Feasibility of Omitting Contralateral Neck Irradiation in Patients with Node-Negative Sinonasal Squamous Cell Carcinoma Crossing the Midline

PURPOSE/OBJECTIVE(S)

This study aims to analyze the nodal target volume in patients with node-negative SNSCC crossing the midline.

MATERIALS/METHODS

One hundred and four patients with node-negative advanced sinonasal squamous cell carcinoma (SNSCC) crossing the midline were included. Survival rates were estimated and compared between treatment groups.

RESULTS

Sixty-four patients received contralateral ENI (contralateral ENI group), while forty patients did not (non-contralateral ENI group). The median follow-up time was 89.99 and 95.01 months in the contralateral and non-contralateral ENI groups, respectively. At 5 years, the regional relapse-free survival and contralateral regional relapse-free survival were 57.68% vs. 55.83% (p = 0.372), and 57.68% vs. 61.62% (p = 0.541), in contralateral ENI group vs. non-contralateral ENI group, respectively. Five-year overall survival, local relapse-free survival, and distant metastasis-free survival were similar in the two groups (all p > 0.05).

CONCLUSION

In patients with node-negative SNSCC crossing the midline, omission of contralateral ENI did not affect regional control and survival outcomes on the premise of receiving ipsilateral ENI covering at least levels Ib and II.

[IL-8 Links NF-κB and Wnt/β-Catenin Pathways in Persistent Inflammatory Response Induced by Chronic Helicobacter pylori Infection]

Helicobacter pylori (H. pylori) infection can cause persistent inflammatory response in human gastric mucosal epithelial cells, which may result in the occurrence of cancer. However, the underlying mechanism of carcinogenesis has not been elucidated yet. Herein, we established the models of chronic H. pylori infection in GES-1 cells and C57BL/6J mice. Interleukin 8 (IL-8) level was detected by ELISA. The expression of NF-κB p65, IL-8, Wnt2 and β-catenin mRNA and proteins was evaluated by real-time PCR, Western blotting, immunofluorescence staining, and immunohistochemistry. The infection of H. pylori in mice was evaluated by rapid urease test, H&E staining and Warthin-Starry silver staining. The morphological changes of gastric mucosa were observed by electron microscopy. Our results showed that in H. pylori infected gastric mucosal cells along with activation of NF-κB signaling pathway and increase of IL-8 level, the expression of Wnt2 was also increased significantly, which preliminarily indicates that IL-8 can positively regulate the expression of Wnt2. Studies in chronic H. pylori infected C57BL/6J mice models showed that there was an increased incidence of premalignant lesions in the gastric mucosa tissue. Through comparing changes of gastric mucosal cell ultrastructure and analyzing the relationship between NF-κB signaling pathway and Wnt2 expression, we found that H. pylori infection activated NF-κB signal pathways, and the massive release of IL-8 was positively correlated with the high expression of Wnt2 protein. Subsequently, the activated Wnt/β-catenin signal pathways may be involved in the malignant transformation of gastric mucosal cells. Collectively, H. pylori chronic infection may continuously lead to persistent inflammatory response: activate NF-κB pathway, promote IL-8 release and thereby activate Wnt/β-catenin pathway. IL-8 probably plays an important role of a linker in coupling these two signal pathways.

Differential expression of nuclear hormone receptors by dendritic cell subsets in human vaginal mucosa and skin

Nuclear hormone receptors (NHRs) expressed by dendritic cells (DCs), the major immune inducers and regulators, could play important roles in host immunity. Assessment of NHRs expressed by DCs in the vaginal mucosa (VM), in comparison with those expressed by DCs in other tissues, will thus help us understand the immunology of human vagina. This study identified 16 NHR transcripts that are differentially expressed among 8 different antigen-presenting cell (APC) subsets isolated from human VM, skin, and blood. The expression profiles of NHRs were largely tissue specific. VM APCs expressed increased levels of LXRA, RXRA, ESRRA, ESRRAP2, and PPARG, whereas skin and blood APCs expressed increased levels of NURR1, NOR1 and RARA. Of interest, female sex hormone receptors, ESR1 and PGR, were found to be mainly expressed by non-APC cell types in the VM; ESR1 by HLA-DR⁺CD34⁺ and PGR by HLA-DR^- cells. ERα and PR were expressed by vimentin⁺ cells in the VM, but not in human skin. ERα, but not PR, was also expressed in CD10⁺ cells in the lamina propria of VM. In conclusion, NHR expression by APC subsets is tissue- and cell type-specific. Future studies on the roles of individual NHRs expressed by different cell types, including DC subsets, in the human VM are warranted.

Same-day Discharge after Robotic Hysterectomy for Benign Conditions: Feasibility and Safety

STUDY OBJECTIVE

To investigate the feasibility and predictive factors for same-day discharge (SDD) after robotic hysterectomy (RH) for benign indications to optimize patient selection by incorporating preoperative, intraoperative, and postoperative variables.

DESIGN

A single-center retrospective cohort study.

SETTING

Tertiary academic hospital.

PATIENTS

Patients undergoing RH for benign indications.

INTERVENTIONS

Patients were designated for SDD by implementing enhanced recovery after surgery protocol.

MEASUREMENTS AND MAIN RESULTS

The study included 890 patients who underwent RH for benign indications between the years 2016 and 2021. Of these, 618 (69.4%) were discharged the same day and 272 (30.5%) were admitted for overnight stay. Both groups had similar age (46.4 vs 46.2 years), body mass index (28.3 vs 28.9), and indications for surgery. In multivariable logistic regression, factors that were significant for overnight stay were American Society of Anesthesiologists score 3, Charlson comorbidity index, previous laparotomy, and operative time. Other factors such as surgery start time and preoperative hemoglobin levels were not statistically significant. Postoperative outcomes were comparable for both groups with similar readmission and reoperation rates.

CONCLUSION

The likelihood of SDD after RH in this cohort after implementing enhanced recovery after surgery protocol was almost 70%, and most of the predictive factors for overnight stay were nonmodifiable. Importantly, both groups had similar outcomes after surgery.

Shared decision-making in opioid prescribing for minimally invasive hysterectomy: A prospective randomized controlled trial

OBJECTIVE

To determine the impact of shared decision-making in postsurgical opioid prescribing in women who underwent minimally invasive (MIS) hysterectomy.

DESIGN

A randomized controlled trial.

SETTING

A single, tertiary care, academic center.

PATIENTS AND PARTICIPANTS

From January 2019 through April 2020, 73 women aged 18 years and older who had a planned MIS hysterectomy with the Department of Gynecology were enrolled into the study (36 in the standard arm and 37 in the patient-directed arm).

INTERVENTIONS

Participants were assigned either to the standard arm (30 tablets) or patient-directed arm (0-30 tablets) of oxycodone 5 mg.

MAIN OUTCOME MEASURES

The primary outcome was the percentage of excess opioid tablets, calculated by the number of unused tablets divided by the number of tablets prescribed. Secondary outcomes included total opioid tablets used, frequency of obtaining additional opioid tablets after discharge, frequency of unscheduled post-operative visits, and patient satisfaction with number of opioid tablets prescribed.

RESULTS

Age, race, and body mass index did not differ between groups. Hysterectomies were performed via laparoscopy (16.9 percent), robotic-assisted laparoscopy (38.5 percent), and vaginal routes (44.6 percent). The median (IQR) number of oxycodone prescribed in the patient-directed arm was 15.0 (12.0 and 24.0) tablets. The standard arm had a greater percentage of excess oxycodone tablets 73.6 percent (0.03) than the patient-directed arm 56.3 percent (0.03, p < .01). However, there was no difference in the total number of oxycodone used by patients in the standard (mean 7.9 [0.5] tablets) and patient-directed arms (mean 8.4 [0.5] tablets, p = .50). The mean number of oxycodone used for the entire cohort was 8.1 (0.4) tablets.

CONCLUSIONS

Shared decision-making significantly decreased the percent of excess oxycodone tablets but did not decrease the total number of oxycodone tablets used in patients undergoing MIS hysterectomy. Patients used about 22 tablets less than the standard 30 tablets prescribed.

[Introduction and implications of WHO position paper: vaccines against influenza, May 2022]

On May 13, 2022, World Health Organization(WHO) Position Paper on Influenza Vaccine (2022 edition) was published. This position paper updates information on influenza epidemiology, high risk population, the impact of immunization on disease, influenza vaccines and effectiveness and safety, and propose WHO's position and recommendation that all countries should consider implementing seasonal influenza vaccine immunization programmes to prepare for an influenza pandemic. In addition, it proposes that the influenza surveillance platform can be integrated with the surveillance of other respiratory viruses, such as SARS-CoV-2 and Respiratory Syncytial Virus. This position paper has some implications for the prevention and control of influenza and other respiratory infectious diseases in China: (1) Optimize influenza vaccine policies to facilitate the implementation of immunization services; (2) Influenza prevention and control should from the perspective of Population Medicine focus on the individual and community to integrate with "Promotion, Prevention, Diagnosis, Control, Treatment, Rehabilitation"; (3) Incorporate prevention and control of other respiratory infectious diseases such as influenza, COVID-19, respiratory syncytial virus and adenovirus, and intelligently monitor by integrating multi-channel data to achieve the goal of co-prevention and control of multiple diseases.

Does a Uterine Manipulator Increase the Distance of the Ureter to the Cervix and Vagina? An Anatomical Cadaver Study

OBJECTIVE

To determine whether advancing a manipulator increased the distances of the ureter to the cervix and/or vagina.

DESIGN

Prospective SETTINGS: Academic institution PATIENTS: 22 intact fresh frozen female pelvises INTERVENTIONS: A total of 6 ureteral distances were measured per pelvis. Included were the following measurements on each side: 1. from the lateral cervical wall to the ureter at the intersection with the uterine artery; 2. from the lateral cervical wall to the parametrial ureter; and 3. from the vagina to the ureter at the intersection with the uterine artery. All measurements were obtained with and without advancement of a uterine manipulator.

MAIN RESULTS

The average distances from the ureter to the cervix and vagina without advancing the manipulator were 2.8 and 3.1 cm, respectively, and the distance from the parametrial ureter to the cervix was 3.3 cm. When the manipulator was advanced all ureteral distances increased by 0.8, 0.6, and 0,6 cm, respectively, in 12 (55%) of the pelvises. Advancing the manipulator did not increase at least 1 of the distances in 10 (45%) of the pelvises. The advancement of the manipulator lengthened the 2 shortest ureteral distances of 1 cm noted in one pelvis (4.5%) by 0.9 and 0.4 cm.

CONCLUSION

The uterine manipulator increased the distance of the ureter to the cervix and vagina for all measurements in 55.5% of the pelvises. The greatest increase was 0.9 cm. The manipulator did not increase at least 1 of the distances in 10 (45.4%) of the pelvises.

Single port robotic assisted sacrocolpopexy: technique and tips

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy is the most durable surgical procedure for the treatment of symptomatic pelvic organ prolapse (Maher et al. Cochrane Database Syst Rev. 2013;(4):CD004014). The single port robotic platform has recently been approved in the USA for use in urological surgery. Innovation in robotic surgery continues to evolve, minimizing abdominal wall trauma while improving instrumentation and technical feasibility. Identifying the appropriate procedures to utilize novel technology is important to understand the role of new surgical tools. Sacrocolpopexy procedure, when performed with supracervical hysterectomy, requires extension of an incision for specimen retrieval, making it ideal for single port surgery. The technique and adaptation to new instrumentation is demonstrated in this video.

METHOD

A surgical demonstration of single port robotic sacrocolpopexy is shown.

RESULTS

Sacrocolpopexy was successfully completed using the single port robotic platform.

CONCLUSIONS

Sacrocolpopexy is technically feasible with use of the single port robotic platform.

Transcriptomic Mapping of Human Parotid Gland at Single-Cell Resolution

As the largest salivary gland in oral cavity, the parotid gland plays an important role in initial digesting and lubricating food. The abnormal secretory function of the parotid gland can lead to dental caries and oral mucosal inflammation. In recent years, single-cell RNA sequencing (scRNA-seq) has been used to explore the heterogeneity and diversity of cells in various organs and tissues. However, the transcription profile of the human parotid gland at single-cell resolution has not been reported yet. In this study, we constructed the cell atlas of human parotid gland using the 10× Genomics platform. Characteristic gene analysis identified the biological functions of serous acinar cell populations in secreting digestive enzymes and antibacterial proteins. We revealed the specificity and similarity of the parotid gland compared to other digestive glands through comparative analyses of other published scRNA-seq data sets. We also identified the cell-specific expression of hub genes for Sjögren syndrome in the human parotid gland by integrating the results of genome-wide association studies and bulk RNA-seq, which highlighted the importance of immune cell dysfunction in parotid Sjögren syndrome pathogenesis.

[Current status and research advances on the use of assisted traction technique in endoscopic full-thickness resection]

Endoscopic full-thickness resection (EFTR) allows completely resecting deep submucosal tumors (SMTs) in the gastrointestinal wall, which has a broad application prospect in clinic. However, its application and promotion are limited by complex surgical procedures and high surgical risk. Various auxiliary traction techniques are expected to reduce the operation difficulty and risk of EFTR and improve its operative success rate. To provide a reference for clinicians, we summarize various auxiliary traction techniques in EFTR in this article. The clip-with-line method is simple to operate and widely used, whereas its traction is limited and there is a risk of clip falling off. The snare traction method and the clip-snare traction method has advantage of large traction force, but its thrust is affected by the hardness of snare. The traction point of the grasping forceps traction method is flexible and easy to adjust. Nevertheless, it requires the use of a dual-channel upper endoscope, which is difficult to operate. The transparent cap traction method and the full-thickness resection device traction method takes a short time and is easy to promote, whereas the resectable lesion is limited, and the size of the lesion may affect the success rate. In contrast, the suture loop needle-T-tag tissue anchors assisted method has a large resection range, but the operation is complicated and the feasibility has not been verified. The robot-assisted method has flexible operation and excellent visualization, whereas it is expensive and difficult to operate. There is no report of the application of magnetic anchor technology in EFTR, but it may have good application prospects in the auxiliary traction of EFTR.

Cell type-specific expression of estrogen and progesterone receptors in the human vaginal mucosa

Female sex hormones affect the immune response in the lower female genital tract. To understand their mechanisms of action, it is essential to define cell types expressing estrogen receptor (ER) and/or progesterone receptor (PR) in the human vaginal mucosa (VM). Here, we report that none of the dendritic cell (DC) subsets in the human VM expressed ERα or PR in situ. However, they were capable of expressing ERα, but not PR, after in vitro culture of the whole VM tissues. Similarly, ERα and/or PR expression by T cells in the VM tissues was also inducible rather than constitutive. In contrast, ERα and/or PR were constitutively expressed in HLA-DR^- non-immune cell types (vimentin⁺, desmin⁺, or CD10⁺). These new findings will help us understand the mechanisms of action of female sex hormones in the modulation of immune response in the human VM and lower female genital tract.

Deep learning for automatic calcium scoring in population based cardiovascular screening

Background

High volumes of standardized coronary artery calcium (CAC) scans are generated in screening that need to be scored accurately and efficiently to risk stratify individuals.

Purpose

To evaluate the performance of deep learning based software for automatic coronary calcium scoring in a screening setting.

Methods

Participants from the Robinsca trial that underwent low-dose ECG-triggered cardiac CT for calcium scoring were included. CAC was measured with fully automated deep learning prototype and compared to the original manual assessment of the Robinsca trial. Detection rate, positive Agatston score and risk categorization (0–99, 100–399, ≥400) were compared using McNemar test, ICC, and Cohen's kappa. False negative (FN), false positive (FP) rate and diagnostic accuracy were determined for preventive treatment initiation (cut-off ≥100 AU).

Results

In total, 997 participants were included between December 2015 and June 2016. Median age was 61.0 y (IQR: 11.0) and 54.4% was male. A high agreement for detection was found between deep learning based and manual scoring, κ=0.87 (95% CI 0.85–0.89). Median Agatston score was 58.4 (IQR: 12.3–200.2) and 61.2 (IQR: 13.9–212.9) for deep learning based and manual assessment respectively, ICC was 0.958 (95% CI 0.951–0.964). Reclassification rate was 2.0%, with a very high agreement with κ=0.960 (95% CI: 0.943–0.997), p&lt;0.001. FN rate was 0.7% and FP rate was 0.1% and diagnostic accuracy was 99.2% for initiation of preventive treatment.

Conclusion

Deep learning based software for automatic CAC scoring can be used in a cardiovascular CT screening setting with high accuracy for risk categorization and initiation of preventive treatment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Robinsca trial was supported by advanced grant of European Research Council

Deep Learning in Biomedical Optics

This article reviews deep learning applications in biomedical optics with a particular emphasis on image formation. The review is organized by imaging domains within biomedical optics and includes microscopy, fluorescence lifetime imaging, in vivo microscopy, widefield endoscopy, optical coherence tomography, photoacoustic imaging, diffuse tomography, and functional optical brain imaging. For each of these domains, we summarize how deep learning has been applied and highlight methods by which deep learning can enable new capabilities for optics in medicine. Challenges and opportunities to improve translation and adoption of deep learning in biomedical optics are also summarized. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Engaging the opioid epidemic head on: Improving proper disposal of unused opioid medications after surgery

BACKGROUND

Currently, in the United States, there is an epidemic of opioid abuse. While this problem is well known to the public due to significant media and political attention, patients are poorly educated on the proper handling and disposal of unused opioids. Instead, the onus has fallen on the healthcare provider to minimize the number of opioids prescribed.

STUDY OBJECTIVE

To improve proper opioid disposal rates after gynecologic surgery by providing educational materials along with a disposal bag.

STUDY DESIGN

We performed a prospective study evaluating baseline understanding of medication disposal using a questionnaire given to the patients during their preoperative visit. Subsequently, patients were provided written information on proper disposal of their medications and an activated charcoal medication disposal bag. Study patients completed a survey about disposal of their unused opioids at their last post-operative visit. The success of education and proper disposal of opioid medications were evaluated.

RESULTS

Thirty-five patients, average age of 45 (range 20-77), were enrolled, and 31 patients successfully completed both surveys. The surgeries performed included hysterectomy 23 percent (n = 7), laparoscopic excision of endometriosis 32 percent (n = 10), laparoscopic ovarian cystectomy 23 percent (n = 7), prolapse repair 3 percent (n = 1), and midurethral sling procedures 19 percent (n = 6). Chronic pelvic pain was identified in 39 percent (n = 12) of our patient population. Prior to education, 52 percent (n = 16) of patients did not dispose of their opioids. Furthermore, 71 percent (n = 22) of patients stated they had never been educated by a medical provider regarding appropriate disposal. Nineteen percent (n = 6) confirmed they have used an opioid medication prescribed to someone else. Demographic data show 65 percent (n = 20) of these patients had completed a college degree or greater. After education and being given a reliable option for medication disposal with the Deterra® bag, 94 percent (n = 29) of patients properly disposed of their opioids after surgery, demonstrating a 45 percent (p < 0.001) increase in proper disposal. In our study alone, 491 tablets of 5mg oxycodone were properly disposed. The majority of patients, 77 percent (n = 24) used the drug disposal bag, and when queried, stated they would be willing to pay on average $7.70 (range 0-20) per bag. Without education and a simple option for disposal, 422 tablets prescribed may have been subject to inappropriate diversion.

CONCLUSION

This study clearly shows that patient education, coupled with a reliable option for opioid disposal, is effective. We strongly encourage other surgical institutions to implement similar practices not only for our surgical patients' safety, but also for the tens of thousands of patients who died of opioid abuse in the last year.

Impact of Uterine Sliding Sign in Routine United States Ultrasound Practice

OBJECTIVES

The study aim was to evaluate the diagnostic performance of the uterine sliding sign in predicting deeply infiltrating endometriosis in the setting of non-physician sonographers performing but not interpreting the maneuver. The impact of uterine sliding sign has not been previously demonstrated in this practice setting.

METHODS

Physicians' remote interpretations of transvaginal ultrasound examinations in 2016, before uterine sliding sign, were compared to examinations in 2019 after addition of uterine sliding sign to determine the diagnostic rates. Surgical and histopathological results were reviewed to determine sensitivity and specificity of the respective exam techniques.

RESULTS

Two hundred eighty-five transvaginal ultrasounds were performed in 2016 and 390 sliding sign ultrasounds in 2019. The number of deeply infiltrating endometriosis cases identified increased significantly from 2% to 6% during the study period (chi-square, Fisher's exact test p = .012). The sensitivity and specificity of routine pelvic sonography for detecting deeply infiltrating endometriosis improved from 36%/94% to 68%/98%.

CONCLUSIONS

Uterine sliding sign videos should be included in the standard sonographic protocol for patients presenting with chronic pelvic pain, endometriosis history, or sonographic evidence of endometriosis in the setting of physicians interpreting sonographic images obtained by non-physicians.

Unusually thick shear-softening surface of micrometer-size metallic glasses

The surface of glass is crucial for understanding many fundamental processes in glassy solids. A common notion is that a glass surface is a thin layer with liquid-like atomic dynamics and a thickness of a few tens of nanometers. Here, we measured the shear modulus at the surface of both millimeter-size and micrometer-size metallic glasses (MGs) through high-sensitivity torsion techniques. We found a pronounced shear-modulus softening at the surface of MGs. Compared with the bulk, the maximum decrease in the surface shear modulus (G) for the micro-scale MGs reaches ~27%, which is close to the decrease in the G upon glass transition, yet it still behaves solid-like. Strikingly, the surface thickness estimated from the shear-modulus softening is at least 400 nm, which is approximately one order of magnitude larger than that revealed from the glass dynamics. The unusually thick surface is also confirmed by measurements using X-ray nano-computed tomography, and this may account for the brittle-to-ductile transition of the MGs with size reductions. The unique and unusual properties at the surface of the micrometer-size MGs are physically related to the negative pressure effect during the thermoplastic formation process, which can dramatically reduce the density of the proximate surface region in the supercooled liquid state.

•

The shear modulus and thickness of metallic glass (MG) surface is determined through torsion testing on micrometer-size wires

•

The surface region of MG wires has a significant shear-modulus softening close to the supercooled liquid, yet still behaves solid-like

•

The thickness of the soft surface of MG wires is at least 400 nm, which is about one order of magnitude larger than those revealed from surface dynamics

•

The unusually thick surface accounts for the brittle-to-ductile transition of the MGs with size reduction

The Flipped Ovary Sign in Ovarian Torsion

The diagnosis of ovarian torsion is challenging and relies mostly on morphologic findings. Occasionally, women or children with acute pelvic pain who have undergone an initial ultrasound (US) evaluation with results interpreted as negative for ovarian torsion will return with recurrent or increasing pain, prompting an US reevaluation. The flipped ovary sign refers to a demonstrable change in the orientation of the ovary on follow-up US examinations, recognized by changing positions of ovarian landmarks established by follicles, cysts, or masses. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion.