.20) than in those with mild baseline acidosis (area under the curve, +453% [213%–1,470%] vs +121% [79%–312%]; p < 0.01).

Conclusions:

We identified an alteration of microvascular reactivity during metabolic acidosis in critically ill patients with diabetic ketoacidosis. Microvascular hyporeactivity recovered after acidosis correction.
Current questions in bone sarcomas
Authors: Strauss Sandra J. , Whelan Jeremy S.
Published: May 2018

Purpose of review

Osteosarcoma and Ewing sarcoma, the most common primary bone tumours in young people, are curable in most patients. However, these tumours remain a significant challenge due to the complexity and intensity of treatment and its long-term morbidity and the significant proportion of patients in whom treatment is unsuccessful. This review addresses questions about current management and emerging therapeutic targets for patients with osteosarcoma, Ewing sarcoma and chondrosarcoma, the commonest bone sarcoma but more common in older patients.

Recent findings

The largest collaborative international study in osteosarcoma, EURAMOS-1 determined that treatment of patients with resectable disease should not be altered on basis of pathological response to neoadjuvant chemotherapy. In view of little improvement in outcome being evident in recent years, novel therapeutic approaches are required. Putative targets and clinical trials of novel agents are discussed, including emerging targets such as poly (ADP-ribose) polymerase inhibition and isocitrate dehydrogenase inhibition in Ewing sarcoma and chondrosarcoma, respectively. Newer radiotherapy techniques including proton beam and particle ion therapy may be important for local tumour control in selected patients.

Collaborative studies are essential to answer current questions and investigate novel therapies in these malignancies to improve outcome and quality of life for patients.
High baseline neutrophil-to-lymphocyte ratio predicts worse outcome in patients with metastatic BRAF-positive melanoma treated with BRAF and MEK inhibitors
Authors: Teterycz Paweł , Jagodzińska-Mucha Paulina , Cybulska-Stopa Bożena , Mariuk-Jarema Anna , Kozak Katarzyna , Koseła-Paterczyk Hanna , Czarnecka Anna M. , Rajczykowski Marcin , Dziura Robert , Galus Łukasz , Mackiewicz Jacek , Świtaj Tomasz , Klimczak Anna , Falkowski Slawomir , Suwiński Rafał , Ziobro Marek , Ługowska Iwona , Rutkowski Piotr
Published: May 2018

Neutrophil-to-lymphocyte ratio (NLR) has been shown to be prognostic in several solid malignancies. There are limited data regarding its value during novel therapies in patients with melanoma. The aim of the study was to assess the practical utility of this ratio in patients with BRAF-mutant melanoma treated with a combination of BRAF and MEK inhibitors (BRAFi/MEKi). We included 215 patients with inoperable or metastatic melanoma who underwent BRAFi/MEKi treatment between October 2015 and June 2017. Baseline NLR and other complete blood count-derived inflammatory markers were tested for association with overall survival and progression-free survival in univariate and multivariate models. On-treatment NLR was also assessed for relationship with these outcomes using the time-dependent Cox’s proportional hazard model. Prognostic model based on NLR and lactate dehydrogenase (LDH) levels was also developed. Patients with NLR values more than four had poorer progression-free survival (P<0.001, 1-year rates 51.6 vs. 26.7%) and overall survival (P<0.001, 1-year rates 77.3 vs. 53.1%). In a multivariate model adjusted for LDH levels, metastatic sites and age baseline NLR ratio and delay in starting MEKi were deemed statistically significant (hazard ratio: 1.81; 95% confidence interval: 1.16–2.85; P=0.009 and hazard ratio: 2.06; 95% confidence interval: 1.24–3.44, P=0.005 respectively). In a model based on NLR and LDH, 1-year survival rates were 57, 40 and 23%, respectively if zero, one or both factors were elevated. Our results demonstrate the usefulness of NLR and a predictive model based on combinations of NLR and LDH as a prognostic markers during BRAFi/MEKi treatment. Our real-world data confirm the efficacy of BRAFi/MEKi therapy showed in the clinical trials.
Breast-conservation Therapy After Neoadjuvant Chemotherapy Does Not Compromise 10-Year Breast Cancer–specific Mortality
Authors: Arlow Renee L. , Paddock Lisa E. , Niu Xiaoling , Kirstein Laurie , Haffty Bruce G. , Goyal Sharad , Kearney Thomas , Toppmeyer Deborah , Stroup Antoinette M. , Khan Atif J.
Published: May 2018

Objectives:

Neoadjuvant chemotherapy can increase the rate of breast-conserving surgery by downstaging disease in patients with breast cancer. The aim of this study was to determine whether patients who received neoadjuvant chemotherapy have equal survival after breast-conservation therapy compared with mastectomy.

Material and Methods:

Using the New Jersey State Cancer Registry (NJSCR) patients with a primary breast cancer diagnosed between 1998 and 2003 who underwent neoadjuvant chemotherapy were selected (n=1,468). Of those, only patients who received lumpectomy plus radiation (n=276) or mastectomy without radiation (n=442) were included in the analysis. The main outcome measured included 10-year breast cancer–specific mortality, with 90% of patients with known vital status through the end of 2011.

Results:

Baseline characteristics did not differ significantly between the breast-conservation and mastectomy without radiation groups except with respect to summary stage and lymph node involvement. After propensity score matching these differences were no longer statistically significant; however, both estrogen and progesterone status achieved statistical significance. The Kaplan-Meier survival curve showed that the breast-conservation group had significantly higher breast cancer–specific survival than the mastectomy group (P=0.0046). After adjusting for the propensity score in the regression model, the breast-conservation group continued to show significantly better survival than the mastectomy group (hazard ratios, 0.46; 95% confidence interval, 0.27-0.78).

Conclusions:

This study is consistent with previous research showing that breast-conserving surgery after neoadjuvant chemotherapy does not reduce breast cancer–specific survival. In fact, patients undergoing breast-conservation after neoadjuvant therapy appeared to have better survival than patients undergoing mastectomy without radiation.
The Significance of Para-Aortic Nodal Size and the Role of Adjuvant Systemic Chemotherapy in Cervical Cancer
Authors: Manders Dustin B. , Sims Travis T. , Bailey April , Hwang Lindsay , Richardson Debra L. , Miller David S. , Kehoe Siobhan M. , Albuquerque Kevin V. , Lea Jayanthi S.
Published: May 2018

Objective:

Cervical cancer metastatic to the para-aortic lymph nodes (PALNs) carries a poor prognosis. Despite extended-field radiation therapy (EFRT), only 30% to 50% of patients will survive 3 years. We sought to examine the treatment regimens used, associated toxicities, and treatment outcomes in patients with cervical cancer metastatic to PALN.

Methods:

A retrospective review was performed of all patients with cervical cancer treated at a single institution between January 1, 2007 and November 1, 2014. Included patients had PALN metastases as the most distant site of disease, and all treatment plans were designated as curative. Excluded patients had other distant disease or treatment plans considered palliative. Standard treatment consisted of EFRT with concurrent platinum-based chemotherapy.

Results:

Fifty-one of 344 patients (14.8%) fulfilled the inclusion criteria. The median age was 48.4 years. Forty-four patients received standard EFRT; 7 also received adjuvant platinum/taxane chemotherapy. Thirty-nine of 51 (76%) of patients achieved a complete response to primary treatment. Twelve of 51 (24%) had persistent disease or progression at the completion of treatment. Of responders, 15 of 39 (38%) recurred for an overall treatment failure rate of 27 of 51 (53%). Nineteen of 27 (70%) of treatment failures occurred outside the radiated field. Adjuvant chemotherapy following EFRT was not predictive of progression-free survival or overall survival. PALN diameter ≥1 cm was a significant negative prognostic indicator for overall survival.

Conclusions:

Over half of patients with cervical cancer metastatic to the PALN failed extended-field chemoradiation. Most failures occurred outside the radiated field suggesting PALN involvement is a surrogate marker of systemic disease. These findings underscore the need for effective systemic therapy, especially in patients with PALN ≥1 cm in size.
Regional Lymph Node Metastases in Groin Sarcomas
Authors: Ng Deanna Wan Jie , Koh Ye Xin , Tan Grace Hwei Ching , Soo Khee Chee , Teo Melissa Ching Ching
Published: May 2018

Introduction:

The evaluation of lymph nodes and the role of groin dissection for groin sarcomas has been controversial where there have not been previous studies or guidelines published. In this study, we aim to first formulate a clinical approach in the evaluation of regional lymph nodal metastases. Second, we aim to also evaluate the role of regional lymphadenectomy in the setting of pathologically involved regional lymph nodes for groin sarcomas.

Materials and Methods:

In total, 43 consecutive patients with groin sarcomas underwent treatment at the National Cancer Centre Singapore between 2002 and 2015. Univariate comparisons were performed using the log-rank test. A Cox multivariate analysis was performed for disease-specific survival to identify independent prognostic factors.

Results:

The median disease-free survival was 18 months (range, 1 to 180 mo). The median overall survival (OS) was 28 months (range, 3 to 180 mo). In total, 28 patients underwent a groin dissection. Of the 28 patients who underwent groin dissections, 15 had negative lymph node involvement, 7 had positive lymph node involvement and 6 had lymphovascular invasion.

On univariate analysis, grade (P=0.047) and clinical and/or radiological involvement (P=0.039) were significant for regional lymph nodal metastases.

The 5-year OS for patients with positive lymph nodes was 31%.

Conclusions:

Our study suggests that the evaluation of lymph nodes via groin dissections in groin sarcomas in the Asian population should be based primarily on clinical and radiologic evidence. Regional lymph node dissection seems to confer OS benefit in patients with these high-risk tumors and can improve local control of disease.
Single-agent Bevacizumab in Recurrent Glioblastoma After Second-line Chemotherapy With Fotemustine
Authors: Pasqualetti Francesco , Pace Andrea , Gonnelli Alessandra , Villani Veronica , Cantarella Martina , Delishaj Durim , Vivaldi Caterina , Molinari Alessandro , Montrone Sabrina , Pellerino Alessia , Franchino Federica , Baldaccini Davide , Lombardi Giuseppe , Lolli Ivan , Catania Francesca , Bazzoli Elena , Morganti Riccardo , Fabi Alessandra , Zagonel Vittorina , Bocci Guido , Fabrini Maria Grazia , Rudà Roberta , Soffietti Riccardo , Paiar Fabiola
Published: May 2018

Objectives:

Bevacizumab is an anti-vascular endothelial growth factor antibody used in the treatment of recurrent glioblastoma (GBM). Despite the large number of studies carried out in patients with recurrent GBM, little is known about the administration of this angiogenesis inhibitor after the failure of the second-line chemotherapy.

Materials and Methods:

In this retrospective multicenter study, on behalf of the Italian Association of Neuro-Oncology, we reported the results obtained in 51 patients with recurrent GBM treated with single-agent bevacizumab after the failure of second-line chemotherapy with fotemustine.

Results:

In March 2016, at the time of data analysis, 3 patients (14.4%) were still alive with stable disease, whereas 48 died due to disease progression. Kaplan-Meier estimated median survival from the diagnosis of GBM was 28 months (95% confidence interval [CI], 22.1-33.9 mo). Median survival measured from the beginning of fotemustine and bevacizumab therapy were 11.3 (95% CI, 8.4-13.6 mo) and 6 months (95% CI, 3.8-8.1 mo), respectively. The 6- and 12-month progression free survival rates from the beginning of bevacizumab treatment were 18% and 13%, respectively.

Conclusions:

On the basis of our data, in patients with recurrent GBM, the failure of a second-line chemotherapy with cytotoxic agents might not exclude the administration of bevacizumab as third-line chemotherapy.
BRCA1 Mutations Associated With Increased Risk of Brain Metastases in Breast Cancer
Authors: Zavitsanos Peter J. , Wazer David E. , Hepel Jaroslaw T. , Wang Yihong , Singh Kamaljeet , Leonard Kara L.
Published: May 2018

Background:

Brain metastases (BM) occur in ∼5% of breast cancer patients. BRCA1-associated cancers are often basal-like and basal-like cancers are known to have a predilection for central nervous system metastases. We performed a matched-pair analysis of breast cancer patients with and without BRCA mutations and compared the frequency of BM in both groups.

Materials and Methods:

From a database of 1935 patients treated for localized breast cancer at our institution from 2009 to 2014 we identified 20 patients with BRCA1 or BRCA2 mutations and manually matched 40 patients without BRCA mutations accounting for age, stage, estrogen receptor expression, and human epidermal growth factor receptor 2 (HER2) expression. Comparisons of freedom from brain metastasis, brain metastasis-free survival, and overall survival were made using the log rank test. Testing for a basal-type phenotype using the immunohistochemistry definition (ER−/PR−/HER2− and either CK 5/6+ or EGFR+) was performed for BRCA+ patients who developed BM and their matched controls.

Results:

We analyzed 60 patients: 20 BRCA+ and 40 were matched controls. Median follow-up was 37 and 49 months, respectively. Three years freedom from brain metastasis was 84% for BRCA+ patients and 97% for BRCA− controls (P=0.049). Three years brain metastasis-free survival was 84% and 97% for the BRCA+ and controls, respectively (P=0.176). Mean time to brain failure was 11 months from diagnosis for the BRCA+ patients. All 3 BRCA1+ patients who developed BM were of a basal-type triple negative phenotype.

Conclusions:

Breast cancer patients with germline BRCA1 mutations appear to have a shorter interval to brain progression while accounting for confounding factors.
Neoadjuvant Interdigitated Chemoradiotherapy Using Mesna, Doxorubicin, and Ifosfamide for Large, High-grade, Soft Tissue Sarcomas of the Extremity
Authors: Chowdhary Mudit , Sen Neilayan , Jeans Elizabeth B. , Miller Luke , Batus Marta , Gitelis Steven , Wang Dian , Abrams Ross A.
Published: May 2018

Objectives:

Patients with large, high-grade extremity soft tissue sarcoma (STS) are at high risk for both local and distant recurrence. RTOG 95-14, using a regimen of neoadjuvant interdigitated chemoradiotherapy with mesna, doxorubicin, ifosfamide, and dacarbazine followed by surgery and 3 cycles of adjuvant mesna, doxorubicin, ifosfamide, and dacarbazine, demonstrated high rates of disease control at the cost of significant toxicity (83% grade 4, 5% grade 5). As such, this regimen has not been widely adopted. Herein, we report our institutional outcomes utilizing a modified interdigitated chemoradiotherapy regimen, without dacarbazine, and current radiotherapy planning and delivery techniques for high-risk STS.

Materials and Methods:

Adults with large (≥5 cm; median, 12.9 cm), grade 3 extremity STS who were prospectively treated as part of our institutional standard of care from 2008 to 2016 are included. Neoadjuvant chemoradiotherapy consisted of 3 cycles of mesna, doxorubicin, and ifosfamide (MAI) and 44 Gy (22 Gy in 11 fractions between cycles of MAI) after which patients underwent surgical resection and received 3 additional cycles of MAI.

Results:

Twenty-six patients received the MAI treatment protocol. At a median follow-up of 47.3 months, 23 (88.5%) patients are still alive. Three year locoregional recurrence-free survival, disease-free survival, and overall survival are 95.0%, 64.0%, and 95.0%, respectively. There have been no therapy-related deaths or secondary malignancies. The nonhematologic grade 4 toxicity rate was 7.7%.

Conclusions:

Neoadjuvant interdigitated MAI radiotherapy followed by resection and 3 cycles of adjuvant MAI has resulted in acceptable and manageable toxicity and highly favorable survival in patients at greatest risk for treatment failure.
Utilization of an Alternative Docetaxel-based Intraperitoneal Chemotherapy Regimen in Patients With Ovarian, Fallopian Tube or Primary Peritoneal Carcinoma
Authors: Becker David A. , Leath Charles A. , Walters-Haygood Christen L. , Smith Brentley Q. , Bevis Kerri S.
Published: May 2018

Objective:

The objective of this study was to report the tolerability and toxicity of a regimen consisting of intravenous (IV) docetaxel and intraperitoneal (IP) cisplatin and paclitaxel with granulocyte colony-stimulating factor support.

Materials and Methods:

We conducted a retrospective cohort study of patients with surgical stage II-IV epithelial ovarian, fallopian tube or primary peritoneal carcinoma treated with an outpatient IP chemotherapy regimen consisting of docetaxel 75 mg/m2 IV and cisplatin 75 mg/m2 IP day 1 followed by paclitaxel 60 mg/m2 IP day 8 every 21 days. Grade 3 and 4 toxicity, dose delays and reductions, port complications, and tolerability are reported. Outcomes, including response rate, progression-free survival (PFS), overall survival (OS) are also reported.

Results:

A total of 60 patients received this IP regimen. Most common toxicities included neutropenia (47%), gastrointestinal (28%), and anemia (25%). Most patients (85%) experienced no IP port complications. Dose delay or reduction was required in 30% of patients. Two-thirds completed all prescribed cycles, with 80% of total planned cycles completed. Complete response was achieved for 88%, and 43% are currently without evidence of disease. Median PFS for all patients was 25.5 months (95% confidence interval [CI], 20.4-30.5 mo) while OS for all patients was 56.8 months (95% CI, 47.7-65.9 mo). For the 44 patients with stage III disease, median PFS was 22.1 months (95% CI, 16.3-28.0 mo), while median OS was 56.8 months (95% CI, 47.3-66.3 mo).

Conclusions:

This docetaxel-based IP chemotherapy regimen demonstrates an improved tolerability profile compared with GOG172. Additional evaluations on alternative IP regimens remain warranted. Short follow-up time limits survival assessment, but results are encouraging.
Income Relates to Adherence in Youth with Type 1 Diabetes Through Parenting Constructs
Authors: Thomas Dexter M. , Lipsky Leah M. , Liu Aiyi , Nansel Tonja R.
Published: May 2018

Objective:

Informed by the family stress and family investment models, this study investigated whether income is indirectly related to adherence and glycemic control through parenting constructs among youth with type 1 diabetes (TID).

Methods:

Youth and their families (n = 390) from 4 geographically dispersed pediatric endocrinology clinics in the United States were participants in a multisite clinical trial from 2006 to 2009 examining the efficacy of a clinic-integrated behavioral intervention targeting family disease management for youth with TID. Baseline data were collected from youth aged 9 to 14 years and their parents. Parents reported family income and completed a semistructured interview assessing diabetes management adherence. Parents and children reported diabetes-specific parent-child conflict. Children completed measures of collaborative parent involvement and authoritative parenting. Hemoglobin A1c (HbA1c), a biomarker of glycemic control, was analyzed centrally at a reference laboratory. The relations of income, parenting variables, regimen, adherence, and HbA1c were examined using structural equation modeling.

Results:

Lower family income was associated with greater parent-child conflict and a less authoritative parenting style. Authoritative parenting was associated with more collaborative parent involvement and less parent-child conflict, both of which were associated with greater adherence, which was associated with more optimal glycemic control (p < 0.05 all associations). Indirect effects of family income on adherence and glycemic control through parenting constructs were significant (p < 0.001).

Conclusion:

Findings lend support for the family stress and family investment models, suggesting that lower family income may negatively impact parent-child constructs, with adverse effects on diabetes management.
Bilateral Anatomic Variation of Anterolateral Thigh Flap in the Same Individual
Authors: Artero Guillermo E. , Ulla Marina , Neligan Peter C. , Angrigiani Claudio H.
Published: May 2018

Background:

Anterolateral thigh flap has gained popularity for its use as a soft-tissue flap for reconstruction of regional and distal defects. There is discrepancy between the predominant skin vessels-musculocutaneous or septocutaneous. The purpose of this study was to demonstrate anatomic variation of bilateral anterolateral thigh flap vasculature in the same individual.

Methods:

We performed an observational retrospective case series study in 11 patients and an observational prospective study in 7 cadavers to confirm our findings.

Results:

We found bilateral anatomic variation in the main cutaneous branch of the descendent branch of the lateral circumflex femoral artery between both thighs in the same individual. In 72.2% of cases, we observed that the main cutaneous branch was septocutaneous in 1 thigh and musculocutaneous in the contralateral thigh; in 16.7%, the main cutaneous branches were musculocutaneous in both thighs, and in 11.1%, the main cutaneous branches were septocutaneous in both thighs.

Conclusions:

Significant anatomic variation exists between the right and the left cutaneous branches of deep circumflex femoral arteries. Hence, preoperative imaging by computed tomography angiography (CTA) aids in determination of the vascular anatomy of the descending branch of the lateral circumflex femoral artery and in selection of septocutaneous branches, thereby reducing operative time.
AlloDerm RTU Integration and Clinical Outcomes When Used for Reconstructive Breast Surgery
Authors: Gabriel Allen , Maxwell G. Patrick
Published: May 2018

Background:

AlloDerm Ready To Use (RTU) is a sterile version of AlloDerm regenerative tissue matrix, developed in response to concerns regarding the potential risk of infectious complications with the latter aseptic matrix. Clinical data on AlloDerm RTU use is, however, limited, particularly with respect to histologic evidence of graft integration and clinical outcomes.

Methods:

Consecutive patients who underwent tissue-expander/implant reconstruction with the use of AlloDerm RTU from March 2011 to September 2012 were included in this analysis. Biopsies of AlloDerm RTU/capsule interface were obtained at the time of expander/implant exchange and evaluated for evidence of cellularization, vascularization, and inflammatory reaction. Data on postoperative complications were retrieved from patient records.

Results:

A total of 116 biopsy specimens from 68 patients were obtained. At biopsy, on visual inspection, nearly all grafts were fully integrated within the host tissue. Histologically, graft specimens demonstrated mild-to-moderate neovascularization and cellular repopulation with no inflammatory cells. All patients were followed for 5 years postoperatively. Short-term postoperative complications of skin necrosis, seroma, and infection occurred in 10.3%, 4.3%, and 2.6% of reconstructions, respectively. Capsular contracture (grade 3) was the only long-term complication (5.2%). Rates of short- and long-term complications are similar to those observed in our previous experience with AlloDerm reconstructive tissue matrix.

Conclusions:

AlloDerm RTU used in breast reconstructive surgery fully integrates and incorporates into host tissue. There were no unexpected safety concerns with its use at short-term or at long-term, at least up to 5 years of follow-up.
Treatment of Dimpling from Cellulite
Authors: Amore Roberto , Amuso Domenico , Leonardi Vincenza , Sbarbati Andrea , Conti Giamaica , Albini Maria , Leva Francesco , Terranova Ferdinando , Guida Antonio , Gkritzalas Konstantinos , Gavashely Liya , Velichenko Roman
Published: May 2018

Background:

Cellulite can be seen on the skin in widespread alterations of the skin surface and dimpling. The purpose of this study was to assess the effectiveness and safety of the manual subcision technique to treat dimpling from cellulite, using a specific class IIA medical device (Celluerase).

Methods:

The multi-center observational study assessed 200 women treated in a single session for different dimpling, using manual subcision administered by Celluerase. Aesthetic outcomes were evaluated by the authors, and the patients assessed satisfaction levels.

Results:

Two hundred women between 20 and 55 years were treated. The medical evaluation of patients saw improvements with an average score of 8.1, whereas the subjective evaluation by patients gave an average improvement score of 7.8. Adverse events were reported.

Discussion:

Women have septa orientation at right angels to the skin surface, and those with cellulite have an irregular septa conformation, with some septa being hypertrophic-thickened, and others being narrowed-lysed. Magnetic resonance imaging has confirmed that cellulite depressions are associated with a significant increase of thickness of underlying subcutaneous fibrous septa. Subcision has immediate results because it eliminates traction on the skin.

Conclusion:

The study has shown the effectiveness and safety of the manual subcision in the treatment of dimpling. The device used, designed specifically for this technique, has shown itself to be very helpful and effective in terms of practical use, aesthetic outcome and safety, with various advantages compared with other commonly used devices.
Compliance and High Reliability in a Complex Healthcare Organization
Authors: Simon Maxine dellaBadia
Published: May 2018

When considering the impact of regulation on healthcare, visualize a spider's web. The spider weaves sections together to create the whole, with each fiber adding to the structure to support its success or lead to its failure. Each section is dependent on the others, and all must be aligned to maintain the structure. Outside forces can cause a shift in the web's fragile equilibrium.

The interdependence of the sections of the spider's web is similar to the way hospital departments and services work together. An organization's structure must be shaped to support its mission and vision. At the same time, the business of healthcare requires the development and achievement of operational objectives and financial performance goals. Establishing a culture that is flexible enough to permit creativity, provide resiliency, and manage complexity as the organization grows is fundamental to success. An organization must address each of these factors while maintaining stability, carrying out its mission, and fostering improvement.

Nature's order maintains the spider's web. Likewise, regulation can strengthen healthcare organizations by initiating disruptive changes that can support efforts to achieve and sustain high reliability in the delivery of care. To that end, leadership must be willing to provide the necessary vision and resources.
Keeping Up with Today's Top Health Law Issues to Avoid a ‘Nasty Surprise’
Authors: Topinka Joseph Baar
Published: May 2018

Just as in fictional television shows and movies, reality in the healthcare industry sometimes includes complications, disruptions, glitches, and nasty surprises. This article reviews several important legal topics, including emergency planning, privacy, fraud, public health, and ethics, to name only a few. Healthcare administrators are not expected to be attorneys or compliance officers, but they must appreciate (or at least be sensitive to) the legal and regulatory issues facing their organizations.
A Qualitative Study on Midwives' Perceptions of Physiologic Birth in Singapore
Authors: Wong Cassandra Yuit Wah , Shorey Shefaly , Liew Kelly , He Hong-Gu , Koh Serena S. L.
Published: May 2018

Midwives are advocates for parturients, and their actions and attitudes can influence a woman's experience during childbirth. Hence, it is valuable to examine midwives' perceptions of physiologic birth in an obstetric-led environment. A descriptive, qualitative study design was utilized. Semistructured face-to-face interviews were conducted with 10 registered midwives from the birthing suite of a public hospital in Singapore. Data were analyzed using thematic analysis. Three major themes were (1) perceptions of physiologic birth, (2) perceived facilitators of physiologic birth, and (3) perceived barriers to physiologic birth. Interestingly, senior midwives in this study experienced more negative outcomes with physiologic birth, resulting in apprehension and reduced confidence levels. This study contributed to the understanding of midwives' perceptions regarding facilitators and barriers to physiologic birth. Factors such as supporting birthing team and antepartum education could be useful in supporting physiologic birth. However, advanced age of some of the midwives was found in this study to be a barrier to physiologic birth.
Skin Injuries and Chlorhexidine Gluconate-Based Antisepsis in Early Premature Infants
Authors: Vanzi Valentina , Pitaro Rosanna
Published: May 2018

Early premature infants are subjected to many invasive procedures in neonatal intensive care units, and effective skin antisepsis is an essential step in caring for these vulnerable patients. Nevertheless, preterm infants have an anatomically and physiologically immature skin and preserving their skin integrity is essential to avoid the risk of local and systemic complications. Skin particularities of newborns reduce the list of available antiseptics in neonatology. Chlorhexidine gluconate (CHG) has excellent antiseptic properties and its antimicrobial efficacy cannot be understated, but there is great concern about its use for premature infants, referring to the risk of development skin injuries, such as skin erythema, burns, and blisters. Current guidelines do not recommend the use of CHG as antiseptic in the neonatal population, but despite the lack of safety data in premature infants, CHG is commonly used worldwide for off-label indications in neonatal intensive care units. A clinical case of an infant born at 26 weeks of gestation who sustained a CHG-related chemical burn after skin antisepsis was reported. A review of the literature was undertaken to evaluate the skin safety of CHG in infants born less than 32 weeks of gestation, to summarize clinical practice' recommendations, and to discuss the wound treatment options available.
The Positive Association Between Duration of Skin-to-Skin Contact and Blood Glucose Level in Full-Term Infants
Authors: Takahashi Yuki , Tamakoshi Koji
Published: May 2018

The aim of this study was to evaluate the contribution of the duration of skin-to-skin contact (SSC) on blood glucose levels at 2 hours after birth in healthy full-term infants. This observational study was done at one of the baby-friendly hospitals located in Aichi, Japan in 2009. Sixty newborn infants who were born vaginally from uncomplicated pregnancies were participated. All infants were held SSC within 5 minutes. All data regarding neonatal information, blood glucose levels at 2 hours of age, and maternal information were obtained from their medical history. Multiple linear regression analysis was performed to identify the independent contribution of the duration of SSC. The mean duration of SSC was 59.6 ± 13.6 minutes (range: 11.0-97.0 minutes) and the infant blood glucose level was 53.1 ± 9.5 (range: 30.0-80.0 mg/dL) mg/dL. The duration of SSC (β [95% confidence interval] = .282 [range: 0.037-0.357], standardized β = .282, P < .017) was significantly and positively associated with infant blood glucose levels independent of gestational age, birth weight, sex, length of second-stage labor, and mode of delivery. Thus, the longer early SSC was associated with higher blood glucose level at 2 hours of age in healthy full-term infants.
Biobehavioral Responses of Preterm Infants to Conventional and Swaddled Tub Baths
Authors: de Freitas Patrícia , Bueno Mariana , Holditch-Davis Diane , Santos Hudson Pires , Kimura Amélia Fumiko
Published: May 2018

Bathing is a routine care procedure that exposes preterm infants to prolonged handling, which could cause stress and potentially disrupt infants' biobehavioral responses. The aim of this double-blind randomized crossover trial was to compare the preterm infant's body temperature, heart rate (HR), peripheral capillary oxygen saturation (Spo2), salivary cortisol levels, and sleep-wake states during and after swaddled and conventional tub baths. Forty-three infants born at 32 to 36 weeks postmenstrual age, weighing 2225 g or less, were enrolled in the study. Infants were videotaped before and after each type of baths. The time interval between baths ranged from 24 to 72 hours to allow a washout period. Physiological, hormonal, and behavioral responses were collected at baseline and during recovery from baths. No significant differences in the mean body temperature, HR, Spo2, salivary cortisol levels, and sleep-wake states between the bath types were observed in the baseline or recovery responses during the first 20 minutes after bath. Regardless of bath type, salivary cortisol levels showed a nonstatistical significant increase.
Effectiveness of the Neonatal Discharge Program for Very Low-Birth-Weight Infants on Parental Efficacy and Psychological Distress
Authors: Shandra Bos Lakshmi , Shorey Shefaly , Kulantaipian Tamill Salvee , Sng Jane S. P. , Tam Wilson W. S. , Koh Serena S. L.
Published: May 2018

This pilot study aimed to (i) evaluate the effectiveness of a neonatal discharge program, (ii) identify relationships between parent and infant factors and parental efficacy and psychological distress, and (iii) identify ways to improve the neonatal discharge program. A quasiexperimental 1-group pretest/posttest design was used. Through consecutive sampling, 42 participants were recruited. Data were collected using self-report questionnaires. Self-administering instruments gathered data on parental efficacy and psychological distress as well as feedback and recommendations on the intervention. A significant increase in parental efficacy and a reduction in psychological distress were observed from pre- to postdischarge intervention. Significant relationships were found between parental efficacy and infants' gestational age, birth weight, gender, and participants' level of education, and a significant relationship was found between psychological distress and number of children from previous pregnancies. Moreover, an Internet-based program, in addition to the face-to-face teaching, was identified as a preferred option to aid in information retention. It is important to evaluate and enhance the neonatal discharge program to suit the parents of today while providing them with informational and emotional support. Future studies should explore parental coping and the long-term effects of their infant's birth and the intervention.