One-Year Efficacy and Safety of Proton-Beam Irradiation Combined with Intravitreal Conbercept for Refractory or Recurrent Polypoidal Choroidal Vasculopathy: A Pilot Study

Introduction

To investigate the efficacy and safety of proton-beam irradiation (PBI) combined with intravitreal conbercept (IVC) injection for refractory or recurrent polypoidal choroidal vasculopathy (PCV).

Methods

A prospective interventional clinical trial included 12 patients with refractory PCV (defined as persistent exudation or fluid after six consecutive injections at monthly intervals and/or photodynamic therapy) or recurrent PCV (defined as new exudative signs after six monthly injections and/or photodynamic therapy) treated between January 2019 and September 2020. Every patient underwent single PBI (14 GyE) with concomitant IVC (0.5 mg) within 1 week and further doses of IVC were administered pro re nata.

Results

By the 12-month follow-up, the subretinal fluid was completely absorbed in 9 eyes (81.8%). The angiographic regression and closure rates of the polyps were 60% (12/20) and 90% (18/20), respectively. The mean number of IVC injections was 3.1 ± 1.37. The mean BCVA improved by 20 letters (P = 0.006). The mean central macular thickness (CMT) decreased from 476.50 ± 123.63 μm to 317.70 ± 89.34 μm (P = 0.004). The areas of branching vascular networks and polyps decreased by 37.2% and 72.3%, respectively. Radiation retinopathy was observed in five eyes, but no systemic adverse events were observed.

Conclusion

PBI combined with IVC appears to promote polyp regression and closure, reduce CMT, and improve BCVA, with a favorable safety profile, after 12 months. Therefore, PBI may be a useful adjuvant therapy for patients with refractory or recurrent PCV.

Trial Registration

Proton-Beam Irradiation Combined with Intravitreal Conbercept for Refractory or Recurrent Polypoidal Choroidal Vasculopathy: Prospective Phase II Clinical Study (ChiCTR2000038987).

Recurrent Cervical Spontaneous Spinal Epidural Hematoma with Conservative Management: A Case Report

Cervical spontaneous spinal epidural hematoma (CSSEH) is a rare condition that can be potentially fatal if not properly diagnosed and managed. While prompt surgical decompression and evacuation of the hematoma are generally considered as the first line of treatment, mild cases that were managed through observation and conservative treatment have been reported. Our patient was a 24-year-old man who experienced two CSSEH events 8 months apart, both of which were managed conservatively. This was a rare case of recurrent CSSEH in which recovery was achieved without surgical intervention. We believe conservative treatment with close observation may be effective in CSSEH patients presenting with mild neurologic symptoms who have a tendency towards spontaneous neurologic improvement.

The effect of radiation therapy and chemotherapy on malignant craniopharyngioma: A review

Background

Malignant craniopharyngioma is a rare tumor with few published case reports. It can form de novo or transform from a benign variant and is associated with a dismal survival rate. We reviewed the literature for all published cases and studied the effect of radiation on the rate of malignant transformation. We analyzed the effect of chemotherapy on survival.

Methods

We used various search engines to locate literature from 1980 onward and identified 31 case reports, one of which was excluded. Statistical analysis using the SAS software was conducted, and a significant value was identified if P < 0.05.

Results

There was equal distribution among male and female patients. The average age at malignant diagnosis is 31.11 years (±15.16) and 12.19 years (±8.41) for the average interval of benign tumor progression to malignancy. The most common clinical presentation was visual loss and/or field deficits in 26/30 patients (86%). Almost 11/30 patients (37%) had endocrinological deficits, with panhypopituitarism as the most common in 8/11 patients (73%). Fifteen patients received radiation before malignant transformation (47%) and demonstrated no effect on malignant transformation (P = 0.379). Gross total resection was achieved in 2/30 patients. The average time to mortality postoperatively is 5.3 months ± 4.3. Ten patients received chemotherapy, and five were alive at last follow-up (P = 0.115).

Conclusion

Malignant craniopharyngioma carries a dismal prognosis with no apparent benefits of radiation therapy and chemotherapy on survival.

Recurrent primary pyogenic ventriculitis in an adult woman: a case report

Background

Recurrent primary pyogenic ventriculitis has not been reported previously. We present a unique case of recurrent primary pyogenic ventriculitis in an adult. And we believe that our study makes a significant contribution to the literature.

Case presentation

An adult woman with uncontrolled diabetes experienced two episodes of pyogenic ventriculitis caused by Escherichia coli over 4 years. She had typical imaging features, and the source of infection was undetermined. After antibiotic treatment, she recovered fully.

Conclusions

Early recognition and therapy will improve patient prognosis.

Pleural hemangioma: A case report and review of the literature

A middle-aged female with history of multinodular goiter, Hashimoto disease, and chronic vitamin B12 deficiency presented with palpitations and subsequent exertional dyspnea. Initial radiographic analysis suggested mediastinal cavernous hemangioma, but biopsy showed features consistent with pleural hemangioma. Pleural hemangioma should be considered among the differential diagnoses for recurrent unilateral pleural effusion. Pleural hemangioma should be distinguished from other more common entities including the similarly benign pulmonary hemangioma and the more aggressive pleural hemangioendothelioma.

Prevalence and associated risk factors of recurrent otitis media with effusion in children in Upper Egypt

OBJECTIVE

We conducted this study to determine the associations of possible risk factors and prevalence of recurrent otitis media with effusion (OME) in a cohort of children in Upper Egypt.

METHODS

This was a cross-sectional study undertaken in two tertiary referral centers in Upper Egypt. Associations of possible risk factors with prevalence of recurrent OME were studied. Multi-factor logistic regression analysis was done to recognize the statistically significant risk factors associated with recurrent OME.

RESULTS

We collected the data of 2003 pediatric patients, of which 1016 were males (50.7%). A total number of 310 children have OME, including 159 males (51.3%). The prevalence rate of OME in our cohort was 15.5%. Multi-factor logistic regression analysis of the risk factors related to recurrent OME showed it was strongly associated with adenoid hypertrophy (P < 0.0001), tonsil hypertrophy (P < 0.0001), sinusitis (P < 0.0001), posterior nostril polyps (P = 0.009), allergic rhinitis (P < 0.0001), recurrent URTIs (P = 0.029) and gastroesophageal reflux (P = 0.031).

CONCLUSIONS

Our study showed that recurrent OME in children in Upper Egypt is a common multifactorial problem, especially in young age. In our locality, allergic rhinitis, recurrent upper respiratory tract infections, gastroesophageal reflux, adenoid and tonsil hypertrophy were the most important associated factors related to the etiopathogenesis of OME.

Bell’s palsy after inactivated COVID-19 vaccination in a patient with history of recurrent Bell’s palsy: A case report

BACKGROUND

With rapid and extensive administration of inactivated coronavirus disease 2019 (COVID-19) vaccine to the general population in China, it is crucial for clinicians to recognize neurological complications or other side effects associated with COVID-19 vaccination.

CASE SUMMARY

Here we report the first case of Bell’s palsy after the first dose of inactivated COVID-19 vaccine in China. The patient was a 36-year-old woman with a past history of Bell’s palsy. Two days after receiving the first dose of the Sinovac Life Sciences inactivated COVID-19 vaccine, the patient developed right-side Bell’s palsy and binoculus keratoconjunctivitis. Prednisone, artificial tears and fluorometholone eye drops were applied. The patient’s symptoms began to improve by day 7 and resolved by day 54.

CONCLUSION

As mRNA COVID-19 vaccine trials reported cases of Bell’s palsy as adverse events, we should pay attention to the occurrence of Bell’s palsy after inactivated COVID-19 vaccination. A history of Bell’s palsy, rapid increase of immunoglobulin M and immunoglobin G-specific antibodies to severe acute respiratory syndrome coronavirus 2 may be risk factors for Bell‘s palsy after COVID-19 vaccination.

The risk of preterm birth in women with history of short cervix delivering at term in the previous pregnancy: a retrospective cohort study

PURPOSE

To investigate whether women with a short cervical length (CL), but delivered at term in the first pregnancy might have increased risks of having short cervix and spontaneous preterm birth (sPTB) in the subsequent pregnancies.

METHODS

This is a retrospective cohort study including singleton gestations who were delivered between Jan 2011 and Dec 2018, who had had one childbirth experience and who had transvaginal sonographic CL assessment performed at mid-trimester (18 ~ 30 weeks) in both pregnancy. The women were divided into four group according to the history of preterm birth and a short cervix (< 25 mm before 30 weeks of gestation): (1) the Preterm-short cervix group, (2) the Preterm-no shortening group, (3) the Term-short cervix group, and (4) the Term-no shortening group. We compared the risk of having short cervix and sPTB during the second pregnancy of women. Secondary outcomes were threatened preterm labor, need for tocolytics, and cerclage placement.

RESULTS

A total of 804 women met our inclusion criteria. The rate of having short cervix (< 25 mm before 28 weeks of gestation) during the second pregnancy in women in the Term-short cervix group (43.2%) was significantly higher than those in women in the Term-no shortening group (6.6%), and in the Preterm-no shortening group (8.8%) (all p < 0.001 with Bonferroni correction), but not higher than those in women with the Preterm-short cervix group (30.8%, p > 0.05 with Bonferroni correction). When compared with women in the Preterm-no shortening group, women in the Term-short cervix group were also at an increased risk of need for need of tocolytics (60.2% vs. 26.5%) and cerclage placement (15.9% vs. 6.1%, all p < 0.001). Women in the Term-short cervix group had an increased risk of sPTB (< 37 weeks) during the second pregnancy, as compared to those in the Term-no shortening group (adjusted odds ratio 5.098, 95% CI 2.107-11.874).

CONCLUSION

Women with a history of short cervix in their first pregnancy, but who delivered at term, were at increased risk of having a short cervix and sPTB in their second pregnancy, as compared to women with a history of term delivery without cervical shortening. Thus, short cervix of the previous pregnancy might be a predictive factors for preterm birth in the subsequent pregnancy.

Add-on interventions for the prevention of recurrent Clostridioides Difficile infection: A systematic review and network meta-analysis

OBJECTIVES

We aimed to assess the comparative efficacy and safety of adjunctive interventions for the prevention of Clostridioides difficile recurrence.

METHODS

We searched Medline, Embase, CENTRAL, and clinicaltrials.gov up to May 2021. We included randomized controlled trials comparing interventions added to antibiotic therapy for prevention of CDI recurrence, to placebo or each other. Efficacy outcomes were CDI and diarrhea recurrence. Safety outcomes included the incidence of any adverse event (AE), serious AEs, and discontinuation due to AEs. We performed random-effects network meta-analysis. We ranked interventions based on SUCRA (surface under the cumulative ranking curve) probabilities. We assessed confidence in estimates utilizing the CINeMA (Confidence in Network Meta-Analysis) framework.

RESULTS

Fifteen trials (3909 patients) assessed 9 interventions. Oligofructose (OR 0.17; 95% CI, 0.07 to 0.46), NTCD-M3 (OR 0.29; 95% CI, 0.12 to 0.68), rifaximin (OR 0.47; 95% CI, 0.24 to 0.93), RBX2660 (OR 0.47; 95% CI, 0.22 to 0.99), the combination bezlotoxumab/actoxumab (OR 0.47; 95% CI, 0.37 to 0.60), and bezlotoxumab (OR, 0.53; 95% CI, 0.42 to 0.68) were associated with lower incidence of CDI recurrence than placebo (moderate confidence). Oligofructose was ranked highest, however data for oligofructose were derived solely from one small trial. Probiotics, actoxumab and SER-109 were not superior to placebo (low confidence). Probiotics were not well tolerated (low confidence) and actoxumab showed high rates of serious AEs (moderate confidence).

CONCLUSION

Add-on treatment with oligofructose, NTCD-M3 spores, rifaximin, RBX2660, and bezlotoxumab likely reduces the risk of CDI. Evidence on probiotics and SER-109 are uncertain, thus adequately powered trials are warranted.

Recurrent and Spontaneous Release of Epiretinal Membrane in a Toddler

We report a case of an epiretinal membrane (ERM) in a 3-year-old girl, which was accidently discovered after a strabismus surgery. The ERM occurred twice in 2 years and spontaneously released within 3 months, which has not been previously reported.

Role of ultrasound in the diagnosis of primary and recurrent dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is a rare, low- to intermediate-grade sarcoma, which represents a diagnostic imaging challenge. This study aimed to analyze the clinical and ultrasound features of primary and recurrent DFSP to improve the diagnosis.

METHODS

Clinical, imaging, and pathological data from a total of 58 patients (23 patients with primary DFSP and 35 patients with recurrent DFSP) were retrospectively reviewed.

RESULTS

There was no statistically significant difference in age, sex, tumor size, or echogenicity between the two groups. Most of the primary DFSP lesions involved the overlying dermis and hypodermis, while most of the recurrent DFSP lesions were fixated to more deeply seated structures at the original surgical incision. Red nodules on the skin were found more frequently in the primary group. There were statistically significant differences in the type of lesion and ultrasound tumor morphology (p < 0.050). The lesions in the primary group showed more tentacle-like projections or a "claw" sign, while the lesions in the recurrent group were more commonly oval, lobulated, and irregularly shaped. Hypervascularity was common in both groups.

CONCLUSIONS

For primary DFSP, a slow-growing, red nodule on the skin involving the overlying dermis and hypodermis, more frequently a hypoechoic mass with tentacle-like projections or a "claw" sign, was observed. For recurrent DFSP, palpable subcutaneous nodules or subcutaneous masses at the original surgical incision and oval, lobulated, and irregularly shaped lesions were more commonly observed. This may be useful for improving diagnostic accuracy.

Clinical characteristics and radiological domains among patients with recurrent strokes-a descriptive cross-sectional study from a tertiary care center in central Nepal

BACKGROUND

Stroke is a significant global health hazard that ripples continuum multi-spectral effects to the patients as well their caretakers.   Methods: We studied 28 consecutive cohorts of patients with recurrent strokes managed in our centre within the last two years.  Results: The most common recurrence stroke pattern was of that of hemorrhagic to hemorrhagic subtype observed in 50% of the patients. The most common anatomical region of involvement was cortical - cortical seen in 39.28% of our cohorts. The surgical intervention was required in 17.85% whereas 42.85% of them were managed conservatively. Paradoxically, 39.28% of patients left against medical advice. The receiver operating curve (ROC) predicting mode of management was highest (area under the curve (AUC) =0.635) for compliance to therapy followed by stroke territory (AUC=0.578), age (AUC=0.457) and motor grading (AUC=0.374). The receiver operating curve (ROC) for influencing decision to leave against medical advice was highest (area under the curve (AUC) =0.861) for motor score followed by sex (AUC=0.701) and age (AUC=0.564). The analysis of variance (ANOVA) study pertaining to the mode of management was significantly connoted by the motor score and the stroke territory only. The ANOVA study pertaining to the decision to leave against medical advice was significantly governed by the motor score, stroke territory, and sex respectively. The multivariate analysis for variables governing mode of management was significant for motor score and the stroke territory only. The multivariate analysis for variables governing leave against medical advice was significant for sex, motor score and the stroke territory.  Conclusions: This study aims to appraise early dichotomization of high-risk patients for recurrent strokes to reduce the continuum of neurological events as well as to mitigate the financial aspects governing stroke care.

Recurrent Auricular Pseudocyst: Successful Treatment Using a Dental Silicon Cast

Auricular pseudocysts (APs) are benign intercartilaginous cysts at the auricle. Various therapeutic options have been used to treat APs, but they frequently recur in usual clinical practice. Here, we report a case of AP successfully treated using a silicon cast. A 65-year-old male presented with a cyst on his right auricle. Although a local injection of steroid was administered, the cyst had recurred. A dental silicon cast was applied after removal of the contents of the cyst by suction. There was no recurrence of the cyst 6 years after that treatment. Dental silicon casts are a novel technique for an appropriate fixation over auricles in the treatment of APs and had an effective therapeutic result in our case.

Recurrent COVID-19 infection in a health care worker: a case report

Background

Recurrent coronavirus disease 2019 (COVID-19) infection is an emerging problem and may prove to be one of the greatest problems in controlling the pandemic in the future. Recurrent infections can be due to reactivation of dormant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or reinfection with similar or different strains of SARS-CoV-2.

Case presentation

Here we present an interesting case of a health care worker working as a laboratory assistant at a COVID-19 laboratory who developed recurrent COVID-19 infection. He did not develop an immune response after the first episode of COVID-19; however, immunoglobulin G (IgG) antibodies were detected after the second episode.

Conclusions

Through this case, we discuss the concept of reactivation and reinfection in the post-COVID period. We suggest that standard guidelines should be established to check for viral shedding and immune response among cured cases of COVID-19 after discharge via serial real-time polymerase chain reaction (RT-PCR) testing and IgG antibody detection. Further, strict hygiene practices should be stressed to these patients with possibility of COVID-19 recurrence.

Mapping patterns of para-aortic lymph node recurrence in cervical cancer: a retrospective cohort analysis

BACKGROUND

To map anatomic patterns of para-aortic lymph node (PALN) recurrence in cervical cancer patients and validate currently available guidelines on PA clinical target volumes (CTV).

METHODS

Cervical cancer patients who developed PALN recurrence were included. The PALNs were classified as left-lateral para-aortic (LPA), aorto-caval (AC), and right para-caval (RPC). Four PA CTVs were contoured for each patient to validate PALN coverage. CTV_RTOG was contoured based on the Radiation Therapy Oncology Group guideline. CTV_K was contoured as proposed by Keenan et al. CTV_M was contoured by expanding symmetrical margins around the aorta and inferior vena cava of 7 mm up to the T12-L1 interspace. CTV_new was created by modifying CTV_RTOG to obtain better coverage.

RESULTS

We identified 92 PALNs in 35 cervical cancer patients. 46.8% of the PALNs were at LPA, 38.0% were at AC, and 15.2% were at RPC areas. CTV_RTOG, CTV_K, and CTV_M covered 87.0%, 88.0%, and 62.0% of all PALNs, respectively. PALN recurrence above the left renal vein was associated with PALN involvement at diagnosis (p = 0.043). Extending upper border to the superior mesenteric artery allowed the CTV_new to cover 96.7% of all PALNs and all nodes in 91.4% of patients.

CONCLUSION

CTV_RTOG and CTV_K encompassed most PALN recurrences. For high-risk patients, such as those having PALN involvement at diagnosis, extending the superior border of CTV from the left renal vein to superior mesenteric artery could be considered.

Recurrent skull vault actinomycosis: A case report and review of literature

Actinomycosis is an uncommon cause of central nervous system infection. A case of skull bone osteomyelitis with epidural empyema is presented. A 44-year-old man presented with chronic osteomyelitis of skull vault with epidural and subgaleal collection diagnosed by histopathology as actinomycosis. He had similar lesion at the same site 10 years ago, which was excised completely. Recurrent Actinomycosis of the skull vault is uncommon in literature. This case highlights the importance of considering actinomycosis as a differential diagnosis of tumorous growths and stresses on the importance of tissue histopathology for diagnosis and need for surgery to control the disease. Treatment is prolonged, therefore compliance with the long-term antibiotic duration is essential to prevent complications and avoid recurrence.

Managing Recurrent Metastatic Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) treatment is often associated with high morbidity especially in the recurrent and/or metastatic (R/M) setting, limiting effective treatment options. Local disease control is important. Therefore, local therapies including reirradiation and salvage surgery, either alone or in combination with systemic treatment, may be used for selected patients with R/M HNSCC. Although chemotherapy and targeted agents have modest efficacy in HNSCC, the advent of immunotherapy has revolutionized the treatment paradigm of R/M HNSCC. Multiple trials have resulted in the past 5 years advocating for its use alone or in combination with chemotherapy.

Radiotherapy versus combination radiotherapy-bevacizumab for the treatment of recurrent high-grade glioma: a systematic review

Background

High-grade gliomas (HGG) comprise the most common primary adult brain cancers and universally recur. Combination of re-irradiation therapy (reRT) and bevacizumab (BVZ) therapy for recurrent HGG is common, but its reported efficacy is mixed.

Objective

To assess clinical outcomes after reRT ± BVZ in recurrent HGG patients receiving stereotactic radiosurgery (SRS), hypofractionated radiosurgery (HFSRT), or fully fractionated radiotherapy (FFRT).

Methods

We performed a systematic review of PubMed, Web of Science, Scopus, Embase, and Cochrane databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified studies reporting outcomes for patients with recurrent HGG treated via reRT ± BVZ. Cohorts were stratified by BVZ treatment status and re-irradiation modality (SRS, HFSRT, and FFRT). Outcome variables were overall survival (OS), progression-free survival (PFS), and radiation necrosis (RN).

Results

Data on 1399 patients was analyzed, with 954 patients receiving reRT alone and 445 patients receiving reRT + BVZ. All patients initially underwent standard-of-care therapy for their primary HGG. In a multivariate analysis that adjusted for median patient age, WHO grade, RT dosing, reRT fractionation regimen, time between primary and re-irradiation, and re-irradiation target volume, BVZ therapy was associated with significantly improved OS (2.51, 95% CI [0.11, 4.92] months, P = .041) but no significant improvement in PFS (1.40, 95% CI [− 0.36, 3.18] months, P = .099). Patients receiving BVZ also had significantly lower rates of RN (2.2% vs 6.5%, P < .001).

Conclusions

Combination of reRT + BVZ may improve OS and reduce RN rates in recurrent HGG, but further controlled studies are needed to confirm these effects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04794-3.

Recurrent adamantinoma metastatic to the spine: Clinical and imaging considerations

Metastatic adamantinoma involving the spine is an extremely rare occurrence. In this case report, we present a patient with recurrent adamantinoma of the tibia which was found to have metastasized to the spine. The metastatic involvement was diagnosed pathologically, status post CT guided percutaneous core needle biopsy, performed after the patient returned with concerning symptoms and imaging findings suggestive of metastasis. The patient was ultimately treated surgically with vertebrectomy and reconstruction. A thoughtful review of this disease process is explored, emphasizing the pathology, imaging characteristics, and pertinent differential diagnostic considerations. While uncommon, knowledge of this rare disease process and its presentation can improve future patient diagnosis and outcomes.

Efficacy and safety of intravenous administration of high-dose selenium for preventing chemotherapy-induced peripheral neuropathy in platinum-sensitive recurrent ovarian, fallopian or primary peritoneal cancer: study protocol for a phase III, double-blind, randomized study

Background

The second-line chemotherapy using paclitaxel, carboplatin, and bevacizumab for treating platinum-sensitive recurrent ovarian, fallopian or primary peritoneal cancer frequently cause chemotherapy-induced peripheral neuropathy (CIPN), which is significantly associated with deterioration of quality of life. Despite the potential of some agents to prevent and treat CIPN, and there is still a lack of evidence of the effect. Although selenium has been suggested as an antioxidant candidate to prevent CIPN, there are insufficient data regarding its effect due to its low dose by oral administration. Thus, we hypothesized intravenous administration of high-dose selenium (2,000 µg/day) at each cycle of the second-line chemotherapy would prevent and reduce CIPN in patients with platinum-sensitive recurrent ovarian, fallopian or primary peritoneal cancer.

Method

This trial is an investigator-initiated, phase III, double-blinded, randomized controlled trial to evaluate the efficacy and safety of intravenous administration of high-dose selenium (2,000 µg/day) for preventing CIPN in patients with platinum-sensitive recurrent ovarian, fallopian or primary peritoneal cancer who receive paclitaxel, carboplatin, and bevacizumab. A total of 68 patients will be randomly assigned to the experimental and control groups at a 1:1 ratio. As the primary endpoint, the incidence rate of CIPN three months after six cycles of chemotherapy will be compared between the two groups according to the combined criteria of neuropathy using the World Health Organization-CIPN criteria and Common Terminology Criteria for Adverse Events version 5.0. As secondary endpoints, we will compare adverse events, patient-reported quality of life, and requirement of concomitant drugs for reducing CIPN between the two groups.

Trial Registration

ClinicalTrials.gov Identifier: NCT04201561

Full-Endoscopic Resection of a Recurrent Posterior Longitudinal Ligament Cyst: Technical Note

BACKGROUND

Posterior longitudinal ligament cysts are very rare lesions and do not usually recur. Microscopic resection is commonly performed. The aim of this article was to report a case of recurrent posterior longitudinal ligament cyst that benefited from full-endoscopic resection.

METHODS

We used the 25° endoscope of the RIWOspine set for interlaminar approach. A step-by-step description of the surgical technique was presented.

RESULTS

Clinical evolution was favorable. The patient remained pain-free 1 month after surgery, and postoperative magnetic resonance imaging showed complete resection of the cyst.

CONCLUSIONS

Endoscopy is a safe and feasible approach for posterior longitudinal ligament cysts, including unusual recurrent cases.

Third time recurrent Boerhaave's syndrome: a case report

Background

Effort rupture of the esophagus or Boerhaave’s syndrome is a rare entity, and prognosis is largely dependent on early diagnosis and treatment. Recurrent effort ruptures are very rare, only reported in a few case reports in English literature. We present a case with a third time effort rupture, and to the best of our knowledge there are no such previous publications. Furthermore, the presented case is also distinct because each episode was treated by different methods, reflecting the pathophysiology of recurrent disease as well as the last decade’s advancements in the management of esophageal perforations in our clinic and globally.

Case presentation

The patient is a 60-year-old White male, suffering from alcohol abuse, mild reflux esophagitis, and a history of effort esophageal ruptures on two previous occasions. He was now admitted to our ward once again because of a third bout of Boerhaave’s syndrome. The first time, 10 years ago, he was managed by thoracotomy and laparotomy with primary repair, and the second time, 5 years ago, by transhiatal mediastinal drainage through a laparotomy and endoscopic stent placement. Now he was successfully managed by endovascular vacuum-assisted closure therapy alone.

Conclusions

Recurrent cases of Boerhaave’s syndrome are very rare, and treatment must be tailored individually. The basic rationale is, however, no different from primary disease: (1) early diagnosis, (2) adequate drainage of extraesophageal contamination, and (3) restoration of esophageal integrity. Recurrent disease is usually contained and exceptionally suitable for primary endoscopic treatment. To cover the full panorama and difficult nature of complex esophageal disease, endoscopic modalities such as stent placement and endovascular vacuum-assisted closure, as well as the capacity for prompt extensive surgical interventions such as esophagectomy, should be readily accessible within every modern esophageal center.

Neurocognitive profiles of patients with first-episode and recurrent depression: a cross-sectional comparative study from China

BACKGROUND

Accumulating evidence has shown that cognitive deficits are prevalent among patients with major depressive disorder (MDD). However, the pattern and extent of cognitive deficits in patients with first-episode and recurrent depression remain unclear.

METHODS

Objective measures of cognitive function were assessed in 433 first-episode of depression (FED) patients, 206 recurrent major depression (RMD) patients during the acute phase and 287 healthy controls (HCs). Five domains of cognition (speed of processing, attention, verbal learning, visual learning and execution function) were assessed by seven neuropsychological tests. Neuropsychological data were transformed into T scores according to the Chinese norm.

RESULTS

Both FED and RMD patients displayed deficits of mild-to-medium severity across all cognitive domains and their subtests, relative to HCs (Cohen's d = 0.12-0.62). Among MDD patients, RMD patients exhibited poorer verbal learning (Cohen's d = 0.17) and visual learning (Cohen's d = 0.21) than FED patients.

CONCLUSIONS

MDD patients in the acute phase exhibited broad cognitive impairments, and there were significant differences in verbal and visual learning between FED and RMD patients. Our findings indicate that more attention should be paid to the domains of verbal and visual learning in future screening assessments and targeted interventions.

Impact of number of previous surgeries on the continence state and healing after repeat surgery for recurrent anal fistula

BACKGROUND

The management of recurrent anal fistulas after previous surgery is usually challenging. The present study aimed to review the characteristics and treatment outcomes of recurrent anal fistulas as compared to primary anal fistulas.

METHODS

The records of patients with anal fistula who underwent surgery were reviewed. Characteristics and treatment outcomes of patients with recurrent anal fistulas were compared to those of patients with primary anal fistula without a history of surgery.

RESULTS

The study included 138 patients with recurrent anal fistulas, 76.8% of which were complex. Failure of healing was recorded in 25 (18.1%) patients and fecal incontinence (FI) in 9 (6.5%). Patients with recurrent anal fistulas had significantly higher percentage of anterior, complex, and horseshoe fistulas than patients with primary fistulas. Surgery for recurrent anal fistulas was followed by a significantly higher rate of failure of healing than primary fistulas (18.1% vs. 9.8%, P=0.011), whereas the rates of FI were comparable amongst the two groups (6.5% vs. 2.8%, P=0.07). Patients who had more than two previous operations for anal fistula had a significantly higher rate of FI than patients who underwent one or two previous surgeries (20% vs. 3.7% vs. 14.3%, P=0.04), yet healing rates were comparable.

CONCLUSION

Recurrent anal fistulas were more complex than primary fistulas. Surgical treatment of recurrent anal fistula was followed by a significantly higher rate of failure of healing and similar rate of FI as compared to primary anal fistulas. The number of previous fistula surgeries had a significant effect on postoperative continence state.

[Channel-assisted fixation and interbody fusion in treating recurrent lumbar disc herniation by muscle-splitting approach]

OBJECTIVE

To explore the clinical value and safety of unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation and interbody fusion by muscle-splitting approach treatment of recurrent lumbar disc herniation.

METHODS

The clinical data of 51 patients with recurrent lumbar disc herniation treated from June 2012 to December 2017 were retrospectively analyzed. There were 32 males and 19 females, aged 34 to 64 years with an average of (51.11± 7.28) years. Lesions invoved L_4,5 in 38 cases and L₅S₁ in 13 cases. All patients had a history of lower back pain and radiation pain of lower limbs(3 bilateral and 48 unilateral)and underwent unilateral pedicle screw combined with contralateral translaminar facet screw fixation and interbody fusion, among which 24 patients were treated through median incision approach (median incision group);other 27 patients were treated through muscle-splitting approach with channel-assisted exposure(muscle-splitting approach group). Operation time, intraoperative blood loss, postoperative drainage and incision length of the two groups were recorded. Visual analogue scale (VAS) was used to score the pain of lumbar incision at 72 h after operation, and JOA low back pain scoring system was used to evaluate the lumbar function preoperatively and at final follow-up. Imaging data were analyzed, including the changes in the height of intervertebral space of diseased segment before operation, 3 to 5 days after operation, and at final follow-up;Cobb angle changes in the coronal and sagittal planes of lumbar spine preoperatively and at final follow-up;multifidus area and multifidus fatty tissue deposition grade before and 12 months after operation; postoperative pedicle screw and laminar process screw position and intervertebral fusion condition. The complications of the two groups were compared.

RESULTS

There was no statistical difference in operation time between two groups (P>0.05). Muscle-splitting approach group was better than median incision group in light of incision length, intraoperative blood loss and postoperative drainage volume (P<0.05). VAS score of lumbar incision pain at 72 h after operation was 1.61±0.54 in median incision group and 0.76±0.28 in muscle-splitting approach group(P<0.05). All patients were followed up for 12 to 84 (43.50±15.84) months. At final follow-up, the JOA scores of the two groups were significantly improved compared with those before operation(P<0.05). The rate of pedicle screw malposition was 6.25%(3/48) in medianincision group and 9.26%(5/54) in muscle-splitting approach group, there was no statistically significant difference between two groups (P>0.05). Rate of translaminar facet screw malposition in median incision group (12.50%) was significant less than the muscle-splitting approach group (18.52%)(P< 0.05). The height of the intervertebral space of the two groups was significantly restored 3 to 5 days after operation (P<0.05), and there was also a significant loss of height at final follow-up (P<0.05). At final follow-up, the balance of lumbar coronal plane and sagittal plane in two groups were improved very well (P<0.05). The comparison of the area and grade of the multifidus muscle in two groups 12 months after operation showed that obvious damage to the multifidus muscle were present in the median incision, while the multifidus muscle was less damaged by muscle-splitting approach (P<0.05). The fusion rate was 91.7%(22/24) in the median incision group and 92.6%(25/27) in muscle-splitting approach group(P>0.05). In median incision group, there were 1 case of intraoperative pedicle entry point fracture, 1 case of intraoperative dural tear and 1 case of postoperative nerve root injury;in muscle-splitting approach group, there were 1 case of intraoperative pedicle entry point fracture, 2 cases of intraoperative dural tear, 1 case of postoperative nerve root injury, 2 cases of incision epidermal necrosis and 1 case of poor incision healing. Nerve root injuries in the two groups were caused by incorrect positions of pedicle screws, the screws were immediately adjusted upon discovery. The nerve root symptoms were completely recovered 3 and 6 months after surgery. No incision infection was occurred in two groups. During the follow-up, no pedicle screw and laminar facet screw were loosened, displaced, broken, or intervertebral fusion cage moved forward and backward. The complication rate of 25.93% in muscle-splitting approach group was higher than 12.50% in the median incision group (P<0.05).

CONCLUSION

Muscle-splitting approach is feasible for thetreatment of recurrent lumbar disc herniation with pedicle screw fixation combined with contralateral translaminar facet screw fixation and interbody fusion. Compared with the median incision approach, the muscle-splitting approach has the advantages of small incision, less trauma, less bleeding, rapid recovery. Also it can protect multifidus and do not increase the incidence of serious complications. Thus, it can be used as a choice for fixation and fusion of recurrent lumbar disc herniation.

Gluteus maximus transfer and mass graft (Capsulorraphy) in recurrent hip dislocation with the history of total hip replacement: A case series

•

Post THR dislocation has been a significant complication.

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Four patients operated by soft tissue procedure of gluteus maximus transfer as an abductor replacement and along with capsule augmentation using synthetic mesh as a synthetic capsule to strengthen and provide more stability.

•

The use of mesh in soft tissue procedures, such as capsulorraphy, with the addition gluteus maximus transfer may assist to prevent (re)dislocations of the hip.

Introduction

Post THR dislocation has been a significant complication that interferes with the patient’s life. Detection of risk factors, careful planning, proper operative procedures, and patient education is essential to prevent the incidence of dislocation. Several operative measures have been studied to achieve this, including the use of mesh for soft tissue procedures and capsulorraphy.

Case Presentation

A total of four patients is included in this case series. Two had a history of trauma that contributes to the necessity of the procedure while the other two had degenerative joint issues. All were operated by soft tissue procedure of gluteus maximus transfer as an abductor replacement and along with capsule augmentation using synthetic mesh as a synthetic capsule to strengthen and provide more stability.

Discussion

The abductor strength from this gluteus maximus procedure is sufficient to stabilize the pelvis and prevent pelvic sag. The primary material of the mesh should produce inflammatory reaction so that a fibro capsular structure is formed surrounding the hip joint to add stability.

Conclusion

The use of mesh in soft tissue procedures, such as capsulorraphy, with the addition gluteus maximus transfer may assist to prevent (re)dislocations of the hip. However, further study should be conducted to validate the routine use of mesh and gluteus maximus transfer to prevent dislocation after the procedure.

Idiopathic granulomatous mastitis: challenges of treatment in iranian women

BACKGROUND AND OBJECTIVE

As a chronic inflammatory disease of an unknown origin, the treatment of granulomatous mastitis has always been controversial. According to some researchers, surgical treatment and certain medications, especially steroids, are more effective in treating the disease. This study aimed at evaluating the results of treatment in a group of patients with granulomatous mastitis.

MATERIALS AND METHODS

This longitudinal cohort study evaluated the treatment outcomes of 87 patients with pathology-confirmed granulomatous mastitis referred to the surgical clinic of Central Hospital in Sari, Iran. Demographic, clinical, and pathological information, treatment methods and results, and the recurrence rate were analyzed.

FINDINGS

A total of 87 female patients with granulomatous mastitis aged 22-52 years with a mean age of 34 years were evaluated. All patients had palpable masses; the breast masses were painful in 48.3% of patients, and 55.2% of patients suffered from erythema and inflammation, and8% had fistulas and ulcers at the inflammation site. The patients were followed-up for an average duration of 26 months (8-48 months) after treatment and recovery. The overall recurrence rate was 24.1%, and the recurrence rate was 29.4% in patients underwent surgery, 34.8% in patients received high-dose prednisolone, and 17% in those received low-dose prednisolone together with drainage (p < 0.001).

CONCLUSIONS

According to the results, the low-dose prednisolone plus drainage was more effective with a lower recurrence rate than only surgical excision or high-dose prednisolone. In fact, the use of minimally invasive methods such as drainage plus low-dose steroids is a more effective method with fewer side effects than the other two methods.

Recurrent giant retroperitoneal liposarcoma: Review of literature and a rare case report

Introduction and importance

Retroperitoneal liposarcomas (RPLS) are usually grow large with frequent recurrences. Complete surgical excision remains the gold standard treatment for primary and even recurrent tumours. Their prognosis depends on their histological type and grade. We report a recurrent giant de-differentiated RPLS weighing 18.55 kg which was completely excised. To the best of our knowledge, this is one of the largest liposarcoma reported in the literature.

Case presentation

A 40 year old female presented with a gradually progressing large abdominal lump for 1year. She had had a similar large lump twice in the past and undergone excision of the tumour elsewhere. Firm non-tender mass felt all over abdomen with edema noted over abdominal wall and bilateral lower limbs. PET CT showed large heterogeneously enhancing mass occupying almost the entire abdominopelvic cavity. 50 × 40 × 40cm tumour was completely excised and biopsy showed grade 2 dedifferentiated liposarcoma (DDLS). She is under close follow up with no recurrence at 12months.

Clinical discussion

DDLS have lower risk of distant metastases but have a high risk of local recurrence. The most important favourable prognostic factor in these tumours is complete resection with negative margins. Because of the ineffectiveness of current chemotherapy and the requirement of intolerably high radiation doses, surgical excision remains the most effective treatment even for the localized recurrences of RPLS.

Conclusion

The dedifferentiated subtype should be suspected in locally aggressive RPLS. Close follow up with early detection of recurrences and prompt excision with negative margins lowers the risk of recurrences and improves survival.

Detection and staging of recurrent or metastatic nasopharyngeal carcinoma in the era of FDG PET/MR

PURPOSE

The aim of this pilot study was to evaluate the accuracy of 18 fluorodeoxyglucose (FDG) PET/MR imaging in detection and staging of recurrent or metastatic NPC.

PATIENTS AND METHODS

The PET/MR scans of 60 patients with clinically diagnosed recurrent or metastatic NPC between April 2017 and November 2019 were included in this study. Findings were evaluated according to the eighth edition of the American Joint Committee on Cancer staging system. Final diagnosis was confirmed at biopsy or imaging follow-up for at least 6 months.

RESULTS

Of the 60 patients, 25, 26 and 42 had developed local lesions, regional nodal metastases and distant metastases, respectively. The overall accuracy of PET/MR imaging for staging of recurrent or metastatic NPC was 88.3%.

CONCLUSIONS

For recurrent or metastatic NPC, 18 FDG PET/MRI might serve as a single-step staging modality.

The immunomodulatory effects of vitamin D drops in children with recurrent respiratory tract infections

OBJECTIVE

To investigate the effects of vitamin D drops on immune function in children with recurrent respiratory tract infections (RRTI).

METHODS

The clinical data of 119 children with RRTI in our hospital were retrospectively retrieved, and they were divided into group A (n=59, receiving routine treatment) and group B (n=60, receiving vitamin D drops) based on their treatment modality. The clinical efficacy, symptom disappearance time, immune function index, insulin-like growth factor (IGF-1), 25-hydroxyvitamin D₃ [25-(OH)D₃], serum y-interferon (INF-y), and the number of episodes of respiratory tract infections were compared between the two groups.

RESULTS

The total effective rate of treatment in group B was 96.67%, which was significantly higher than 71.19% in group A (P<0.05). Children in group B had shorter time to disappearance of lung rales, cough, and fever than group A (P<0.05). Group B had higher IgA, IgG, and IgM levels, higher CD4⁺, CD3⁺ levels and lower CD8⁺ levels as well as higher IGF-1, 25-(OH)D₃, INF-y levels, and fewer respiratory infections after treatment than group A (P<0.05).

CONCLUSION

Vitamin D drops are effective in the treatment of children with RRTI, which is beneficial to the improvement of clinical symptoms and immune function.

Giant Darier-Ferrand dermatofibrosarcoma protuberans of the abdomen and pelvis: a case report

Background

Darier–Ferrand dermatofibrosarcoma (DFS) is a rare malignant cutaneous neoplasm characterized by local aggressiveness, high risk of recurrence, and low metastatic potential.

Case presentation

A 60-year-old Tunisian man with recurrent abdominopelvic DFS for which he had undergone multiple excisions presented with an extensive DFS that invaded the external genitals. He underwent a large excision with emasculation and thin cutaneous graft of the abdominal wall and local skin flap in the pelvis.

Conclusion

DFS is a rare yet recurrent skin tumor. Wide excision with free margins remains the cornerstone of treatment. We report a case of a giant DFS treated with wide excision and reconstructive surgery to cover the defect.

Clinical and Imaging Features of Adults with Recurrent Pulmonary Tuberculosis - A Prospective Case-Controlled Study

BACKGROUND

Recurrent pulmonary tuberculosis (RPTB) is a growing, important and neglected problem affecting treated TB patients and TB health services across the world, particularly in sub-Saharan Africa. Analyses and identification of differences in clinical features between recurrent PTB and newly diagnosed PTB may lead to improved management recommendations.

METHODS

Between September 1^st 2019 and January 31^st 2020, we performed a prospective case controlled study of clinical and imaging features of patients with recurrent pulmonary tuberculosis and compared them with those of newly diagnosed PTB cases. Recurrent PTB was defined as a patient with bacteriologically confirmed active PTB who was previously successfully treated for PTB and was cured. A control was defined as a patient who presents for the first time with bacteriologically confirmed PTB. Clinical and radiological features were assessed and documented. Chi-square and t-test were used to test the difference between proportion and continuous data, respectively. Logistic regression analysis was done to determine factors associated with RPTB using SPSS version 23 software.

RESULTS

A total of 312 patients with PTB were enrolled (104 RPTB cases and 208 newly diagnosed controls). Clinically hemoptysis was more common in RPTB compared to controls 28/104 (26.9%) vs 35/208 (16.8%), P = 0.036. Chest pain was significantly less common among patients with RPTB compared to controls 33 (31.7%) vs 92 (44.2%), P = 0.034. A higher proportion of RPTB presented with cavitation 34/104 (32.7%) compared to control 44/208 (21.2%) P = 0.027. The median score for lung pathology was higher among patients with RPTB (50) compared to controls (30); P = 0.001. Lung function of patients with RPTB at diagnosis of index TB were more likely to show mixed restrictive and obstructive pattern 36/104 (34.6%) compared to controls 31/208 (14.9%). p<0.001. Multivariate analysis showed that patients older than 45 years of age (adjusted odds ratio [aOR]: 3.59, 95% CI: 1.38 - 9.32), those with hemoptysis (aOR 1.96, 95% CI: 1.04 - 3.69) p=0.04) and fibrosis on chest x rays (aOR 2.18, 95% CI: 1.16 - 4.10) were significantly associated with recurrent PTB.

CONCLUSIONS

Hemoptysis, lung parenchymal damage, and patients being older than 45 years of age are significant features of RPTB. Management should focus on risk factors for recurrence, and a more holistic model of care to prevent long term lung injury.

Irreversible Electroporation of Recurrent Hepatocellular Carcinoma After Liver Transplantation: Report of Two Cases

The treatment strategies of post-transplant hepatocellular carcinoma (HCC) recurrence have not been completely clarified. Thermal ablative techniques have been increasingly performed for the treatment of post-transplant HCC recurrences. However, thermal ablation can create abnormal communication with the biliary tract and the ablation site by causing biliary injury. This abnormal communication may cause bacterial contamination and abscess formation. Irreversible electroporation (IRE) is a nonthermal ablative technique which may reduce the risk of abscess development at the ablation site due to its low risk of thermal injury to the biliary system. IRE may also preserve the perilesional blood vessels. This report describes two cases of post-transplant intrahepatic HCC recurrence which were successfully treated with IRE.

Efficacy and safety of apatinib in recurrent/metastatic nasopharyngeal carcinoma: A pilot study

BACKGROUND

There is no standard-of-care for recurrent, metastatic nasopharyngeal carcinoma (rmNPC) after first-line chemotherapy. Here, we report the efficacy and safety data of apatinib in rmNPC patients.

METHODS

Thirty-five biopsy-proven rmNPC patients received apatinib at 500 mg/day under a compassionate access programme. Primary end-point was objective response rate (ORR; RECIST v1.1). Kaplan-meier method was used to estimate progression-free survival (PFS) and overall survival (OS). Toxicity was assessed by CTCAE v4.0.

RESULTS

82.9% (29 of 35) of patients had poly-metastatic rmNPC. All patients, except five, were platinum-refractory; 37.1% (13 of 35) received ≥ 2 lines. Median number of apatinib cycles was 4.0 (IQR: 2.0-8.0). ORR was 31.4% (11 of 35 [95% CI: 16.9-49.3]) and disease control rate was 74.3% (26 of 35 [95% CI: 56.7-87.5]); 11 (31.4%) and 4 (11.4%) patients demonstrated response for ≥ 6 and ≥ 12 months, respectively. Median PFS and OS was 3.9 (95% CI: 3.1-5.5) months and 5.8 (95% CI: 4.5-8.0) months, respectively. Among the ≥ 12-month responders, all patients had pre-apatinib EBV DNA titer of <700 (range: 353-622) copies/ml; this was consistent with the association of PFS with pre-apatinib EBV DNA titer (adjusted HR 3.364 [95% CI: 1.428-7.923] for ≥ 4000 copies/ml, P = 0.006). 42.9% (15 of 35) of patients required dose reduction. Nonetheless, only five (14.3%) patients suffered from G3 toxicities (two haematological, one hypertension, one hand-foot syndrome and one elevated aminotransferases).

CONCLUSION

Our data suggests potential efficacy of apatinib in rmNPC patients. Although incidence of severe toxicities was low, dose modification was required in 42.9% of patients.

Recurrent Morel-Lavallée lesion obliterated with povidone iodine, a case report

INTRODUCTION AND IMPORTANCE

A Morel-Lavallee lesion is a closed degloving injury due to traumatic separation of the hypodermis from underlying fascia. Accumulation of hemolymphatic fluid that occurs is a potential habitat for bacteria. Management options include percutaneous aspiration, open debridement, or a non-surgical approach, each with recurrence risk. In the event of recurrence, sclerotherapy is used. In this case report, after reviewing povidone iodine's efficacy in treating seromas, we used it as a sclerosant for recurrent Morel-Lavallee lesion as the more established options were unavailable in our setting.

CASE PRESENTATION

A 49-year-old with no known comorbid presented following a motor traffic accident, with left lateral thigh swelling. He was stable systematically, with a tense, tender left lateral thigh swelling and intact neurovascular assessment distally. X-ray and computed tomography ruled out skeletal and vascular injuries. Magnetic resonance imaging revealed a 580 ml type 1 Morell-Lavallee lesion. Open surgical debridement was done to drain and debride the lesion. He developed two recurrences that necessitated percutaneous aspiration. Doxycycline and talc sclerosants were considered; however, due to their unavailability, povidone iodine was used. It is now five months post-intervention without increased pain, recurrence, or wound complications.

CLINICAL DISCUSSION

Recurrence is hypothesized to be due to the persistence of fluid loculations, unobliterated dead space, and pseudocyst formation. Sclerotherapy stimulates inflammation that results in fibrosis of the cavity walls causing its obliteration. Doxycycline, the most studied sclerosant in Morel-Lavallée lesion has an efficacy of 95.7%.

CONCLUSION

The current report is the first successful use of povidone iodine for sclerotherapy of recurring Morel-Lavallée lesions. Based on povidone iodine experiences as a sclerosant, it is associated with increased analgesic requirements. We cautiously propose its use as an alternative in settings where talc powder and doxycycline powder are unavailable.

Risk factors of recurrent erysipelas in adult Chinese patients: a prospective cohort study

BACKGROUND

Erysipelas is a common skin infection that is prone to recur. Recurrent erysipelas has a severe effect on the quality of life of patients. The present study aimed to investigate the risk factors of recurrent erysipelas in adult Chinese patients.

METHODS

A total of 428 Chinese patients with erysipelas who met the inclusion criteria were studied. The patients were divided into the nonrecurrent erysipelas group and the recurrent erysipelas group. Clinical data were collected on the first episode and relapse of erysipelas. The patients were followed up every 3 months. Statistical analysis was performed to analyze and determine the risk factors of erysipelas relapse.

RESULTS

Univariate analysis was performed to analyze the data, including surgery, types of antibiotics administered in the first episode, obesity, diabetes mellitus, venous insufficiency, lymphedema, and malignancy. The differences between the groups were statistically significant (p < 0.05). The Cox proportional hazards regression model analysis showed that the final risk factors included surgery, obesity, diabetes mellitus, venous insufficiency, and lymphedema.

CONCLUSIONS

Surgery, obesity, diabetes mellitus, venous insufficiency, and lymphedema are considered as risk factors for recurrent erysipelas.

Do palliative embolization in unresectable, unsalvageable recurrent and metastatic head and neck cancer patients help?

BACKGROUND

Bleeding from the unsalvageable recurrent and metastatic head and neck cancer is not an uncommon occurrence. It is extremely distressing for the patients and their family members and also to the treating doctors. One of the ways to manage this crisis is by selective embolization of the bleeding vessel.

METHODOLOGY

In this retrospective study, we audited the patients with unresectable, unsalvageable recurrent and/or metastatic head and neck cancer who underwent selective (palliative) embolization for bleeding at our institute between Jan 2015 and Nov 2019, and assessed its possible benefit in terms of bleeding free interval achieved.

RESULTS

Twenty-six palliative embolization was done during the above mentioned period. The majority were male patients (n = 23, 88.4%) with a median age of 54.5 years. The performance status (PS) of most patients was 2 (n = 15, 57.6%). The most common bleeding vessel was the external carotid artery or one of its branches, most commonly lingual artery (n = 5). The bleeding vessel was identified and embolized with PVA/gel foam/coil/glue. All the procedures were uneventful. Out of 26 patients, 3 patients had another bleeding episode subsequently. Most patients had 20 days to 21 months of bleeding free interval. The cost involved in the procedure was between 400 and 2100 US dollars.

CONCLUSIONS

Selective embolization is an option to be considered in certain patients with unresectable, unsalvageable recurrent and/or metastatic head and neck cancer, when they present with sudden and massive bleeding to the emergency department, at centres where the facility and expertise for this procedure might be available.

Recurrent anti-NMDAR encephalitis during pregnancy combined with two antibodies positive

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune synaptic encephalitis likely mediated by neuronal surface antibody. Clinically, it is characterized by a variety of neurological and psychiatric symptoms, predominantly affecting young women. Recurrent anti-NMDAR cases combined with double-antibody positive during pregnancy have not been reported. We report a 19-year-old pregnant woman with recurrent anti-NMDAR encephalitis and double-antibody positive. Through our case report and a review of the literature, we hope to heighten an awareness of anti-NMDAR encephalitis, particularly in a pregnant setting.

Recurrent Extubation Failure Following Neonatal Cardiac Surgery Is Associated with Increased Mortality

Extubation failure (EF) following neonatal cardiac surgery is associated with increased mortality. Neonates who experienced EF twice or more (recurrent EF) may have worse outcomes than those who have a single EF or no-EF. The aims of this study are to investigate the in hospital mortality for neonates with recurrent EF compared to those with single or no-EF, and determine factors associated with recurrent EF. Neonates' ≤ 28 days who underwent cardiac surgery from January 2008 to December 2019 were included. EF was defined as unplanned reintubation within 72 h after a planned extubation. 1187 (18 recurrent EF, 84 single EF and 1085 no-EF) neonates were included. Recurrent EF occurred in 18 (17.6%) of 102 neonates undergoing a second extubation. The median time (IQR) to reintubation after the first and second extubations were similar, being 20.9 (3.3-45.2) versus 19.4 (5.5-47) h. The reason for a second-time EF was respiratory in 39% and cardiovascular in 33%. Recurrent EF and single EF was associated with increased mortality (odds ratio, 95% confidence interval (CI) 23.5, 6.9-79.9) and (odds ratio, 95% CI 5.2, 2.3-12.0) compared to no-EF. Based on the final model with risk adjustment, predicted mortality was 29.0% in recurrent EF, 6.5% in single EF, and 1.2% in no-EF. First-time EF due to cardiovascular compromise was associated with recurrent EF (odds ratio, 95% CI 3.1, 1.0-9.7). This study confirmed that patients with recurrent EF have a high morality. Neonates with a cardiovascular reason for first-time EF are more likely to have a recurrent EF than those with other causes.

Survival and Operative Outcomes After Salvage Surgery for Recurrent or Persistent Anal Cancer

Anal squamous cell carcinoma (SCC) is a relatively rare cancer comprising less than 2.5% of all gastrointestinal malignancies. The standard treatment for anal SCC is primary chemoradiation therapy which can result in complete regression. After successful treatment, the 5-year survival is approximately 80%. However, up to 30% of patients experience recurrent persistent or recurrent disease. The role of surgery in the treatment of anal cancer, therefore, is limited to the management of recurrent or persistent disease with abdominoperineal resection and/or en bloc adjacent organ excision. Salvage surgery after irradiated anal cancer can be technically demanding in terms of acquisition of oncologically safe surgical margins and minimization of postoperative morbidity. In addition, 5-year survival outcomes after salvage resection have been reported to vary from 23% to 69%. Positive resection margins are generally regarded as the important risk factor associated with poor survival outcome. Perineal wound complications are the most common major postoperative morbidity. Because of the challenges of primary wound closure after salvage abdominoperineal resection, myocutaneous flap reconstruction has been performed to reduce the severity of perianal would complications. We, therefore, descriptively reviewed contemporary published evidence describing the treatment and outcomes after salvage surgery for persistent or recurrent anal SCC.

Recurrent bilateral asynchronous cellulitis: Report of two cases and a literature review

Bilateral recurrent periorbital cellulitis is a very rare condition, with only five cases having been reported. Two cases are presented of recurrent bilateral asynchronous eyelid oedema in two paediatric patients. It was associated with respiratory infections, with no systemic disease. The patients had recurrent episodes (three times) since nine months old. They received oral and intravenous antibiotics, with a good response. There were no complications and no surgery was needed.

Recurrent and Subsequent Injuries in Professional and Elite Sport: a Systematic Review

BACKGROUND

Injury surveillance in professional sport categorises injuries as either "new" or "recurrent". In an attempt to make categorisation more specific, subsequent injury categorisation models have been developed, but it is not known how often these models are used. The aim was to assess how recurrent and subsequent injuries are reported within professional and elite sport.

METHODS

Online databases were searched using a search strategy. Studies needed to prospectively report injury rates within professional or elite sports that have published consensus statements for injury surveillance.

RESULTS

A total of 1322 titles and abstract were identified and screened. One hundred and ninety-nine studies were screened at full text resulting in 81 eligible studies. Thirty studies did not report recurrent injuries and were excluded from data extraction. Within the studies that reported recurrent injuries, 21 reported the number and percentage; 13 reported only the proportion within all injuries; three reported only the number; five reported the number, percentage and incidence; and two only reported the incidence. Seven studies used subsequent injury terminology, with three reporting subsequent injury following concussion, one using an amended subsequent injury model and three using specific subsequent injury categorisation models. The majority of subsequent injuries (ranging from 51 to 80%) were categorised as different and unrelated to the index injury. The proportion of recurrent injuries (exact same body area and nature related to index injury) ranged from 5 to 21%.

CONCLUSIONS

Reporting recurrent or subsequent injuries remains inconsistent, and few studies have utilised subsequent injury models. There is limited understanding of subsequent injury risk, which may affect the development of injury prevention strategies.

TRIAL REGISTRATION

CRD42019119264.

Radiofrequency ablation versus hepatic resection for recurrent hepatocellular carcinoma: an updated meta-analysis

BACKGROUND

The clinical benefits of treatment with radiofrequency ablation (RFA) and repeat hepatic resection (RHR) for recurrent hepatocellular carcinoma (RHCC) remain controversial. This meta-analysis aims to evaluate the outcomes and major complications of RFA versus RHR in patients with early-stage RHCC.

METHODS

PubMed, Embase, Web of Science and the Cochrane Library were systematically searched for comparative studies on the evaluation of RHR versus RFA for RHCC. The primary outcome was overall survival (OS), and the secondary outcomes were progression-free survival (PFS) and major complications. Meta-analysis was performed using a random-effects model or fixed-effects model, and heterogeneity was tested by the Cochran Q statistic.

RESULTS

Ten studies with 1612 patients (RHR = 654, RFA = 958) were included in the meta-analysis. The meta-analysis showed that RHR had superior OS (HR 0.77, 95% CI =0.65-0.92, P = 0.004) and PFS (HR 0.81, 95% CI =0.67-0.98, P = 0.027) compared to RFA, whereas major complications may be less frequent in the RFA group (OR 0.15, 95% CI = 0.06-0.39, P < 0.001). In the subgroup analysis of patients with single RHCC ≤3 cm, OS (HR 1.03, 95% CI =0.69-1.52, P = 0.897) and PFS (HR 0.99, 95% CI = 0.71-1.37, P = 0.929) showed no significant differences in the comparison of RHR and RFA. In single RHCC> 3 cm and ≤ 5 cm, RFA showed an increased mortality in terms of OS (HR 0.57, 95% CI = 0.37-0.89, P = 0.014).

CONCLUSION

RHR offers a longer OS and PFS than RFA for patients with RHCC, but no statistically significant difference was observed for single RHCC ≤3 cm. The advantages of fewer major complications may render RFA an alternative treatment option for selected patients.

ACR Appropriateness Criteria® Recurrent Lower Urinary Tract Infections in Females

Urinary tract infections (UTIs) in women are common, with an overall lifetime risk over >50%. UTIs are considered recurrent when they follow complete clinical resolution of a previous UTI and are usually defined as at least three episodes of infection within the preceding 12 months. An uncomplicated UTI is classified as a UTI without structural or functional abnormalities of the urinary tract and without relevant comorbidities. Complicated UTIs are those occurring in patients with underlying structural or medical problems. In women with recurrent uncomplicated UTIs, cystoscopy and imaging are not routinely used. In women suspected of having a recurrent complicated UTI, cystoscopy and imaging should be considered. CT urography or MR urography are usually appropriate for the evaluation of recurrent complicated lower urinary tract infections or for women who are nonresponders to conventional therapy, develop frequent reinfections or relapses, or have known underlying risk factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Using cyproterone acetate to treat recurrent ischemic priapism in a patient with sickle cell anemia as a comorbidity: a case report

Introduction

The management of recurrent ischemic priapism is unclear in contemporary practice. Yet, if left untreated, the condition may evolve into an acute ischemic priapism and in some cases result in erectile dysfunction. This report documents the results of successful management of recurrent ischemic priapism using cyproterone acetate in a 30-year-old Saudi man with sickle cell anemia as a comorbidity.

Case presentation

A 30-year-old Saudi man denoted visited the emergency room with a painful erection which had lasted for more than four hours. The patient has sickle cell anemia and a family history of sickle cell disease. He is married and has two children. His first priapism case occurred when he was 7 years old. At the age of 15, the condition recurred, and the patient’s doctor prescribed cyproterone acetate 50 mg twice daily for 5 days. The doctor had told him that whenever he was experiencing priapism, he should adhere to this regimen for 5 days. The doctor could not find any guidelines for the prescription of cyproterone acetate.

Conclusion

Priapism cases represent a significant challenge in therapeutic management because of the elevated risk of structural damage to the penis. The fact that there lacks a clinically approved standard approach to managing the condition make it difficult for physicians to effectively manage the condition. Management of the condition is further complicated by existence of comorbidities such as sickle cell anemia. This patient’s case demonstrates that cyproterone acetate prescription is a great preventative strategy that limits priapism recurrences.

The Risk Factors for Death within 6 Months After Ischemic Stroke in Patients with Cancer

OBJECTIVES

While the intravenous recombinant tissue plasminogen activator (rt-PA) therapy for acute ischemic stroke patients with cancer is recommended when survival of ≥ 6 months is expected, the risk factors for death and stroke recurrence within 6 months after stroke are not well known. Thus, we aimed to identify markers for death and recurrence risks within six months from stroke onset in patients with cancer.

MATERIALS AND METHODS

In a retrospective cohort study, the subjects comprised acute ischemic stroke patients with cancer hospitalized at St. Marianna University hospital from 2008 through 2019. To evaluate the associations between the clinical factors within 24 h of the initial stroke and death or stroke recurrence events within 6 months from stroke onset, Logistic analysis and Cox proportional hazards regression analysis was used respectively. Next, the optimal cutoff point of markers for different mortality groups was determined using the receiver operating characteristic curve analysis and cumulative outcome rate of each group was compared using the Kaplan-Meier method.

RESULTS

Among 194 patients with cancer who developed acute stroke, 167 were ultimately selected for analysis. 47 subjects (28.14%) passed away within 6 months following stroke onset, and 20 subjects (11.98%) had stroke recurrence. High D-dimer levels, low fibrinogen levels, high Glasgow prognostic scores (GPS), and multiple vascular territory infarctions was independently associated with death, where higher death rate was significantly confirmed in the group with D-dimer levels of ≥3.95 mg/dl, fibrinogen levels <277.5 mg/dl and GPS scores of 2. Low fibrinogen level, lack of antithrombotic therapy, and the presence of metastasis were associated with stroke recurrence.

CONCLUSIONS

When patients with cancer suffer stroke, D-dimer levels, fibrinogen levels, GPS, and multiple vascular territory infarctions would be associated with the risk of death within 6 months. Low fibrinogen levels, lack of antithrombotic therapy, and the presence of metastasis correlated with high risk of stroke recurrence.