bluuebunny/crossref_metadata_2025 huggingface dataset:
The Psychobiological Etiology of Gastrointestinal Distress in Sport
Authors: Wilson Patrick B.
Published: December 2019

Gastrointestinal (GI) disturbances are common during training and competition, especially among endurance athletes. Historically, little attention has been paid to the psychobiological etiology of GI problems in sport. The aim of this review is to: (1) provide a physiological overview of how psychological stress and anxiety impact GI system function; (2) review the literature that has examined the role of stress and anxiety in GI distress in athletes; and (3) provide suggestions for future research. Animal and human studies have documented that psychological stressors reduce gastric motility and delay stomach emptying while simultaneously increasing large intestine motility. These functional changes are likely mediated through the secretion of corticotropin-releasing factor and subsequent alterations in autonomic nervous system activity, which act to reduce splanchnic blood flow and increase GI permeability. In addition, chronic stress and anxiety may worsen GI discomfort by increasing visceral hypersensitization. Still, only a couple of studies have found modest associations between stress, anxiety, and the occurrence/severity of GI distress in active populations. As such, future work should attempt to confirm that experimentally inducing psychological stress results in the aforementioned GI problems during exercise. Furthermore, studies are needed to determine how psychological stress impacts the tolerance to nutritional fueling and whether it worsens the GI permeability that normally occurs with exercise.
Diagnostic role of ultrasound elastography for nail bed involvement in psoriasis
Authors: Asil Kiyasettin , Yaldiz Mahizer
Published: December 2019

Objective:

Psoriasis is a chronic inflammatory disease that affects the skin, joints, and nails. To investigate the efficacy of sonoelastographic evaluation for assessing nail involvement and severity in psoriasis.

Materials and methods:

Thirty-one psoriasis patients and 31 healthy control subjects were included in the study. The nail thickness and nail bed thickness of the thumbs of all cases were measured by gray scale ultrasonography. In addition, the values of strain elastography were measured by sonoelastography.

Results:

Of the participants, 38 were male and 24 were female; the ratio of males and females was equal in both groups. There was no significant difference between the patient and control group in terms of gender and age. In the patient group, the mean duration of illness was 13.87 ± 9.8 years, mean PASI score was 5.53 ± 2.38, and mean NAPSI score was 33.97 ± 37.99. The nail plate thickness and elastography strain ratios were found to be statistically higher in the psoriasis group compared to the control group. There was also significant correlation between elastography strain ratios and nail thickness (P = .014), nail bed thickness (P < .001) and NAPSI scores (P = .01).

Conclusion:

Due to the superiority of ultrasound in real-time imaging of the nail structure and the compatibility of sonographic elastography with clinical scores in the assessment of the nail bed, we believe that it can be used as a complementary method.
The prevalence, risk factors, and prognostic value of anxiety and depression in refractory or relapsed acute myeloid leukemia patients of North China
Authors: Gu Mianmian , Hao Xiaohong , Cong Lin , Sun Jie
Published: December 2019

This study aimed at investigating the prevalence of anxiety and depression, and their risk factors as well as their correlation with prognosis in refractory or relapsed (R/R) acute myeloid leukemia (AML) patients.

A total of 180 R/R AML patients were enrolled and their anxiety and depression were assessed by Hospital Anxiety and Depression Scale (HADS) before treatment. Besides, HADS was also evaluated in 180 de novo AML patients prior treatment and 180 healthy controls (HCs), respectively.

Both the HADS-Anxiety and HADS-Depression scores were increased in R/R AML patients compared with de novo AML patients and HCs (all P < .001). Meanwhile, the prevalence of anxiety and depression was 53.9% and 45.6% in R/R AML patients, which were also greatly higher compared with de novo AML patients and HCs (all P < .01). Regarding risk factors, higher Eastern Cooperative Oncology Group score and lines of salvage therapy were correlated with anxiety and depression in R/R AML patients (all P < .05). Furthermore, anxiety and depression were associated with shorter overall survival (OS) in R/R AML patients (all P < .05), while no association of different degrees of anxiety and depression with OS was observed (all P > .05).

Anxiety and depression are highly prevalent and implicated in the management and prognosis of R/R AML.
Nodal size ranking as a predictor of mediastinal involvement in clinical early-stage non-small cell lung cancer
Authors: Caupena Cristina , Costa Roser , Pérez-Ochoa Francisco , Call Sergi , Jaen Àngels , Rami-Porta Ramón , Obiols Carme , Esteban Lluis , Albero-González Raquel , Luizaga Luis Antonio , Serra Mireia , Belda Josep , Tarroch Xavier , Sanz-Santos José
Published: December 2019

In non-small cell lung cancer (NSCLC) patients, the recommended minimum requirement for an endoscopy-based mediastinal staging procedure is sampling the largest lymph node (LN) in right and left inferior paratracheal, and subcarinal stations. We aimed to analyze the percentage of cases where the largest LN in each mediastinal station was malignant in a cohort of NSCLC patients with mediastinal metastases diagnosed in the lymphadenectomy specimen. Furthermore, we investigated the sensitivity of a preoperative staging procedure in a hypothetical scenario where only the largest LN of each station would have been sampled.

Prospective data of patients with mediastinal nodal metastases diagnosed in the lymphadenectomy specimens were retrospectively analyzed. The long-axis diameter of the maximal cut surface of all LNs was measured on hematoxylin and eosin-stained sections.

Seven hundred seventy five patients underwent operation and 49 (6%) with mediastinal nodal disease were included. A total of 713 LNs were resected and 119 were involved. Sixty seven nodal stations revealed malignant LNs: in these, the largest LN was malignant in 39 (58%). In a “per patient” analysis, a preoperative staging procedure that sampled only the largest LN would have attained a sensitivity of 0.67; and if the largest and the second largest were sampled, sensitivity would be 0.87.

In patients with NSCLC, nodal size ranking is not reliable enough to predict malignancy. In clinical practice, regardless of the preoperative staging method, systematic thorough sampling of all visible LNs is to be recommended over selective random samplings.
NR3C2 gene polymorphism is associated with risk of gestational hypertension in Han Chinese women
Authors: Cui Zhenghui , Xu Jianyun , Jiang Wenying
Published: December 2019

Background:

The influence of genetic polymorphisms on the development of gestational hypertension (GH) is unclear. The aim of this study was to examine whether single-nucleotide polymorphisms (SNPs) of the nuclear receptor subfamily 3, group C, member 2 (NR3C2) genes, rs5522, rs2070951, rs5534, s2248038, and s9992256 are associated with GH in Han Chinese women.

Method:

Sanger sequencing was used to analyze the genotypes of rs5522, rs2070951, rs5534, rs2248038, and rs9992256 loci of theNR3C2gene in 450 patients with GH and 450 healthy controls.

Results:

The rs5522 dominant model (odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.13–1.47,P < .001) and the recessive model (OR = 1.64, 95% CI: 1.33–1.86,P < .001) had higher GH risk. The rs2070951 dominant model (OR = 1.18, 95% CI: 1.03–1.35,P = .02) had higher risk of GH, and the recessive model (OR = 1.09, 95% CI: 0.84–1.34,P = .55) was not significant for GH risk. The rs5534 dominant model (OR = 1.25, 95% CI: 1.09–1.43,P = .001) had a higher GH risk. The rs2248038 and rs9992256 sites were not significantly related to GH risk. Gene–gene interactions at the rs5522, rs2070951, and rs5534 loci affected GH risk (OR = 1.34, 95% CI: 1.12–1.64,P < .001).

Conclusion:

The SNPs of theNR3C2gene rs5522, rs2070951, and rs5534 are associated with GH in Han Chinese women.
Carotid artery blood flow velocities during open-heart surgery and its association with delirium
Authors: Bernardi Martin H. , Wahrmann Martin , Dworschak Martin , Kietaibl Clemens , Ristl Robin , Edlinger-Stanger Maximilian , Lassnigg Andrea , Hiesmayr Michael J. , Weber Ulrike
Published: December 2019

The aim of this prospective observational single-centre pilot study was to evaluate the association between alterations in carotid artery blood flow velocities during cardiac surgery and postoperative delirium.

Carotid artery blood flow velocity was determined perioperatively at 5 different timepoints by duplex sonography in 36 adult cardiac surgical patients. Delirium was assessed using the Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist. Additionally, blood flow velocities in the middle cerebral arteries, differences in regional cerebral tissue oxygenation and quantity and quality of microemboli were measured.

Delirium was detected in 7 of 36 patients. After cardiopulmonary bypass carotid artery blood flow velocities increased by +23 cm/second (95% confidence interval (CI) 9–36 cm/second) in non-delirious patients compared to preoperative values (P = .002), but not in delirious patients (+3 cm/second [95% CI −25 to 32 cm/second], P = .5781). Middle cerebral artery blood flow velocities were higher at aortic de-cannulation in non-delirious patients (29 cm/second [inter-quartile range (IQR), 24–36 cm/second] vs 12 cm/second [IQR, 10–19 cm/second]; P = .017). Furthermore, brain tissue oxygenation was higher in non-delirious patients during surgery.

Our results suggest that higher cerebral blood flow velocities after aortic de-clamping and probably also improved brain oxygenation might be beneficial to prevent postoperative delirium.
Association between triglyceride glucose index and abnormal liver function in both urban and rural Chinese adult populations
Authors: Yu Lanfang , Cai Yamei , Qin Rui , Zhao Bin , Li Xiaona
Published: December 2019

The purpose of this study was to investigate the association between triglyceride glucose (TyG) index and abnormal liver function both in urban and rural Chinese adult populations. The 5824 urban (Nanjing) and 20,269 rural (Hefei) Chinese adults, from random selected households provided clinical history, glucose, lipids, anthropometric, and blood pressure measurements. Liver functions were assessed using Alanine Aminotransferase (ALT). Linear regression was applied to examine the dose-response relationship between TyG index and ALT. Logistic regression was used to estimate the association between TyG index and abnormal liver and function. Cubic spline models were applied to investigate the dose-response association between TyG index and abnormal liver function. C-statistics was used to compare the discriminable capacity over triglyceride, glucose and TyG index. Linear dose-response relationship was identified between TyG index and ALT as 1.222 IU increase by 1 unit increase of TyG index (1.242 for urban population and 1.210 for rural population). The 6.0% of urban and 11.0% of rural Chinese adults were observed to have abnormal liver function. The linear association between TyG index and abnormal liver function was revealed as 2.044 (1.930 to 2.165) of odds ratio by in unit increase of TyG index (2.334 for urban population and 1.990 for rural population). Higher C-statistics was found for TyG index compared with fasting glucose and triglyceride both in Chinese urban and rural populations. This study suggested in both urban and rural Chinese adult populations, TyG index is associated with abnormal liver function. TyG index is a potential indicator to identify high-risk individuals with metabolic disorders, for example impaired liver function in Chinese population, especially in Chinese urban population.
The limited area decompression, intervertebral fusion, and pedicle screw fixation for treating degenerative lumbar spinal stenosis with instability
Authors: Yang Fengguang , Ren Enhui , Yang Liang , Wang Yonggang , Hu Xuchang , Yang Yong , Kang Xuewen
Published: December 2019

The aim of the study was to evaluate the clinical effect of the limited area decompression, intervertebral fusion, and pedicle screw fixation for treating degenerative lumbar spinal stenosis (DLSS) with instability. Hemilaminectomy decompression, intervertebral fusion, and pedicle screw fixation for treating DLSS with instability as the control group.

Follow-up of 54 patients (26 males and 28 females; average age, 59.74 ± 10.38 years) with DLSS with instability treated by limited area decompression, intervertebral fusion, and pedicle screw fixation (LIFP group), and 52 patients as control group with hemilaminectomy decompression, intervertebral fusion, and pedicle screw fixation (HIFP group). We assessed clinical effect according to the patients’ functional outcome grading (good to excellent, fair, or poor), Oswestry Disability Index (ODI) and visual analogue scale (VAS) for low back pain and lower limb pain, which was administered preoperatively and at 3, 6, and 12 months postoperatively. Fusion status was assessed by radiologists at the last follow-up. Treatment satisfaction was assessed according to the subjective evaluations of the patients.

At the 12-month follow-up, 96.2% (52/54) and 90.3% (47/52) of group LIFP and HIFP belonged to good to excellent outcome categories, respectively, while 3.7% (2/54) and 9.6% (5/52) of group LIFP and HIFP belonged to fair respectively, neither group belonged to poor. Satisfaction rates of patients in group LIFP and group HIFP were 98.1% (53/54) and 92.3% (48/52), respectively. The patients’ functional outcome grading and satisfaction rate in group LIFP were better than that in group HIFP. The VAS for low back and lower limb pain and the ODI improved significantly during the 12 months after surgery (all P < .001) in 2 groups. The VAS for low back and lower limb pain were no difference between two groups, however, the ODI of group LIFP was lower than that of group HIFP (P < .001). All patients achieved radiological fusion.

The limited area decompression, intervertebral fusion, and pedicle screw fixation had a satisfactory effect on patients with DLSS with instability.
Sex-dependent changes in physical, mental, and quality of life outcomes in metoprolol-treated Chinese chronic heart failure patients
Authors: Wu Liyong , Zhang Qian , Shu Qiuhong , Zhang Ran , Meng Yong
Published: December 2019

This study assessed sex differences in cardiac and motor functions, quality of life (QoL), and mental status in Chinese chronic heart failure (CHF) patients after metoprolol treatment.

This single-center prospective study, conducted from February 2013 to April 2016, included CHF patients (men and women) with resting heart rate (HR) >80 beats/min using metoprolol continuous release tablets. Metoprolol-induced changes in cardiac and motor functions, QoL, and mental status at 1, 3, 6, 9, and 12 months from baseline, within and between the sexes, were analyzed. Descriptive data were represented as counts, percentages, and mean ± standard deviation. Differences at various follow-up periods were compared using repeated measures one-way analysis of variance, followed by post hoc Dunnett's multiple comparison test. Statistical significance was considered atP < .05.

Compared with men, women reported significantly higher systolic blood pressure (SBP) (122.28 ± 6.76 vs 125.47 ± 6.67 mm Hg,P < .05) and Veterans Specific Activity Questionnaire score (8.16 ± 0.98 vs 8.47 ± 0.89,P = .05) at 12 months. Men reported higher Hospital Anxiety and Depression Scale scores for depression than women at 1 month (10.27 vs 8.83,P < .05) and for anxiety at 12 months (8.4 vs 7.72,P < .05). Metoprolol significantly decreased HR and Minnesota Living with Heart Failure Questionnaire score in men (64.5 ± 3.13 and 53.7 ± 8.00) and women (65.38 ± 3.32 and 53.85 ± 8.42, respectively). Ejection fraction (%, men: 50.00 ± 4.45, women: 50.72 ± 4.09), cardiac index (L/min/m2, men: 2.70 ± 0.25, women: 2.78 ± 0.23), 6-minute walk test distance (m, men: 414.41 ± 20.84, women: 420.34 ± 20.35), and short form-8 questionnaire scores (men: 52.05 ± 1.94, women: 52.19 ± 2.58) increased significantly in both the sexes (P < .001 for all) at 12 months. Copenhagen Burnout Inventory score significantly increased in men (mean score 62.43,P < .05).

Metoprolol treatment improves cardiac and motor functions, QoL, and anxiety scores but causes greater depression and burnout in men and women. Sex was seen to affect mental status of CHF patients the most.
Risk factors associated with hypophosphatemia in chronic Hepatitis B patients treated with tenofovir disoproxil fumarate
Authors: Lee Dohyeong , Yun Byung Cheol , Seo Kwang Il , Han Byung Hoon , Lee Sang Uk , Park Eun Taek , Lee Jin Wook , Jeong Joonho
Published: December 2019

Tenofovir disoproxil fumarate (TDF) is thought to cause varying degrees of hypophosphatemia in patients with chronic hepatitis B (CHB). Therefore, we investigated factors that cause hypophosphatemia in patients treated with TDF and methods to increase serum phosphorus concentrations in clinical practice.

We completed a retrospective review of patients with CHB treated with TDF initially at Kosin University Gospel Hospital, Busan, Korea from January 2012 to January 2017. Subclinical hypophosphatemia and hypophosphatemia were defined as serum phosphorus below 3.0 mg/dL and 2.5 mg/dL, respectively.

We screened 206 patients with CHB treated with TDF, among which 135 were excluded for the following reasons: baseline malignancy (59), limited data (50), co-administered other antivirals (14), hypophosphatemia at baseline (7), and other reasons (5). The final study population comprised 71 patients. Subclinical hypophosphatemia developed in 43 (60.5%) patients. Hypophosphatemia occurred in 18 patients (25.3%). Liver cirrhosis was the most significant predictor of hypophosphatemia (P = .038, OR = 3.440, CI = 1.082–10.937) Patients diagnosed with subclinical hypophosphatemia were encouraged to increase their intake of nuts and dairy products (25 patients) or reduce their alcohol intake (2), dose reduction of TDF (4) or placed under observation (4). Among patients with subclinical hypophosphatemia, serum phosphorus concentrations were elevated (>3.0 mg/dL) in 23 of 36 patients (63.8%). Increased nut and dairy intake increased phosphorus concentrations to more than 3.0 mg/dl in 16 of 25 patients (64.0%).

Entecavir or tenofovir alafenamide fumarate (TAF) should be considered rather than TDF in patients with liver cirrhosis because of the risk of hypophosphatemia. Instead of stopping TDF treatment, encouraging increased intake of phosphorus-rich foods could increase serum phosphorus concentrations in clinical practice.
Interleukin-6 gene polymorphisms and susceptibility to liver diseases
Authors: Wang Xuehan , Yan Zhenghui , Ye Qingjian
Published: December 2019

Background:

Several studies have explored the associations between interleukin-6 (IL-6) gene polymorphisms and the susceptibility to liver diseases, however, results remain ambiguous. The goal of this study was to conduct a meta-analysis to provide more credible evidence.

Methods:

Studies identified in the PubMed, Cochrane Library, and EMBASE databases were used to perform a meta-analysis via the STATA software. Pooled odds ratios (OR) were calculated under fixed- and random-effects models to estimate the potential genetic associations.

Results:

Twenty-five case-control studies involving 5813 cases and 5298 controls were included in this meta-analysis. Overall, the pooled results suggested that rs1800795 polymorphism was significantly associated with the risk of liver diseases in heterozygote (GC vs CC; OR = 1.57) and dominant (GG+GC vs CC: OR = 1.47) models; rs1800796 polymorphism was significantly associated with the susceptibility to liver diseases in heterozygote (GG vs GC; OR = 0.58) and recessive (GG vs GC+CC: OR = 0.68) models; rs1800797 polymorphism was significantly associated with genetic predisposition to liver diseases in homozygote (GG vs AA: OR = 1.63), heterozygote (GA vs AA; OR = 1.53) and dominant (GG + GA vs AA: OR = 1.61) models. A similar conclusion was found in the HBV, HCV, HCC, NASH and alcoholic liver disease of all ethnic populations for rs1800795; HBV and Asian subgroups for rs1800796; HCV and non-Asian subgroups for rs1800797. However, IL-6 rs2069837 and rs2066992 polymorphisms did not exhibit significant associations with the risk of liver diseases under any genetic models.

Conclusion:

This meta-analysis suggests that patients carrying G (rs1800795), C (rs1800796) or G (rs1800797) allele or genotypes of IL-6 may be more likely to suffer from liver diseases, which was ethnic-dependent.
Closed atraumatic complete rupture of the flexor halluces longus tendon during forward lunge exercise
Authors: Chun Dong Il , Lee Hong Seop , Won Sung Hun , Moon Sang Il , Jung Ki Jin , Seo Jong Hyun , Cho Hyung Ki , Lee Dhong Won , Ryu Aeli , Manggala Yudha , Kim Woo Jong
Published: December 2019

Rationale:

Acute rupture of the flexor halluces longus (FHL) tendon due to trauma or laceration is a well-known phenomenon. Partial rupture of the FHL tendon caused by tendinitis or stenosing tenosynovitis is common in ballet dancers and athletes. However, atraumatic complete rupture of the FHL is rare: as of 2018, only 7 cases of closed atraumatic complete rupture of the FHL tendon have been reported in the literature. Here, we report on a patient who presented with a closed atraumatic complete rupture of the FHL tendon during a forward lunge exercise.

Patient concerns:

A 35-year-old female visited the clinic with pain in the plantar medial aspect of the left foot, along with weakness and loss of great toe flexion. The patient had a normal foot structure and no history of trauma or systemic disease. She performed a forward lunge exercise more than 50 times on 1 leg per day, more than once a week to strengthen her leg muscles. She reported that she felt a slight pain in her left, great toe while exercising for 3 weeks prior to her visit. One week prior to presentation, severe pain occurred suddenly when her left hallux dorsiflexed strongly during an anterior lunge exercise motion.

Diagnosis:

Magnetic resonance imaging revealed complete rupture of the FHL tendon near the level of the metatarsal head and neck junction. The lesion was prolonged, with the proximal end displaced to the metatarsal shaft region.

Interventions:

Complete rupture of the FHL tendon was treated with a primary suture.

Outcomes:

At the 1-year follow-up, active plantar flexion of the interphalangeal joint was possible but joint function had a range of 0° to 25°. Flexion strength was reduced slightly, measuring about 70% when compared to the contralateral side, but flexion strength of the metatarsophalangeal joint was normal.

Lessons:

We describe an extremely rare case of complete rupture of the FHL tendon at the level of metatarsal head and neck junction. It should be understood that this injury can occur not only in professional athletes but also in the general public, and we recommend educating personal trainers on how to prevent it.
Genetically engineered animal models of biliary tract cancers
Authors: Pirenne Sophie , Lemaigre Frédéric P.
Published: December 2019

Purpose of review

Biliary tract cancers which include intrahepatic and extrahepatic cholangiocarcinomas and gallbladder cancer, are characterized by poor outcome. Therefore, identifying the molecular mechanisms of the disease has become a priority. However, such identification has to cope with extreme heterogeneity of the disease, which results from the variable anatomical location, the numerous cell types of origin and the high number of known genetic alterations.

Recent findings

Animal models can develop invasive and metastatic tumours that recapitulate as faithfully as possible the molecular features of the human tumours. To generate animal models of cholangiocarcinoma, investigators resorted to the administration of carcinogens, induction of cholestasis, grafting of tumour cells and induction of genetic modifications.

Here, we summarize the currently available genetically engineered animal models, and focus on mice and zebrafish. The experimental strategies that were selected to induce cholangiocarcinoma in a time-controlled and cell-type-specific manner are critically examined. We discuss their strengths and limitations while considering their relevance to human pathophysiology.
Multidisciplinary approaches to odontogenic lesions
Authors: Shanti Rabie M. , Alawi Faizan , Lee Su-Min , Henderson Aaron J. , Sangal Neel R. , Adappa Nithin D.
Published: December 2019

Purpose of review

To give an overview of technical considerations and relevant literature in the management odontogenic pathology with involvement of the maxillary sinus.

Recent findings

Infections, cysts, benign neoplasms (odontogenic and nonodontogenic), and inflammatory conditions impact the maxillary sinus in various ways, could result in significant expansion within the maxillary sinus and significant infections.

This manuscript provides an overview of common pathologic entities of the oral cavity proper that impacts the maxillary sinus health, with discussion of the role of the otorhinolaryngologist and the dental specialist.
Striving for more just allocation of liver allografts between patients with and without hepatocellular carcinoma: successes and challenges
Authors: Ahearn Aaron
Published: December 2019

Purpose of review

Recently the United Network for Organ Sharing (UNOS) adopted new rules for the allocation of liver allografts for recipients with hepatocellular carcinoma (HCC) in hopes of removing regional variation in HCC practice and regional differences in patient survival. Understanding how previous changes to HCC allocation have both succeeded and failed to match the pretransplant mortality of HCC and non-HCC patients on the waitlist will help us to better evaluate these changes and predict where we may again fail.

Recent findings

Previous revisions of the HCC allocation rules were successful in more accurately matching the waitlist mortality of HCC and non-HCC patients. Efforts to select for less aggressive tumor biology have resulted in better disease free and patient survival. Several articles have also supported the practice of using locoregional therapies to downstage the patients to within Milan criteria. New rules seek to reduce the amount of geographic disparity in the allocation system.

Over time UNOS has steady improved the liver allocation polices to attempt to match pretransplant mortality for patients with HCC and without HCC. The latest changes to the organ allocation rules succeed in implementing some of these best practices. However, one can also predict several ongoing challenges to fair allocation that may not have been addressed by recent changes.
Routine Depression Screenings for Advanced Cancer Patients
Authors: Larkin Danielle R.
Published: December 2019

Advanced cancer patients are at an increased risk of developing depressive symptoms, which can lead to major depressive disorder and a poor quality of life. It is important that symptoms of depression to be addressed early and frequently throughout the trajectory of the disease process. Depression is underdiagnosed and therefore undertreated in advanced cancer patients. Clinicians often fail to perform regular depression screenings as recommended by the National Comprehensive Cancer Network. Depressive symptoms are overlooked as they tend to overlap with the effects of disease progression and cancer treatments. Patients' complaints of anorexia, chronic pain, and sleep disturbances do not necessarily trigger practitioners to perform depression screenings. African Americans with advanced cancer are at a higher risk of developing depression, but may not identify as depressed due to the stigma of mental health in the black community. Screening tools such as the 2- and 9-item Patient Health Questionnaire, Beck Depression Inventory II, Hospital Anxiety and Depression Scale, and the Distress Thermometer and Problem List are common brief instruments that can screen for depression. Providing early symptom relief of depressive symptoms through psychotherapy and pharmacologic interventions will benefit the patient, family, and caregivers while improving the quality of life throughout the trajectory of the illness.
New or Persistent Right Ventricular Systolic Dysfunction Is Associated With Worse Outcomes in Pediatric Acute Respiratory Distress Syndrome
Authors: Himebauch Adam S. , Yehya Nadir , Wang Yan , McGowan Francis X. , Mercer-Rosa Laura
Published: December 2019

Objectives:

The trajectory and importance of right ventricular systolic function and pulmonary hypertension during the course of pediatric acute respiratory distress syndrome are unknown. We hypothesized that new or persistent right ventricular systolic dysfunction and pulmonary hypertension would be associated with worse patient outcomes.

Design:

Retrospective, single-center cohort study.

Setting:

Tertiary care, university-affiliated PICU.

Patients:

Children who had at least two echocardiograms less than 8 days following pediatric acute respiratory distress syndrome diagnosis.

Interventions:

None.

Measurements and Main Results:

Between July 1, 2012, and April 30, 2018, 74 children met inclusion criteria. The first echocardiogram was performed a median of 0.61 days (interquartile range, 0.36–0.94 d) and the second echocardiogram was performed a median of 2.57 days (interquartile range, 1.67–3.63 d) after pediatric acute respiratory distress syndrome diagnosis. Univariate analyses showed that new or persistent right ventricular systolic dysfunction as defined by global longitudinal strain or free wall strain was associated with a greater number of ICU days in survivors (global longitudinal strain p = 0.04, free wall strain p = 0.04), lower ventilator-free days at 28 days (global longitudinal strain p = 0.03, free wall strain p = 0.01), and higher rate of PICU death (global longitudinal strain p = 0.046, free wall strain p = 0.01). Mixed-effects multivariate modeling showed that right ventricular global longitudinal strain and right ventricular fractional area change stayed relatively constant over the course of the first 8 days in nonsurvivors and that there was a linear improvement in global longitudinal strain (p = 0.037) and fractional area change (p = 0.05) in survivors. Worsening right ventricular dysfunction at the time of repeat echocardiogram as defined by global longitudinal strain and free wall strain were independently associated with decreased probability of extubation (subdistribution hazard ratio, 0.30 [0.14–0.67]; p = 0.003 and subdistribution hazard ratio, 0.47 [0.23–0.98]; p = 0.043, respectively). In univariate and multivariate analyses, pulmonary hypertension had no significant associations with outcomes in his cohort.

Conclusions:

New or persistent right ventricular systolic dysfunction over the first week following pediatric acute respiratory distress syndrome onset is associated with worse patient outcomes, including decreased probability of extubation and higher PICU mortality.
PNL2: A Useful Adjunct Biomarker to HMB45 in the Diagnosis of Uterine Perivascular Epithelioid Cell Tumor (PEComa)
Authors: Valencia-Guerrero Aida , Pinto Andre , Anderson William J. , Trevisan Giorgia , Nucci Marisa R. , Hirsch Michelle S.
Published: December 2019

Perivascular epithelioid cell tumors (PEComa) are rare neoplasms characterized by co-expression of melanocytic and muscle markers. HMB45 and Melan-A are used to confirm a PEComa diagnosis; however, both are often focally expressed and sensitivity for Melan-A is low. PNL2 is a reliable biomarker for epithelioid melanoma and renal angiomyolipoma/PEComa. The objective of this study was to determine PNL2 utility in diagnosing uterine PEComas as well as distinguishing PEComas from uterine smooth muscle tumors (SMTs). Twenty-one uterine PEComas and 45 SMTs were analyzed for PNL2; a subset was also stained for HMB45, Melan-A, Cathepsin-K, Desmin, and h-Caldesmon. Cases were scored as negative (0), focal (<10% of tumor cells), or patchy to diffusely positive (>10% of tumor cells). PEComas were positive for PNL2, HMB45, and Melan-A in 86%, 100%, and 57% of cases, respectively. In PEComas, PNL2 was patchy to diffusely positive more frequently (10/18, 56%) than Melan-A (4/12, 33%). In contrast, 2 of 45 (4%) SMTs were focally PNL2 positive; HMB45 was focally positive in 4 SMTs (11%) and all were negative for Melan-A. Desmin and h-Caldesmon were positive in 90% and 57% of PEComas, and 91% and 82% of SMTs. Cathepsin-K was positive in 100% of PEComas and 93% of SMTs. PNL2 is a useful biomarker for the diagnosis of uterine PEComa, with comparable sensitivity and specificity to HMB45. In contrast, PNL2 stains more PEComas when compared with Melan-A. Cathepsin-K, Desmin, and h-Caldesmon are of little utility for distinguishing PEComas and SMTs; however, lack of Cathepsin-K argues against PEComa. These results suggest that PNL2 should be used in conjunction with HMB45 in the diagnosis of PEComa of the uterine corpus.
Axillary Osmidrosis
Authors: Morioka Daichi , Nomura Misako , Lan Lan , Tanaka Ryutaro , Kadomatsu Koichi
Published: December 2019

Axillary osmidrosis is characterized by offensive odor resulting from bacterial decomposition of apocrine secretions in the axillae, and individuals with axillary osmidrosis suffer detrimental effects to their psychosocial functioning. We searched the literature in January 2019 for all English-language publications discussing axillary osmidrosis to identify previous reports, present trends, and emerging treatments. Studies were listed chronologically by the country of the first author's institution. Publications were also classified regarding the study type (literature review), pathophysiology, and treatments. We identified 133 publications on axillary osmidrosis, and of these, 120 were from East-Asian countries. Before 1990, there were only 9 publications, but after 2000, publications increased in number. One hundred of 133 reports discussed treatment, namely, 39 reports on suction curettage, 28 reports on open surgery, and 8 reports on subdermal laser. Other studies focused on the pathophysiology of axillary osmidrosis. This literature review revealed unique trends in the identified studies. Because control of axillary odor is a universal subject, the etiology and pathophysiology of axillary osmidrosis have been studied throughout the world and are clearly described. However, almost all studies of surgical treatments have been performed in East-Asian countries. After the year 2000, various surgical and nonsurgical treatments, namely, laser therapy and suction curettage, have been attempted. Emerging treatments for axillary osmidrosis include ethanol injections, microwave therapy, and microneedle radiofrequency technologies; however, further studies of these treatments are needed.
Bipedicled Nipple-Sparing Mastectomy Versus Traditional Nipple-Sparing Mastectomy
Authors: Falco Giuseppe , Curcio Annalisa , Marongiu Francesco , Buggi Federico , Mingozzi Matteo , Mele Simone , Ferrari Guglielmo , Folli Secondo
Published: December 2019

Background

Nipple-areola complex–sparing mastectomy (NSM) represents, when a mastectomy is unavoidable, the best treatment possible that can be offered to attenuate the negative impact of surgery on patients' quality of life. Unfortunately, NSM can be used only in selected patients with small and nonptotic breasts. In order to save the nipple-areola complex (NAC) also in patients with large and ptotic breast, otherwise subjected to a skin-sparing mastectomy with the sacrifice of the NAC, we described the bipedicled nipple-sparing mastectomy (BNSM). The aim of this study is to obtain a formal outcome assessment of BNSM and analyze the complications rate of this technique compared with traditional NSM. We furthermore attempt to describe the surgical procedures present in the literature that allow to preserve NAC also in large and ptotic breasts presenting the complication rates observed and comparing with our technique. Aesthetic outcome has also been evaluated.

Methods

We retrospectively reviewed 42 procedures of consecutive patients undergoing immediate reconstruction with tissue expanders after NSM (20 patients) or BNSM (19 patients). We divided them in 2 groups focused on surgical complications and aesthetic outcome.

Results

On a total of 42 procedures, the principal major complication was dehiscence of surgical wound procedures needing 1-day surgery revision occurring in 3 (14.3%) of the BNSM group and 1 (4.8%) of the NSM group, whereas as principal minor complication 4 partial NAC necrosis not requiring surgery in BNSM (19%) and 2 (9.5%) in NSM. No tissue expanders required explantation. Concerning cosmetic results, the overall appearance of the breast and NAC was acceptable in 85.7 % and 77.2%, respectively, in the NSM group and 80.7% and 66.7%, respectively, in the BNSM group.

Conclusions

Bipedicled nipple-sparing mastectomy is a valid technique to improve patients' quality of life in large and ptotic breasts otherwise candidate to a skin-sparing mastectomy, but only a progressive learning curve can minimize complications. No significant statistical differences have been observed in terms of complication rates and aesthetical outcomes between the 2 groups. An accurate selection of patients is mandatory in order to obtain low complication rates and good aesthetical outcome.
Revision of Pancreatic Neck Margins Based on Intraoperative Frozen Section Analysis Is Associated With Improved Survival in Patients Undergoing Pancreatectomy for Ductal Adenocarcinoma
Authors: Zhang Biqi , Lee Grace C. , Qadan Motaz , Fong Zhi Ven , Mino-Kenudson Mari , Desphande Vikram , Malleo Giuseppe , Maggino Laura , Marchegiani Giovanni , Salvia Roberto , Scarpa Aldo , Luchini Claudio , De Gregorio Lucia , Ferrone Cristina R. , Warshaw Andrew L. , Lillemoe Keith D. , Bassi Claudio , Castillo Carlos Fernández-del
Published: December 2019

Objective:

To test the hypothesis that complete, tumor-free resection at the pancreatic neck, achieved either en-bloc or non-en-bloc (ie, revision based on intraoperative frozen section [FS] analysis), is associated with improved survival as compared with incomplete resection (IR) in pancreatic ductal adenocarcinoma.

Summary Background Data:

Given the likely systemic nature of pancreatic ductal adenocarcinoma, the oncologic benefit of achieving a histologically complete local resection, particularly through revision of a positive intraoperative FS at the pancreatic neck, remains controversial.

Methods:

Clinicopathologic and treatment data were reviewed for 986 consecutive patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas who underwent open pancreatectomy as well as intraoperative FS analysis between 1998 and 2012 at Massachusetts General Hospital and between 1998 and 2013 at the University of Verona. Overall survival (OS) and perioperative morbidity and mortality were compared across 3 groups: complete resection achieved en-bloc (CR-EB), complete resection achieved non-en-bloc (CR-NEB), and IR.

Results:

The CR-EB cohort comprised 749 (76%) patients, CR-NEB 159 patients (16%), and IR 78 patients (8%). Other than a higher incidence of vascular resection among CR-NEB and IR patients, no demographic, pathologic (eg, tumor grade, lymph node positivity, superior mesenteric artery involvement), or treatment factors (eg, neoadjuvant and adjuvant therapy use) differed between the groups. Median OS was significantly higher in patients with CR-EB (28 mo, P = 0.01) and CR-NEB resections (24 mo, P = 0.02) as compared with patients with IR resections (19 mo). After adjusting for clinicopathologic and treatment characteristics, CR-EB and CR-NEB margin status were found to be independent predictors of improved OS (relative to IR, CR-EB hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49–0.86; CR-NEB HR 0.69, 95% CI 0.50–0.96). There were no intergroup differences in perioperative morbidity and mortality, including rates of pancreatic fistula.

Conclusions:

For patients with ductal adenocarcinoma at the head, neck, or uncinate process of the pancreas undergoing pancreatectomy, complete tumor extirpation via either en-bloc or non-en-bloc complete resection based on FS analysis is associated with improved OS, without an associated increased perioperative morbidity or mortality.
500 Minimally Invasive Robotic Pancreatoduodenectomies
Authors: Zureikat Amer H. , Beane Joal D. , Zenati Mazen S. , Al Abbas Amr I. , Boone Brian A. , Moser A. James , Bartlett David L. , Hogg Melissa E. , Zeh Herbert J.
Published: December 2019

Objectives:

This study aims to present the outcomes of our decade-long experience of robotic pancreatoduodenectomy and provide insights into successful program implementation.

Background:

Despite significant improvement in mortality over the past 30 years, morbidity following open pancreatoduodenectomy remains high. We implemented a minimally invasive pancreatic surgery program based on the robotic platform as one potential method of improving outcomes for this operation.

Methods:

A retrospective review of a prospectively maintained institutional database was performed to identify patients who underwent robotic pancreatoduodenectomy (RPD) between 2008 and 2017 at the University of Pittsburgh.

Results:

In total, 500 consecutive RPDs were included. Operative time, conversion to open, blood loss, and clinically relevant postoperative pancreatic fistula improved early in the experience and have remained low despite increasing complexity of case selection as reflected by increasing number of patients with pancreatic cancer, vascular resections, and higher Charlson Comorbidity scores (all P<0.05). Operating room time plateaued after 240 cases at a median time of 391 minutes (interquartile rang 340–477). Major complications (Clavien >2) occurred in less than 24%, clinically relevant postoperative pancreatic fistula in 7.8%, 30- and 90-day mortality were 1.4% and 3.1% respectively, and median length of stay was 8 days. Outcomes were not impacted by integration of trainees or expansion of selection criteria.

Conclusions:

Structured implementation of robotic pancreatoduodenectomy can be associated with excellent outcomes. In the largest series of RPD, we establish benchmarks for the surgical community to consider when adopting this approach.
National Quality Forum Guidelines for Evaluating the Scientific Acceptability of Risk-adjusted Clinical Outcome Measures
Authors: Glance Laurent G. , Joynt Maddox Karen , Johnson Karen , Nerenz David , Cella David , Borah Bijan , Kunisch Joseph , Kurlansky Paul , Perloff Jennifer , Stoto Michael , Walters Ronald , White Susan , Lin Zhenquiu
Published: December 2019

Quality measurement is at the heart of efforts to achieve high-quality surgical and medical care at a lower cost. Without accurate quality measures, it is not possible to appropriately align incentives with quality. The aim of these National Quality Forum (NQF) guidelines is to provide measure developers and other stakeholders with guidance on the standards used by the NQF to evaluate the scientific acceptability of performance measures. Using a methodologically rigorous and transparent process for evaluating health care quality measures is the best insurance that alternative payment plans will truly reward and promote higher quality care. Performance measures need to be credible in order for physicians and hospitals to willingly partner with payers in efforts to improve population outcomes. Our goal in creating this position paper is to promote the transparency of NQF evaluations, improve the quality of performance measurements, and engage surgeons and all other stakeholders to work together to advance the science of performance measurement.
Randomized Controlled Trial of Compression After Endovenous Thermal Ablation of Varicose Veins (COMETA Trial)
Authors: Bootun Roshan , Belramman Amjad , Bolton-Saghdaoui Layla , Lane Tristan R. A. , Riga Celia , Davies Alun H.
Published: December 2019

Background:

The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now considered to be the “gold-standard” treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment.

Method:

Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation.

Results:

In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2–5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1–3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates.

Conclusions:

These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.