Impact of Acute Inflammation on the Survival Outcomes of Patients with Resected Pancreatic Ductal Adenocarcinoma

INTRODUCTION

The impact of acute inflammation on cancer progression is still not well elucidated. Pancreatic head cancer is occasionally associated with acute cholangitis. C-reactive protein (CRP) is a biomarker that indicates presence of acute inflammation.

METHODS

We reviewed the patients' data with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy between 2004 and 2018.

RESULTS

Two hundred ninety-one patients were included. Median preoperative CRP was 0.45 mg/dL (0-18.9). Median follow-up duration was 22 months (4-152). The 1-, 3-, and 5-year overall survival (OS) rates were 76.4%, 32.2%, and 22.9%, respectively. Recurrence occurred in 168 cases (57.7%). The 1-, 3-, and 5-year disease-free survival (DFS) rates were 53.9%, 27.1%, and 21.9%, respectively. The median OS was higher in normal CRP patients (27 months) than those with elevated CRP (18 months) (log-rank 0.038). The median DFS was higher in normal CRP patients (17 months) than those with elevated CRP (9 months) (log-rank < 0.001). Predictive factors for OS included BMI, CRP, adjuvant therapy, positive lymph nodes, and microvascular invasion. Predictive factors for DFS included CRP, positive lymph nodes, and microvascular invasion.

CONCLUSION

Preoperative CRP was an independent poor prognostic factor for OS and DFS of patients with resected PDAC.

Comparison of postoperative complications and long-term oncological outcomes in minimally invasive versus open pancreatoduodenectomy for distal cholangiocarcinoma: A propensity score-matched analysis

BACKGROUND

Pancreatoduodenectomy (PD) is the only curative therapy for distal cholangiocarcinoma (dCC). There has been no study to compare outcomes between minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD) for dCC. The aim of the study is to compare the two operation types for dCC in terms of postoperative and oncologic outcomes.

METHODS

Data from 426 patients who underwent MIPD (n = 91) or OPD (n = 335) for dCC from January 2012 to December 2019 at two tertiary hospitals were retrospectively reviewed. After 1:2 propensity score matching, postoperative and oncologic outcomes were compared.

RESULTS

Minimally invasive pancreatoduodenectomy group showed more favorable results than OPD group in terms of blood loss (MIPD vs OPD, 250 [150-400] vs 400 [200-600], mL, P < .001), and length of hospital stay (19.8 ± 11.3 vs 26.6 ± 14.3 days, P < .001). OPD group showed more favorable results than MIPD group in terms of operation time (MIPD vs OPD, 457 ± 70 vs 398 ± 85 min, P < .001) and harvested lymph nodes (14.9 ± 7.8 vs 20.7 ± 11.5, P < .001). There was no statistical difference between the two groups in the R0 resection rate and complications. In long-term survival analysis, there was no significant difference between the two groups.

CONCLUSION

Minimally invasive pancreatoduodenectomy showed comparable postoperative complications and long-term oncologic survival with OPD in the treatment of dCC.

Cystic angiomatosis of the bone, liver, and spleen

Introduction/Objective

Cystic angiomatosis is a very rare entity characterized by multifocal cystic angiomatous lesions of the skeletal system, occasionally involving visceral organ systems. Clinical presentation and progression are extremely variable. Cases with liver involvement are even rarer, and have been described as invariably fatal. The pathogenesis of this disorder is poorly understood, and no treatments are currently available.

Methods/Case Report

A 24 year old man with history of polysubstance abuse and untreated hepatitis C presented with acute abdominal pain. Imaging revealed hepatosplenomegaly and multiple liver, spleen, and skeletal lesions. Differential diagnoses included metastatic disease, lymphoma, and infection. Apart from known untreated chronic hepatitis C, all infectious, autoimmune and hypercoagulability work-ups were negative. Biopsies of the liver and iliac bone lesions showed areas of benign-appearing vascular proliferation in a background of fibrosis. The vascular endothelial cells were positive for CD34 and CD31 but negative for D2-40. On follow-up approximately eight months later, the patient was asymptomatic.

Results (if a Case Study enter NA)

NA

Conclusion

Liver involvement by cystic angiomatosis is exceedingly rare and has been associated with increased mortality. This case provides an example of a patient with incidentally discovered cystic angiomatosis involving liver, spleen, and bone who remains asymptomatic at follow-up. Additional cases are required to understand the pathophysiology and disease course in this group of patients, and to investigate possible therapeutic targets.

Comparative long-term outcomes of laparoscopic hepatectomy and radiofrequency ablation for hepatocellular carcinoma located in the anterolateral segments of the liver

BACKGROUND

Laparoscopic liver resection (LLR) is considered the standard surgical approach for resecting small hepatocellular carcinomas (HCC) located in the anterolateral segments of the liver. However, few studies have compared LLR and radiofrequency ablation (RFA) in such cases.

METHODS

We retrospectively compared the short- and long-term outcomes of 101 patients who underwent LLR and 264 patients who underwent RFA because of a newly diagnosed single, small (≤4 cm) HCC located in the anterolateral segments of the liver. By applying 1:1 propensity score matching, we matched 61 patients in both groups.

RESULTS

Although the 5-year overall survival rates were similar (83.6% vs 84.5%; P = .913), the 5-year disease-free survival rate was greater in the LLR group (56.4% vs 41.8%; P = .009). In patients with an α-fetoprotein level of ≥100 ng/mL, the 5-year overall (100% vs 80.0%; P = .022) and disease-free survival (76.6% vs 45.5%; P = .006) rates were greater in the LCC group.

CONCLUSIONS

For patients with a single, small HCC located in the anterolateral segments of the liver, LLR was associated with similar complication and overall survival rates, but better disease-free survival compared with RFA. LLR may be recommended for patients with higher α-fetoprotein levels.

Association between oncological outcomes of patients with colorectal liver metastasis and additional gadoxetic acid-enhanced magnetic resonance imaging

BACKGROUND

Gadoxetic acid-enhanced magnetic resonance imaging (MRI) has shown to be superior to contrast-enhanced computed tomography (CT) in studies, there is no adequate data on its impact on overall survival and recurrence-free survival in patients with colorectal liver metastasis. Our objective was to study the benefit afforded by gadoxetic acid-enhanced MRI in patients with colorectal liver metastasis, especially in terms of overall survival and recurrence-free survival.

METHODS

Patients who underwent surgical treatment for colorectal liver metastasis between January 2003 and December 2018 were divided into groups depending on the pro-operative imaging carried out. Overall survival and recurrence-free survival were compared between both groups.

RESULTS

Totally, 480 cases were included. Gadoxetic acid-enhanced MRI detected 220 new lesions in 123 cases. Presence of metastatic nodules was confirmed by gadoxetic acid-enhanced MRI in 33 of the 55 patients (60.0%) with indeterminate nodules on contrast-enhanced CT. Gadoxetic acid-enhanced MRI detected significantly more nodules than contrast-enhanced CT (932 vs. 673, respectively, P<0.001). There was no difference in the 5-year overall survival (P=0.390) or in the 3-month (85.1% vs. 86.7%, respectively, P=0.790), 6-month (78.0% vs. 81.7%, respectively, P=0.570), or 1-year (65.7% vs. 69.6%, respectively, P=0.446) recurrence-free survival in patients examined with contrast-enhanced CT or gadoxetic acid-enhanced MRI.

CONCLUSIONS

Although gadoxetic acid-enhanced MRI is more sensitive than contrast-enhanced CT, its utilization does not significantly affect the recurrence-free survival of the patient.

Clinical Impact of Unexpected Para-Aortic Lymph Node Metastasis in Surgery for Resectable Pancreatic Cancer

Radiologically identified para-aortic lymph node (PALN) metastasis is contraindicated for pancreatic cancer (PC) surgery. There is no clinical consensus for unexpected intraoperative PALN enlargement. To analyze the prognostic role of unexpected PALN enlargement in resectable PC, we retrospectively reviewed data of 1953 PC patients in a single tertiary center. Patients with unexpected intraoperative PALN enlargement (group A1, negative pathology, n = 59; group A2, positive pathology, n = 13) showed median overall survival (OS) of 24.6 (95% CI: 15.2-33.2) and 13.0 (95% CI: 4.9-19.7) months, respectively. Patients with radiological PALN metastasis without other metastases (group B, n = 91) showed median OS of 8.6 months (95% CI: 7.4-11.6). Compared with group A1, groups A2 and B had hazard ratios (HRs) of 2.79 (95% CI, 1.4-5.7) and 2.67 (95% CI: 1.8-4.0), respectively. Compared with group A2, group B had HR of 0.96 (95% CI: 0.5-1.9). Multivariable analysis also showed positive PALN as a negative prognostic factor (HR 2.57, 95% CI: 1.2-5.3), whereas positive regional lymph node did not (HR 1.32 95% CI: 0.8-2.3). Thus, unexpected malignant PALN has a negative prognostic impact comparable to radiological PALN metastasis. This results suggests prompt pathologic evaluation for unexpected PALN enlargements is needed and on-site modification of surgical strategy would be considered.

Surgical Resection or Ablation for Recurrent Pancreatic Ductal Adenocarcinoma: An Analysis of Oncologic Outcomes According to the Recurrence Type

Objective

To evaluate the survival benefits of curative-intent treatment (CIT, including surgery or ablation) for recurrent pancreatic ductal adenocarcinoma (PDAC) depending on the recurrence type and compared the survival outcomes with other treatment modalities.

Background

The treatment for recurrent PDAC is mostly chemotherapy or best supportive care (BSC). Still, the role of CIT for recurrent PDAC is not well established.

Methods

PDAC patients who underwent pancreatectomy between 2004 and 2019 were included. Recurrences were categorized as locoregional (LR), distant, or disseminated. Recurrent PDAC management was classified as CIT, chemotherapy ± radiation therapy (CTX ± RTX), or BSC. The survival after recurrence (SAR) rate was measured from the first day of recurrence to the date of death or last follow-up.

Results

Two hundred eighteen patients had recurrent PDAC and were analyzed (27 CIT, 128 CTX ± RTX, 63 BSC). The 1-, 3-, and 5-year SAR rates were 65.4%, 11.5%, and 11.5% for CIT, 42.1%, 4.0%, and 0% for CTX ± RTX, and 15.9%, 1.6%, and 0% for BSC, respectively. Subgroup analysis indicated the SAR rate was significantly better in the CIT group than in the CTX ± RTX and BSC groups in LR type (P = 0.027) and distant type (P < 0.001). In multivariate analysis, the albumin level at recurrence (hazard ratio, 2.14; 95% confidence interval, 1.15-18.3, P = 0.038) and operation time of the second operation (hazard ratio, 0.98; 95% confidence interval, 0.97-0.99, P = 0.021) were associated with a favorable prognosis of SAR in the CIT group.

Conclusions

CIT should be considered in recurrent PDAC for LR and distant metastases in selected patients.

Associations of hemoglobin and change in hemoglobin with risk of incident hip fracture in older men and women: the cardiovascular health study

In a multi-site longitudinal cohort study, decreasing hemoglobin was associated with increased hip fracture risk in men. Anemia was associated with hip fracture in men and in African American women. Decreasing hemoglobin may be a marker of progressing bone fragility, making its serial measurement useful for fracture risk stratification.

INTRODUCTION

Hematopoiesis and bone health are interdependent. Anemia has been associated with risk of fracture in humans. To further elucidate this relationship, we hypothesized that decreasing hemoglobin could indicate defective hematopoiesis and would also predict fracture risk.

METHODS

We performed a prospective analysis from study baseline (1992) of the Cardiovascular Health Study, a multi-site longitudinal cohort study. A total of 4670 men and women, ages >65 years, who were able to consent and not institutionalized or wheelchair bound, had hemoglobin (Hb) measured in 1992. For 4006 subjects, Hb change from 1989 to 1992 was annualized and divided into sex-specific quartiles. Incident hip fractures were verified against Medicare claims data during a median follow-up of 11.8 years.

RESULTS

Nested Cox proportional-hazard models estimated association of hip fracture with anemia (men Hb <13 g/dL, women Hb <12 g/dL) and separately, greatest Hb decrease (versus others). Anemia was associated with increased hip fracture risk in all men (HR 1.59; 95% CI 1.01-2.50) and African American women (HR 3.21; 95% CI 1.07-9.63). In men, an annualized Hb loss of >0.36 g/dL/year was associated with a higher risk of hip fracture (HR 1.67; 95% CI 1.10-2.54), which was lessened by anemia at the start of fracture follow-up (HR 1.53; 95% CI 0.99-2.39).

CONCLUSIONS

Decreasing Hb may be an early marker for subsequent hip fracture risk in men, which may be less informative once an anemia threshold is crossed. Only African American women with anemia had increased hip fracture risk, suggesting a race difference in this relationship.

The Safety of Intra-arterial Tirofiban during Endovascular Therapy after Intravenous Thrombolysis

BACKGROUND AND PURPOSE

The safety and efficacy of tirofiban during endovascular therapy in patients undergoing intravenous thrombolysis with recombinant IV tPA remain unclear. This study aimed to investigate the safety and efficacy of intra-arterial tirofiban use during endovascular therapy in patients treated with IV tPA.

MATERIALS AND METHODS

Using a multicenter registry, we enrolled patients with acute ischemic stroke who underwent endovascular therapy. Safety outcomes included postprocedural parenchymal hematoma type 2 and/or thick subarachnoid hemorrhage, intraventricular hemorrhage, and 3-month mortality. Efficacy outcomes included the successful reperfusion rate, postprocedural reocclusion, and good outcomes at 3 months (mRS scores of 0-2). The tirofiban effect on the outcomes was evaluated using a multivariable analysis while adjusting for potential confounders.

RESULTS

Among enrolled patients, we identified 314 patients with stroke (279 and 35 patients in the no tirofiban and tirofiban groups, respectively) due to an intracranial artery occlusion who underwent endovascular therapy with intravenous thrombolysis. A multivariable analysis revealed no association of intra-arterial tirofiban with postprocedural parenchymal hematoma type and/or thick subarachnoid hemorrhage (adjusted OR, 1.07; 95% CI, 0.20-4.10; P = .918), intraventricular hemorrhage (adjusted OR, 0.43; 95% CI, 0.02-2.85; P = .467), and 3-month mortality (adjusted OR, 0.38; 95% CI, 0.04-1.87; P = .299). Intra-arterial tirofiban was not associated with good outcome (adjusted OR, 2.22; 95% CI, 0.89 -6.12; P = .099).

CONCLUSIONS

Using intra-arterial tirofiban during endovascular therapy after IV tPA could be safe.

Management of indeterminate hepatic nodules and evaluation of factors predicting their malignant potential in patients with colorectal cancer

Some liver nodules remain indeterminate despite hepatocyte-specific contrast MRI in patients with colorectal liver metastasis (CRLM). Our objective was to study the natural course and evaluate possible treatment strategies for indeterminate nodules. We retrospectively evaluated patients in whom MRI revealed 'indeterminate' or 'equivocal' nodules between January 2008 and October 2018. Patients were followed up until October 2019 or until death (median, 18 months; (1-130 months)). The incidence of patients with indeterminate nodules on MRI was 15.4% (60 of 389). The sensitivity and specificity of intraoperative ultrasound for detecting indeterminate nodules were 73.68% and 93.75%, respectively, with a positive predictive value of 96.6%. Over half of the patients followed up had benign nodules (58.8%). By comparing characteristics of patients with benign or malignant nodules in the follow up group, the ratio of positive lymph nodes to total number of lymph nodes resected (pLNR) was significantly greater in patients with malignant nodules (P = 0.006). Intraoperative ultrasound could be considered as an adjunct to MRI in patients with indeterminate nodules owing to its high positive predictive value. The pLNR could be used to help select which patients can undergo conservative therapy, at least in metachronous CRLM.

Left atrial wall stress and the outcome of catheter ablation for atrial fibrillation: artificial intelligence-based prediction of clinical outcome

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Left atrial (LA) wall stress (LAW-str) may contribute to the mechanism of atrial fibrillation (AF).

Purpose

We explored the clinical characteristics and the rhythm outcome of AF depending on LAW-str among the patients who underwent AF catheter ablation (AFCA). We also tested whether artificial intelligence (AI) properly estimate LAW-str without invasive parameters.

Methods

We included 2223 patients (72.8% male, 59.0 [52.0–67.0] years old, 28.7% with persistent AF [PeAF]) who underwent radiofrequency catheter ablation (RFCA). LAW-str was calculated by the Law of Laplace using LA diameter (echocardiogram), peak LA pressure, and mean LA wall thickness (computed tomography) measured by customized software. Based on the quartile (Q1–4) or AI-estimated values of LAW-str, we compared clinical characteristics and rhythm outcome.

Results

LAW-str was independently associated with PeAF (p &lt; 0.001), diabetes (p = 0.012) and vascular disease (p = 0.002), body mass index (p &lt; 0.001), E/Em (p &lt; 0.001), and mean LA voltage (p &lt; 0.001). During 26.0 (12.0–52.0) months follow-up, clinical recurrence of AF was significantly higher in the Q4 of LAW-str group (log rank p = 0.001). LAW-str was independently associated with clinical recurrence after AFCA (HR 1.001 [1.000–1.002], p = 0.013). AI-based model using non-invasive parameters predicted Q4 of LAW-str with area under the curve (AUC) 0.734, which was similar to logistic regression based predictive model using all data including invasive parameters (AUC 0.726). Patients in Q4 of LAW-str showed consistently worse rhythm outcome regardless of the type of AF, sex, or AI-based prediction (p = 0.039).

Conclusions

The LAW-str seems to be associated with rhythm outcome of AFCA and AI can predict this complex parameter with moderate accuracy. TableMultivariateβ (95% CI)PPersistent AF31.08 (21.77-40.39)&lt;0.001Diabetes mellitus15.36 (3.35-27.38)0.012Vascular disease22.27 (8.4-36.14)0.002Body mass index2.91 (1.53-4.29)&lt;0.001E/Em4.95 (3.87-6.02)&lt;0.001Mean LA voltage-22.24 (-27.96–16.52)&lt;0.001Linear regression analysis for clinical variables predictive of LA wall stress (10^3 dyn/cm2).Abstract Figure. AF recurrence by LAW-str, AI-prediction

Parity-preserving and magnetic field-resilient superconductivity in InSb nanowires with Sn shells

Improving materials used to make qubits is crucial to further progress in quantum information processing. Of particular interest are semiconductor-superconductor heterostructures that are expected to form the basis of topological quantum computing. We grew semiconductor indium antimonide nanowires that were coated with shells of tin of uniform thickness. No interdiffusion was observed at the interface between Sn and InSb. Tunnel junctions were prepared by in situ shadowing. Despite the lack of lattice matching between Sn and InSb, a 15-nanometer-thick shell of tin was found to induce a hard superconducting gap, with superconductivity persisting in magnetic field up to 4 teslas. A small island of Sn-InSb exhibits the two-electron charging effect. These findings suggest a less restrictive approach to fabricating superconducting and topological quantum circuits.

Distinctive patterns of pulmonary function change according to baseline lung volume and diffusing capacity

SETTING: Multicentre retrospective study in South Korea.OBJECTIVE: To longitudinally evaluate changes in lung volume and diffusing capacity for carbon monoxide (DLCO) with forced expiratory volume in 1 sec (FEV₁).DESIGN: A total of 155 patients with chronic obstructive pulmonary disease (COPD), whose pulmonary function parameters were measured annually for 5 years, were selected from a prospective cohort in South Korea. A random coefficients model was used to estimate mean annual FEV₁, lung volume parameter and DLCO change rates.RESULTS: Patients were classified into four groups based on baseline DLCO and residual volume/total lung capacity (RV/TLC) measurements. The annual FEV₁ decline rate was greater in patients with low DLCO than in those with normal DLCO, with the greatest decline occurring in patients with low DLCO and normal RV/TLC. RV and RV/TLC declined in patients with high RV/TLC, whereas these increased in patients with normal RV/TLC. DLCO decreased longitudinally in all four groups, with the greatest decline occurring in patients with normal DLCO and normal RV/TLC.CONCLUSIONS: Different subgroups of patients with COPD exhibited distinctive pulmonary function change patterns. Baseline DLCO and RV/TLC may be used as physiological markers to predict long-term changes in pulmonary function.

Hepatic Artery Embolization for Postoperative Hemorrhage: Importance of Arterial Collateral Vessels and Portal Venous Impairment

PURPOSE

To investigate the association between hepatic ischemic complications and hepatic artery (HA) collateral vessels and portal venous (PV) impairment after HA embolization for postoperative hemorrhage.

MATERIALS AND METHODS

From October 2003 to November 2019, 42 patients underwent HA embolization for postoperative hemorrhage. HA collateral vessels were classified according to visualization after embolization (grade 1, none; grade 2, 1-4 segmental HA; and grade 3, ≥4 segmental HA). Transhepatic portal vein stent placements were performed in the same session for 5 patients (11.9%) with poor HA collateral vessels (grade 1 or 2) and compromised PV flow (>70% stenosis). Hepatic ischemic complications were analyzed for relevance to HA collateral vessels and PV compromise.

RESULTS

After HA embolization, HA flow was found to be preserved (grade 3) through intra- and/or extrahepatic collateral vessels in 23 patients (54.8%), and hepatic complications did not occur regardless of PV flow status (0%). Of the 19 patients (45.2%) with poor HA collateral vessels (grade 1 or 2), segmental hepatic infarction occurred in 2 of 15 patients (13.3%) with preserved PV flow (10 naïve and 5 stented). The remaining 4 patients with poor HA collateral vessels and untreated compromised PV flow experienced multisegmental hepatic infarction (n = 3) or hepatic failure (n = 1) (100%) (P < .005).

CONCLUSIONS

After HA embolization, preserved HA flow (≥4 segmental HA) lowered the risk of hepatic complications regardless of the PV flow. Based on these findings, transhepatic PV stent placement seems to be an effective intervention for the prevention of hepatic complications in cases of poor HA collateral vessels and compromised PV flow.

Improved Outcomes of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver

BACKGROUND

LLR is widely adapted for HCC, while LLR in PS segments is still challenging. With recent improvement of techniques and accumulation of experiences, LLR in PS segments is feasible, but studies investigating the result after the modifications are lacking.

METHODS

In this single-center, retrospective study, 149 patients who underwent LLR for HCC located in PS segments from September 2003 to December 2016 were analyzed. The patients were divided into Group 1 (n=43) and Group 2 (n=106) who underwent LLR before and after 2012, respectively, when advanced techniques including use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. Also, these patients were compared with those who underwent open liver resection (OLR; n=124) for HCC in PS segments during the same period.

RESULTS

Mean operative time (394.7 minutes vs 331.2 minutes; P=0.013), intraoperative blood loss (1545.8 ml vs 1208.2 ml; P=0.020), and hospital stay (11.6 days vs 9.2, P<0.001) were significantly less in Group 2. Postoperative complication rate (18.6% vs 18.9%; P=0.970), open conversion rate (23% vs 17%; P=0.374), 5-year overall (79% vs 89%; P=0.607) and 5-year disease-free (52% vs 53%; P=0.657) survival rates were not significantly different between the groups. Compared to the OLR group, complication rate (40.3% vs 18.8%; P< 0.001) and hospital stay (17.6 days vs 9.7 days; P< 0.001) were significantly lower in the LLR group.

CONCLUSION

The complexity of LLR for HCC in PS segments is being gradually overcome by the introduction of advanced techniques.

Fistula risk score-adjusted comparison of postoperative pancreatic fistula following laparoscopic vs open pancreatoduodenectomy

BACKGROUND

To evaluate a risk-adjusted comparison of clinically relevant postoperative pancreatic fistula POPF (CR-POPF) following laparoscopic pancreatoduodenectomy (LPD) vs open pancreatoduodenectomy (OPD) using the fistula risk score (FRS).

METHODS

We retrospectively analyzed 579 patients who underwent LPD (n = 274) or OPD (n = 305) between 2012 and 2019 at two tertiary hospitals. Using the FRS, the risk was stratified into four categories; negligible, low, intermediate and high risk.

RESULTS

The median FRS was significantly higher in the LPD than in the OPD group (5.4 ± 1.2 vs 3.9 ± 1.8, P < .001). The overall incidence of CR-POPF in the LPD vs OPD groups were 16.4% vs 17.7% (P = .187). When POPF risks were stratified by FRS, CR-POPF following LPD vs OPD in patients with low risk (0% vs 6.3%, P = .294), intermediate risk (16.1% vs 22.9%, P = .053) and high risk (33.3% vs 27.3%, P = .577) were not significantly different.

CONCLUSION

Despite a higher risk score in the LPD group, the CR-POPF was similar following both procedures in the unadjusted and FRS-risk-adjusted comparisons. The CR-POPF was more significantly affected by patient risk factors such as the soft pancreas and small pancreatic duct.

Addressing Syndemics and Self-care in Individuals with Uncontrolled HIV: An Open Trial of a Transdiagnostic Treatment

Interventions addressing syndemics and ART adherence are needed for individuals with uncontrolled HIV and psychosocial problems. Twenty-seven participants with detectable HIV plasma viral load (PVL) or recent STI participated in an open trial of transdiagnostic adherence counseling and cognitive behavioral therapy. Outcomes were collected at baseline, 4-, and 8-months. Log PVL improved from baseline to 4-month (γ = - 1.13, 95% CI - 1.72, - 0.55, p < 0.001) and 8-month (γ = - 0.93, 95% CI - 1.57, - 0.30, p = 0.006), with more participants suppressed at 4- (χ2(1) = 9.09, p = 0.001) and 8-month (χ2(1) = 5.14, p = 0.016). Self-reported adherence improved across major assessments (γ = 0.87, 95% CI 0.28, 1.46, p = .005); Wisepill adherence did not. Negative affect declined during treatment (γ = - 0.28, 95% CI - 0.40, - 0.16, p < 0.001), with improvement at 4- (γ = - 4.34, 95% CI - 6.99, - 1.69, p = 0.002) but not 8-month. Positive affect trended positively during treatment and from baseline to 4-month, with significant 8-month improvement (γ = 3.84, 95% CI 0.33, 7.44, p = 0.04). Depressive symptoms did not change. In a complicated sample of participants selected for uncontrolled HIV, the intervention yielded improved PVL and self-reported adherence. Efforts to end HIV should improve upon strategies such as these, addressing syndemics. Registration: clinicaltrial.gov: NCT02696681.

Impact of preoperative malnutrition, based on albumin level and body mass index, on operative outcomes in patients with pancreatic head cancer

BACKGROUND

To investigate whether preoperative malnutrition in patients who underwent curative pancreaticoduodenectomy (PD) in pancreatic head cancer correlated with short-term outcomes.

METHODS

This study was a retrospective review of medical records from January 2004 to December 2018. Preoperative malnutrition was defined as body mass index (BMI) <18.5 kg/m² , or hypoalbuminemia with serum albumin level < 3.5 g/dL within 30 days before surgery.

RESULTS

Of the 289 eligible patients, 60 patients (20.7%) were classified as the malnutrition group. The estimated blood loss (EBL, mL) (964.1 ± 879.7 vs 597.7 ± 501.7, P = .044) and transfusion rate (51.7% vs 18.8%, P < .001) was significantly higher in the malnutrition group than no-malnutrition group. The hospital stay (days) (20.5 ± 12.2 vs 18.1 ± 13.6, P = .05) was significantly longer in the malnutrition group. The open conversion rate (45.4% vs 6.67%, P < .001) and major complication rate (36.7% vs 21.8%, P = .032) was significantly higher in the malnutrition group. In multivariate analysis, preoperative malnutrition was found to be the predictor of postoperative complication (HR 1.971 95% confidence interval 1.071-3.624, P = .029).

CONCLUSION

Preoperative malnutrition in patients who underwent curative PD for pancreatic head cancer is associated with adverse short-term outcomes.

Improved outcomes of major laparoscopic liver resection for hepatocellular carcinoma

BACKGROUND

Minor laparoscopic liver resection (LLR) is currently becoming standard treatment option for hepatocellular carcinoma (HCC) while major LLR is still challenging. Recent advancement of surgical techniques has enabled surgeons to perform major LLR. This study compared the outcomes of major LLR for HCC before and after the adaptation of technological improvements.

METHODS

We retrospectively analyzed 141 patients who underwent major LLR for HCC from January 2004 to July 2018.32 open conversion cases were excluded. We divided the patients into two groups according to the date of operation: Group 1 (n = 38) and Group 2 (n = 71) who underwent major LLR before and after 2012, when advanced techniques including the use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. We also compared these patients including open conversion cases (n = 141) with those who underwent major open liver resection (OLR; n = 131) during the same period.

RESULTS

Mean operative time (413.0 min vs 331.0 min; P = 0.009), transfusion rate (31.6% vs 11.3%, P = 0.009) and hospital stay (9.8 days vs 8.5 days; P = 0.001) were significantly less in Group 2. Intraoperative blood loss (1269.7 ml vs 844.5 ml; P = 0.341) and postoperative complication (15.8% vs 23.9%; P = 0.320) were not significantly different between the groups. Although tumor size in OLR group and type of resection was different, transfusion rate (36.6% vs 24.1%; P = 0.026), postoperative complication (41.2% vs 25.5%; P = 0.007), and hospital stay (17.2 days vs 10.0 days; P < 0.001) were significantly lower in LLR group.

CONCLUSION

Development of surgical techniques have gradually improved the surgical outcomes of the laparoscopic major liver resection.

Laparoscopic bile duct resection with lymph node dissection for gallbladder cancer diagnosed after laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic reoperation of postoperatively diagnosed gallbladder cancer is a technically challenging procedure due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed [1,2]. Here we describe a technique for laparoscopic bile duct resection with lymph node dissection in a patient with cystic duct cancer diagnosed after laparoscopic cholecystectomy.

VIDEO

A 73-year-old woman presented with postoperatively diagnosed gallbladder cancer. She underwent laparoscopic cholecystectomy to treat symptomatic gallbladder stones at another hospital, 2 months earlier. Postoperative pathology revealed a 0.9 × 0.7 cm, T2 lesion of adenosquamous carcinoma located at the cystic duct. The cystic duct margin showed high-grade dysplasia. We planned to perform laparoscopic bile duct resection with lymph node dissection. After adhesiolysis to expose the hepatoduodenal ligament, the lymph nodes were dissected around the retropancreatic area, hepatoduodenal ligament, and common hepatic artery in an en bloc fashion. Combined segmental resection of the bile duct, including the fibrotic scar around the cystic duct stump, was completed with negative resection margins. Retrocolic choledochojejunostomy and side-to-side jejunojejunostomy were then performed intracorporeally.

RESULTS

The operation time was 195 minutes and the estimated intraoperative blood loss was minimal. The postoperative pathologic report revealed no residual tumor tissue and negative resection margins. Lymph node metastasis was found in one of eight retrieved lymph nodes. The patient was discharged on postoperative day 4 with no postoperative complications.

CONCLUSION

Laparoscopic radical surgery involving bile duct resection and lymph node dissection can be safely performed in patients with postoperatively diagnosed gallbladder cancer.

Identification of Pistacia-associated flexivirus 1, a putative mycovirus of the family Gammaflexiviridae, in the mastic tree (Pistacia lentiscus) transcriptome

In this study, we identified the genome sequence of the novel virus Pistacia-associated flexivirus 1 (PAFV1), a putative member of the mycovirus family Gammaflexiviridae (the order Tymovirales), via analysis of a transcriptome dataset for the mastic tree (Pistacia lentiscus, the family Anacardiaceae). PAFV1 was predicted to have three open reading frames (ORFs): ORF1, encoding a replicase (REP) with RNA-dependent RNA polymerase activity; ORF2, a movement protein (MP); and ORF3, a hypothetical protein. The PAFV1 REP sequence showed high similarity to those of three known members of the family Gammaflexiviridae i.e., Entoleuca gammaflexivirus 1 (EnFV1), Entoleuca gammaflexivirus 2 (EnFV2), and Botrytis virus F (BVF). A genome contig of the fungus Monosporascus cannonballus also contained a sequence of an endogenous virus similar to that of PAFV1. Sequence comparison and phylogenetic analysis indicated that PAFV1, EnFV1, and the endogenous virus of M. cannonballus formed a distinct subgroup (apart from EnFV2 and BVF), and may be the founding members of a novel genus in the family Gammaflexiviridae. Notably, MP sequences of PAFV1/EnFV1 showed similarity to the MP sequences of the mycovirus group called tobamo-like mycoviruses (an unassigned taxon), implying that genomic recombination occurred between members of the family Gammaflexiviridae and tobamo-like mycoviruses. Since PAFV1 is phylogenetically related to mycoviruses, PAFV1 may also be a mycovirus that infected a fungus associated with the mastic tree sample, which is evidenced by the presence of fungal ribosomal RNA sequences in the mastic tree transcriptome. Thus, the PAFV1 genome sequence may be useful in elucidating the genome evolution of Gammaflexiviridae and tobamo-like mycoviruses. Keywords: Pistacia-associated flexivirus 1; Gammaflexiviridae; mycovirus, mastic tree.

Outcome of using vaginal misoprostol for treatment of retained products of conception after first trimester miscarriage: a retrospective cohort study

PURPOSE

Standard treatment for retained products of conception (RPOC) is dilation and curettage (D&C), however, this brings a risk of intrauterine synechiae and subsequent fertility issues. A treatment strategy to avoid D&C is medical management with misoprostol. The justification for misoprostol in this setting is extrapolated from miscarriage and termination literature, however, no studies have looked specifically in the setting of RPOC. The purpose of this study is to determine the efficacy of misoprostol as definitive management of RPOC.

MATERIALS AND METHODS

A retrospective cohort study was conducted from January 2016 to March 2017 at an Early Pregnancy Assessment Clinic. Patients diagnosed with RPOC with clinical symptoms and ultrasound findings of endometrial mass and/or doppler flow treated expectantly, medically with vaginal misoprostol or with a suction D&C underwent a chart review. Primary outcome was resolution of RPOC without surgical intervention.

RESULTS AND CONCLUSIONS

Of 1743 unique pregnancies, 189 women were diagnosed with RPOC. 34% (65/178) chose misoprostol for management of RPOC. Baseline demographics between the three treatment modalities (expectant, medical, surgical) were comparable. 65% (42/65) of patients who took misoprostol avoided D&C. Misoprostol is most effective (76%) in the setting of RPOC if the primary treatment for miscarriage was expectant management, with less success with primary medical management (44%) and primary surgical management (40%).

Endoscopically assisted malarplasty: L-rotation technique

INTRODUCTION

Endoscopically assisted malarplasty with a greenstick fracture is a method for preserving the body eminence and improving arch protrusion. However, this technique is inadequate when malar body reduction is required. To compensate for these limitations, we developed a new surgical technique using the endoscope to reduce body protrusion.

MATERIAL AND METHODS

We enrolled 261 patients who visited our clinic for zygoma reduction from January 2017 to December 2018. Their mean age was 31 (range 17-63) years. After a scalp incision, an incomplete osteotomy was created from the most prominent portion of the zygoma body to the zygomaticomaxillary suture line. A complete osteotomy was performed on the arch. These osteotomies resulted in an L-shaped zygoma segment after tapping the bone with a mallet.

RESULTS

Of the 261 patients who underwent our L-rotation technique, 242 also received a corticotomy. Of those patients, 15 underwent a different degree of zygoma reduction on both sides. A floating zygomatic segment occurred in four cases, although no further surgery was required. One patient's zygomatic segment dropped on one side, requiring rigid fixation through the intraoral approach. Most patients were satisfied and there were no specific complications.

CONCLUSIONS

Endoscopically assisted malarplasty using an L-rotation technique enables the protrusion of both the arch and body to be reduced. The zygoma reduction can be modified based on the location of the incomplete osteotomoy line and the number of corticotomies required.

Detecting Depression in People Living with HIV in South Africa: The Factor Structure and Convergent Validity of the South African Depression Scale (SADS)

Screening measures for depression developed in high-income countries have not always demonstrated strong psychometric properties in South Africa and with people living with HIV (PLWH). The present study explored the psychometric properties of the 16-item South African Depression Scale (SADS) comprised of idioms of distress specific to isiXhosa culture in PLWH. The SADS was administered to 137 Xhosa-speaking PLWH who met diagnostic criteria for major depressive disorder (MDD) together with the Hamilton Depression Scale (HAM-D) and the Center for Epidemiological Studies Depression Scale (CES-D). We conducted exploratory factor analysis, correlation, and reliability statistics. Four factors of the SADS emerged: Sadness, lethargy/burdened, anhedonia/withdrawal, and cognitive/somatic. All factors correlated significantly with the HAM-D and CES-D. Internal consistency of the overall measure was high (α = .89). The SADS promises to be a robust measure of depression in isiXhosa-speaking PLWH in South Africa likely due to the inclusion of local idioms of distress.