Upper gastrointestinal bleeding: Diagnosis of Helicobacter pylori infection-Descriptive study

Background and Aim

The presence of blood in the stomach has been thought to affect the performance of diagnostic tests used in detecting Helicobacter pylori (H. pylori) in the stomach. This study evaluates the effect of upper gastrointestinal bleeding on the efficacy of a rapid urease test (RUT) and compares the results with the pathologic method.

Methods

In this descriptive study, 100 patients presented with upper gastrointestinal bleeding, confirmed from endoscopy, referred to Shahid Rahimi Hospital in Khorramabad were enrolled. Antral biopsy was performed in all the patients and the samples were extracted for histopathology and RUT. A questionnaire was used to collect rapid urease test outcomes and associated parameters (antibiotic, bismuth, and proton pump inhibitors), histology and demographic data. Histopathology was used as the gold standard for diagnosis of H. pylori.

Results

Of the 52 patients who were reported positive for H. pylori in pathology, 36 had RUT-positive H. pylori, sensitivity 69.2%, and of 48 patients whose pathology was negative, 25 had negative RUT, specificity 52.1%. Of 59 RUT, 36 had positive pathology, positive predictive value was 61% and from 41 with negative RUT, 25 had negative pathology, negative predictive value was 61%. The prevalence of H. pylori infection was significantly associated with the age of 50 years and above, p = 0.042, and previous history of bleeding, p = 0.019.

Conclusion

Gastrointestinal bleeding can reduce the sensitivity of RUT. The negative results of these tests in acute upper gastrointestinal bleeding should therefore be interpreted carefully.

Bilateral simultaneous presentation of posterior canal benign paroxysmal positional vertigo

OBJECTIVE

To outline the clinical picture of bilateral posterior canal benign paroxysmal positional vertigo.

METHODS

A total of 573 patients with posterior canal benign paroxysmal positional vertigo were classified as having unilateral, or true or pseudo bilateral, posterior canal benign paroxysmal positional vertigo, and were treated with the Epley manoeuvre. Statistical significance was set at p < 0.05.

RESULTS

Of the patients, 483 had unilateral and 90 (15.7 per cent) had bilateral presentation. Of the latter, 72 patients had pseudo bilateral posterior canal benign paroxysmal positional vertigo. Comparisons of site of involvement, male to female ratio and the incidence of associated problems in unilateral, and true and pseudo bilateral posterior canal benign paroxysmal positional vertigo did not reveal any statistically significant differences (p = 0.828, p = 0.200, p = 0.142). Comparisons of the number of manoeuvres required to provide symptom relief and the rate of recurrence were significant (p < 0.05).

CONCLUSION

Identification of true and pseudo bilateral posterior canal benign paroxysmal positional vertigo is important given the differences in aetiology and treatment outcome. Treatment of patients with true bilateral posterior canal benign paroxysmal positional vertigo requires several therapeutic manoeuvre attempts, and patients should be warned about recurrence.

Development and validation of a nomogram to predict cervical lymph node metastasis in head and neck squamous cell carcinoma

Background

Head and neck cancers are a heterogeneous, aggressive, and genetically complex collection of malignancies of the oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, paranasal sinuses and salivary glands, which are difficult to treat. Regional lymph nodes metastasis is a significant poor prognosis factor for head and neck squamous cell carcinoma. Metastasis to the regional lymph nodes reduces the 5-year survival rate by 50% compared with that of patients with early-stage disease. Accurate evaluation of cervical lymph node is a vital component in the overall treatment plan for patients with squamous cell carcinoma of the head and neck. However, current models are struggle to accurately to predict cervical lymph node metastasis. Here, we analyzed the clinical, imaging, and pathological data of 272 patients with HNSCC confirmed by postoperative pathology and sought to develop and validate a nomogram for prediction of lymph node metastasis in patients with head and neck squamous cell carcinoma.

Methods

We retrospectively analyzed the clinical, imaging, and pathological data of 272 patients with head and neck squamous cell carcinoma (HNSCC) confirmed by postoperative pathology at the Affiliated Hospital of Qingdao University from June 2017 to June 2021. Patients were randomly divided into the training and validation cohorts in a 3:1 ratio, and after screening risk factors by logistic regression, nomogram was developed for predicting lymph nodes metastasis, then the prediction model was verified by C-index, area under curve (AUC), and calibration curve.

Results

Of the 272 patients, seven variables were screened to establish the predictive model, including the differentiation degree of the tumor [95% confidence interval(CI):1.224~6.735, P=0.015], long-to-short axis ratio of the lymph nodes (95%CI: 0.019~0.217, P<0.001), uneven/circular enhancement (95%CI: 1.476~16.715, P=0.010), aggregation of lymph nodes (95%CI:1.373~10.849, P=0.010), inhomogeneous echo (95%CI: 1.337~23.389, P=0.018), unclear/absent medulla of lymph nodes (95%CI: 2.514~43.989, P=0.001), and rich blood flow (95%CI: 1.952~85.632, P=0.008). The C-index was 0.910, areas under the curve of training cohort and verification cohort were 0.953 and 0.938 respectively, indicating the discriminative ability of this nomogram. The calibration curve showed a favorable compliance between the prediction of the model and actual observations. The clinical decision curve showed this model is clinically useful and had better discriminative ability between 0.25 and 0.9 for the probability of cervical LNs metastasis.

Conclusions

We established a good prediction model for cervical lymph node metastasis in head and neck squamous cell carcinoma patients which can provide reference value and auxiliary diagnosis for clinicians in making neck management decisions of HNSCC patients.

Roles of lipocalin-type and hematopoietic prostaglandin D synthases in mouse retinal angiogenesis

Normal angiogenesis is essential for retinal development and maintenance of visual function in the eye, and its abnormality can cause retinopathy and other eye diseases. Prostaglandin D2 is an anti-angiogenic lipid mediator produced by lipocalin-type PGD synthase (L-PGDS) or hematopoietic PGD synthase (H-PGDS). However, the exact role of these PGD synthases remains unclear. Therefore, we compared the roles of these synthases in murine retinal angiogenesis under physiological and pathological conditions. On postnatal day (P) 8, the WT murine retina was covered with an elongated vessel. L-PGDS deficiency, but not H-PGDS, reduced the physiological vessel elongation with sprouts increase. L-PGDS expression was observed in endothelial cells and neural cells. In vitro, L-PGDS inhibition increased the hypoxia-induced vascular endothelial growth factor expression in isolated endothelial cells, inhibited by a prostaglandin D2 metabolite, 15-deoxy-Δ12,14 -PGJ2 (15d-PGJ2) treatment. Pericyte depletion, using antiplatelet-derived growth factor receptor-β antibody, caused retinal hemorrhage with vessel elongation impairment and macrophage infiltration in the WT P8 retina. H-PGDS deficiency promoted hemorrhage but inhibited the impairment of vessel elongation, while L-PGDS did not. In the pericyte-depleted WT retina, H-PGDS was expressed in the infiltrated macrophages. Deficiency of the D prostanoid receptor also inhibited the vessel elongation impairment. These results suggest the endogenous role of L-PGDS signaling in physiological angiogenesis and that of H-PGDS/D prostanoid 1 signaling in pathological angiogenesis.

Pathological Outcomes of Patients With Advanced Renal Cell Carcinoma Who Receive Nephrectomy Following Immunotherapy

BACKGROUND

Even though cytoreductive nephrectomy (CN) was once the standard of care for patients with advanced renal cell carcinoma (RCC), its role in treatment has not been well analyzed or defined in the era of immunotherapy (IO).

MATERIALS AND METHODS

This study analyzed pathological outcomes in patients with advanced or metastatic RCC who received IO prior to CN. This was a multi-institutional, retrospective study of patients with advanced or metastatic RCC. Patients were required to receive IO monotherapy or combination therapy prior to radical or partial CN. The primary endpoint assessed surgical pathologic outcomes, including American Joint Committee on Cancer (AJCC) staging and frequency of downstaging, at the time of surgery. Pathologic outcomes were correlated to clinical variables using a Wald-chi squared test from Cox regression in a multi-variable analysis. Secondary outcomes included objective response rate (ORR) defined by response evaluation criteria in solid tumors (RECIST) version 1.1 and progression-free survival (PFS), which were estimated using the Kaplan-Meier method with reported 95% CIs.

RESULTS

Fifty-two patients from 9 sites were included. Most patients were male (65%), 81% had clear cell histology, 11% had sarcomatoid differentiation. Overall, 44% of patients experienced pathologic downstaging, and 13% had a complete pathologic response. The ORR immediately prior to nephrectomy was stable disease in 29% of patients, partial response in 63%, progressive disease in 4%, and 4% unknown. Median follow-up for the entire cohort was 25.3 months and median PFS was 3.5 years (95% CI, 2.1-4.9).

CONCLUSIONS

IO-based interventions prior to CN in patients with advanced or metastatic RCC demonstrates efficacy, with a small fraction of patients showing a complete response. Additional prospective studies are warranted to investigate the role of CN in the modern IO-era.

Endometrial Angiogenesis of Abnormal Uterine Bleeding and Infertility in Patients with Uterine Fibroids-A Systematic Review

Uterine fibroids are the most common benign tumors in women, with abnormal uterine bleeding (AUB) as the main reported symptom. Additionally, an association between fibroids and infertility has been established, especially if the fibroid protrudes in the uterine cavity. Hormonal therapy is associated with side-effects and as well as hysterectomy, which is incompatible with a desire to conceive. To improve treatment, it is essential to unravel the etiology of fibroid-related symptoms. We aim to evaluate endometrial angiogenesis in women with fibroids, with and without AUB, and the influence of pharmaceutical therapies in these patients. Furthermore, we explore the possible role of altered angiogenesis in patients with fibroids and infertility. We performed a systematic review according to PRISMA-guidelines (PROSPERO: CRD42020169061), and included 15 eligible studies. Endometrial expression of vascular endothelial growth factor (VEGF) and adrenomedullin was increased in patients with fibroids. This suggests aberrant angiogenesis, potentially involving disturbed vessel maturation, resulting in immature and fragile vessels. Treatment with gonadotropin-releasing hormone agonist, ulipristal acetate, and continuous oral contraception pills reduced several angiogenic parameters, including VEGF. If infertile and fertile patients with fibroids were compared, a significant decreased expression of the bone morphogenetic protein/Smad-protein pathway was found, possibly caused by the increased expression of transforming growth factor-beta. For future therapeutic development, these different angiogenic pathways could be of interest as possible targets to treat fibroid-related symptoms.

Prescribing Exercise to Cancer Patients Suffering from Increased Bone Fracture Risk Due to Metastatic Bone Disease or Multiple Myeloma in Austria-An Inter- and Multidisciplinary Evaluation Measure

INTRODUCTION

In the current absence of specific functional fracture risk assessment technology, the planning of physical exercise interventions for cancer patients suffering from increased bone fracture risk remains a serious clinical challenge. Until a reliable, solely technical solution is available for the clinician, fracture risk assessment remains an inter- and multidisciplinary decision to be made by various medical experts. The aim of this short paper is depicting how this challenge should be approached in the clinical reality according to Austrian experts in cancer rehabilitation, presenting the best-practice model in Austria. Following referral from the specialist responsible for the primary cancer treatment (oncologist, surgeon, etc.), the physiatrist takes on the role of rehabilitation case manager for each individual patient. Fracture risk assessment is then undertaken by specialists in radiology, orthopedics, oncology, and radiation therapy, with the result that the affected bone regions are classified as being at highly/slightly/not increased fracture risk. Following internal clearance, exercise planning is undertaken by a specialist in exercise therapy together with the physiatrist based on the individual's fracture risk assessment. In the case in which the patient shows exercise limitations due to additional musculoskeletal impairments, adjuvant physical modalities such as physiotherapy should be prescribed to increase exercisability.

CONCLUSION

Exercise prescription for cancer patients suffering from increased fracture risk is an inter- and multidisciplinary team decision for each individual patient.

Challenges of Differential Diagnosis Between Primary Hyperparathyroidism and Bone Metastases of Breast Cancer

Breast cancer might be complicated by distant metastases accompanied by hypercalcemia, but hyperparathyroidism is not commonly considered in the differential diagnosis. We present a case of 38 years old female patient who was diagnosed with ductal breast carcinoma. Eight months after the initial diagnosis the patient was diagnosed with distant bone metastases. However, this diagnosis was reconsidered at follow up, because we identified elevation of PTH 137.2 pg/ml, Ca²⁺ 1.19 mmol/l, albumin corrected calcium 2.42 mmol/l, 25(OH)D 39.4 nmol/l, indicating hyperparathyroidism. Scintigraphy with 99mTC-sestamibi confirmed parathyroid adenoma. Postoperative histopathology confirmed 1.2 g chief-cell PTA. Two months after the operation both PTH and Ca²⁺ levels were within the normal ranges. This study emphasizes the importance of considering possible hyperparathyroidism in patients with breast cancer and hypercalcemia. Routine evaluation of PTH is considered as a reasonable test in patients with breast cancer accompanied by bone lesions.

Some important inhibitors and mechanisms of rheumatoid arthritis

Rheumatoid arthritis is a chronic disease that seriously affects human health and quality of life, and it is one of the main causes of labor loss and disability. Many countries have listed rheumatoid arthritis as one of the national a key diseases to tackle. The pathogenesis of RA in humans is still unknown, and medical researchers believe that the pathogenesis of RA may be the result of a combination of genetic and environmental factors. RA is an incurable condition that can only be controlled and treated with conventional drugs. In this paper, the pathologic features and pathogenesis of RA were introduced, and the research progress of new anti-rheumatoid arthritis chemical drugs in recent years was reviewed.

Selective IL-1 activity on CD8+ T cells empowers antitumor immunity and synergizes with neovasculature-targeted TNF for full tumor eradication

Background

Clinical success of therapeutic cancer vaccines depends on the ability to mount strong and durable antitumor T cell responses. To achieve this, potent cellular adjuvants are highly needed. Interleukin-1β (IL-1β) acts on CD8⁺ T cells and promotes their expansion and effector differentiation, but toxicity and undesired tumor-promoting side effects hamper efficient clinical application of this cytokine.

Methods

This ‘cytokine problem’ can be solved by use of AcTakines (Activity-on-Target cytokines), which represent fusions between low-activity cytokine mutants and cell type-specific single-domain antibodies. AcTakines deliver cytokine activity to a priori selected cell types and as such evade toxicity and unwanted off-target side effects. Here, we employ subcutaneous melanoma and lung carcinoma models to evaluate the antitumor effects of AcTakines.

Results

In this work, we use an IL-1β-based AcTakine to drive proliferation and effector functionality of antitumor CD8⁺ T cells without inducing measurable toxicity. AcTakine treatment enhances diversity of the T cell receptor repertoire and empowers adoptive T cell transfer. Combination treatment with a neovasculature-targeted tumor necrosis factor (TNF) AcTakine mediates full tumor eradication and establishes immunological memory that protects against secondary tumor challenge. Interferon-γ was found to empower this AcTakine synergy by sensitizing the tumor microenvironment to TNF.

Conclusions

Our data illustrate that anticancer cellular immunity can be safely promoted with an IL-1β-based AcTakine, which synergizes with other immunotherapies for efficient tumor destruction.

Eosinophilic features in clear cell renal cell carcinoma correlate with outcomes of immune checkpoint and angiogenesis blockade

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) displays heterogeneity in appearance-a distinctive pale clear to eosinophilic cytoplasm; however, little is known about the underlying mechanisms and clinical implications. We investigated the role of these eosinophilic features in ccRCC on oncological outcomes and response to tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs).

METHODS

One-hundred and thirty-eight ccRCC cases undergoing radical surgery (cohort 1) and 54 metastatic ccRCC cases receiving either TKIs or ICIs (cohort 2) were included. After histological evaluation, all cases were divided into three phenotypes based on the eosinophilic features at the highest-grade area: clear, mixed, or eosinophilic type. Gene expression and immunohistochemical analyses were performed to explore the potential mechanisms of these phenotypes in cohort 1. Further, the association of the three phenotypes with the best objective response to TKI or ICI, clinical benefit (complete/partial response or stable disease), and overall survival (OS) was assessed in cohort 2.

RESULTS

The clear type was significantly associated with increased hypoxia as well as angiogenesis gene signatures compared with the eosinophilic type. Gene signatures and protein expression related to effector T cell and immune checkpoint molecules were elevated to a greater extent in the eosinophilic type, followed by the mixed and clear types. The mixed and eosinophilic types exhibited greater PBRM1-negativity and increased prevalence of the epithelial-mesenchymal transition gene signature than the clear type. In the mixed/eosinophilic types of cohort 2, significant clinical benefit was observed in the ICI therapy group versus the TKI therapy group (p=0.035), and TKI therapy vs ICI therapy was an independent factor for worse prognosis of OS (HR 3.236; p=0.012).

CONCLUSION

The histological phenotype based on the eosinophilic features, which are linked to major immunological mechanisms of ccRCC, was significantly correlated with therapeutic efficacy.

Current trends in aortic valve-preserving surgery

The natural history of aortic regurgitation is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival in these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery has attracted a great deal of attention because it has a significant survival benefit over replacement. Nonetheless, aortic valve-preserving surgery has not been widely adopted due to the complexity of the technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, aortic valve-preserving surgery has increasingly been performed with better outcomes, and therefore earlier surgical intervention in cases of aortic regurgitation has been considered. Recent advances in aortic valve-preserving surgery include repair-oriented classification of the etiology of aortic regurgitation, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of aortic valve-preserving surgery, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of aortic valve-preserving surgery in the treatment of aortic regurgitation in the near future.

Large sinus of Valsalva aneurysm presenting as acute coronary syndrome

A sinus of Valsalva aneurysm is a rare defect that is usually asymptomatic. We report a sinus of Valsalva aneurysm arising from the left coronary sinus with compression of the left main coronary artery in a 56-year-old man who presented with worsening chest pain. Coronary imaging revealed a 4.6-cm sinus of Valsalva aneurysm with compression of the left main stem, left anterior descending, and proximal circumflex arteries. He underwent aortic root and ascending aortic replacement. Large sinus of Valsalva aneurysms can be life-threatening and can be managed safely surgically.

Surgical repair for post-tuberculosis tracheobronchial stenosis

AIM

Post-tuberculosis tracheobronchial stenosis is rare but one of the most dangerous complications of tracheobronchial tuberculosis. Balloon dilatation, stent insertion, laser photoresection, argon plasma coagulation, and cryotherapy are some of the initial treatments recommended for mild to moderate cases. Here, we report a case series of patients who underwent segmental resection and end-to-end anastomosis for bronchial stenosis and a sliding technique for severe and long-segment tracheal stenosis.

METHODS

We retrospectively reviewed the medical records of patients with post-tuberculosis tracheobronchial stenosis operated on in our thoracic surgery department. Of the 7 cases that were treated, two had severe tracheal stenosis stretching over 50% of the tracheal length, one was operated on using resection and end-to-end anastomosis, and the other had sliding tracheoplasty. The other 5 cases of bronchial stem stenosis were treated with segmental resection and end-to-end anastomosis.

RESULTS

All five patients with bronchial stenosis had a good outcome; the ipsilateral lung was well ventilated and respiratory function was good. One patient with tracheal stenosis, treated with segmental resection and end-to-end anastomosis, died after the surgery, and the other patient, treated with slide tracheoplasty, had a good recovery.

CONCLUSION

The treatment plan for patients with post-tuberculosis tracheobronchial stenosis should be on a patient-by-patient basis. Sliding tracheoplasty can be a treatment option in patients with long-segment tracheal stenosis.

Use of Bisphosphonates, Calcium and Vitamin D for Bone Demineralization in Patients with Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome: A Systematic Review and Meta-Analysis of Clinical Trials

Background

The present study performed a systematic review and meta-analysis of clinical trials using bisphosphonates for bone demineralization in human immunodeficiency virus (HIV) patients.

Methods

A comprehensive literature search was performed from January 2004 to January 2020 considering the bone mineral density (BMD) of the lumbar spine (LS) as the main outcome. Out of 214 titles that met criteria, 9 studies fulfilled the selection criteria.

Results

A total of 394 patients were identified, and they were allocated into 2 groups: the intervention group (200 patients), to whom a combination of alendronate or zoledronate with calcium and vitamin D was administered; and control group (194 patients), to whom only calcium and vitamin D was administered. Clinical profile and indicators of bone metabolism of the participants were evaluated regarding effect size, homogeneity, and consistency. No substantial heterogeneity between the groups was found for the baseline variables, and there was high consistency to the main outcome. The meta-analysis shows a significant difference in post-treatment BMD, favoring the intervention over the control treatment. The intervention improved LS density up to 0.227 g/cm², raising the average to the levels of general population. Adverse effects related to intervention were fever immediately after zoledronate administration and gastrointestinal complaints during alendronate usage. Other adverse effects were barely reported and poorly connected to intervention by studies’ authors, despite all of them have been successfully resolved.

Conclusions

This study provides evidence that BMD post-treatment is better in HIV patients who used bisphosphonates combined with calcium and vitamin D.

Clinical Versus Pathologic Laryngeal Cancer Staging and the Impact of Stage Change on Outcomes

OBJECTIVES/HYPOTHESIS

Evaluate the impact and accuracy of clinical laryngeal cancer staging.

STUDY DESIGN

Retrospective cohort study.

METHODS

Two hundred sixty-five consecutive patients with laryngeal squamous cell carcinoma who underwent total laryngectomy from 2001 to 2017 were studied. Clinical versus pathologic tumor (T) and nodal (N) categories were compared. Logistic regression and Cox proportional hazards analyzed the association of stage change with perioperative factors and outcomes.

RESULTS

Forty-seven patients (17.7%, accuracy = 0.969 ± 0.010 [standard error]) changed between T1-2 and T3-4. Sixty-four patients (24.1%, accuracy = 0.866 ± 0.020) had inaccurate N category. Salvage patients were less likely to have stage change (downstage: odds ratio [OR] = 0.20, 95% confidence interval [CI]: 0.08-0.50, P < .001; upstage: OR = 0.41, 95% CI: 0.23-0.74, P = .003), but more likely to have inaccurate nodal category (39.8% vs. 11.7%, P < .001). Patients with stage change tended to have greater odds of positive/close margins (upstage: OR = 1.78, 95% CI: 0.91-3.5, P = .092) and chemotherapy (downstage: OR = 2.21, 95% CI: 0.80-6.14, P = .128; upstage: OR = 1.87, 95% CI: 0.85-4.11, P = .119). Stage change was associated with recurrence (P = .047) with downstaged patients less likely to recur (hazard ratio = 0.26, 95% CI: 0.08-0.82, P = .021). Stage change was not associated with positron emission tomography scan, subsite, time to surgery, or mortality.

CONCLUSIONS

A third of laryngeal cancer patients were downstaged or upstaged after laryngectomy with 18% and 24% of clinical T and N categories inaccurate, respectively. Stage change was less common for salvage patients and associated with risk of recurrence.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:559-565, 2021.

Frequency of risk factors in patients of acute coronary syndrome due to coronary ectasia

BACKGROUND

Coronary artery ectasia is a relatively common entity characterized by inappropriate dilatation of the coronary vasculature. In some cases of acute coronary syndrome without obstructive coronary lesions, coronary ectasia is the sole cause. The exact mechanism of its development is unknown but evidence suggests a combination of genetic predisposition, common risk factors for coronary artery disease, and abnormal vessel wall metabolism. As there are few data regarding the pattern of coronary risk factors in patients with coronary ectasia, the objective of the study was to determine the frequency and distribution of coronary risk factors in patients with acute coronary syndrome solely due to coronary ectasia.

METHODS

The study included 155 patients over a period of 6 months, with coronary angiographic evidence of coronary ectasia as the sole cause of acute coronary syndrome. There were 79 (51%) men and 76 (49%) women with a mean age 51.92 ± 7.83 years; 73 (47.10%) were aged 20-50 years and 82 (52.90%) were 51-80 years of age. The frequencies of coronary risk factors were stratified according to sex and the two age groups.

RESULTS

Seventy-one patients (45.80%) had diabetes mellitus, 83 (53.54%) had hypertension, 55 (35.48%) were smokers, 46 (29.68%) had dyslipidemia, and 47 (30.3%) were obese.

CONCLUSION

Hypertension is the leading coronary risk factors in patients with acute coronary syndrome solely due to coronary ectasia, followed by diabetes mellitus and smoking.

Molecular and pathological investigation of a natural outbreak of Newcastle disease caused by genotype XVII in White Leghorn chickens

ABSTRACT Newcastle disease (ND) is an infectious viral poultry disease with great economic consequences. In developing countries, outbreaks of ND caused by virulent Newcastle disease virus (NDV) have been identified as a limiting factor to the growth of the poultry industry. Limited reports exist on the pathology of natural field infection caused by NDV genotype XVII in chickens. Here, we present clinical, pathological and molecular investigation of confirmed ND in a 24-week-old layer-type, semi-intensive poultry flock with recorded mortality of over 50%. During PM examination, tissues were harvested for virus isolation, histopathology and immunohistochemistry. Virus isolation was performed in 10-day-old embryonated chicken eggs, and a haemagglutinating agent thereof identified by one-step reverse transcription-polymerase chain reaction (RT-PCR). For the genotyping of the isolate, the full fusion gene was sequenced. Clinical signs observed included general body lethargy, inappetence and greenish diarrhoeic faeces from the cloaca before death with daily mortality exceeding 100 chickens. The pathology was characteristic of a viral haemorrhagic infection, with serosal haemorrhages, mucosal surface erosion and ulceration. In most of the carcasses, the main lesions seen included airsacculitis, meningeal congestion, haemorrhagic oophoritis, pancreatic necrosis, enteritis and faecal matting of the vent. Virus isolation and RT-PCR made a confirmatory diagnosis of ND. Based on the cleavage site motif sequence (¹¹²RRQKR/F¹¹⁷), the isolate was identified as a virulent strain with phylogenetic analysis showing clustering in genotype XVII viruses. To the best of the authors' knowledge, this is the first report describing the pathological findings of a natural outbreak caused by NDV involving viruses of genotype XVII. RESEARCH HIGHLIGHTS First report of a natural outbreak of Newcastle disease in White Yarkon Leghorns. The outbreak was caused by virulent NDV belonging to genotype XVII. Pathology differed slightly from those in experimental studies using SPF and other unvaccinated chickens.

Anatomical structure responsible for direction changing bilateral gaze-evoked nystagmus in patients with unilateral cerebellar infarction

The direction-changing bilateral gaze-evoked nystagmus (GEN) (BGEN) is a more specific sign for a gaze-holding deficit than unilateral GEN (UGEN) in a central lesion. We sought to clarify which cerebellar structure is responsible for the generation of BGEN compared with UGEN.We studied 47 cases of UGEN or BGEN associated with isolated unilateral cerebellar infarction in the territories of the cerebellar arteries diagnosed by brain magnetic resonance image (MRI) from June 2007 to April 2014. To identify the structures involved in the generation of BGEN, the overlapped lesions of the BGEN group were subtracted from those of UGEN group and vice versa.About half of the patients (25/47, 53%) showed BGEN and others showed UGEN. There was no difference in the interval from symptom onset to examination between 2 groups (1.3 days vs 2.5 days, P = .24). Thirty-five patients (35/47, 75%) with GEN also showed spontaneous nystagmus. Lesion subtraction analyses revealed that both of the patients with BGEN and UGEN had damage around the vermal pyramid, the uvula and the tonsil, parts of the biventer lobule, and the inferior semilunar lobule.Midline and lower cerebellar structures are related to both BGEN and UGEN in patients with unilateral cerebellar infarction. Regardless of unilateral or bilateral, GEN may represent damage of the gaze-holding neural integrator control system in human.

Analysis of the impact of EEA stapler size on risk of anastomotic complications in colorectal anastomosis: does size matter?

BACKGROUND

Colorectal anastomotic complications are dreaded and dramatically affect outcomes. Causes are multifactorial, with the size of the end-to-end anastomosis (EEA) stapler a modifiable factor and potential target for risk reduction. Our goal was to examine the impact of the EEA stapler size on the risk of anastomotic complications in left-sided colorectal resections.

METHODS

A prospective divisional database was reviewed for consecutive elective left-sided resections with a colorectal anastomosis using an EEA stapler from January 2013 May 2018 inclusive. Patients were stratified into 25-29 mm or 30-33 mm cohorts. Patient and disease demographics, operative variables, and postoperative outcomes were evaluated. The main outcome measures were the rate and factors associated with anastomotic complications.

RESULTS

Four hundred seventy-three cases were evaluated, 185 ( 39.1%) were in the 25-29 mm group and 288 (60.9%) in the 30-33 mm group. Patients were comparable in demographics and operative variables. More males were anastomosed with the 30-33 mm than with the 25-29 mm stapler (57.6% vs 28.6%, p < 0.01). Significantly more patients developed an anastomotic stricture with the 25-29 mm than with the 30-33 mm staplers (7.1% vs. 2.1%; p = 0.007). There was no significant difference in leak rates or reoperation/interventions between groups. On logistic regression, neither gender, operative indication nor approach were associated with anastomotic leak, readmission, or reoperation/intervention. Stapler size remained significantly associated with stricture (p = 0.032).

CONCLUSIONS

The 25-29 mm EEA staplers were associated with an increased rate of anastomotic stricture compared to 30-33 mm staplers in left-sided colorectal anastomoses. As stapler size is a simple process measure that is easily modifyable, this is a potential target for improving anastomotic complication rates. Further controlled trials may help assess the impact of stapler size on improving patient and quality outcomes.

Pathologic fracture healing after femoral limb salvage in a dog

BACKGROUND

Bone sarcomas are a significant cause of pain, disability, and mortality in dogs. A variety of surgical limb salvage options are available to preserve limb function with comparable prognosis to amputation.

CASE REPORT

This report describes successful healing after plate fixation of an undifferentiated sarcoma pathologic femoral fracture in a dog. The fracture was treated surgically with curettage of the tumour site, placement of autogenous bone graft, and then stabilized using a locking plate rod construct. The patient regained excellent mobility after surgery and was managed with monthly pamidronate therapy. Serial radiographs demonstrate progressive healing of the pathologic fracture. Ultimately, the patient developed a maxillary fibrosarcoma and was euthanased 1 year after treatment of the femoral fracture. Postmortem histopathological evaluation of the pathologic fracture site demonstrated complete bone healing.

CONCLUSION

This case highlights the possibilities of limb salvage by fracture stabilization and bone healing as a viable option in select patients.

Natural internal thoracic-to-coronary artery collateral network

We describe a rare case of three-vessel coronary disease in a 67-year-old man who had spontaneous communication between the left internal mammary artery and the left anterior descending artery. We decided to perform elective coronary artery bypass grafting. However, he died from sudden cardiac arrest before surgery.

Reduction in Narcotic Use After Lumbar Decompression and Fusion in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The purpose of this study is to assess change in opioid use before and after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis.

METHODS

A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Opioid use 6 months preoperatively through 2 years postoperatively was assessed.

RESULTS

The study included 13 257 patients that underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion. Overall, 57.8% of patients used opioids preoperatively. Throughout the 6-month preoperative period, 2 368 008 opioid pills were billed for (51.6 opioid pills/opioid user/month). When compared with preoperative opioid use, patients billed fewer opioid medications in the 2-year period postoperatively: 33.6 pills/patient/month (8 851 616 total pills). In a multivariate logistic regression analysis, obesity (odds ratio [OR] 1.10, 95% CI 1.004-1.212), preoperative narcotic use (OR 3.43, 95% CI 3.179-3.708), length of hospital stay (OR 1.02, 95% CI 1.010-1.021), and receiving treatment in the South (OR 1.18, 95% CI 1.074-1.287) or West (OR 1.26, 95% CI 1.095-1.452) were independently associated with prolonged postoperative (>1 year) opioid use. Additionally, males (OR 0.87, 95% CI 0.808-0.945) were less likely to use long-term opioid therapy.

CONCLUSIONS

This study demonstrates that reduction in opioid use was observed postoperatively in comparison with preoperative values in patients with symptomatic lumbar stenosis or spondylolisthesis that underwent lumbar decompression with fusion. Further prospective studies that are more methodologically stringent are needed to corroborate our findings.

Bayesian modeling to predict malignant hyperthermia susceptibility and pathogenicity of RYR1, CACNA1S and STAC3 variants

Aim: Identify variants in RYR1, CACNA1S and STAC3, and predict malignant hyperthermia (MH) pathogenicity using Bayesian statistics in individuals clinically treated as MH susceptible (MHS). Materials & methods: Whole exome sequencing including RYR1, CACNA1S and STAC3 performed on 64 subjects with: MHS; suspected MH event or first-degree relative; and MH negative. Variant pathogenicity was estimated using in silico analysis, allele frequency and prior data to calculate Bayesian posterior probabilities. Results: Bayesian statistics predicted CACNA1S variant p.Thr1009Lys and RYR1 variants p.Ser1728Phe and p.Leu4824Pro are likely pathogenic, and novel STAC3 variant p.Met187Thr has uncertain significance. Nearly a third of MHS subjects had only benign variants. Conclusion: Bayesian method provides new approach to predict MH pathogenicity of genetic variants.

Trends in the surgical treatment of pathological proximal femur fractures in the United States

BACKGROUND AND OBJECTIVES

Large scale data on the treatment of pathologic proximal femur fractures (PPFFs) are lacking. The purpose of this study was to evaluate trends in patient demographics, complication rates, and relative utilization rates of various techniques associated with PPFFs.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database was queried for PPFFs from 2009 to 2017. Patient demographics, 30-day complications, and utilization rates were recorded. Trends in these variables were determined over the study period.

RESULTS

Most patient demographics did not change during the study period. There were no trends toward decreasing rates of major complications (P = .82), reoperations (P = .65), non-home discharges (P = .17), readmissions (P = .07), or deaths (P = .75); transfusion rates significantly decreased (P < .001). Rates of hemiarthroplasty decreased (P = .03) and rates of intramedullary nailing increased (P = .001).

DISCUSSION

Despite advances in cancer therapeutics, the average PPFF patient has not significantly changed over the past decade. Similarly, most short-term outcomes after PPFF surgery have not improved, demonstrating a need for improved perioperative protocols. Finally, rates of IMN fixation are increasing while rates of HA are falling at NSQIP hospitals. Given that orthopedic oncologists favor endoprosthetic reconstruction in most cases, there may be a need for increased communication between orthopedic oncologists and other members of the orthopedic community treating PPFFs.

Adrenal collision tumor: a case report of the coexistence of myelolipoma and ganglioneuroma

Adrenal collision tumor (ACT), where distinct tumors can coexist and do not intermingle in the same adrenal gland, is rarely reported and its cause and prevalence are unclear. Few papers have reported a connection between myelolipoma and adrenal ganglioneuroma. Case Report: A 40-year-old man had a physical examination one month prior to surgery. Physical examination as well as the laboratory data involving endocrine studies showed normal findings. MRI (magnetic resonance imaging) revealed a mixed signal lesion in the right suprarenal fossa. A laparoscopic left adrenalectomy was conducted. Pathologic examination revealed two distinct tumors: myelolipoma and ganglioneuroma. Conclusion: The two kinds of tumors are rarely seen in the adrenal gland and they exceptionally exist as ACT only. This case should arouse our attention in future clinical work.

18F-FDG-PET Can Predict Microvessel Density in Head and Neck Squamous Cell Carcinoma

Aim: Positron emission tomography (PET) with ¹⁸F-fluordeoxyglucose (¹⁸F-FDG) plays an essential role in the staging and tumor monitoring of head and neck squamous cell carcinoma (HNSCC). Microvessel density (MVD) is one of the clinically important histopathological features in HNSCC. The purpose of this study was to analyze possible associations between ¹⁸F-FDG-PET findings and MVD parameters in HNSCC. Materials and Methods: Overall, 22 patients with a mean age of 55.2 ± 11.0 and with different HNSCC were acquired. In all cases, whole-body ¹⁸F-FDG-PET was performed. For each tumor, the maximum and mean standardized uptake values (SUV_max; SUV_mean) were determined. The MVD, including stained vessel area and total number of vessels, was estimated on CD105 stained specimens. All specimens were digitalized and analyzed by using ImageJ software 1.48v. Spearman's correlation coefficient (r) was used to analyze associations between investigated parameters. p-values of <0.05 were taken to indicate statistical significance. Results: SUV_max correlated with vessel area (r = 0.532, p = 0.011) and vessel count (r = 0.434, p = 0.043). Receiver operating characteristic analysis identified a threshold SUV_max of 15 to predict tumors with high MVD with a sensitivity of 72.7% and specificity of 81.8%, with an area under the curve of 82.6%. Conclusion: ⁸F-FDG-PET parameters correlate statistically significantly with MVD in HNSCC. SUV_max may be used for discrimination of tumors with high tumor-related MVD.

Atrial septal defect causing angina

Left coronary artery compression syndrome is characterized by compression of the left main coronary artery between the aorta and an enlarged main pulmonary artery. A 39-year-old woman presented with angina with dyspnea on exertion for two years. Detailed investigations revealed an atrial septal defect, valvular lesions, and severe pulmonary hypertension with left main coronary artery compression. Patch closure of the atrial septal defect, left coronary artery bypass, and valve repair was carried out. The patient recovered well and was asymptomatic on follow-up. The optimal management of such patients is yet to be clarified.

Clinical presentation and management of atraumatic splenic rupture

Atraumatic splenic rupture is a rare, but well-documented and life-threatening clinical entity that is often misdiagnosed. Clinicians should include this entity in their differential diagnosis using clinical judgement even in the absence of a history of trauma.

Mucosal injury following short-term tracheal intubation: A novel animal model and composite tracheal injury score

OBJECTIVES

Postintubation laryngotracheal injury is common. Assessment of histopathological changes currently requires animal models. We set about developing a viable, resource effective animal model to study these effects and to develop a detailed tissue injury score.

METHODS

Six pigs were anesthetized using a standard regimen. We intubated the tracheas using a standard endotracheal tube modified to include optical sensors. Animals were anesthetized for a duration of two to four hours, and their lungs were ventilated using a normoxic gas mixture. Following euthanasia, the tracheas were removed and underwent histological assessment by two independent veterinary pathologists. The histological lesions, including controls, were described and quantified, and two pathologists classified tissues according to a novel injury score.

RESULTS

Mean duration of tracheal intubation was 191 minutes (SD ± 41.6). In all except one animal, cuff pressures were maintained in the range of 25-45 cmH20. Histopathological findings in all study animals showed more extensive changes than previously described with short-term intubation. Changes were seen in all mucosal layers consistent with acute, suppurative, and ulcerative tracheitis. The range of scores of the developed composite scoring system among the animals was wider than in earlier descriptions. There was a high percentage of agreement between both pathologists.

CONCLUSIONS

We have described a novel tracheal injury score to assess pathological changes following short term intubation in a viable animal model. The scoring system distinguished between the test animals as well as controls and may be appropriate for continuing study of intubation injury.

LEVEL OF EVIDENCE

3.

Combined small-cell lung carcinoma

Currently, studies assessing combined small-cell lung carcinoma (C-SCLC) are relatively scarce and limited. Indeed the clinicopathological features, treatment, and prognosis of patients with C-SCLC have not been fully determined. The incidence of C-SCLC ranges from 5%–28% in different studies, which is related to the specimen types used. The clinical features of C-SCLC are characterized by the higher proportion of peripheral locations, earlier stage, and more opportunity to experience surgery. Surgery is more important for earlier stage C-SCLC. There have been no recent changes in the chemotherapy of C-SCLC, which is recommended by the treatment guidelines for SCLC, neither showing survival benefit from the 3-agent regimen. Meanwhile, the efficacy of epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in EGFR-mutated C-SCLC patients remains inconclusive. This review focuses on clinical and pathologic features, prognostic factors, and optimized treatment model in C-SCLC.

Femoral Neck Fractures in Children: A Review

Paediatric femoral neck fractures are uncommon injuries and are usually caused by high-energy trauma. Low-energy trauma can result in pathologic neck fractures and stress fractures of the neck, due to repetitive activity. Surgical options can vary based on age, Delbet classification and displacement of the fracture. Treatment for displaced fractures is by closed or open reduction and smooth/cancellous screw fixation. Compression screw and side plate fixation is indicated for basal fractures. Fixation should be supplemented by spica cast immobilization in younger children. The high rate of complications occurs due to the vascular anatomy of the hip and proximal femur. Avascular necrosis, coxa vara, premature physeal closure, and nonunion are the most common and these often result in poor outcome.

The Role of Cancer-Derived Exosomes in Tumorigenicity & Epithelial-to-Mesenchymal Transition

Epithelial-to-mesenchymal transition (EMT) is a process by which epithelial cells lose their basement membrane interaction and acquire a more migratory, mesenchymal phenotype. EMT has been implicated in cancer cell progression, as cells transform and increase motility and invasiveness, induce angiogenesis, and metastasize. Exosomes are 30-100 nm membrane-bound vesicles that are formed and excreted by all cell types and released into the extracellular environment. Exosomal contents include DNA, mRNA, miRNA, as well as transmembrane- and membrane-bound proteins derived from their host cell contents. Exosomes are involved in intercellular signaling, both by membrane fusion to recipient cells with deposition of exosomal contents into the cytoplasm and by the binding of recipient cell membrane receptors. Recent work has implicated cancer-derived exosomes as an important mediator of intercellular signaling and EMT, with resultant transformation of cancer cells to a more aggressive phenotype, as well as the tropism of metastatic disease in specific cancer types with the establishment of the pre-metastatic niche.

Longitudinal Quantification of Eye-Movement Impairments after Pontine Hemorrhage

INTRODUCTION

We report a case of hypertrophic olivary degeneration due to pontine hemorrhage. A 59-year-old male with untreated hypertension suffered a primary pontine hemorrhage, which caused horizontal eye-movement limitation. Progressive neurological deterioration with involuntary eye and palatal movements began months after hemorrhage. This was accompanied by magnetic resonance imaging evidence of hypertrophic olivary degeneration at 4.5 months.

BACKGROUND

Primary pontine hemorrhage often leads to impairment of eye movements and diplopia. Hypertrophic olivary degeneration can also emerge months after hemorrhage, producing involuntary pendular eye movements. Neither the natural history of voluntary eye movements nor the emergence of involuntary eye movements after pontine hemorrhage has been previously quantified.

METHODS

We used an optokinetic task that enabled measurement of eye movements. It provided real-time feedback on the ability to track continuously and saccade quickly in a pursuit task. The feedback motivated the patient to use the system repeatedly in his home. From 3 months after hemorrhage, the patient used the system for 9 months, allowing us to quantify changes in his eye movements.

RESULTS

Horizontal gaze impairments were manifest in our task as limitation in horizontal range of motion, as well as delay in initiation of the right eye's movement during left-to-right pursuit. Improvement in these impairments was measured over the course of months 3-7 post hemorrhage. In addition, the emergence of vertical pendular nystagmus was identified in the subject at 4 months. Analysis of the eye-movement records revealed presymptomatic oscillatory eye movements whose amplitude had grown steadily over the course of 3 weeks, prior to a sharp increase in amplitude that coincided with the patient's first report of oscillopsia. Horizontal pendular nystagmus emerged 7.4 months after the hemorrhage, primarily in the left eye.

CONCLUSION

An eye-tracking system deployed in a patient's home enabled prospective longitudinal quantification of the natural history and improvement in voluntary eye-movement impairments after pontine hemorrhage. It also characterized prospectively for the first time, the emergence of involuntary eye movements resulting from the rare complication of hypertrophic olivary degeneration. Results suggest that brief weekly measurements with an eye-tracker may allow early detection of this complication.

The Importance of Labyrinthine Examination in the Prognosis and Therapy for Balance in Spinocerebellar Ataxia

INTRODUCTION

Spinocerebellar ataxias (SCAs) are a heterogeneous group of neurodegenerative diseases that are characterized by the presence of progressive cerebellar ataxia.

OBJECTIVE

Identify vestibular disorders and demonstrate the importance of labyrinthine examination in the prognosis and therapy for balance in patients with SCAs.

MATERIALS AND METHODS

The study had a retrospective cross-sectional design and evaluated 57 patients, mean age of 41.6 years and standard deviation of 13 years. Patients underwent the following procedures: anamnesis, ENT examination and vestibular exam using electronystagmography (ENG).

RESULTS

The most frequent complaints were gait imbalance (71.9%), dysarthria (49.1%), dizziness (43.8%) and dysphagia (36.8%). 84.2% of the tests showed alterations. The most common tests with alterations were the caloric test (78.9%), slow saccades (61.4%) and the rotating chair test (49.1%).

CONCLUSION

The clinical history of the patient and oculomotor alterations in the labyrinthine examination provide sufficient information for the proper use of virtual rehabilitation protocols in the treatment of imbalance, making it the most effective therapy method. It was evident that changes in ENG are related to the severity of the SCA or the clinical stage of the disease. The labyrinthine examination proved to be an important concomitant tool to clinical and genetic study.

Can CK-MB be used as a marker in benign paroxysmal positional vertigo attack?

OBJECTIVES

Benign paroxysmal positional vertigo (BPPV) is one of the main causes of vertigo. More than 90% of cases of positional vertigo and nystagmus can be associated with BPPV. There is no known specific laboratory test for BPPV. Because of the possible muscle activity in BPPV (especially result of nause, vomiting and increasing heart rate) we thought the CK-MB levels may change in this situation. The purpose of this study was to investigate the relation between serum CK-MB levels and BPPV and attacks.

MATERIALS AND METHODS

The medical records of 35 patients with BPPV presenting to our clinic between November 2014 and November 2015 were investigated retrospectively. Thirty-two control patients with no vertigo, muscular or cardiac disease and with measured CK-MB levels were randomized into a control group. Both groups' existing CK-MB levels were obtained from the patient records. CK-MB values measured before BPPV attack from 11 patients in the patient group were also recorded.

RESULTS

The patient and control groups were similar in terms of demographic parameters. CK-MB values at time of attack in the patient group ranged between 5.4 and 38.9 (mean: 19.67 ± 6.81), while control group values ranged between 12 and 27.9 (mean: 20.31 ± 4.54). CK-MB values in 11 patients in the patient group measured before attack ranged between 8.9 and 24 (mean: 17.02 ± 4.97), and CK-MB values during attack ranged between 9 and 34 (mean: 19.74 ± 7.64).

CONCLUSION

Although CK-MB elevation at time of attack was determined in patients with BPPV, this was not statistically significant.

Aortic assessment of bicuspid aortic valve patients and their first-degree relatives

Background Bicuspid aortic valve patients have an increased risk of aortic dilatation. A deficit of nitric oxide synthase has been proposed as the causative factor. No correlation between flow-mediated dilation and aortic diameter has been performed in patients with bicuspid aortic valves and normal aortic diameters. Being a hereditary disease, we compared echocardiographic features and endothelial function in these patients and their first-degree relatives. Methods Comprehensive physical examinations, routine laboratory tests, transthoracic echocardiography, and measurements of endothelium-dependent and non-dependent flow-mediated vasodilatation were performed in 18 bicuspid aortic valve patients (14 type 1 and 4 type 2) and 19 of their first-degree relatives. Results The first-degree relatives were younger (36.7 ± 18.8 vs. 50.5 ± 13.9 years, p = 0.019) with higher ejection fractions (64.6% ± 1.7% vs. 58.4% ± 9.5%, p = 0.015). Aortic diameters indexed to body surface area were similar in both groups, the except the tubular aorta which was larger in bicuspid aortic valve patients (19.3 ± 2.7 vs. 17.4 ± 2.2 mm·m^-2, p = 0.033). Flow-dependent vasodilation was similar in both groups. A significant inverse correlation was found between non-flow-dependent vasodilation and aortic root diameter in patients with bicuspid aortic valve ( R = -0.57, p = 0.05). Conclusions Bicuspid aortic valve patients without aortopathy have larger ascending aortic diameters than their first-degree relatives. Endothelial function is similar in both groups, and there is no correlation with ascending aorta diameter. Nonetheless, an inverse correlation exists between non-endothelial-dependent dilation and aortic root diameter in bicuspid aortic valve patients.

Natural History, Predictors and Management of Ureteroenteric Strictures after Robot Assisted Radical Cystectomy

PURPOSE

Ureteroenteric strictures represent the most common complication requiring reoperation after radical cystectomy. We investigated the prevalence, outcomes, predictors and management of ureteroenteric strictures.

MATERIALS AND METHODS

We retrospectively reviewed our quality assurance, robot assisted radical cystectomy database to identify patients in whom ureteroenteric strictures developed. Data were reviewed for demographics, perioperative outcomes and ureteroenteric stricture characteristics. The Kaplan-Meier method was used to calculate time to ureteroenteric stricture and multivariable stepwise regression was done to evaluate predictors of ureteroenteric strictures.

RESULTS

Ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1, 3 and 5 years after robot assisted radical cystectomy, respectively. All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in 6 and robot assisted repair in 16. At a median followup of 23 months 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and 5 after open revision. Open and robot assisted revisions showed comparable perioperative outcomes. On multivariable analysis the predictors of ureteroenteric anastomotic strictures were body mass index (OR 1.07, 95% CI 1.01-1.13, p = 0.02), intracorporeal urinary diversion (OR 3.28, 95% CI 1.41-7.61, p = 0.006), length of the right resected ureter (OR 0.66, 95% CI 0.50-0.88, p = 0.004), estimated glomerular filtration rate 30 days after assisted radical cystectomy (OR 0.85, 95% CI 0.74-0.98, p = 0.03), urinary tract infection (OR 2.68, 95% CI 1.31-5.49, p = 0.007) and leakage (OR 3.85, 95% CI 1.05-14.1, p = 0.04). Male gender (OR 0.19, 95% CI 0.04-0.96, p = 0.04) and higher body mass index (OR 0.85, 95% CI 0.72-0.996, p = 0.05) were associated with lower odds of successful endoscopic management.

CONCLUSIONS

Multiple modifiable factors were associated with ureteroenteric anastomotic strictures following robot assisted radical cystectomy. Surgical revision can provide a definitive management with comparable outcomes for open and robotic repairs.

C-2 arteriovenous fistula presenting as a pathologic hangman's fracture: case report

The authors report on an 81-year-old woman with a pathologic hangman's fracture secondary to a complex arteriovenous fistula (AVF). The patient presented with severe, unremitting neck pain and was found to have fractures bilaterally through the pars interarticularis of C-2 with significant anterior subluxation of C-2 over C-3 along with widening of the left transverse foramen. Due to an abnormally appearing left vertebral artery (VA) on CT angiography, the patient underwent conventional angiography, which revealed a complex AVF stemming from the left VA at the level of C-2 with dilated posterior cervical veins and a large venous varix. Given the radiographic evidence of bone remodeling and the chronicity of the AVF, it is believed that the C-2 vertebra was weakened over time by the pulsatile and compressive force of the vascular malformation eventually leading to fracture with minimal stress. Coil embolization of the AVF was performed followed by surgical fixation of C-1 to C-4. This case highlights the importance of investigating an underlying disease process in patients who present with significant spinal fractures in the absence of trauma.

Plasma D-dimer as a predictor of the progression of abdominal aortic aneurysm

Essentials D-dimer could provide important information about abdominal aortic aneurysm (AAA) progression. The greatest diameter of the infrarenal aorta and the value of plasma D-dimer were determined. AAA progression is correlated with increasing plasma D-dimer levels. The increasing value of plasma D-dimer could be a predictor of aneurysm progression.

SUMMARY

Background The natural course of abdominal aortic aneurysm (AAA) is mostly asymptomatic and unpredictable. D-dimer could provide potentially important information about subsequent AAA progression. Objectives The aims of this study were to establish the relationship between the progression of an abdominal aortic aneurysm (AAA) and plasma D-dimer concentration over a 12-month period and determine the value of plasma D-dimer in patients with sub-aneurysmal aortic dilatation. Patients/Methods This was a prospective observational study that involved 33 patients with an AAA, 30 patients with sub-aneurysmal aortic dilatation and 30 control subjects. The greatest diameter of the infrarenal aorta, which was assessed by ultrasound, and the value of plasma D-dimer were determined for all subjects at baseline assessment, as well as after 12 months for those with an AAA. Results A positive correlation was found between the diameter of an AAA and plasma D-dimer concentration at the baseline and the control measurement stages. There was a strong positive correlation between AAA progression and increasing plasma D-dimer concentration over a 12-month period. Among patients with sub-aneurysmal aortic dilatation (n = 30), the value of plasma D-dimer was higher compared with matched controls (n = 30). Conclusions There is a strongly positive correlation between AAA progression and increasing plasma D-dimer concentration. The value of plasma D-dimer is higher in patients with sub-aneurysmal aortic dilatation than in control subjects.

Associations of Initial Society for Fetal Urology Grades and Urinary Tract Dilatation Risk Groups with Clinical Outcomes in Patients with Isolated Prenatal Hydronephrosis

PURPOSE

There are limited comparative data on the predictive value of the 2 most commonly used classification systems, that is SFU (Society for Fetal Urology) hydronephrosis grades and urinary tract dilatation risk groups, in regard to the future risk of surgical intervention and the development of febrile urinary tract infection. We explored this topic in infants with isolated hydronephrosis.

MATERIALS AND METHODS

After screening 938 patients with prenatal hydronephrosis from 2009 to 2016 we selected 322 patients with ureteropelvic junction obstruction-like hydronephrosis for study. Hydronephrosis grades were prospectively collected at baseline, surgery and last followup. Gender, circumcision status, antibiotic prophylaxis and renal pelvis anteroposterior diameter were captured. The primary outcome was pyeloplasty and the development of febrile urinary tract infection. Comparative analyses between SFU grades/urinary tract dilatation groups and the primary outcome were performed with the Fisher exact and log rank tests.

RESULTS

Mean ± SD age at presentation was 3.3 ± 2.6 months and mean followup was 22 ± 19 months. Pyeloplasty was performed in 32% of patients with SFU III/IV vs 31% with urinary tract dilatation 2/3. The rate of febrile urinary tract infection in patients with SFU III/IV was similar to that in those with urinary tract dilatation group 2/3 (8% vs 10%). Children with SFU III/IV showed a significantly higher rate of surgery than those with SFU I/II (32% vs 2%, p <0.01). Similar findings were seen when using urinary tract dilatation groups to compare patients at low risk (1) vs moderate/high risk (2/3).

CONCLUSIONS

Both grading systems equally allowed for proper risk stratification and prediction of clinical outcomes based on baseline ultrasound. They correctly separated most infants who underwent surgery or in whom febrile urinary tract infection developed from those who could be treated nonsurgically. Use of the new urinary tract dilatation classification should not affect how families of children with isolated hydronephrosis are counseled regarding surgical intervention and the risk of febrile urinary tract infection.

Dumb-bell in the heart: rare case of biatrial myxoma with mitral regurgitation

Cardiac myxomas are rare intracardiac tumors, and the majority are benign myxomas involving the left atrium. We report a case of the very rare occurrence of biatrial myxoma associated with mitral regurgitation, which was successfully treated.

Clinical and pathologic diagnosis and different diagnosis of syphilis cervical lymphadenitis

PURPOSE

To study the clinical pathologic characteristics and differential diagnosis of syphilitic cervical lymphadenitis, and to improve the rate of its diagnosis and treatment.

METHODS

Retrospectively analyzed the clinical history, Trepone pallidum-ELISA (TP-ELISA), rapid plasma regain test (RPR) and routine pathological examination of the patient diagnosed as syphilis lymphadenitis. And review related literatures.

RESULTS

The main clinical presentation was multiple palpable cervical lymph nodes. The multiple nodes were hard, fixed, and the major diameter of the larger one was 2 cm. The main pathological changes included: the capsule was significantly thickened; reactive hyperplasia of lymphoid follicular with sky star phenomenon; occlusive endovasculitis; perivascular inflammation; the proliferation of epithelioid histiocytes can form granulomas with few multinucleated giant cells; few necrosis. TP-ELISA and RPR were positive.

CONCLUSIONS

The pathological changes of syphilitic lymphadenitis have a variety of performance with relatively specific and suggestive alterations which requires a combination of clinical history and laboratory test before the diagnosis, and the clinicians can reduce misdiagnosis and missed diagnosis of the disease by increasing vigilance of it.

A rat model of aortic arch aneurysm with excellent survival

BACKGROUND

The complex mechanisms of aortic arch aneurysm have not been well studied. An animal model of aortic arch aneurysm would be beneficial to study this fatal disease. In this study, we tried to establish a rat model of aortic arch aneurysm by constricting the aortic isthmus.

METHODS

Forty-eight male Sprague-Dawley rats were randomly divided into three groups. Rats with no aortic isthmus constriction were assigned to group A (control group). The aortic isthmus was constricted to 1.5 mm in group B and to 0.8 mm in group C. The blood pressure of the rats was measured at 0, 1, 3 and 6 months after the operation. The diameter and wall thickness of aortic arch were measured at 3 and 6 months after surgery.

RESULTS

Compared to group A, group B showed no significant increase in blood pressure or aortic diameter after the operation. Compared to the control group, group B showed a marked increase in wall thickness at 3 and 6 months after surgery (p < 0.05). Compared to group A, group C showed significant increases in both blood pressure (p < 0.05) and aortic diameter (p < 0.05) after the operation. Group C also showed a more than 50% increase in wall thickness at 3 and 6 months after surgery (P < 0.05).

CONCLUSIONS

By constricting the aortic isthmus to 0.8 mm, a rat model of aortic arch aneurysm could be induced at 3 and 6 months after surgery.

Gingival depigmentation: A split mouth comparative study between scalpel and cryosurgery

Gingival hyperpigmentation is a major esthetic concern for many people. Although it is not a medical problem, many people complain of dark gums as unesthetic. Gingival depigmentation is a periodontal plastic surgical procedure, whereby the hyperpigmentation is removed or reduced by various techniques. For depigmentation of gingival, different treatment modalities have been reported, such as scalpel, cryosurgery, electrosurgery, lasers, etc., this article compares the management of three cases with scalpel and cryosurgery and also highlights the relevance of cryosurgery.

Evaluation of patient response and recurrence of pigmentation following gingival depigmentation using laser and scalpel technique: A clinical study

Aim:

The present study was undertaken to evaluate patient response and recurrence of pigmentation following gingival depigmentation carried out with a surgical blade and diode laser.

Materials and Methods:

Twenty patients who were esthetically conscious of their dark gums and requested treatment for the same were selected for this study. Complete phase I therapy was performed for all the patients before performing the gingival depigmentation procedures with laser and scalpel on a split-mouth basis. Patients were evaluated for pain (1 day, 1 week), wound healing and melanin repigmentation (Melanin Pigmentation Index) immediately and at 1 week, 1 month and 3 months, respectively.

Results:

The final results were statistically analyzed and significance was evaluated. The results of this study indicated that both scalpel and laser were efficient for gingival depigmentation. Comparative pain assessment (P = 0.148) and repigmentation scores (P = 0.288) at various time intervals between the two groups did not show any statistical significance.

Conclusion:

Both the procedures did not result in any post-operative complications and the gingiva healed uneventfully. When compared, both the techniques were found to be equally efficacious. Care must be taken to assess the gingival biotype and the degree of pigmentation in deciding which technique is to be used.

Clinical Significance:

Various methods of depigmentation are available with comparable efficacies. Depigmentation is not a clinical indication but a treatment of choice where esthetics is a concern and is desired by the patient.

Effect of angiogenesis inhibitor SU6668 in combination with 5-Fu on liver metastasis from transplantation tumors of human colorectal cancer in nude mice

This study was to investigate inhibiting effect of angiogenesis inhibitor SU6668 in combination with 5-Fu on liver metastasis from human colon cancer. Results showed that metastasis rates in SU6668+5-Fu group, SU6668 group, 5-Fu group decreased obviously (P<0.01). Compared with 5-Fu group and control group, microvessel density significantly decreased in SU6668+5-Fu group and SU6668 group (P<0.05). Vascular endothelial growth factor and base fibroblast growth factor reduced obviously in SU6668+5-Fu group, SU6668 group and 5-Fu group compared with control group, and there were significant differences among SU6668+5-Fu group, SU6668 group and 5-Fu group (P<0.05). Thus, SU6668 can inhibit liver metastasis from colorectal cancer through anti-angiogenesis, and it would have a synergistic effect in combination with 5-Fu. Therefore, SU6668 combined with 5-Fu could be considered as a safe and effective antitumor strategy.

Chest wall reconstruction in Marfan syndrome following aortic root replacement

Chest wall and spine deformities are common in Marfan syndrome, and often coexist with cardiac defects. Surgery is often needed to both the aortic root and the anterior chest wall, and early spinal surgery is not uncommon. We describe a case of severe thoracic cage deformity with aortic root dilatation, which was managed by a staged approach, with a very good final result.

Lichen sclerosus and isolated bulbar urethral stricture disease

PURPOSE

Lichen sclerosus is a chronic inflammatory genital skin condition that can cause destructive urethral scarring. To our knowledge no prior study has described lichen sclerosus in isolated bulbar urethral stricture segments without progressive disease originating from the penile urethra. We report the incidence of lichen sclerosus in isolated bulbar urethral stricture segments.

MATERIALS AND METHODS

We retrospectively reviewed the records of 70 patients after urethroplasty for isolated bulbar stricture disease was performed from 2007 to 2013. Stricture specimens were re-reviewed by a single uropathologist. Cases were evaluated using common histological features of lichen sclerosus, including hyperkeratosis or epithelial atrophy, basal cell vacuolar degeneration, lichenoid lymphocytic infiltrate and superepithelial sclerosis.

RESULTS

Average patient age was 46.5 years (range 19 to 77) and average stricture length was 3.5 cm (range 1 to 7). Of the patients 51 (73.0%) underwent excision and primary anastomosis, and 19 (27.1%) underwent buccal mucosal onlay. In 6 patients (8.6%) stricture recurred during a median followup of 22 months (IQR 14, 44). Three of those patients had lichen sclerosus. Initial pathology assessment revealed lichen sclerosus in 5 patients (7.1%, 95% CI 1.0-13.3). On re-review of specimens using pathology criteria specific to lichen sclerosus 31 patients (44.3%, 95% CI 32.4-56.2) showed pathology findings highly suggestive of (13) or diagnostic for (18) lichen sclerosus (p = 0.0001). On pathological re-review lichen sclerosus was associated with recurrent stricture.

CONCLUSIONS

On re-review of surgical specimens we noted a significant incidence of lichen sclerosus in isolated bulbar strictures in men undergoing urethroplasty. The incidence of lichen sclerosus may be higher than reported in isolated bulbar urethral segments without evidence of distal to proximal progressive urethral disease.