Early-onset gastrointestinal cancer: An epidemiological reality with great significance and implications

During the last few years, epidemiological data from many countries suggest that the incidence and prevalence of many cancers of the digestive system are shifting from the older to the younger ages, the so-called "early-onset cancer". This is particularly evident in colorectal cancer and secondarily in other malignant digestive neoplasms, mainly stomach and in a lesser degree pancreas, and biliary tract. It should be emphasized that data concerning digestive neoplasms, except for those referring to the colon and stomach, could be characterized as rather insufficient. The exact magnitude of the shift in younger ages is expected to become clearer shortly, as long as relevant epidemiological data from many parts of the world would be available. The most important question concerns the etiology of this phenomenon, since its magnitude cannot be explained solely by the better diagnostic methodology and the preventive programs applied in many countries. The existing data support the assumption that a number of environmental factors may play a primary role in influencing carcinogenesis, sometimes from childhood. Changes that have appeared in the last decades related mainly to eating habits, consistency of gut microbiome and an increase of obese people interacting with genetic factors, ultimately favor the process of carcinogenesis. Even these factors however, are not entirely sufficient to explain the age-related changes in the frequency of digestive neoplasms. Studies of the individual effect of each of the already known factors or factors likely to be involved in the etiology of this phenomenon and studies using state-of-the-art technologies to accurately determine the degree of the population exposure to these factors are required. In this article, we attempt to describe the epidemiological data supporting the age-shifting of digestive malignancies and their possible pathogenesis. Finally, we propose some measures regarding the attitude of the scientific community to this alarming phenomenon.

Differences in Health-Related Quality of Life among Patients with Heart Failure

Heart failure (HF) is characterized by a progressive clinical course marked by frequent exacerbations and repeated hospitalizations, leading to considerably high morbidity and mortality rates. Patients with HF present with a constellation of bothersome symptoms, which range from physical to psychological and mental manifestations. With the transition to more advanced HF stages, symptoms become increasingly more debilitating, interfere with activities of daily living and disrupt multiple domains of life, including physical functioning, psychological status, emotional state, cognitive function, intimate relationships, lifestyle status, usual role activities, social contact and support. By inflicting profuse limitations in numerous aspects of life, HF exerts a profoundly negative impact on health-related quality of life (HRQOL). It is therefore not surprising that patients with HF display lower levels of HRQOL compared not only to the general healthy population but also to patients suffering from other chronic diseases. On top of this, poor HRQOL in patients with HF becomes an even greater concern considering that it has been associated with unfavorable long-term outcomes and poor prognosis. Nevertheless, HRQOL may differ significantly among patients with HF. Indeed, it has consistently been reported that women with HF display poorer HRQOL compared to men, while younger patients with HF tend to exhibit lower levels of HRQOL than their older counterparts. Moreover, patients presenting with higher New York Heart Association (NYHA) functional class (III-IV) have significantly more impaired HRQOL than those in a better NYHA class (I-II). Furthermore, most studies report worse levels of HRQOL in patients suffering from HF with preserved ejection fraction (HFpEF) compared to patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF). Last, but not least, differences in HRQOL have been noted depending on geographic location, with lower HRQOL levels having been recorded in Africa and Eastern Europe and higher in Western Europe in a recent large global study. Based on the observed disparities that have been invariably reported in the literature, this review article aims to provide insight into the underlying differences in HRQOL among patients with HF. Through an overview of currently existing evidence, fundamental differences in HRQOL among patients with HF are analyzed based on sex, age, NYHA functional class, ejection fraction and geographic location or ethnicity.

Validity of a virtual reality endoscopic retrograde cholangiopancreatography simulator: can it distinguish experts from novices?

Background

There is a lack of evidence regarding the effectiveness of virtual simulators as a means to acquire hands-on exposure to endoscopic retrograde cholangiopancreatography (ERCP). The present study aimed to assess the outcome and construct validity of virtual ERCP when training on the GI II Mentor simulator.

Methods

A group of seven experienced endoscopists were compared with 31 novices. After a short introduction, they were requested to carry out three virtual ERCP procedures: diagnosing and removing a common bile duct (CBD) stone; diagnosing and taking brush cytology from a hilar stenosis; and, finally, diagnosing and treating a cystic leakage with a BD stent. For each task, the total time required to complete the task, time required to correctly view the papilla, total time of irradiation, time to deep cannulation, time to define diagnosis, time to complete sphincterotomy, and time to complete the respective intervention were measured. Cannulation of the BD, correct diagnosis, sphincterotomy, and time to complete intervention were assessed by an assessor blinded to the status of the endoscopist who performed the virtual ERCP.

Results

The time required to visualize the papilla and to cannulate deeply when removing the BD stone was significantly shorter for the experts (both p < 0.05). The time to visualize the papilla, cannulate deeply, reach a diagnosis, complete sphincterotomy, and complete the intervention was significantly shorter for the experts when managing cystic leakage (all p < 0.05). In diagnosing and taking brush cytology from a hilar stenosis, there was only a trend toward the experts needing less time for the deep cannulation of the BD (p = 0.077).

Conclusion

The performance differed between experts and novices, especially in the management of cystic leakage. This corroborates the construct validity of the GI II Mentor simulator.

Bibliometric research analysis of molecularly imprinted polymers (MIPs): evidence and research activity dynamics

The escalating issue of water pollution has become a worldwide issue that has captured the attention of numerous scientists. Molecularly imprinted polymers (MIPs) have emerged as adaptable materials with exceptional attributes, including easy synthesis, low cost, remarkable durability, long life, and accessibility. These attributes have motivated researchers to develop novel materials based on MIPs to tackle hazardous contaminants in environmental matrices. The purpose of this paper was to conduct a bibliometric analysis on MIPs' publications, in order to shed light on the developments and focus points of the field. The selected publications were obtained from Scopus database and subjected to a filtering process, resulting in 11,131 relevant publications. The analysis revealed that the leading publication source (journal) is Biosensors and Bioelectronics; the mostly employed keywords are solid-phase extraction, electrochemical sensor, and molecular recognition; and the top contributing countries are China, Iran, and the USA. The Latent Dirichlet Allocation (LDA) algorithm was used for extracting thematic axes from the textual content of the publications. The results of the LDA model showcase that the topic of synthesis and performance of MIPs for environmental applications can be considered as the most dominant topic with a share value of 72.71%. From the analysis, it can be concluded that MIPs are a cross-disciplinary research field.

The use of simulators to acquire ERCP skills: a systematic review

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding diagnostic and therapeutic endoscopic procedure with a high risk for adverse events such as post-ERCP pancreatitis and bleeding. Since endoscopists with less experience have higher adverse event rates, the training of new residents on ERCP simulators has been suggested to improve the resident's technical skills necessary for ERCP. However, there is a lack of consensus on whether the training program should focus on a threshold number of procedures or be more tailored to the individual's performance. Furthermore, there is also disagreement on which form of simulator(s) should be used. Therefore, the primary outcome of this systematic review was to study the extent to which simulators used for ERCP training are correctly validated.

Methods

In 2022, a systematic search of the literature was conducted on MEDLINE and SCOPUS under the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 protocol seeking articles with the MeSH terms 'Endoscopic Retrograde Cholangiopancreatography' OR 'ERCP' in combination with 'simulation' OR 'simulator'.

Results

The search resulted in 41 references. A total of 19 articles met the inclusion criteria and were included in the qualitative analysis. Only one of the articles fulfilled the criteria of a robust validation study.

Conclusions

Since only one of the 19 articles met the requirements for a thorough and correct validation, further studies with sufficient numbers of subjects, that evaluate complete preclinical training programs based on validated ERCP simulators are warranted.

Breaking down the silos of artificial intelligence in surgery: glossary of terms

BACKGROUND

The literature on artificial intelligence (AI) in surgery has advanced rapidly during the past few years. However, the published studies on AI are mostly reported by computer scientists using their own jargon which is unfamiliar to surgeons.

METHODS

A literature search was conducted in using PubMed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The primary outcome of this review is to provide a glossary with definitions of the commonly used AI terms in surgery to improve their understanding by surgeons.

RESULTS

One hundred ninety-five studies were included in this review, and 38 AI terms related to surgery were retrieved. Convolutional neural networks were the most frequently culled term by the search, accounting for 74 studies on AI in surgery, followed by classification task (n = 62), artificial neural networks (n = 53), and regression (n = 49). Then, the most frequent expressions were supervised learning (reported in 24 articles), support vector machine (SVM) in 21, and logistic regression in 16. The rest of the 38 terms was seldom mentioned.

CONCLUSIONS

The proposed glossary can be used by several stakeholders. First and foremost, by residents and attending consultant surgeons, both having to understand the fundamentals of AI when reading such articles. Secondly, junior researchers at the start of their career in Surgical Data Science and thirdly experts working in the regulatory sections of companies involved in the AI Business Software as a Medical Device (SaMD) preparing documents for submission to the Food and Drug Administration (FDA) or other agencies for approval.

5G in Healthcare: from COVID-19 to Future Challenges

Worldwide up to May 2022 there have been 515 million cases of COVID-19 infection and over 6 million deaths. The World Health Organization estimated that 115,000 healthcare workers died from COVID-19 from January 2020 to May 2021. This toll on human lives prompted this review on 5G based networking primarily on major components of healthcare delivery: diagnosis, patient monitoring, contact tracing, diagnostic imaging tests, vaccines distribution, emergency medical services, telesurgery and robot-assisted tele-ultrasound. The positive impact of 5G as core technology for COVID-19 applications enabled exchange of huge data sets in fangcang (cabin) hospitals and real-time contact tracing, while the low latency enhanced robot-assisted tele-ultrasound, and telementoring during ophthalmic surgery. In other instances, 5G provided a supportive technology for applications related to COVID-19, e.g., patient monitoring. The feasibility of 5G telesurgery was proven, albeit by a few studies on real patients, in very low samples size in most instances. The important future applications of 5G in healthcare include surveillance of elderly people, the immunosuppressed, and nano- oncology for Internet of Nano Things (IoNT). Issues remain and these require resolution before routine clinical adoption. These include infrastructure and coverage; health risks; security and privacy protection of patients' data; 5G implementation with artificial intelligence, blockchain, and IoT; validation, patient acceptance and training of end-users on these technologies.

Gut microbiome: Linking together obesity, bariatric surgery and associated clinical outcomes under a single focus

Obesity is increasingly prevalent in the post-industrial era, with increased mortality rates. The gut microbiota has a central role in immunological, nutritional and metabolism mediated functions, and due to its multiplexity, it is considered an independent organ. Modern high-throughput sequencing techniques have allowed phylogenetic exploration and quantitative analyses of gut microbiome and improved our current understanding of the gut microbiota in health and disease. Its role in obesity and its changes following bariatric surgery have been highlighted in several studies. According to current literature, obesity is linked to a particular microbiota profile that grants the host an augmented potential for calorie release, while limited diversity of gut microbiome has also been observed. Moreover, bariatric surgery procedures represent effective interventions for sustained weight loss and restore a healthier microbiota, contributing to the observed fat mass reduction and lean mass increase. However, newer evidence has shown that gut microbiota is only partially recovered following bariatric surgery. Moreover, several targets including FGF15/19 (a gut-derived peptide), could be responsible for the favorable metabolic changes of bariatric surgery. More randomized controlled trials and larger prospective studies that include well-defined cohorts are required to better identify associations between gut microbiota, obesity, and bariatric surgery.

Intraoperative cholangiography 2020: Quo vadis? A systematic review of the literature

BACKGROUND

There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography (IOC) in the detection and treatment of common bile duct injury (BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large population-based cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting.

DATA SOURCES

A systematic literature search was conducted in 2020 to search for articles that contained the terms "bile duct injury", "critical view of safety", "bile duct imaging" or "retained stones" in combination with IOC. All identified references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias.

RESULTS

The search revealed 273 references. A total of 30 articles fulfilled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately.

CONCLUSIONS

IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defined outcome measures and sufficient statistical power are needed.

793 COLLATERAL HISTORY IN PATIENTS WITH CONFUSION

Introduction

The aims of the project were to intervene early on admission, by taking a collateral history for patients with confusion; to improve the quality and detail of collateral history being taken to better establish certain clinically important specks of information. These include triggers for delirium, the patient’s baseline cognition, any patterns in the change of a patient’s cognition to help determine if a patient was displaying aspects of a certain type of dementia prior to admission, baseline mobility and housing situation, baseline continence, history of substance misuse and alcohol etc. Ultimately, this project aims to identify next of kin from which collateral history can be obtained, but also to establish a firm communication platform to facilitate future discussions on behalf of patients undergoing delirium. This will ultimately, improve care but also making sure family members are involved early on in admission, exploring their ideas, concerns, and expectations.

Methods

We created a collateral history template booklet that was introduced to a geriatric ward. Specific parameters were set and measured, pre-intervention and post-intervention. A second round of post-intervention data collection was performed with an improved collateral history sheet outlook. We measured the outcome of 22 collateral histories for each round.

Results

We found that in both rounds, post intervention, there was an improved outcome compared to pre-intervention in almost all the parameters that were measured. For example, in 100% of the collateral histories there was documentation of the patient’s baseline concentrations and attention, issues with orientation, issues with expressive and receptive dysphasia and the main concerns of the next of kin, any problems with executive functioning and the baseline functional status of the patients.

Conclusion

The collateral history, both improved the overall quality and the quantity of the information gathered in patients with confusion and, contributed to a structured management.

Comparison of Postoperative and Oncologic Outcomes in Laparoscopic and Open Right Colectomy for Colon Cancer: A 5-year Experience

BACKGROUND/AIM

Laparoscopic colectomy is a procedure which is being performed for three decades and is gaining popularity continuously over the traditional open colectomy. This study was conducted in order to compare postoperative and oncologic results based on several factors in laparoscopic and open right colectomy for right colon cancer.

PATIENTS AND METHODS

This is a retrospective study of right colectomy at a single institution from 2015 until 2020. The factors that were studied included postoperative values of C-reactive protein (CRP), lactate dehydrogenase (LDH), creatine phosphokinase (CPK), the number of excised lymph nodes, the use of postoperative analgesics and the length of hospital stay.

RESULTS

We collected data from 21 open and 17 laparoscopic right colectomies through a 5-year period. Measurements on the second postoperative day revealed mean CRP and CPK values significantly lower in the laparoscopic group compared to the open group, while LDH levels did not affirm major differences between the two groups. The mean number of lymph nodes excised during the open procedure was superior to those harvested in the laparoscopic group. The use of analgesics throughout the entire hospital stay was a combination of pethidine and tramadol for the first three postoperative days in open procedures, while paracetamol and, occasionally, tramadol were administered upon patient request following laparoscopic procedures. The mean hospital stay was substantially shorter in the laparoscopic group compared to the open surgery group.

CONCLUSION

Laparoscopic right colectomy is superior compared to open right colectomy with regards to postoperative analgesia and length of hospital stay, but also in certain postoperative laboratory values. Despite these there was no supremacy considering oncologic clearance.

An empirical study of COVID-19 related posts on Stack Overflow: Topics and technologies

The COVID-19 outbreak, also known as the coronavirus pandemic, has left its mark on every aspect of our lives and at the time of this writing is still an ongoing battle. Beyond the immediate global-wide health response, the pandemic has triggered a significant number of IT initiatives to track, visualize, analyze and potentially mitigate the phenomenon. For individuals or organizations interested in developing COVID-19 related software, knowledge-sharing communities such as Stack Overflow proved to be an effective source of information for tackling commonly encountered problems. As an additional contribution to the investigation of this unprecedented health crisis and to assess how fast and how well the community of developers has responded, we performed a study on COVID-19 related posts in Stack Overflow. In particular, we profiled relevant questions based on key post features and their evolution, identified the most prominent technologies adopted for developing COVID-19 software and their interrelations and focused on the most persevering problems faced by developers. For the analysis of posts we employed descriptive statistics, Association Rule Graphs, Survival Analysis and Latent Dirichlet Allocation. The results reveal that the response of the developers' community to the pandemic was immediate and that the interest of developers on COVID-19 related challenges was sustained after its initial peak. In terms of the problems addressed, the results show a clear focus on COVID-19 data collection, analysis and visualization from/to the web, in line with the general needs for monitoring the pandemic.

Use of saliva stress biomarkers to estimate novice male endoscopist's stress during training in a high-end simulator

OBJECTIVE

Simulated endoscopic training can be challenging and stressful for the novice trainee. The absence of a reliable stress detection method during simulated endoscopic training makes estimating trainees' mental stress difficult to quantify. This study concomitantly measures the responses of four saliva stress biomarkers and compares them to the video score (VS) achieved by novice endoscopists in a reproducibly stressful simulation environment.

METHODS

Thirty-six male endoscopy naïve surgery residents were enrolled. After an orientation phase, a saliva specimen was collected for cortisol (sC), alpha-amylase (sAA), Chromogranin A (sCgA), and immunoglobulin A (sIgA) measurements (baseline phase, BL). Thereafter, the simulation exercise phase (E) started, practicing in the Fundamentals of Endoscopic Surgery Skills module (GI-Bronch Mentor). Immediately after, a second saliva sample for measuring the above-cited biomarkers was collected. The whole experiment was videotaped, and the VS was calculated. The percentage (E-BL)_diff of each of the four saliva biomarkers was calculated and examined for correlation to VS.

RESULTS

sCgA_diff showed the best correlation with VS, followed by sAA_diff.

CONCLUSIONS

sCgA and sAA, are saliva stress biomarkers that are easy to collect non-invasively and showed the best correlation with novice endoscopist's performance in our simulation setting, and therefore, they could be used for monitoring stress.

A systematic review on artificial intelligence in robot-assisted surgery

BACKGROUND

Despite the extensive published literature on the significant potential of artificial intelligence (AI) there are no reports on its efficacy in improving patient safety in robot-assisted surgery (RAS). The purposes of this work are to systematically review the published literature on AI in RAS, and to identify and discuss current limitations and challenges.

MATERIALS AND METHODS

A literature search was conducted on PubMed, Web of Science, Scopus, and IEEExplore according to PRISMA 2020 statement. Eligible articles were peer-review studies published in English language from January 1, 2016 to December 31, 2020. Amstar 2 was used for quality assessment. Risk of bias was evaluated with the Newcastle Ottawa Quality assessment tool. Data of the studies were visually presented in tables using SPIDER tool.

RESULTS

Thirty-five publications, representing 3436 patients, met the search criteria and were included in the analysis. The selected reports concern: motion analysis (n = 17), urology (n = 12), gynecology (n = 1), other specialties (n = 1), training (n = 3), and tissue retraction (n = 1). Precision for surgical tools detection varied from 76.0% to 90.6%. Mean absolute error on prediction of urinary continence after robot-assisted radical prostatectomy (RARP) ranged from 85.9 to 134.7 days. Accuracy on prediction of length of stay after RARP was 88.5%. Accuracy on recognition of the next surgical task during robot-assisted partial nephrectomy (RAPN) achieved 75.7%.

CONCLUSION

The reviewed studies were of low quality. The findings are limited by the small size of the datasets. Comparison between studies on the same topic was restricted due to algorithms and datasets heterogeneity. There is no proof that currently AI can identify the critical tasks of RAS operations, which determine patient outcome. There is an urgent need for studies on large datasets and external validation of the AI algorithms used. Furthermore, the results should be transparent and meaningful to surgeons, enabling them to inform patients in layman's words.

REGISTRATION

Review Registry Unique Identifying Number: reviewregistry1225.

Effect of video games playing on surgical simulation training: a systematic review

Introduction: Video games have a positive impact on the skills required for laparoscopic surgery. Several studies have assessed the impact of video games on laparoscopic skills.

Aim: This study aims to systematically review the existing evidence.

Materials and methods: A search strategy was implemented to retrieve relevant articles from MEDLINE and SCOPUS databases. The retrieved articles were reviewed for further evaluation according to the predetermined inclusion/exclusion criteria.

Results: Twenty-six studies were included in this systematic review. These included prospective (n=9), retrospective (n=5) and interventional (n=12). Other review papers were cited in the discussion section. Studies with positive outcomes significantly outweighed the negative ones (21 vs. 5, respectively).

Conclusions: Although there is some evidence that video game experience could give some advantage in laparoscopy no firm conclusions could be drawn yet. The reasons for that lay in the various aims, approaches and results of different study reports. Gaming could be used as a daily warm-up or as a tool to speed-up mastering new skills. A standardized protocol is needed for answering the different questions regarding the impact of video game exposure to laparoscopic skills development and progression.

Gut Microbiota in Lung Cancer: Where Do We Stand?

The gut microbiota (GM) is considered to constitute a powerful "organ" capable of influencing the majority of the metabolic, nutritional, physiological, and immunological processes of the human body. To date, five microbial-mediated mechanisms have been revealed that either endorse or inhibit tumorigenesis. Although the gastrointestinal and respiratory tracts are distant physically, they have common embryonic origin and similarity in structure. The lung microbiota is far less understood, and it is suggested that the crosslink between the human microbiome and lung cancer is a complex, multifactorial relationship. Several pathways linking their respective microbiota have reinforced the existence of a gut-lung axis (GLA). Regarding implications of specific GM in lung cancer therapy, a few studies showed that the GM considerably affects immune checkpoint inhibitor (ICI) therapy by altering the differentiation of regulatory T cells and thus resulting in changes in immunomodulation mechanisms, as discovered by assessing drug metabolism directly and by assessing the host immune modulation response. Additionally, the GM may increase the efficacy of chemotherapeutic treatment in lung cancer. The mechanism underlying the role of the GLA in the pathogenesis and progression of lung cancer and its capability for diagnosis, manipulation, and treatment need to be further explored.

Genetic Polymorphisms Involved in Mitochondrial Metabolism and Pancreatic Cancer Risk

BACKGROUND

The mitochondrial metabolism has been associated with pancreatic ductal adenocarcinoma (PDAC) risk. Recent evidence also suggests the involvement of the genetic variability of the mitochondrial function in several traits involved in PDAC etiology. However, a systematic investigation of the genetic variability of mitochondrial genome (mtSNP) and of all the nuclear genes involved in its functioning (n-mtSNPs) has never been reported.

METHODS

We conducted a two-phase association study of mtSNPs and n-mtSNPs to assess their effect on PDAC risk. We analyzed 35,297 n-mtSNPs and 101 mtSNPs in up to 55,870 individuals (12,884 PDAC cases and 42,986 controls). In addition, we also conducted a gene-based analysis on 1,588 genes involved in mitochondrial metabolism using Multi-marker Analysis of GenoMic Annotation (MAGMA) software.

RESULTS

In the discovery phase, we identified 49 n-mtSNPs and no mtSNPs associated with PDAC risk (P < 0.05). In the second phase, none of the findings were replicated. In the gene-level analysis, we observed that three genes (TERT, SUGCT, and SURF1) involved in the mitochondrial metabolism showed an association below the Bonferroni-corrected threshold of statistical significance (P = 0.05/1588 = 3.1 × 10^-5).

CONCLUSIONS

Even though the mitochondrial metabolism might be involved in PDAC etiology, our results, obtained in a study with one of the largest sample sizes to date, show that neither n-mtSNPs nor mtSNPs are associated with PDAC risk.

IMPACT

This large case-control study does not support a role of the genetic variability of the mitochondrial function in PDAC risk.

"But Who Knows What Autism Is?" Negotiating the Notion of Autism During Free Associative Narrative Interviews with Psychoanalytic Psychotherapists

Background:

Critically informed discursive research has rarely been used to capture the way psychoanalytic psychotherapists organize their talk with regards to Autism Spectrum Disorders (ASD).

Objective:

To understand the language about autism in psychoanalytic talk in terms of i) interpretive repertoires, ii) subject positions and iii) autistic ways of being that circulate inside psychoanalysts’ discourses.

Methods:

This paper presents the data and findings of a critical discursive psychological research which analyzed the talk of eight experienced psychoanalysts. As part of a wider research project this study strived to provide an understanding of the way autism was deployed in free associative narrative interviews.

Results:

Focusing on the micro and the macro level of discourse, the analysis of the data pointed to a rather dilemmatic framework mobilizing therapeutic talk. This framework was organised around a quadrant of interpretive repertoires, which on the one hand fought against the traditional medicalized discourses about autism, while on the other repositioned autism in the same subordinate positions crafted by biomedical regimes.

Conclusion:

A need for breaking from this rather malleable discursive ecosystem is advocated in order to give life to a more democratic let alone emancipating clinical and political environment.

B-cell activating factor (BAFF) expression is associated with Crohn's disease and can serve as a potential prognostic indicator of disease response to Infliximab treatment

BACKGROUND

Several studies correlated elevated B-cell activating factor (BAFF) levels and its polymorphisms (SNPs) in patients with autoimmunity. Limited data existed regarding the role of BAFF in Crohn's Disease (CD) susceptibility and/or treatment response to infliximab.

AIM

This study aims to evaluate BAFF expression in CD patients, investigate if its expression can predict response to infliximab treatment, and examine the association of BAFF SNPs with CD susceptibility.

METHODS

One hundred twelve CD patients and 164 healthy controls were recruited. Serum BAFF levels were determined using an enzyme-linked immunosorbent assay. Participants were genotyped for rs9514828, rs1041569 and rs2893321 SNPs.

RESULTS

Serum BAFF concentration was elevated in CD patients (472.86 ± 223.60 pg/ml) compared with controls (128.16 ± 70.10 pg/ml) before treatment. Responders to IFX treatment had increased serum BAFF levels at baseline (610.03 ± 167.55 pg/ml) compared to non-responders (267.09 ± 107 pg/ml). In responders, BAFF concentration reduced after IFX administration, while increased in non-responders. The rs1041569, TA and AA genotypes frequencies, and the minor allele A were increased significantly in CD patients, indicating an association of the SNP with CD susceptibility.

CONCLUSIONS

Our study suggests that BAFF could be a potential biomarker of CD, while SNP rs1041569 was associated with CD susceptibility.

Open versus endovascular repair for extracranial carotid aneurysms

BACKGROUND

Extracranial carotid artery aneurysms (ECCAs) are rare; however, they are associated with a high risk of stroke and mortality if untreated. In the present review, we compared the major outcomes between open and endovascular repair of ECCAs.

METHODS

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for clinical studies reported online up to September 2020 that had evaluated major outcomes after both open and endovascular repair of ECCAs. Eligible studies were required to have evaluated at least the 30-day mortality or stroke and/or transient ischemic attack rates. The quality of the studies was also evaluated.

RESULTS

Overall, seven studies (three high quality, two medium quality, and two low quality) with 374 patients and 383 ECCAs were eligible. All the studies had been reported from 2004 to 2020. In total, 220 open repairs were compared with 81 endovascular repairs. The open and endovascular treatments showed similar 30-day mortality rates (4% vs 0%; pooled odds ratio [OR], 2.67; 95% confidence interval [CI], 0.291-24.451) and stroke and transient ischemic attack rates (5.5% vs 1.2%; pooled OR, 1.42; 95% CI, 0.412-4.886). Open repair was associated in six studies with a greater incidence of cranial nerve injury compared with endovascular repair (14.5% vs 0%; OR, 3.98; 95% CI, 1.178-13.471). The hematoma or bleeding rate was also similar between the two methods in six studies (5.2% vs 0%; OR, 1.92; 95% CI, 0.518-7.094).

CONCLUSIONS

Open and endovascular repair of ECCAs is associated with similarly low early mortality and cerebrovascular event rates, although open repair showed a greater risk of cranial nerve injuries. An endovascular approach could be more appropriate when the aneurysm is located distally or requires extensive dissection. More studies are needed with standardized follow-up durations to evaluate late outcomes.

Soil organic carbon is not just for soil scientists: measurement recommendations for diverse practitioners

Soil organic carbon (SOC) regulates terrestrial ecosystem functioning, provides diverse energy sources for soil microorganisms, governs soil structure, and regulates the availability of organically bound nutrients. Investigators in increasingly diverse disciplines recognize how quantifying SOC attributes can provide insight about ecological states and processes. Today, multiple research networks collect and provide SOC data, and robust, new technologies are available for managing, sharing, and analyzing large data sets. We advocate that the scientific community capitalize on these developments to augment SOC data sets via standardized protocols. We describe why such efforts are important and the breadth of disciplines for which it will be helpful, and outline a tiered approach for standardized sampling of SOC and ancillary variables that ranges from simple to more complex. We target scientists ranging from those with little to no background in soil science to those with more soil-related expertise, and offer examples of the ways in which the resulting data can be organized, shared, and discoverable.

Association between homeobox protein transcript antisense intergenic ribonucleic acid genetic polymorphisms and cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma (CCA) represents a rare but highly aggressive malignancy that is often challenging to diagnose, especially in early stages. The role of existing tumor biomarkers for CCA diagnosis, remains controversial due to their low sensitivity and specificity. Increasing evidence has implicated long non-coding ribonucleic acid polymorphisms with cancer susceptibility in a variety of tumor types. The association between long non-coding ribonucleic acid homeobox protein transcript antisense intergenic ribonucleic acid (HOTAIR) polymorphisms and CCA risk has not been reported yet.

AIM

To investigate the influence of HOTAIR variants on the risk of CCA development.

METHODS

We conducted a case-control study in which three HOTAIR single nucleotide polymorphisms (rs920778, rs4759314 and rs7958904) were genotyped in a Greek cohort. Our study population included 122 CCA patients (80 males and 42 females) and 165 healthy controls. The polymorphisms under investigation were examined in peripheral blood samples.

RESULTS

HOTAIR rs4759314 AG and GG genotypes were associated with a significantly increased CCA risk [P = 0.004, odds ratio: 3.13; 95% confidence interval: 1.65-5.91 and P = 0.005, odds ratio: 12.31; 95% confidence interval: 1.48-101.87, respectively]. However, no significant associations of HOTAIR rs920778, and rs7958904 were detected. Similarly, we found no significant associations between rs4759314 AA genotype and CCA susceptibility.

CONCLUSION

HOTAIR rs4759314 AG and GG genotypes may be implicated with CCA development and may serve as a potential diagnostic biomarker.

Photon beam energy dependent single-arc volumetric modulated arc optimization

PURPOSE

The purpose of this work was to present a new single-arc mixed photon (6&18MV) VMAT (SAMP) optimization framework that concurrently optimizes for two photon energies with corresponding partial arc lengths.

METHODS AND MATERIALS

Owing to simultaneous optimization of energy dependent intensity maps and corresponding arc locations, the proposed model poses nonlinearity. Unique relaxation constraints based on McCormick approximations were introduced for linearization. Energy dependent intensity maps were then decomposed to generate apertures. Feasibility of the proposed framework was tested on a sample of ten prostate cancer cases with lateral separation ranging from 34 cm (case no.1) to 52 cm (case no.6). The SAMP plans were compared against single energy (6MV) VMAT (SE) plans through dose volume histograms (DVHs) and radiobiological parameters including normal tissue complication probability (NTCP) and equivalent uniform dose (EUD).

RESULTS

The contribution of higher energy photon beam optimized by the algorithm demonstrated an increase for cases with a lateral separation >40 cm. SAMP-VMAT notably improved bladder and rectum sparing in large size cases. Compared to single energy, SAMP-VMAT plans reduced bladder and rectum NTCP in cases with large lateral separation. With the exception of one case, SAMP-VMAT either improved or maintained femoral heads compared to SE-VMAT. SAMP-VMAT reduced the nontarget tissue integral dose in all ten cases.

CONCLUSIONS

A single-arc VMAT optimization framework comprising mixed photon energy partial arcs was presented. Overall results underline the feasibility and potential of the proposed approach for improving OAR sparing in large size patients without compromising the target homogeneity and coverage.

Place of hyperthermic intraperitoneal chemotherapy in the armament against pancreatic adenocarcinoma: A survival, mortality and morbidity systematic review

Pancreatic adenocarcinoma is one of the deadliest types of cancer worldwide, with a 5-year survival rate of 8% despite recent treatment advancements. The present systematic review aimed to investigate the role of hyperthermic intraperitoneal chemotherapy (HIPEC) following surgical resection for pancreatic adenocarcinoma, with or without peritoneal carcinomatosis. A systematic search of the MEDLINE and SCOPUS electronic databases was performed according to PRISMA guidelines. All possible relevant articles published between January 1980 and May 2019 were retrieved using multiple search terms associated with HIPEC and pancreatic adenocarcinoma. The initial search resulted in 1,244 reports, which condensed to 41 reports following screening of titles and abstracts, and subsequently to four reports following full-text thorough examination. The four reports included involved a prospective cohort study of HIPEC use in resectable pancreatic adenocarcinoma, and three retrospective studies of HIPEC use following cytoreductive surgery for peritoneal carcinomatosis due to pancreatic adenocarcinoma, resulting in a total of 47 patients. The overall survival ranged between 2 and 62 months, and the hospital mortality rate was 8.5%. Morbidity (34%) was mainly attributed to anastomotic leak or respiratory failure. Due to the small sample size and low quality of evidence of the included studies, no valid conclusions could be drawn. Therefore, further studies are required to justify the use of HIPEC as an adjuvant therapy in resectable pancreatic adenocarcinoma, while cytoreductive surgery and HIPEC in peritoneal carcinomatosis of pancreatic origin seems not only not useful but also unsafe at this level of evidence.

Strong Coupling of Organic Dyes Located at the Surface of a Dielectric Slab Microcavity

Strong coupling to the electronic or vibronic transitions of an organic semiconductor has been extensively studied in microcavity structures in which a molecular film is placed between two closely spaced mirrors. Recent experiments suggest that such strong coupling can be used to modify chemical reactions; however, the geometry of conventional microcavity structures makes such studies difficult as they limit the ability of molecules to interact with their local environment. Here, we show that optical strong coupling to a molecular film can be achieved even when such molecules are located on the surface of a dielectric slab. We then show that such molecules on the surface of the slab can undergo facile interactions with molecules in their surrounding environment, and evidence a reversible protonation/deprotonation reaction by exposing a surface-bound porphyrin to an acidic or basic vapor. Although our proof-of-principle measurements do not evidence any change in reaction rates, we believe our structures represent a promising system in which to explore polariton-driven chemical phenomena.

Strong Coupling of Organic Dyes Located at the Surface of a Dielectric Slab Microcavity

Strong coupling to the electronic or vibronic transitions of an organic semiconductor has been extensively studied in microcavity structures in which a molecular film is placed between two closely spaced mirrors. Recent experiments suggest that such strong coupling can be used to modify chemical reactions; however, the geometry of conventional microcavity structures makes such studies difficult as they limit the ability of molecules to interact with their local environment. Here, we show that optical strong coupling to a molecular film can be achieved even when such molecules are located on the surface of a dielectric slab. We then show that such molecules on the surface of the slab can undergo facile interactions with molecules in their surrounding environment, and evidence a reversible protonation/deprotonation reaction by exposing a surface-bound porphyrin to an acidic or basic vapor. Although our proof-of-principle measurements do not evidence any change in reaction rates, we believe our structures represent a promising system in which to explore polariton-driven chemical phenomena.

Performance Assessment of Subjects With Nursing Education Trained in Sigmoidoscopy by Means of a Simulator

Reports evaluating simulation-based sigmoidoscopy training among nurses are scarce. The aim of this prospective nonrandomized study was to assess the performance of nurses in simulated sigmoidoscopy training and the potential impact on their performance of endoscopy unit experience, general professional experience, and skills in manual activities requiring coordinated maneuvers. Forty-four subjects were included: 12 nurses with (Group A) and 14 nurses without endoscopy unit experience (Group B) as well as 18 senior nursing students (Group C). All received simulator training in sigmoidoscopy. Participants were evaluated with respect to predetermined validated metrics. Skills in manual activities requiring coordinated maneuvers were analyzed to draw possible correlations with their performance. The total population required a median number of 5 attempts to achieve all predetermined goals. Groups A and C outperformed Group B regarding the number of attempts needed to achieve the predetermined percentage of visualized mucosa (p = .017, p = .027, respectively). Furthermore, Group A outperformed Group B regarding the predetermined duration of procedure (p = .046). A tendency was observed for fewer attempts needed to achieve the overall successful endoscopy in both Groups A and C compared with Group B. Increased score on playing stringed instruments was associated with decreased total time of procedure (rs = -.34, p = .03) and with decreased number of total attempts for successful endoscopy (rs = -.31, p = .046). This study suggests that training nurses and nursing students in simulated sigmoidoscopy is feasible by means of a proper training program. Experience in endoscopy unit and skills in manual activities have a positive impact on the training process.

Salivary dysfunction caused by medication usage

A considerable number of patients arriving in dental offices are being treated with ongoing medication for a variety of chronic diseases. As a result, dentists must be familiar with the potential side effects these therapeutic agents may have on the tissues of the oral cavity, and in particular on the salivary gland. Salivary gland function may be altered by a wide range of medications, leading to effects such as xerostomia, hyposalivation, hypersalivation or even swelling of the glands. These disorders can cause a variety of other health complications. This review will focus on the most common groups of drugs responsible for salivary gland dysfunction, including psychoactive drugs, antidepressants, antipsychotics, antihypertensives, and antihistamines.

Intraoperative Indocyanine Green (ICG) Angiography for the Identification of the Parathyroid Glands: Current Evidence and Future Perspectives

BACKGROUND/AIM

Recently, indocyanine green (ICG) fluorescence imaging has been used for the identification of the parathyroid glands (PG) during thyroid and parathyroid surgery. However, an overall consensus on the optimal technique, the dosage, the timing of the ICG administration and finally its interpretation and clinical usefulness is still lacking evidence. The aim of this review is to investigate the use of ICG angiography during thyroidectomy and/or parathyroidectomy for identification as well as for the perfusion integrity of the parathyroid glands.

MATERIALS AND METHODS

The PubMed database was systematically searched for publications regarding intraoperative ICG imaging in patients that undergo thyroidectomy or parathyroidectomy.

RESULTS

Eighteen publications reporting on 612 patients, namely 71 parathyroidectomy and 541 thyroidectomy patients met the inclusion criteria. Eleven publications reported the use of ICG angiography for the identification of the parathyroid glands during thyroidectomy and seven during parathyroidectomy for primary and secondary hyperparathyroidism.

CONCLUSION

ICG fluorescence imaging is a simple, fast and reproducible method capable of intraoperatively visualizing and assessing the function of parathyroid glands, and can, therefore, assist surgeons in their decision-making. Despite all this, ICG fluorescence imaging technique for PG detection still lacks standardization and further studies are needed to establish its clinical utility.

Validation of a Novel Needle Holder to Train Advanced Laparoscopy Skills to Novices in a Simulator Environment

Background. Our aim was to determine if a newly designed Najar needle holder (NNH) shortens the time for novices to improve advanced laparoscopy (AL) techniques (suturing/knot tying), compared with a conventional macro needle holder (MNH) in a simulator. Furthermore, we aimed to validate a new video scoring system determining AL skills. Methods. Forty-six medical students performed identical surgical tasks in a prospective, crossover study evaluating AL skills (NNH vs MNH). All subjects performed a double-throw knot, 2 single-throw knots following 3 running sutures in the Simball Box (SB) simulator. After resting, subjects switched needle holders. All tasks were videotaped and analyzed using SB software and by 2 independent reviewers using the Objective Video Evaluation Scoring Table (OVEST). Trial performance expressed as SB Overall Score (SBOS) and OVEST. Results. In the group starting with NNH (followed by MNH) OVEST was consistently high during both trials (median = 12.5, range = 6.5-18.0, and median = 13.5, range = 6.5-21.0; P = .2360). However, in the group starting with MNH, OVEST improved significantly when the participants changed to NNH (median = 10.0, range = 2.5-19.5, vs median = 14.5, range = 4.5-18.0; P = .0003); an improvement was also found with SBOS (median = 37%, range = 27% to 92%, vs median = 48%, range = 34% to 70%; P = .0289). In both trials, both independent reviewers' OVEST measures correlated well: Trial 1: β = 0.97, P < .0001; and Trial 2: β = 0.95, P < .0001. A correlation also existed between SBOS and OVEST in both trials (β = 2.1, P < .0001; and β = 1.9, P = .0002). Conclusions. This study indicates a significantly higher improvement in laparoscopic suturing skills in novices training AL skills using NNH compared with MNH. Starting early, AL training in novices using NNH is a feasible option. Furthermore, OVEST used in experimental settings as an evaluation tool is comparable with the validated SBOS.

Can 3D Vision Improve Laparoscopic Performance in Box Simulation Training when Compared to Conventional 2D Vision?

INTRODUCTION

Three-dimensional (3D) imaging systems have been introduced in laparoscopic surgery to facilitate binocular vision and dexterity to improve surgical performance and safety. Several studies have shown the benefits of 3D imaging in laparoscopy, but until now only a few studies have assessed the outcome by using objective variables. Box trainers are affordable alternatives to virtual laparoscopic surgical training, and the possibility of using real surgical instruments makes them more realistic to use. However, the data and feedback by a virtual simulator have not, until now, been able to assess. Simball Box®, equipped with G-coder sensors®, registers the instrument movements during training and gives the same feedback like a virtual simulator.

AIM

The aim of this study was to objectively evaluate the laparoscopic performance in 3D compared to conventional 2D vision by using a box simulation trainer.

MATERIALS AND METHODS

Thirty surgeons, residents and consultants, participated in the study. Eighteen had no, or minimal, laparoscopic experience (novices) whereas 12 were experts. They all performed three standard box training exercises (rope race, precision cutting, and basic suturing) in Simball Box. The participants were randomized and started with either 3D HD or traditional 2D HD cameras. The exercises were instructed and supervised. All instrument movements were registered. Variations in time, linear distance, average speed, and motion smoothness were analyzed.

RESULTS

The parameters time, distance, speed, and motion smoothness were significantly better when the 3D camera was used.

CONCLUSION

All individuals of both subgroups achieved significantly higher speed and better motion smoothness when using 3D.

Simultaneous optimization of mixed photon energy beams in volumetric modulated arc therapy

PURPOSE

Despite the availability of multiple energy photon beams on clinical linear accelerators, volumetric modulated arc therapy (VMAT) optimization is currently limited to a single photon beam. The purpose of this work was to present a proof-of-principle study on an algorithm for simultaneous optimization of mixed photon beams for VMAT (MP - VMAT), utilizing an additional photon energy as an additional degree of freedom.

METHODS

The MP - VMAT optimization algorithm is presented as a two-step heuristic approach. First, a convex linear programming problem is solved for simultaneous optimization of nonuniform dual energy intensity maps (DEIMs) for an angular resolution of 36 equi-spaced beam segments. Subsequently, for a given gantry speed schedule, the second step aims to best replicate each DEIM by dispersing MP - VMAT apertures along with their corresponding intensities over their respective beam segment. This constitutes a nonlinear problem, which is linearized using McCormick relaxation. The final large-scale mixed integer linear programming (MILP) dispersion model ensures a contiguous and smooth transition of multileaf collimators (MLCs) from one beam segment to the next. To demonstrate the proof-of-principle, we first compared the quality of dose volume histograms (DVHs) of MP - VMAT to the ones calculated from 36 DEIMs following the step 1 of MP - VMAT model. Additionally, the MLCs motion violations were evaluated for the complete 360° gantry rotation for gantry speeds ranging from 1 to 6° per second. The quality of MP - VMAT plans were also compared to conventional single energy VMAT plans via DVH, homogeneity index (HI), and conformity number (CN) for two prostate cases.

RESULTS

The MP - VMAT model resulted in a successful convergence of DVHs relative to the ones from DEIMs with HI and CN of 0.05 and 0.9, respectively, for 1 and 2° per second gantry speed schedules. In replicating the DEIMs, the MILP dispersion model was able to achieve optimality for almost all segments at 1° per second and for majority of segments at 2° per second. Although, DVHs quality was slightly inferior for 3° per second gantry speed, the target conformity of 0.9 and heterogeneity of 0.08 were achievable even for the suboptimal solutions. No violations of the MLC constraints were observed throughout the complete 360 degree arc rotation for any gantry speed schedule, thereby confirming MILP dispersion model. For the two prostate cases, the results showed MP - VMAT's ability to achieve substantial dose reduction in rectum and bladder while yielding similar target coverage compared to single energy VMAT. Bladder volume was mostly spared in low-to-intermediate dose region. Rectal volume sparing (3 % to 12 %) was observed in the intermediate (from 25 to 50 Gy) dose region.

CONCLUSION

We demonstrate the first formalism of a large-scale simultaneous optimization of mixed photon energy beams for VMAT. Dosimetric comparison of MP - VMAT to single energy VMAT demonstrated potential advantages of using mixed photon energy beams for prostate plans, thus providing an impetus for further testing on a large clinical cohort.

The Role of 3D Printing in Colorectal Surgery: Current Evidence and Future Perspectives

BACKGROUND

Three-dimensional (3D) printing is an emerging and evolving technology with a variety of possible applications in surgery. The purpose of this study was to examine its potential applications in the field of colorectal surgery, as a tool in pre-operative planning and peri-operative navigation, as well as in training. Its cost-efficiency was also examined.

MATERIALS AND METHODS

A literature review was conducted on articles specifically presenting various applications of 3D printing in the field of colorectal surgery. PubMed was the primary database researched.

RESULTS

A total of seven studies were found to meet the inclusion criteria. The majority of the articles employed 3D printing technology to produce patient-specific anatomic replicas to enhance pre-operative planning, providing satisfactory results. One study used 3D printing technology as a therapy tool, stating superior results over traditional methods.

CONCLUSION

3D printing is a novel technology with a broad spectrum of possible applications in colorectal surgery. Anatomic replicas specific to the anatomy of a patient with acceptable dimensional correlations can be produced using the currently available technology. Surgical and patient training can also be enhanced. Depending on the technology used, costs greatly vary and can thus hinder popularization of this technology in surgery.

MRI-Related Geometric Distortions in Stereotactic Radiotherapy Treatment Planning: Evaluation and Dosimetric Impact

In view of their superior soft tissue contrast compared to computed tomography, magnetic resonance images are commonly involved in stereotactic radiosurgery/radiotherapy applications for target delineation purposes. It is known, however, that magnetic resonance images are geometrically distorted, thus deteriorating dose delivery accuracy. The present work focuses on the assessment of geometric distortion inherent in magnetic resonance images used in stereotactic radiosurgery/radiotherapy treatment planning and attempts to quantitively evaluate the consequent impact on dose delivery. The geometric distortions for 3 clinical magnetic resonance protocols (at both 1.5 and 3.0 T) used for stereotactic radiosurgery/radiotherapy treatment planning were evaluated using a recently proposed phantom and methodology. Areas of increased distortion were identified at the edges of the imaged volume which was comparable to a brain scan. Although mean absolute distortion did not exceed 0.5 mm on any spatial axis, maximum detected control point disposition reached 2 mm. In an effort to establish what could be considered as acceptable geometric uncertainty, highly conformal plans were utilized to irradiate targets of different diameters (5-50 mm). The targets were mispositioned by 0.5 up to 3 mm, and dose–volume histograms and plan quality indices clinically used for plan evaluation and acceptance were derived and used to investigate the effect of geometrical uncertainty (distortion) on dose delivery accuracy and plan quality. The latter was found to be strongly dependent on target size. For targets less than 20 mm in diameter, a spatial disposition of the order of 1 mm could significantly affect (>5%) plan acceptance/quality indices. For targets with diameter greater than 2 cm, the corresponding disposition was found greater than 1.5 mm. Overall results of this work suggest that efficacy of stereotactic radiosurgery/radiotherapy applications could be compromised in case of very small targets lying distant from the scanner’s isocenter (eg, the periphery of the brain).

Surgeons' and surgical trainees' acute stress in real operations or simulation: A systematic review

BACKGROUND AND PURPOSE

Acute stress in surgery is ubiquitous and has an immediate impact on surgical performance and patient safety. Surgeons react with several coping strategies; however, they recognise the necessity of formal stress management training. Thus, stress assessment is a direct need. Surgical simulation is a validated standardised training milieu designed to replicate real-life situations. It replicates stress, prevents biases, and provides objective metrics. The complexity of stress mechanisms makes stress measurement difficult to quantify and interpret. This systematic review aims to identify studies that have used acute stress estimation measurements in surgeons or surgical trainees during real operations or surgical simulation, and to collectively present the rationale of these tools, with special emphasis in salivary markers.

METHODS

A search strategy was implemented to retrieve relevant articles from MEDLINE and SCOPUS databases. The 738 articles retrieved were reviewed for further evaluation according to the predetermined inclusion/exclusion criteria.

RESULTS

Thirty-three studies were included in this systematic review. The methods for acute stress assessment varied greatly among studies with the non-invasive techniques being the most commonly used. Subjective and objective tests for surgeons' acute stress assessment are being presented.

CONCLUSION

There is a broad spectrum of acute mental stress assessment tools in the surgical field and simulation and salivary biomarkers have recently gained popularity. There is a need to maintain a consistent methodology in future research, towards a deeper understanding of acute stress in the surgical field.

Video analysis in basic skills training: a way to expand the value and use of BlackBox training?

Background

Basic skills training in laparoscopic high-fidelity simulators (LHFS) improves laparoscopic skills. However, since LHFS are expensive, their availability is limited. The aim of this study was to assess whether automated video analysis of low-cost BlackBox laparoscopic training could provide an alternative to LHFS in basic skills training.

Methods

Medical students volunteered to participate during their surgical semester at the Karolinska University Hospital. After written informed consent, they performed two laparoscopic tasks (PEG-transfer and precision-cutting) on a BlackBox trainer. All tasks were videotaped and sent to MPLSC for automated video analysis, generating two parameters (Pl and Prtcl_tot) that assess the total motion activity. The students then carried out final tests on the MIST-VR simulator. This study was a European collaboration among two simulation centers, located in Sweden and Greece, within the framework of ACS-AEI.

Results

31 students (19 females and 12 males), mean age of 26.2 ± 0.8 years, participated in the study. However, since two of the students completed only one of the three MIST-VR tasks, they were excluded. The three MIST-VR scores showed significant positive correlations to both the Pl variable in the automated video analysis of the PEG-transfer (RSquare 0.48, P < 0.0001; 0.34, P = 0.0009; 0.45, P < 0.0001, respectively) as well as to the Prtcl_tot variable in that same exercise (RSquare 0.42, P = 0.0002; 0.29, P = 0.0024; 0.45, P < 0.0001). However, the correlations were exclusively shown in the group with less PC gaming experience as well as in the female group.

Conclusions

Automated video analysis provides accurate results in line with those of the validated MIST-VR. We believe that a more frequent use of automated video analysis could provide an extended value to cost-efficient laparoscopic BlackBox training. However, since there are gender-specific as well as PC gaming experience differences, this should be taken in account regarding the value of automated video analysis.

Virtual reality-based assessment of basic laparoscopic skills using the Leap Motion controller

BACKGROUND

The majority of the current surgical simulators employ specialized sensory equipment for instrument tracking. The Leap Motion controller is a new device able to track linear objects with sub-millimeter accuracy. The aim of this study was to investigate the potential of a virtual reality (VR) simulator for assessment of basic laparoscopic skills, based on the low-cost Leap Motion controller.

METHODS

A simple interface was constructed to simulate the insertion point of the instruments into the abdominal cavity. The controller provided information about the position and orientation of the instruments. Custom tools were constructed to simulate the laparoscopic setup. Three basic VR tasks were developed: camera navigation (CN), instrument navigation (IN), and bimanual operation (BO). The experiments were carried out in two simulation centers: MPLSC (Athens, Greece) and CRESENT (Riyadh, Kingdom of Saudi Arabia). Two groups of surgeons (28 experts and 21 novices) participated in the study by performing the VR tasks. Skills assessment metrics included time, pathlength, and two task-specific errors. The face validity of the training scenarios was also investigated via a questionnaire completed by the participants.

RESULTS

Expert surgeons significantly outperformed novices in all assessment metrics for IN and BO (p < 0.05). For CN, a significant difference was found in one error metric (p < 0.05). The greatest difference between the performances of the two groups occurred for BO. Qualitative analysis of the instrument trajectory revealed that experts performed more delicate movements compared to novices. Subjects' ratings on the feedback questionnaire highlighted the training value of the system.

CONCLUSIONS

This study provides evidence regarding the potential use of the Leap Motion controller for assessment of basic laparoscopic skills. The proposed system allowed the evaluation of dexterity of the hand movements. Future work will involve comparison studies with validated simulators and development of advanced training scenarios on current Leap Motion controller.

DNA repair genes are selectively mutated in diffuse large B cell lymphomas

DNA repair mechanisms are fundamental for B cell development, which relies on the somatic diversification of the immunoglobulin genes by V(D)J recombination, somatic hypermutation, and class switch recombination. Their failure is postulated to promote genomic instability and malignant transformation in B cells. By performing targeted sequencing of 73 key DNA repair genes in 29 B cell lymphoma samples, somatic and germline mutations were identified in various DNA repair pathways, mainly in diffuse large B cell lymphomas (DLBCLs). Mutations in mismatch repair genes (EXO1, MSH2, and MSH6) were associated with microsatellite instability, increased number of somatic insertions/deletions, and altered mutation signatures in tumors. Somatic mutations in nonhomologous end-joining (NHEJ) genes (DCLRE1C/ARTEMIS, PRKDC/DNA-PKcs, XRCC5/KU80, and XRCC6/KU70) were identified in four DLBCL tumors and cytogenetic analyses revealed that translocations involving the immunoglobulin-heavy chain locus occurred exclusively in NHEJ-mutated samples. The novel mutation targets, CHEK2 and PARP1, were further screened in expanded DLBCL cohorts, and somatic as well as novel and rare germline mutations were identified in 8 and 5% of analyzed tumors, respectively. By correlating defects in a subset of DNA damage response and repair genes with genomic instability events in tumors, we propose that these genes play a role in DLBCL lymphomagenesis.

Epstein-Barr virus immortalization of human B-cells leads to stabilization of hypoxia-induced factor 1 alpha, congruent with the Warburg effect

BACKGROUND

Epstein-Barr virus (EBV) encodes six nuclear transformation-associated proteins that induce extensive changes in cellular gene expression and signaling and induce B-cell transformation. The role of HIF1A in EBV-induced B-cell immortalization has not been previously studied.

METHODS AND FINDINGS

Using Western blotting and Q-PCR, we found that HIF1A protein is stabilized in EBV-transformed lymphoblastoid cells. Western blotting, GST pulldown assays, and immunoprecipitation showed that EBV-encoded nuclear antigens EBNA-5 and EBNA-3 bind to prolylhydroxylases 1 and 2, respectively, thus inhibiting HIF1A hydroxylation and degradation. Immunostaining and Q-PCR showed that the stabilized HIF1A translocates to the nucleus, forms a heterodimer with ARNT, and transactivates several genes involved in aerobic glycolysis. Using biochemical assays and Q-PCR, we also found that lymphoblastoid cells produce high levels of lactate, lactate dehydrogenase and pyruvate.

CONCLUSIONS

Our data suggest that activation of the aerobic glycolytic pathway, corresponding to the Warburg effect, occurs in EBV-transformed lymphoblastoid cells, in contrast to mitogen-activated B-cells.

Reovirus-induced tenosynovitis in chickens the influence of age at infection

Groups of specific pathogen-free (SPF) light hybrid chickens were infected with an arthrotropic reovirus at 1 day old, or at 2, 4, 6 or 9 weeks of age. In each group, approximately 20 were infected orally and 6 via the footpad. For each age group clinical signs of tenosynovitis, gross and microscopic lesions in the legs, virus excretion in the faeces, virus persistence in the joints, and precipitin response to reovirus were observed over a period of 9 weeks post infection (p.i.). For both routes of infection an age-limited susceptibility was shown, the most serious effects, both in numbers of affected birds and severity of gross lesions including tendon rupture, being seen in the youngest group. Gross lesions were rarely seen after oral infection of 6- and 9-week-old chickens. Footpad inoculation of virus had a more severe effect overall, and extended the age susceptibility, mild leg swellings being seen in some birds infected at 6 and 9 weeks of age. After oral infection, higher virus titres in the faeces and a more prolonged persistence in the gut and hock joint were recorded in chicks infected at 1 day old compared with the other age groups. Also, compared with the older groups, a delayed precipitin response was found in those infected at 1 day old. Footpad inoculation provoked earlier virus replication in the gut and a more rapid precipitin response.

Distortion of the gizzard in Cyprus pigeons (Columba livia) associated with Hadjelia truncata infestation

Hadjelia truncata is well recognised as an avian parasite but is rarely reported as pathogenic. This paper describes severe disease in pigeons due to this parasite and is the first to describe the condition in Cyprus. The morphology of the parasite and the associated lesions are described and illustrated and the pathogenesis of the condition is discussed.