bluuebunny/crossref_metadata_2025 huggingface dataset:
Jugular Bulb Resurfacing With Bone Cement for Patients With High Dehiscent Jugular Bulb and Ipsilateral Pulsatile Tinnitus
Authors: Lee Sang-Yeon , Song Seul-Ki , Park Sung Joon , Park Han Gyeol , Choi Byung Yoon , Koo Ja-Won , Song Jae-Jin
Published: January 2019

Objective:

To discuss the possible pathophysiologic mechanism of pulsatile tinnitus (PT) perception due to high jugular bulb with bony dehiscence (HJBD) and its improvement after the dehiscent jugular bulb (JB) resurfacing using bone cement, and to describe the efficacy of an objective measure of PT using transcanal sound recording and spectro-temporal analysis (TSR/STA).

Study Design:

Retrospective case series study.

Setting:

A university-based, tertiary care cancer center.

Patients:

Three PT patients with HJBD.

Main Outcome Measure(s):

All patients underwent transtympanic resurfacing after the source of PT was confirmed by temporal bone imaging and TSR/STA. Improvement of symptom and the changes in the TSR/STA were analyzed.

Results:

In the first case, a revision operation was performed due to slightly improved but persistent PT after initial resurfacing with bone pate and a piece of conchal cartilage. Revision transtympanic JB resurfacing was performed in this case using bone cement, and PT resolved immediately after the surgery. In the second and third cases, PT resolved completely, or was much abated, immediately after transtympanic resurfacing with bone cement. The TSR/STA also revealed improvement of PT. The median follow-up duration was 28 months, and all three patients remained asymptomatic or much improved compared with their preoperative status.

Conclusions:

Transtympanic resurfacing with bone cement, reinforcing the dehiscent JB to reduce focal turbulent flow, is a simple and effective surgical treatment option in patients with PT due to HJBD. In patients with HJBD, the objective measurement of PT by TSR/STA may be of help in selecting appropriate surgical candidates and objective evaluation of the treatment outcome.
Fracture of the Incus Caused by Digital Manipulation of the Ear Canal and its Diagnosis Using Wideband Acoustic Immittance
Authors: Masud Salwa F. , Knudson Inge M. , Stankovic Konstantina M. , Nakajima Hideko Heidi
Published: January 2019

Objective:

To describe the first reported case of a fracture of the long process of the incus due to digital manipulation of the ear canal and to discuss diagnostic markers for ossicular fractures.

Patient:

A 46-year-old woman with incessant clicking and crunching in her left ear, and hearing loss after digital manipulation of the ear canal.

Intervention:

Diagnostic evaluation and therapeutic ossiculoplasty.

Main Outcome Measure(s):

Audiometric and wideband acoustic immittance (WAI) measurements were made before surgery to investigate the cause of clicking sounds and mild conductive hearing loss (CHL).

Results:

The clinical suspicion of a loose ossicular chain was confirmed by a large narrow-band decrease in power reflectance (calculated from WAI) at frequencies between 600 and 700 Hz, and a mid- to high-frequency air-bone gap. Exploratory tympanotomy revealed an ossicular fracture of the distal aspect of the long process of the incus. Ossiculoplasty with bone cement resolved bothersome clicking sounds.

Conclusion:

A finger inserted into the ear canal can produce an air seal, and subsequent quick removal of the finger can result in the fracture of an ossicle. Clinicians should be cognizant of this form of trauma because insertion of a finger, ear plug, and earphone into the ear canal are common. Ossicular fractures can result in high-frequency CHL, and can be misdiagnosed as sensorineural loss because bone conduction thresholds are not measured above 4 kHz. As in this case, an ossicular fracture may be misdiagnosed and result in inappropriate treatment. Here, WAI, a non-invasive measure of ear mechanics, diagnosed a loose ossicular chain.
Audiometric Results of Stapedotomy Surgery for Otoscelorsis: Influence of the Radiological Stage
Authors: Meranger Antoine , David Alina , Beigner Baptiste Marcel , Charpiot Anne , Tavernier Laurent
Published: January 2019

Background:

The objective of this study was to identify a correlation between the radiological stage of otosclerosis and the pre- and postoperative audiometric results of patients who underwent a stapedotomy.

Methods:

Ninety-three patients with radiologically and surgically confirmed otosclerosis who underwent stapedotomy surgery and CT scanning within 18 months before the operation were included. The CT scans were interpreted by an otologist and a specialised radiologist to determine their radiological stage according to the classification of Veillon and Fraysse. The patients received a pre- and postoperative audiogram in the short and long term.

Results:

The preoperative bone conduction thresholds were higher in patients who presented with an advanced radiological stage of otosclerosis: 32.7 dB ± 12.4 compared with those who presented with a less advanced radiological stage: 24.3 dB ± 10.0. The preoperative air conduction thresholds were higher in patients who presented with an impairment of the round window: 58.1 dB ± 13.5 compared with those who presented with no impairment of the round window: 48.7 dB ± 14.5. The postoperative improvement in the air-bone gap was significantly higher for the localised foci: 16.9 dB ± 8.6 versus 11.0 dB ± 9.2, but only in the short term.

Conclusion:

There was a clinical radiological correlation with the preoperative results: In BC, there was a correlation with the radiological stage of Veillon and in AC, there was a correlation with impairment of the round window. The link between the radiological stage of otosclerosis and the postoperative audiometric results is less obvious. In the short term, the audiometric improvements in the air-bone gap were greater in patients in the early stages according to the Veillon classification, but this result was not sustained in the long-term.
Objective Measures of Tinnitus: a Systematic Review
Authors: Jackson Richard , Vijendren Ananth , Phillips John
Published: January 2019

Background:

The purpose of this review is to systematically appraise the English-language literature to identify methods of objectively diagnosing and measuring the severity of subjective idiopathic nonpulsatile tinnitus.

Materials and Methods:

A systematic literature search was undertaken from the databases of MEDLINE (1946–May 2018), EMBASE (1980–May 2018), CINAHL (1981–May 2018), and BNI (1992–May 2018) according to predefined inclusion and exclusion criteria.

Results:

We identified 21 articles in this field. Reported objective tests include blood tests, electrophysiology measures, radiological measures, and balance tests. The overall quality of evidence was low, with most studies being low-powered.

Discussion:

Our review has not identified any reliable or reproducible objective measures of tinnitus. However, this piece of work has highlighted emerging areas where further high quality research may lead to the development of an effective method for objectively identifying and measuring the severity of tinnitus.
Update on the management of acute liver failure
Authors: Trovato Francesca M. , Rabinowich Liane , McPhail Mark J.W.
Published: January 2019

Purpose of review

This review describes the current intensive care management of acute liver failure (ALF) and the latest evidence for emerging therapies.

Recent findings

Mortality from ALF continues to improve and in some cases, medical therapy can negate the need for liver transplantation because of protocolized management in specialist centres. Liver transplantation remains the cornerstone of management for poor prognosis ALF. The reduced use of blood products in ALF reflects growing evidence of balanced haemostasis in severe liver disease. Prophylactic therapeutic hypothermia is no longer recommended for neuroprotection. In cases not suitable for liver transplantation, high-volume plasma exchange (HVP) has potential benefit, although further research on the optimal timing and dosing is needed. Although sepsis remains an important complication in ALF, the use of prophylactic antimicrobials is being questioned in the era of emerging bacterial resistance.

ICU management of ALF has improved such that liver transplantation is not required in some cases. HVP has emerged as a potential therapy for patients who may not be good liver transplantation candidates. Nevertheless in suitable patients with poor prognosis liver transplantation remains the optimal therapy.
Acute-on-chronic liver failure: management and prognosis
Authors: Olson Jody C.
Published: January 2019

Purpose of review

Hospitalizations due to complications of cirrhosis continue to rise. Patients with chronic liver disease who suffer acute decompensation [acute-on-chronic liver failure (ACLF)] often require intensive care support and are at high risk for short-term mortality. Given the high mortality rate associated with this condition is incumbent on intensive care providers who care for this patient population to have a working knowledge of ACLF with its associated complications, management strategies and prognosis.

Recent findings

Recognizing ACLF as a distinct clinical entity has gained international attention in recent years though a consensus does not exist. There has been progress on better defining this clinical entity and recent studies have begun to address the critical care needs of these patients. Additional studies are required to define the best care practices for patients with ACLF.

ACLF is a condition occurring in patients with chronic liver disease which is commonly associated with a need for intensive care support and carries a high risk of short-term mortality. Intensive care specialists must be familiar with diagnosis and management of this condition.
Implementation of Value-based Medicine (VBM) to Patients With Chronic Hepatitis C (HCV) Infection
Authors: Bush Haley , Rafiq Nila , Younossi Zobair M.
Published: January 2019

Introduction:

With the significant clinical and economic burden of chronic HCV, effective treatment must be provided efficiently and appropriately. VBM is predicated upon improving health outcomes (clinical and quality) while optimizing the cost of delivering these outcomes. This review explores the concepts of VBM and how it can be used as a strategy for HCV eradication, using the United States as a case example. Once treated with interferon-based regimens, patients with HCV experienced low cure rates, very poor health-related quality of life (HRQoL), decreased work productivity and significant costs. In this context, the old treatment of HCV produced little value to the patient and the society. However, the development of new antiviral regimens for HCV which are free of interferon, has greatly improved treatment success rates as documented with very high cure rates and by improving patient-reported outcomes (PROs), including HRQoL. However, the short-term economic investment to deliver this curative treatment to all HCV-infected patients can be sizeable. In contrast, if one takes the long-term view from the societal perspective, these new treatment regimens can lead to savings by reducing the costs of long-term complications of HCV infection.

Conclusions:

All of the necessary tools are now available to implement strategies to eradicate HCV. The new all oral direct acting antivirals brings value to the patients and the society because it leads to improvements of clinically important outcomes. Furthermore, the costs associated with these treatment regimens can be recovered by preventing the future economic burden of HCV-complications.
Triglycerides and triglyceride-rich lipoproteins in the development and progression of atherosclerosis
Authors: Generoso Giuliano , Janovsky Carolina C.P.S. , Bittencourt Marcio S.
Published: January 2019

Purpose of review

In this review, we intend to show the heterogenicity of the triglyceride group, including the triglyceride-rich lipoproteins and its subparticles, apolipoproteins, and its role in atherogenesis through epidemiological and genetic studies, observing the association of these various components and subclasses with subclinical atherosclerosis and cardiovascular events. Also, we reevaluated the moment of blood collection for the triglyceride measurement and its repercussion in atherosclerosis. Finally, we present the current scenario and new insights about the pharmacologic treatment of hypertriglyceridemia.

Recent findings

Recent studies have been observed, a correlation between cardiovascular disease and triglyceride components (as apolipoproteins A-V, C-I, C-III) as well as proteins involved in the metabolism pathway, such as the angiopoietin-like proteins. Also, the triglyceride-rich lipoproteins, also known as remnants, were recently associated with atherogenesis. Another important topic addressed is about nonfasting triglyceride level, which has been postulated as a better predictor of cardiovascular events than fasting collection.

Regarding hypertriglyceridemia treatment, the drug therapy was updated, as the omega-3 polyunsaturated fatty acids were tested in primary prevention as eicosapentaenoic acid and docosahexaenoic acid combination resulted in no benefit, whereas the administration of icosapent ethyl in secondary prevention and high-risk patients showed a robust decrease of the cardiovascular outcomes.
Rationally designed small molecules to prevent type 1 diabetes
Authors: Ostrov David A. , Gottlieb Peter A. , Michels Aaron W.
Published: January 2019

Purpose of review

To review the recent findings that small ‘drug-like’ compounds block disease-specific human leukocyte antigen (HLA) molecules in type 1 diabetes (T1D).

Recent findings

The predominant genetic risk for developing T1D, the immune-mediated form of diabetes, is conferred through HLA genes. One such gene, termed HLA-DQ8, is present in 50–60% of patients with T1D and those at-risk. DQ8 presents disease-relevant peptides to T cells, which mediate tissue-specific destruction of pancreatic islets. Using a structure-based approach to evaluate the ‘druggability’ of the DQ8 molecule, methyldopa, a clinically well-established oral antihypertensive agent, was discovered to bind DQ8. Methyldopa blocked the activation of DQ8-specific T cells responding to self-antigens such as insulin but not influenza. In a proof-of-concept clinical trial (NCT01883804), methyldopa was administered to recent-onset T1D patients with the DQ8 gene that confirmed the mechanism of action and diminished inflammatory T cell responses toward insulin.

Methyldopa blocks the diabetes-specific function of HLA-DQ8, which represents a personalized medicine approach to treat the underlying autoimmunity in T1D. Clinical trials are warranted and underway to evaluate methyldopa in potentially preserving residual β-cell function in those with new onset and at risk for T1D.
Systemic treatment in elderly head and neck cancer patients: recommendations for clinical practice
Authors: Szturz Petr , Bossi Paolo , Vermorken Jan B.
Published: January 2019

Purpose of review

Despite the constantly growing number of elderly patients with squamous cell carcinoma of the head and neck (SCCHN), the majority of clinical trials have been focusing on their younger counterparts. However, because of age-related changes and the resulting higher prevalence of frailty, senior people need an adapted evidence-based approach.

Recent findings

Recommendations presented in this article proceed from those relevant for the general patient population taking into consideration the individual process of aging. In this respect, categorization into fit, vulnerable and frail elderly patients was used to guide systemic treatment.

The fit and vulnerable subgroups with locoregionally advanced SCCHN may still benefit from curative treatment, whereas for the remaining cases only palliative measures are usually appropriate. Advanced calendar age is not a contraindication for cisplatin making part of the standard regimens in locally advanced (high-dose 3-weekly schedule concurrent with radiotherapy) and recurrent/metastatic disease (in combination with 5-fluorouracil and cetuximab). In the latter setting, modern immunotherapy with immune checkpoint inhibitors, particularly the antiprogrammed cell death protein-1 (anti-PD-1) agents nivolumab and pembrolizumab, changed clinical practice. These drugs have a favourable toxicity profile making them good candidates even for management of vulnerable patients. Regardless of the chosen strategy, attentive supportive care is of paramount importance.
Living donor liver transplantation
Authors: Goldaracena Nicolas , Barbas Andrew S.
Published: January 2019

Purpose of review

As experience grows, living donor liver transplantation (LDLT) has become an effective treatment option to overcome the deceased donor organ shortage.

Recent findings

Donor safety is the highest priority in LDLT. Strict donor selection according to structured protocols and center experience are the main factors that determine donor safety. However, with increased experience, many centers have explored increasing organ availability within living donation by means of ABO incompatible LDLT, dual graft LDLT, and anonymous living donation. Also, this growing experience in LDLT has allowed the transplant community to cautiously explore the role of liver transplantation for hepatocellular carcinoma outside of Milan criteria and patients with unresectable colorectal liver metastases.

LDLT has become established as a viable strategy to ameliorate the organ shortage experienced by centers around the world. Improved understanding of this technique has allowed the improved utilization of live donor graft resources, without compromising donor safety. Moreover, LDLT may offer some advantages over deceased donor liver transplantation and a unique opportunity to assess the broader applicability of liver transplantation.
Understanding and managing cardiovascular outcomes in liver transplant recipients
Authors: Izzy Manhal , VanWagner Lisa B. , Lee Samuel S. , Altieri Mario , Angirekula Mounika , Watt Kymberly D.
Published: January 2019

Purpose of review

Cardiovascular disease (CVD) is a common cause of mortality after liver transplantation. The transplant community is focused on improving long-term survival. Understanding the prevalence of CVD in liver transplant recipients, precipitating factors as well as prevention and management strategies is essential to achieving this goal.

Recent findings

CVD is the leading cause of death within the first year after transplant. Arrhythmia and heart failure are the most often cardiovascular morbidities in the first year after transplant which could be related to pretransplant diastolic dysfunction. Pretransplant diastolic dysfunction is reflective of presence of cirrhotic cardiomyopathy which is not as harmless as it was thought. Multiple cardiovascular risk prediction models have become available to aid management in liver transplant recipients.

A comprehensive prevention and treatment strategy is critical to minimize cardiovascular morbidity and mortality after liver transplant. Weight management and metabolic syndrome control are cornerstones to any prevention and management strategy. Bariatric surgery is an underutilized tool in liver transplant recipients. Awareness of ‘metabolic-friendly’ immunosuppressive regimens should be sought. Strict adherence to the cardiology and endocrine society guidelines with regard to managing metabolic derangements post liver transplantation is instrumental for CVD prevention until transplant specific recommendations can be made.
Enhanced Recovery in Mild Acute Pancreatitis
Authors: Dong Elizabeth , Chang Jonathan I. , Verma Dhruv , Butler Rebecca K. , Villarin Cecia K. , Kwok Karl K. , Chen Wansu , Wu Bechien U.
Published: January 2019

Objectives

Acute pancreatitis (AP) is a leading cause of hospitalization for a gastrointestinal illness in the United States. We hypothesized that enhanced recovery approaches may lead to earlier time to refeeding in patients with AP.

Methods

We performed a double-blind, randomized controlled trial of patients admitted with mild AP from July 2016 to April 2017 at a tertiary medical center. Participants were randomly assigned to receive either enhanced recovery consisting of nonopioid analgesia, patient-directed oral intake, and early ambulation versus standard treatment with opioid analgesia and physician-directed diet. Primary study end point was time to oral refeeding on an intent-to-treat basis. Secondary end points included differences in pancreatitis activity scores, morphine equivalents, length of stay, and 30-day readmissions.

Results

Forty-six participants enrolled. Median age was 53.1 years, and 54.3% were female. There was significant reduction in time to successful oral refeeding in the enhanced recovery versus standard treatment group (median, 13.8 vs 124.8 hours, P < 0.001). Pancreatitis activity scores trended lower at 48 to 96 hours among patients assigned to enhanced recovery (mean, 43.6 vs. 58.9, P = 0.32). No differences found in length of stay or 30-day readmissions.

Conclusion

In this randomized controlled trial, enhanced recovery was safe and effective in promoting earlier time to refeeding in patients hospitalized with AP.
Comparative Accuracy of Tumor Size Assessment and Stage Analysis by Imaging Modalities Versus Gross Examination for Pancreatic Ductal Adenocarcinoma
Authors: Kassardjian Ari , Stanzione Nicholas , Wang Hanlin L.
Published: January 2019

Objectives

Tumor size has been shown to be a strong predictor of patient survival in pancreatic ductal adenocarcinoma (PDAC). The aims of this study were to assess the consistency of preoperative imaging and gross examination for PDAC tumor size measurement and to evaluate the impact on T and overall tumor staging when size measurements by imaging and gross examination were different.

Methods

Patients diagnosed with PDAC who underwent pancreaticoduodenectomy or distal pancreatectomy from 2007 to 2017 were retrospectively reviewed. A total of 268 cases were included.

Results

Imaging studies underestimated tumor size in comparison with gross examination. Staging the tumors based on imaging size using the eighth edition American Joint Committee on Cancer resulted in an altered T stage in 106 cases (39.6%). There was no T-stage change in the remaining 162 cases (60.4%) despite the presence of variable size discrepancies (0.1–1.7 cm). When nodal metastases were also considered, there was no change in the overall tumor stage in most cases.

Conclusions

Although discrepancies exist between tumor size measurements by imaging modalities and gross examination, which may result in an altered T stage in a substantial number of cases, the overall tumor stage is only rarely altered.
The Benefit-Risk Balance of Nab-Paclitaxel in Metastatic Pancreatic Adenocarcinoma
Authors: Péron Julien , Giai Joris , Maucort-Boulch Delphine , Buyse Marc
Published: January 2019

Objectives

The benefit-risk balance of 5-fluorouracil, oxaliplatin, irinotecan, and leucovorin versus gemcitabine assessed using generalized pairwise comparison was strongly positive. We sought to assess the benefit-risk balance of nab-paclitaxel plus gemcitabine using the data of the MPACT trial, as it is an alternative to 5-fluorouracil, oxaliplatin, irinotecan, and leucovorin.

Methods

This statistical method allows for the simultaneous analysis of several prioritized outcomes. The first priority outcome was survival time (overall survival). The second priority outcome was toxicity. The overall treatment effect was quantified using the overall net benefit. Multiple sensitivity analyses were performed to assess the consistency of the results according to possible patients' preferences.

Results

In this trial, 861 patients received nab-paclitaxel plus gemcitabine or gemcitabine alone. The overall net benefit favored strongly and significantly the combination group. When only large survival differences were considered clinically relevant, the net benefit was not in favor of the combination group.

Conclusions

The overall net benefit is a clinically intuitive way of comparing patients with respect to all important efficacy and toxicity outcomes. The nab-paclitaxel plus gemcitabine combination has a positive benefit-risk balance, but it might not be suitable for patients who would consider losing several months of survival to avoid a significant toxic event.
Microvessel Density and Impact of Angiogenesis on Survival of Resected Pancreatic Cancer Patients
Authors: Ntellas Panagiotis , Dadouli Katerina , Perivoliotis Konstantinos , Sogka Eleni , Pentheroudakis Georgios , Ioannou Maria , Hadjichristodoulou Christos , Tepetes Konstantinos , Mauri Davide
Published: January 2019

Objectives

Angiogenesis plays a major role in tumor progression and metastasis; however, its role in pancreatic cancer (PC) remains unclear. The aim of the study was to explore the cumulative evidence concerning the impact of microvessel density (MVD), an estimator of angiogenesis, on resected PC patients.

Methods

A systematic review of literature and a meta-analysis of relevant reports were performed. Overall survival and disease-free survival were scrutinized.

Results

One thousand five hundred patients were analyzed. Overall survival (hazard ratio, 2.0; 95% confidence interval, 1.57–2.54; P < 0.001) and disease-free survival (hazard ratio, 1.99; 95% confidence interval, 1.24–3.2; P = 0.004) were in favor of the low-MVD group. Use of CD105 antibody and of a computerized image analysis system was found to significantly reduce the heterogeneity. Disease staging, tumor location, and grading showed significant effect on survival.

Conclusions

High-MVD expression was strongly associated with poorer survival and recurrence among resected PC patients, demonstrating a negative prognostic value. Use of CD105 antibody and of a computerized image analysis system is recommended in future studies because they reduce heterogeneity of results. The potential role of MVD as a marker to select PC patients who would benefit from antiangiogenetic treatment should be further explored in clinical trials.
Closing the Disparity in Pancreatic Cancer Outcomes
Authors: Vick Alexis D. , Hery Danielle N. , Markowiak Stephen F. , Brunicardi F. Charles
Published: January 2019

Objectives

African Americans (AAs) have disproportionately higher incidence and lower survival rates from pancreatic cancer compared with whites. Historically, this disparity has been attributed to modifiable risk factors. Recent studies suggest that nonmodifiable aspects may also play an important role. We review these new contributions as potential targets for closing the disparity.

Methods

A PubMed search was conducted to review studies of nonmodifiable elements contributing to pancreatic cancer disparities in AAs.

Results

Several nonmodifiable risks are associated with the racial disparity in pancreatic cancer. SSTR5 P335L, Kaiso, and KDM4/JMJD2A demonstrate differential racial expression, increasing their potential as therapeutic targets. Many social determinants of health and their associations with diabetes, obesity, and the microbiome are partially modifiable risk factors that significantly contribute to outcomes in minorities. Barriers to progress include the low minority inclusion in research studies.

Conclusions

Genomics, epigenetics, the microbiome, and social determinants of health are components that contribute to the pancreatic cancer disparity in AAs. These factors can be researched, targeted, and modified to improve mortality rates. Closing the disparity in pancreatic cancer will require an integrated approach of personalized medicine, increased minority recruitment to studies, and advanced health care/education access.
Contribution of Inhibition of Protein Catabolism in Myeloma
Authors: Bianchi Giada , Anderson Kenneth C.
Published: January 2019

Multiple myeloma (MM) is a cancer of plasma cells, characterized by abundant synthesis of monoclonal immunoglobulins and/or free light chains. Although MM remains incurable, median overall survival has considerably improved over the past 2 decades largely due to the introduction of novel agents, including proteasome inhibitors (PIs) and immunomodulatory drugs. Bortezomib, a reversible boronate PI, was the first Food and Drug Administration–approved PI in MM and subsequently mantle cell lymphoma. Carfilzomib and ixazomib, the former an irreversible epoxyketone and the latter an orally bioavailable reversible PI, have been subsequently approved in MM. Altogether, these drugs represent the first effort to disrupt protein homeostasis as a therapeutic strategy in MM. Although effective, de novo resistance is a recognized phenomenon, and acquired resistance to PI is common, prompting the development of biology-based combination therapies. Based on laboratory evidence of increased, constitutive proteotoxic stress, targeting protein catabolism with single or combination therapies is an effective strategy in MM. In this article, we review the scientific rationale and bases for therapeutic application and effectiveness of Food and Drug Administration–approved and investigational drugs targeting protein homeostasis in MM.
Smoldering Multiple Myeloma
Authors: Kapoor Prashant , Rajkumar S. Vincent
Published: January 2019

Smoldering multiple myeloma (SMM) is an asymptomatic, intermediate stage positioned between the plasma cell disorders of monoclonal gammopathy of undermined significance and overt multiple myeloma (MM). Although the patients with SMM have a higher risk of progression to MM in comparison to their counterparts with monoclonal gammopathy of undermined significance, their clinical course can be highly variable. The standard of care for SMM, irrespective of the risk status, continues to be observation due to paucity of high-level evidence demonstrating survival or quality-of-life benefit with early intervention. With the expanded 2014 criteria for MM utilizing biomarkers, the subset of SMM patients with 70% to 80% risk of progression at 2 years (ultra-high risk SMM) is now categorized as active MM and treated prior to the development of end-organ damage. After exclusion of this group, patients with approximately 50% risk of progression in 2 years are now considered high-risk SMM, and the value of early treatment in this subset can be established only through clinical trials. Despite its limitations, a recent phase III trial (QuiRedex) has shown survival advantage to using lenalidomide and dexamethasone doublet over observation in high-risk SMM. In this article, we review the evolving concepts in the diagnosis, risk stratification, and management of SMM.
Are 4-Drug Regimens Here to Stay? Role in Induction and Salvage Therapies
Authors: Richter Joshua , Jagannath Sundar
Published: January 2019

With 10 novel therapies approved across the decade, the multiple myeloma (MM) treatment paradigm continues to evolve in breadth and complexity. The current gestalt of the day has been the emergence of data to support 3-drug combinations over their 2-drug counterparts. Current guidelines and consensus statements support this approach. With the recent incorporation of monoclonal antibodies into the fray of myeloma therapy, we have begun to ask what the roles of 4-drug combinations are in both the upfront and the relapsed and refractory settings. The recent approval of daratumumab in combination with bortezomib, melphalan, and prednisone (Dara-VMP/ALCYONE) supports the role of quadruplet therapy in some patients with newly diagnosed disease who do not plan to proceed toward autologous transplant. There are a number of ongoing studies evaluating this type of strategy in both transplant-eligible and non–transplant-eligible newly diagnosed MM patients and in relapsed and refractory MM patients. Many of these seek to enhance standard-of-care treatments with the addition of monoclonal antibodies. We evaluate the historical and current data supporting the role of quadruplet- versus triplet-based therapies in MM.
Risk-Based Therapeutic Strategies
Authors: Corre Jill , Avet-Loiseau Hervé
Published: January 2019

Although therapeutic strategies have been adapted to age and comorbidities of myeloma patients for a long time, all patients currently experiment the same treatment whatever their genomic risk. However, high-risk patients should benefit right now from the most efficient drugs combinations. Herein, we review and discuss how to optimally define risk to adapt treatment and why a modern multiparametric definition of genomic risk is urgently needed. Minimal residual disease status will probably also take a growing place in patient's management, including in treatment adaptation. We also discuss how next-generation sequencing will definitively represent an essential tool to manage risk-based therapeutic strategies. Finally, despite an explosive knowledge of myeloma molecular landscape, targeted therapy perspectives remain poor, with only few exceptions.
Postoperative Outcomes in Obese Patients That Undergo Ventral Hernia Repair versus Ventral Hernia Repair with Concurrent Panniculectomy
Authors: Diaconu Silviu C. , McNichols Colton H. L. , AlFadil Sara , Liang Yuanyuan , Bai Jennifer , Silverman Ronald P. , Grant Michael P. , Nam Arthur J. , Rasko Yvonne M.
Published: January 2019

Background:

The safety of concurrent panniculectomy during ventral hernia repair remains a widely debated topic. This study aims to compare outcomes in obese patients who undergo ventral hernia repair with concurrent panniculectomy versus ventral hernia repair alone.

Methods:

An 8-year retrospective cohort study was performed on obese patients who underwent ventral hernia repair. Patients were divided into those who underwent concurrent panniculectomy and those who did not. Postoperative complications were compared between these groups.

Results:

A total of 223 patients were analyzed: 122 in the ventral hernia repair with concurrent panniculectomy group and 101 in the ventral hernia repair–only group. Median follow-up duration was 141 days. Patients in the ventral hernia repair with concurrent panniculectomy group had more surgical-site occurrences (57 percent versus 40 percent; p = 0.012). Both groups had similar rates of surgical-site occurrences that required an intervention (39 percent versus 31 percent; p = 0.179) and similar rates of hernia recurrence (23 percent versus 29 percent; p = 0.326). Multivariate analysis showed that concurrent panniculectomy increased the risk of surgical-site occurrences by two-fold; however, it did not increase the risk of surgical-site occurrences that required an intervention.

Conclusions:

The addition of a panniculectomy to ventral hernia repair increases surgical-site occurrences but does not increase complications that require an intervention. As such, ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation and the lifestyle benefits of a panniculectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Intramedullary Screw Fixation of Metacarpal Fractures Results in Excellent Functional Outcomes: A Literature Review
Authors: Beck Christina M. , Horesh Elan , Taub Peter J.
Published: January 2019

Background:

Intramedullary fixation of a comminuted subcapital metacarpal fracture using a headless compression screw was first described in 2010. The purpose of this study was to identify and evaluate all studies reporting clinical outcomes of intramedullary screw fixation of metacarpal fractures.

Methods:

A comprehensive search of the literature was performed under Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify all relevant studies. Outcome measures included mean follow-up, evidence of radiographic union, functional outcomes, and quality-of-life measures.

Results:

Nine articles for a total of 169 metacarpal fractures were identified. Average patient age was 32 years; 86.5 percent of the patients were men; and the majority of fractures occurred in the small finger (74 percent). Most fractures occurred in the neck (n = 66), followed by shaft (n = 31) and head (n = 10). The average follow-up was 11 months, with an average metacarpophalangeal joint flexion of 86 degrees (n = 83) and digit total active motion of 251 degrees (n = 72). Radiographic union was achieved in 100% of reported cases (n = 132) at or before the latest follow-up. Grip strength in four studies showed an average of 96 percent compared to the contralateral hand. No serious complications were reported. Nine minor complications were reported, including four cases of hardware removal in asymptomatic patients.

Conclusion:

The review of the literature suggests intramedullary fixation of metacarpal neck and shaft fractures using headless compression screws has thus far proven to be a safe and successful surgical treatment option resulting in excellent clinical outcomes.
Skin and soft tissue infections after breast surgery
Authors: Corcione Silvia , Lupia Tommaso , De Rosa Francesco G.
Published: January 2019

Purpose of review

Breast surgery is considered a clean surgical procedure; nevertheless, infection rates are often higher than those reported after other similarly considered clean surgeries (e.g., thyroid, hernia). Acute bacterial skin and soft tissue infections, mostly surgical site infections and implant-associated infections are commonest events that could complicate postoperative care.

Recent findings

Risk of infection is closely related to surgery procedure itself and patients host factors. Gram-positive bacteria with pattern of antimicrobial resistance are increasingly isolated and before today less frequent causes such as gram negative and mycobacteria infections. Impact of postoperative complications is underestimated and lacking an appropriate care and education for local and systemic management.

We report the current evidence on the management of infections after breast surgery. New drugs options for methicillin-resistant Staphylococcus aureus and other gram positive should have a place in this setting. Stewardship activities aiming at reducing infections risks with the correct considerations of host, microbiological and surgical risk factors.
Ultrashort Time to Echo Magnetic Resonance Evaluation of Calcium Pyrophosphate Crystal Deposition in Human Menisci
Authors: Finkenstaedt Tim , Biswas Reni , Abeydeera Nirusha A. , Siriwanarangsun Palanan , Healey Robert , Statum Sheronda , Bae Won C. , Chung Christine B.
Published: January 2019

Objectives

In human menisci, we aimed to investigate whether calcium pyrophosphate crystal deposition (CPPD) affects biomechanical and quantitative MR properties, and their zonal distribution.

Materials and Methods

From 9 cadaveric knees, sectioned triangular meniscus pieces were harvested. Samples were classified into “normal” or “CPPD” groups based upon visual inspection. Micro computed tomography scan verified CPPD. Using magnetic resonance imaging, ultrashort echo time (UTE) T2* and spin echo (SE) T2, quantitative values in 3 zones (red, red-white, and white) were determined. Using biomechanical test, indentation forces in the same zones were determined. Effects of CPPD and meniscal zone on indentation force and quantitative MR values were compared.

Results

On UTE MRI scans, CPPD-affected menisci exhibited punctate dark regions, found mostly (92%) in avascular white and red-white zones. Indentation forces were significantly higher for CPPD samples in the red-white (all P < 0.02) and white (all P < 0.004) zones but not in the vascular red zone (all P > 0.2). Similarly, UTE T2* red zone values were similar between both groups (~6.6 milliseconds, P = 0.8), whereas in the red-white and white zones, CPPD samples had significantly lower values (~5.1 milliseconds, P = 0.005 to 0.007). In contrast, SE T2 values showed no difference with CPPD (P = 0.12 to 0.16). UTE T2*, but not SE T2, correlated significantly with indentation force (R = −0.29, P = 0.009).

Conclusions

Dark CPP deposits were detectable on UTE images featuring high signal intensity from surrounding meniscal tissue. Preliminary results indicate that CPP deposits were almost exclusively found in the avascular zones. Compared with normal, CPPD menisci featured higher indentation stiffness and lower UTE T2* values in the affected zones.
Transcutaneous Electrical Nerve Stimulation on Acupuncture Points Improves Myofascial Pain, Moods, and Sleep Quality
Authors: Chiou Yar-Fang , Yeh Mei-Ling , Wang Yu-Jen
Published: January 2019

Purpose

The aim of this study was to evaluate the effects of transcutaneous electrical nerve stimulation at acupuncture points versus trigger points on myofascial pain, moods, and sleep quality.

Design

A randomized controlled study recruited 64 patients with spinal cord injury with myofascial pain.

Methods

Outcomes of pain, moods, and sleep quality were measured and analyzed by the generalized estimation equation, analysis of covariance, and paired t test. Transcutaneous electrical nerve stimulation was applied for seven consecutive days at Hegu (LI4) and Daling (PC7) acupuncture points or myofascial trigger points.

Finding

Significant differences were found in pain intensity from Day 3 forward, after controlling for confounders. Significant within-group differences were found in pain, moods, and sleep quality.

Conclusions

Transcutaneous electrical nerve stimulation at acupuncture and trigger points effectively improved pain, moods, and sleep quality in patients with spinal cord injury with myofascial pain. Acupuncture points had superior improvement in pain intensity and slight improvement in sleep quality than did trigger points.

Clinical Relevance

Transcutaneous electrical nerve stimulation at acupuncture points could be applied for improving myofascial pain.
The Reliability and Validity of the Korean Short Version of the Stroke-Specific Quality of Life Scale
Authors: Yoon Susie , Kim Sung Reul , Kim Hye Young , Yoo Sung-Hee , Choi Jay Chol
Published: January 2019

Purpose

The aim of this study was to assess the reliability and validity of the Korean short version of the Stroke-Specific Quality of Life Scale (SS-QoL-12K).

Design

A descriptive, cross-sectional design was used.

Methods

We recruited 233 outpatients with ischemic stroke.

Findings

The Cronbach’s alpha coefficients for internal consistency was .93, and the test–retest reliability value was .98. Confirmatory factor analysis identified two dimensions for the SS-QoL-12K. The SS-QoL-12K was correlated positively with the 36-Item Short Form Health Survey score and Instrumental Activities of Daily Living and negatively with the modified Rankin Scale score. The SS-QoL scores in the National Institutes of Health Stroke Scale mild group were higher than those in the National Institutes of Health Stroke Scale moderate and severe groups.

Conclusions

This study shows that the SS-QoL-12K has a satisfactory level of reliability and validity in patients with ischemic stroke.

Clinical Relevance

This instrument will be helpful in advancing research and clinical care for stroke patients.
Constructing Recovery Narratives: Experiences and Expectations Following Spinal Cord Injury
Authors: Bender Alexis A. , Burgess Elisabeth O.
Published: January 2019

Purpose

This study aimed to explore how married individuals construct narratives following spinal cord injury (SCI).

Design

Prospective qualitative study.

Methods

Eighteen married people with SCI were recruited during inpatient hospitalization. In-depth interviews were conducted at approximately 1, 4, and 7 months post-SCI. Interviews were analyzed using thematic analysis.

Findings

Participants constructed three primary narrative types (optimistic, anxious, and stability) about their trajectories following SCI, focusing on their expectations about recovery and their past and current experiences with their spouse, peers, and health professionals. These narrative types are the foundation for understanding how people make sense of the rehabilitation experience in relation to others.

Conclusions

Findings provide an initial understanding of how expectations of life with SCI as well as social interactions in the healthcare setting influence experiences of injury and recovery.

Clinical Relevance

Findings can inform future interventions during SCI rehabilitation to ease transitions and decrease anxiety following SCI.
Prepectoral Wise-Pattern Staged Implant-Based Breast Reconstruction for Obese or Ptotic Patients
Authors: Thuman Jenna , Freitas Alessandrina M. , Schaeffer Christie , Campbell Chris A.
Published: January 2019

Introduction

The obese or ptotic breast demonstrates significant difficulty in breast reconstruction after mastectomy with increased rates of perioperative complications compared with the general population, regardless of reconstruction type. Implant-based reconstruction in this patient population with the traditional horizontal elliptical skin-sparing mastectomy tends to have aesthetically displeasing qualities secondary to skin flap redundancy and blunting of the breast contour. Wise-pattern closures have been described with submuscular direct-to-implant and 2-stage reconstructions, with more favorable complication profile when staged. Our study aims to report outcomes and safety of a prepectoral 2-stage wise-pattern closure technique in the obese and/or ptotic population.

Methods

A retrospective chart review was performed to identify all overweight, obese, and/or grade III ptotic patients who have undergone a 2-stage, wise-pattern skin closure with prepectoral placement of tissue expander by a single surgeon. Patient demographics, comorbidities, and perioperative descriptors were reported. Delayed wound healing, infection, seroma formation, and explantation or reoperation were recorded for each patient involved in the study.

Results

Thirty-seven obese and/or ptotic breasts among 21 patients underwent immediate prepectoral tissue expander placement with wise-pattern skin reduction closure with mean body mass index of 35.3 kg/m2, and 25% of patients were diabetic The most common complication rates by breast were seroma formation (50%) and wound/dehiscence at T-point (28.6%), which all ultimately healed with intervention as described. One major (2.7%) and 1 minor (2.7%) infection were successfully treated with antibiotics. There were no cases of implant exposure. Two operative complex repairs and 1 elective explantation were performed. Diabetes and increasing body mass index were statistically associated with an increased overall perioperative complication rate.

Conclusions

Prepectoral, 2-stage breast reconstruction with wise-pattern skin reduction performs well in obese and/or ptotic patients with favorable rates of perioperative complications. Wound dehiscence was prevalent but managed with wound care when complex repair was not required to expedite adjuvant chemotherapy. Infection rates and reoperation rates were low, and all patients reported positive aesthetic results at the completion of reconstruction.