Clinical Frailty Score is a good predictor of postoperative mortality in patients undergoing open abdomen surgery: a multicenter retrospective cohort study

BACKGROUND

Open Abdomen (OA) is gaining popularity in damage control surgery (DCS) but there is not an absolute prognostic score to identify patients that may benefit from it. Our study investigates the correlation between the clinical frailty scale score (CFSS) and postoperative morbidity and mortality in patients undergoing OA.

METHODS

Patients ≥65 yo undergoing OA in two referral centres between 2015 and 2020 were included and stratified according to CFSS in non-frail (NF), frail (F) and highly-frail (HF). The primary endpoint was 30-day mortality. Secondary endpoints were postoperative morbidity and 1- year survival.

RESULTS

One hundred and thirty-six patients were included: 35 NF (25.7%), 56 F (41.2%), 45 HF (33.1%). Average age 76.8. The 73.5% of cases were non-traumatic diseases with no difference in preoperative characteristics. 95 (71.4%) had one complication, 26 NF (74.3%), 34 F (63.2%), 35 HF (77.8%) (P=0.301) and 59.4% had a complication with a CD≥3, 57.1% NF, 56.6% F and 64.4 HF. The 30-day mortality was 32.4%, higher in HF (46.7%) and F (30.4%) compared to NF (17.1%, P=0.018). The Overall 1-year survival was 41% (SE ±4) with statistically significant difference between HF vs. NF and HF vs. F (P=0.009 and P=0.029, respectively). In the univariate analysis, the only significant prognostic factor impacting mortality was CFSS, with HF having an HR of 1.948 (95% CI 1.097-3.460, P=0.023).

CONCLUSIONS

When OA is a surgical option, frail patients should not be precluded, while HF should be carefully evaluated. The CFSS might be a good prognostic score for patients that may safely benefit from OA.

Roux-en-Y with or without jejunal J-pouch reconstruction after total gastrectomy for gastric cancer: systematic review and meta-analysis of long-term functional outcomes

BACKGROUND

Increased survival of patients undergoing total gastrectomy for gastric cancer has prompted several efforts to improve long-term postgastrectomy syndrome (PGS) outcomes. Whether a J-pouch (JP) reconstruction may be more beneficial than a standard Roux-en-Y (RY) is controversial.

METHODS

A systematic review with meta-analysis was conducted, including studies reporting long-term outcomes of patients treated with total gastrectomy and JP vs RY esophagojejunostomy for gastric adenocarcinoma. A literature search was performed on PubMed, Scopus, and Google Scholar. Primary endpoints were symptom control, weight loss, eating capacity (EC), and quality of life (QoL) with at least 6 months of follow-up. Safety endpoints were explored.

RESULTS

Overall, 892 patients were included from 15 studies (6 randomized controlled trials [RCTs] and 9 non-RCTs): 452 (50.7%) in the JP group and 440 (49.3%) in the RY group. Compared with RY, JP showed a significantly lower rate of dumping syndrome (13.8% vs 26.9%, odds ratio [OR], 0.29; 95% confidence interval [CI], 0.14-0.58; P < .001; I2 = 22%) and heartburn symptoms (20.4% vs 39.0%; OR, 0.29; 95% CI, 0.14-0.64; P = .002; I2 = 0%). Reflux (OR, 0.61; 95% CI, 0.28-1.32; P = .21; I2 = 42%) and epigastric fullness (OR, 0.60; 95% CI, 0.18-2.05; P = .41; I2 = 69%) were similar in both groups. Weight loss and EC were similar between the groups. QoL outcome seemed to be burdened by bias. There was no difference in morbidity, mortality, and anastomotic leak rate between groups. Operative time was significantly longer for JP than for RY (271.9 vs 251.6 minutes, respectively; mean difference, 21.55; 95% CI, 4.64-38.47; P = .01; I2 = 96%).

CONCLUSION

JP reconstruction after total gastrectomy for gastric cancer is as safe as RY and may provide an advantage in postgastrectomy dumping syndrome and heartburn symptoms.

Efficacy and findings of a blinded randomized reintroduction phase for the low FODMAP diet in Irritable Bowel Syndrome

BACKGROUND AND AIMS

The efficacy of a low fermentable oligo-, di-, monosaccharides and polyols (FODMAP) diet in Irritable Bowel Syndrome (IBS) is well established. After the elimination period, a reintroduction phase aims to identify triggers. We studied the impact of a blinded reintroduction using FODMAP-powders to objectively identify triggers and evaluated the effect on symptoms, quality of life (QoL), and psychosocial co-morbidities.

METHODS

Responders to a 6-week low-FODMAP diet, defined by a drop in IBS-symptom severity score (IBS-SSS) compared to baseline, entered a 9-week blinded randomized reintroduction phase with 6 FODMAP powders (fructans, fructose, galacto-oligosaccharides, lactose, mannitol, sorbitol) or control (glucose). A rise in IBS-SSS (≥50 points) defined a FODMAP-trigger. Patients completed daily symptom diaries and questionnaires for QoL and psychosocial co-morbidities.

RESULTS

In 117 recruited IBS patients, IBS-SSS improved significantly after the elimination period compared to baseline (150±116 vs 301±97, P < .0001, 80% responders). Symptom recurrence was triggered in 85% of the FODMAP powders, by an average of 2.5±2 FODMAPs/patient. The most prevalent triggers were fructans (56%) and mannitol (54%), followed by galacto-oligosaccharides, lactose, fructose, sorbitol, and glucose (respectively 35%, 28%, 27%, 23%, and 26%) with a significant increase in abdominal pain at day 1 for sorbitol/mannitol, day 2 for fructans/galacto-oligosaccharides and day 3 for lactose.

CONCLUSION

We confirmed the significant benefit of the low-FODMAP diet in tertiary care IBS. A blinded reintroduction revealed a personalized pattern of symptom recurrence, with fructans and mannitol as the most prevalent, and allows the most objective identification of individual FODMAP-triggers; Clinicaltrial.gov number: NCT04373304.

Third whole-brain radiation therapy for multiple brain metastases. Should it be considered in selected patients?

Whole brain reirradiation for the treatment of multiple brain metastases has shown promising results. However, concerns remain over the possible neurotoxic effects of the cumulative dose as well as the questionable radiosensitivity of recurrent metastases. A second reirradiation of the whole brain is ordinarily performed in our department for palliative purposes in patients presenting with multiple metastatic brain progression. For this study, an investigational third whole brain reirradiation has been administered to highly selected patients to obtain disease control and delay progression. Clinical outcomes and neurological toxicity were also evaluated.

Tumour-specific mesorectal excision for rectal cancer: Systematic review and meta-analysis of oncological and functional outcomes

BACKGROUND

Tumour-specific mesorectal excision (TSME) practice for rectal cancer only relies on small retrospective studies. This study aimed to perform a systematic review and meta-analysis to assess the oncological and functional outcomes of TSME practice.

METHODS

A systematic review protocol was drawn to include all the studies that compared partial versus total mesorectal excision (PME vs TME) practised for rectal adenocarcinoma up to 16 cm from the anal verge. A systematic literature search was conducted on EMBASE-Medline, Pubmed and Cochrane Library. Reports were screened for the study's outcomes: oncological radicality, postoperative anastomotic leak risk and functional outcomes. Included studies were appraised for risk-of-bias and meta-analysed. Evidence was rated with the GRADE approach.

RESULTS

Twenty-seven studies were included, consisting of 12325 patients (PME n = 4460, 36.2%; TME n = 7865, 63.8%). PME was performed for tumours higher than 10 cm from the anal verge in 54.5% of patients. There was no difference between PME and TME in circumferential resection margin positivity (OR 1.31, 95%CI 0.43-3.95, p = 0.64; I2 = 38%), and local recurrence risk (HR 1.05, 95%CI 0.52-2.10, p = 0.90; I2 = 40%). The postoperative leak risk (OR 0.42, 95%CI 0.27-0.67, p < 0.001; I2 = 60%) and the major low anterior resection syndrome risk (OR 0.34, 95%CI 0.28-0.40, p < 0.001; I2 = 0%) were lower after PME surgery. No difference was found in urinary incontinence (OR 0.68, 95%CI 0.13-3.67, p = 0.66) and urinary retention after early catheter removal (OR 2.00, 95%CI 0.24-16.51, p = 0.52).

CONCLUSIONS

Evidence from this meta-analysis shows that TSME for rectal cancer has good oncological results and leads to the best-fitted functional results possible for the patient's condition.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Review article: Functional dyspepsia-a gastric disorder, a duodenal disorder or a combination of both?

BACKGROUND

Functional dyspepsia (FD) is one of the most frequent conditions in gastroenterological outpatient health care. Most recent research in FD has shifted its focus to duodenal pathophysiological mechanisms, although current treatments still focus mainly the stomach.

AIM

The aim of the study was to provide a comprehensive overview of the pathophysiology of FD focusing on a paradigm shift from gastric towards duodenal mechanisms.

METHODS

We conducted a literature search in PubMed for studies describing mechanisms that could possibly cause FD.

RESULTS

The pathophysiology of FD remains incompletely understood. Recent studies show that duodenal factors such as acid, bile salt exposure and eosinophil and mast cell activation correlate with symptom pattern and burden and can be associated with gastric sensorimotor dysfunction. The evolving data identify the duodenum an interesting target for new therapeutic approaches. Furthermore, the current first-line treatment, that is proton pump inhibitors, reduces duodenal low-grade inflammation and FD symptoms.

CONCLUSION

Future research for the treatment of FD should focus on the inhibition of duodenal mast cell activation, eosinophilia and loss of mucosal integrity.

Systemic GDF11 replenishment ignites myocardial injury through diminishing anti-apoptotic activity of cardiac progenitor cells

Background

Tissue damage due to acute myocardial infarction is caused by both the ischemic insult and subsequent reperfusion injury (I/R). Restoration of coronary blood flow accelerates cardiomyocyte death, a phenomenon referred to as reperfusion injury, the extent of which is partly modulated by cardiac progenitor cells (CPC). Development of novel therapies to reduce infarct size, the main determinant of outcome, represent a huge unmet medical need (1). Systemic levels of growth differentiation factor 11 (GDF11), a TGF-β superfamily member that shares 90% homology with myostatin, decline with age, and GDF11 replenishment by heterochronic parabiosis or systemic recombinant GDF11 (rGDF11) delivery was postulated to have rejuvenating effects (2).

Purpose

We aimed to probe the effects of systemic GDF11 replenishment on I/R injury and deepen insights into the molecular mechanisms involved.

Methods

We designed a vehicle-controlled study in which young (3–4 months) and old (22–24 months) C57Bl/6 mice were randomly assigned to either daily systemic rGDF11 or control treatment over 30 days before myocardial I/R injury was induced. Dissected hearts were subjected to in-depth profiling followed by IPA-guided -omics to identify key regulatory mechanisms. Finally, in vitro experiments on human CPCs and HL-1 cardiomyocytes were performed.

Results

Myocardial Gdf11 expression declined with age, whereas myostatin (Mstn) showed an opposing expression pattern (Fig. 1A), a trend similarly observed upon I/R (Fig. 1B). Surprisingly, after the 30-day study period (Fig. 1C), young and aged rGDF11-treated mice showed higher I/R-induced infarct size and serum cardiac troponin I levels than controls, despite comparable areas at risk (Fig. 1D). Importantly, while proxies of necroptosis/pyroptosis remained unchanged, rGDF11-treated animals showed reduced cardiomyocyte viability irrespective of their age (Fig. 2A). Targeted transcriptomics applied on cardiac tissues of both groups identified the CPC-marker Nkx2–5 to be differentially regulated (Fig. 2B-C), an expression pattern validated in an independent cohort at both mRNA and protein levels (Fig. 2D). In the adult myocardium, the expression of both Nkx2–5 and its cofactor Gata4 is mainly confined to CPCs; indeed, similar reductions in Nkx2–5 and Gata4 expression were observed in CPCs exposed to rGDF11 (Fig. 2E) which coincided with accelerated cardiomyocyte death if cultured in conditioned media obtained from CPCs treated with rGDF11 (Fig. 2F), pointing toward a paracrine signalling pathway.

Conclusions

Myocardial expression of GDF11 declines with age, and is blunted upon I/R injury, thereby opposing the expression pattern of myostatin. Surprisingly, however, systemic GDF11 replenishment by rGDF11 supplementation enhances rather than reduces myocardial infarct size through augmented apoptosis, a phenomenon mediated by diminished cardioprotective function of CPCs.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Foundation for Cardiovascular Research – Zurich Heart House

Which surgical strategy for colorectal cancer with synchronous hepatic metastases provides the best outcome? A comparison between primary first, liver first and simultaneous approach

BACKGROUND

There is no clear consensus about the best surgical strategy for patients with colorectal cancer (CRC) and synchronous liver metastases (SCRLM).

METHODS

Between 2009 and 2019, patients with CRC and SCRLM considered for curative treatment were included. Perioperative and follow-up data were analysed to examine the safety and survival outcomes of primary first (PF), liver first (LF) and simultaneous resection (SR) strategies.

RESULTS

204 patients were identified, consisting of PF (n = 129), LF (n = 26) and SR (n = 49). Forty-five patients (22.1%) failed to have either the primary or the liver metastases resected following initial LF (n = 11, 42.3%) or PF (n = 34, 26.4%), respectively (p < 0.001). The postoperative morbidity rates were 31.0%, 38.4% and 40.8% in PF, LF and SR group, respectively (p = 0.409); the mortality rates were 2.3%, 0% and 4.1%, respectively (p = 0.547). The 1-, 3- and 5-year overall survival (OS) were 94%, 72%, 53% in the PF group, 74%, 54%, 36% in the LF group, and 91%, 74%, 63% in the SR group. LF group had the worst OS compared to PF and SR (p = 0.040, p = 0.052). The 1-, 3- and 5-year disease-free survival (DFS) were 31%, 15%, 10% in PF, 21%, 9% and 9% in LF and 45%, 28% and 28% in SR group, respectively. SR group had a better DFS compared to PF and LF (p = 0.005, p = 0.008). At the multivariate analysis, there was no difference between the three strategies in terms of OS (PF vs SR OS-HR 1.090, p = 0.808; LF vs SR OS-HR 1.582, p = 0.365) and the PF had a worse DFS compared to the SR approach (PF vs SR DFS-HR 1.803, p = 0.007; LF vs SR DFS-HR 1.252, p = 0.492).

CONCLUSIONS

PF, LF and SR had comparable postoperative morbidity and mortality. The three surgical strategies had similar OS outcomes. The PF strategy was associated with a worse DFS than SR, while the LF approach was associated with a high failure rate to progress to the second stage (primary tumour resection).

Robotic surgery for colorectal liver metastases resection: A systematic review

BACKGROUND

The role of robotic surgery for colorectal cancer liver metastases (CRCLMs) has never been investigated in large series.

METHODS

A systematic literature review was carried out on PubMed and Cochrane libraries.

RESULTS

We selected nine studies between 2008 and 2021. Two hundred sixty-two patients were included. One hundred thirty-one patients underwent simultaneous resections. The mean blood loss was 309.4 ml (range, 200-450 ml), the mean operative time was 250.5 min (range, 198.5-449.0 min). The mean length of hospital stay was 7.98 days (range, 4.5 to 12 days). The overall postoperative mortality was 0.4%. The overall morbidity rate was 37.0%, Clavien-Dindo grade III-IV complications were 8.4%. The mean 3-year overall survival was 55.25% (range, 44.4-66.1%), the mean 3-year disease free survival was 37% (range, 33.3-41.9%) CONCLUSION: We can conclude that robotic-assisted surgery might be considered as a technical upgrade option for minimally invasive approach to CRCLM resections even for simultaneous operations and challenging cases.

Short stump and high anastomosis pull-through (SHiP) procedure for delayed coloanal anastomosis with no protective stoma for low rectal cancer

Despite advances in coloanal anastomosis techniques, satisfactory procedures completed without complications remain lacking. We investigated the effectiveness of our recently developed ‘Short stump and High anastomosis Pull-through’ (SHiP) procedure for delayed coloanal anastomosis without a stoma. In this retrospective study, we analysed functional outcomes, morbidity, and mortality rates and local recurrence of 37 patients treated using SHiP procedure, out of the 282 patients affected by rectal cancer treated in our institution between 2012 and 2020. The inclusion criterion was that the rectal cancer be located within 4 cm from the anal margin. One patient died of local and pulmonary recurrence after 6 years, one developed lung and liver metastases after 2 years, and one experienced local recurrence 2.5 years after surgery. No major leak, retraction, or ischaemia of the colonic stump occurred; the perioperative mortality rate was zero. Five patients (13.51%) had early complications. Stenosis of the anastomosis, which occurred in nine patients (24.3%), was the only long-term complication; only three (8.1%) were symptomatic and were treated with endoscopic dilation. The mean Wexner scores at 24 and 36 months were 8.3 and 8.1 points, respectively. At the 36-month check-up, six patients (24%) had major LARS, ten (40%) had minor LARS, and nine (36%) had no LARS. The functional results in terms of LARS were similar to those previously reported after immediate coloanal anastomosis with protective stoma. The SHiP procedure resulted in a drastic reduction in major complications, and none of the patients had a stoma.

PCSK9 is associated with mortality in patients with septic shock: data from the ALBIOS study

BACKGROUND

Pro-protein convertase subtilisin/kexin 9 (PCSK9) is a proenzyme primarily known to regulate low-density lipoprotein receptor re-uptake on hepatocytes. Whether PCSK9 can concurrently trigger inflammation or not remains unclear. Here, we investigated the potential association between circulating levels of PCSK9 and mortality in patients with severe sepsis or septic shock.

METHODS

Plasma PCSK9 levels at days 1, 2 and 7 were measured in 958 patients with severe sepsis or septic shock previously enrolled in the Albumin Italian Outcome Sepsis (ALBIOS) trial. Correlations between levels of PCSK9 and pentraxin 3 (PTX3), a biomarker of disease severity, were evaluated with ranked Spearman's coefficients. Cox proportional hazards models were used to assess the association of PCSK9 levels at day 1 with 28- and 90-day mortality.

RESULTS

Median plasma PCSK9 levels were 278 [182-452] ng mL^-1 on day 1. PCSK9 correlated positively with PTX3 at the three time-points, and patients with septic shock within the first quartile of PCSK9 showed higher levels of PTX3. Similar mortality rates were observed in patients with severe sepsis across PCSK9 quartiles. Patients with septic shock with lower PCSK9 levels on day 1 (within the first quartile) showed the highest 28- and 90-day mortality rate as compared to other quartiles.

CONCLUSION

In our sub-analysis of the ALBIOS trial, we found that patients with septic shock presenting with lower plasma PCSK9 levels experienced higher mortality rate. Further studies are warranted to better evaluate the pathophysiological role of PCSK9 in sepsis.

Extending and adapting the concept of quality management for museums and cultural heritage attractions: A comparative study of southern European cultural heritage managers' perceptions

Quality in cultural heritage attractions is mainly approached from the visitors' satisfaction perspective, and the literature does not contain a clear definition of quality in the management of cultural heritage sites open to the public. The present study aims to reframe this trend. By way of theoretical contribution, we propose a definition of quality in cultural heritage attractions management based on dimensions such as the capacity of preserving the cultural assets, the ability to communicate effectively their significance, the quality of commodification for visitor use, and the ability to boost intercultural competence and promote intercultural dialogue. Based on the above, an empirical, qualitative study was conducted on the cultural heritage managers' current perceptions of quality. The results suggest that a profound asymmetry exists among practitioners' opinions and practices, and four types of cultural heritage managers were defined with regard to their perception of quality: Reactionary, Reticent, Pragmatic, Enthusiastic.

Endometrial stromal sarcoma arising from polypoid endometriosis: Case report and literature review

BACKGROUND

Polypoid endometriosis (PE) is a rare and uncommon variant of endometriosis that may present as a polypoid mass that simulates a malignant neoplasm. Typically, PE develops locally as a large benign pelvic mass. However, it may sometimes conceal a malignant disease in its context.

CASE PRESENTATION

A 53 years old, nulliparous lady, had been treated over a 10-year period for recurrent and symptomatic polypoid endometriosis of the pelvis. During this time, she underwent four surgical resections, the final one being a total pelvic exenteration, with histology demonstrating the presence of a rare myxoid low grade Endometrial Stromal Sarcoma (ESS) that had arisen in PE.

CONCLUSION

PE is a rare variant growth pattern of endometriosis which may involve different pelvic organs and can mimic a malignant mass in the pelvis. It mostly affects women in their peri- or post-menopausal age and it is not always related to hormonal therapy. Malignances, such as Endometrial Stromal Sarcoma in this case, can arise in the context of PE and their diagnosis can be challenging. Surgical excision may constitute radical multi-organ resection, particularly for recurrent and symptomatic cases. However, the recurrence rates after surgery can be significant.

Analysis of Postprandial Symptom Patterns in Subgroups of Patients With Rome III or Rome IV Functional Dyspepsia

BACKGROUND & AIMS

Among patients with functional dyspepsia (FD), there is overlap in symptoms between those in the Rome III subgroups of postprandial distress syndrome (PDS) and those with epigastric pain syndrome (EPS). The Rome IV consensus proposed to incorporate all patients with postprandial symptoms into the PDS group. We aimed to evaluate the assessment of meal-related dyspepsia symptoms in patients with FD according to the Rome III vs Rome IV subdivisions.

METHODS

Consecutive patients with FD referred for a gastric emptying test (n = 96) were asked to fill out the Rome III gastroduodenal questionnaire, with questions on meal-related occurrence. Study participants underwent a gastric emptying breath test, during which the intensity of dyspeptic symptoms (fullness, bloating, belching, nausea, epigastric pain, and burning) was scored before and up to 4 hours after a meal. We analyzed the association between the Rome subdivision and symptom severity and pattern during the breath test.

RESULTS

According to Rome III, 10% had EPS alone, 29% PDS alone, and 61% overlapping EPS and PDS. The frequency of the symptoms reported in the Rome questionnaire associated with the intensity of the symptoms during the breath test in the PDS group and in the groups with PDS and EPS overlap, but not in the group with EPS. We adapted the definition of the PDS subgroup to include patients with meal-related non-PDS symptoms (Rome IV); this reduced the proportion of patients with overlap of EPS and PDS symptoms from 61% to 18% and in this group the association of symptoms with the meal was reduced.

CONCLUSIONS

In an analysis of patients with FD, a meal induced or exacerbated symptoms in most patients. The Rome IV criteria for PDS reduce the proportions categorized as having both PDS and EPS and identify a patient group whose symptoms are associated with the meals. University hospital of Leuven study no: S55426.

Current and emerging therapeutic options for the management of functional dyspepsia

Introduction: Functional Dyspepsia (FD), defined as chronic symptoms originating from the gastroduodenal region in absence of readily identifiable organic disease, is one of the most common gastrointestinal disorders. FD is divided into two subgroups: Post-Prandial Distress Syndrome (PDS) or meal-related FD, characterized by postprandial fullness and early satiation, and Epigastric Pain Syndrome (EPS) or meal-unrelated FD, characterized by epigastric pain and burning.Areas covered: This review summarizes the existing and off-label therapeutic options for FD.Expert opinion: The identification of mechanisms, the Rome IV classification, the reduction of PDS/EPS overlap and pictograms for symptom identification allow a better diagnosis and a more targeted treatment choice. Acotiamide, a first-in-class prokinetic agent available only in Japan and India, is the only agent of proven efficacy for FD, but clinicians use acid-suppressive therapy, prokinetics, neuromodulators and herbal therapies for treating FD symptoms. New emerging targets are duodenal low-grade inflammation with eosinophils and duodenal or other modified luminal microbiota.

Lymph node assessment in colorectal cancer surgery: laparoscopic versus open techniques

AIM

The aim of our study is to compare the outcomes of laparoscopic resection (LR) and open resection (OR) for colorectal cancer surgery evaluating lymph node assessment. It may be important to remove and examine an adequate number of lymph nodes because a more extensive nodal resection has been associated to higher survival rate and lower recurrences.

PATIENTS AND METHODS

150 patients (74 females and 76 males) with colorectal cancer were enrolled and analyzed from January 2006 to March 2010 in our Unit. 100 procedures were performed with traditional laparotomy and 50 procedures laparoscopically. A strict follow-up was scheduled every 1-3-6 months after surgery and, therefore, every year.

RESULTS

Laparoscopic techniques require a longer operating time. 2484 total lymph nodes examined with a mean of 16,56 removed per resection in all procedures. 1632 lymph nodes were removed during open procedures and 852 removed during laparoscopy. The scheduled follow-up demonstrated that local recurrence and distant metastasis presented with no significant differences between two groups and overall survival and disease-free survival were assessed over 5 year in 80% of patients.

CONCLUSIONS

According to our experience, laparoscopic colorectal surgery is safe and feasible, with better short-term outcomes and oncological adequacy comparable to open approach.

Ultrafast generation and control of an electron vortex beam via chiral plasmonic near fields

Vortex-carrying matter waves, such as chiral electron beams, are of significant interest in both applied and fundamental science. Continuous-wave electron vortex beams are commonly prepared via passive phase masks imprinting a transverse phase modulation on the electron's wavefunction. Here, we show that femtosecond chiral plasmonic near fields enable the generation and dynamic control on the ultrafast timescale of an electron vortex beam. The vortex structure of the resulting electron wavepacket is probed in both real and reciprocal space using ultrafast transmission electron microscopy. This method offers a high degree of scalability to small length scales and a highly efficient manipulation of the electron vorticity with attosecond precision. Besides the direct implications in the investigation of nanoscale ultrafast processes in which chirality plays a major role, we further discuss the perspectives of using this technique to shape the wavefunction of charged composite particles, such as protons, and how it can be used to probe their internal structure.

Holographic imaging of electromagnetic fields via electron-light quantum interference

Holography relies on the interference between a known reference and a signal of interest to reconstruct both the amplitude and the phase of that signal. With electrons, the extension of holography to the ultrafast time domain remains a challenge, although it would yield the highest possible combined spatiotemporal resolution. Here, we show that holograms of local electromagnetic fields can be obtained with combined attosecond/nanometer resolution in an ultrafast transmission electron microscope (UEM). Unlike conventional holography, where signal and reference are spatially separated and then recombined to interfere, our method relies on electromagnetic fields to split an electron wave function in a quantum coherent superposition of different energy states. In the image plane, spatial modulation of the electron energy distribution reflects the phase relation between reference and signal fields. Beyond imaging applications, this approach allows implementing quantum measurements in parallel, providing an efficient and versatile tool for electron quantum optics.

Prevalence and impact of self-reported irritable bowel symptoms in the general population

Background and aims

The symptom-based diagnostic criteria for irritable bowel syndrome (IBS) have recently been revised in the Rome IV consensus. On the other hand, with rising public awareness of IBS, self-diagnosis and self-management is also increasing. We compared the prevalence and impact of Rome IV-based IBS vs self-diagnosed IBS in the general population.

Methods

An internet panel filled out an online survey on bowel symptoms and their impact on health care utilization and daily activities.

Results

A representative internet panel of 1012 individuals completed the online survey. Bowel symptoms were present in 68.6% of the population. Of these, 21% consulted a physician for these symptoms in the last year and 42% earlier. Rome IV IBS criteria were fulfilled by 5.5%, and these were younger and more likely to be female. In this subset, 37% had consulted a physician for IBS symptoms in the preceding year and 29% had done so earlier. A colonoscopy had been performed in 22%. Based on a brief description, 17.6% of the population self-identified as suffering from IBS (p < 0.001 compared to Rome IV IBS prevalence), and these were more likely to be female. Concordance with the Rome IV criteria was only 25%, but except for a lower reporting of pain, the symptom pattern, severity, impact on daily life, inability to work and health care utilization were similar to the Rome IV group. A total of 134 days of absence from work were attributed to bowel symptoms in those self-reporting with IBS.

Conclusion

In the general population, bowel symptoms are highly prevalent, and the self-reported "IBS" is three times more prevalent than according to Rome IV criteria. Self-reported IBS is associated with a similar impact on health care utilization and quality of life but a higher impact on absence from work.

Serum levels of osteopontin predict diabetes remission after bariatric surgery

AIM

Bariatric surgery has been shown to effectively improve glycaemic control in morbidly obese subjects. However, the molecular bases of this association are still elusive and may act independently of weight loss. Here, our retrospective study has investigated the inflammatory molecule osteopontin (OPN) as a potential predictor of type 2 diabetes mellitus (T2DM) remission.

METHODS

Baseline serum levels of OPN were analyzed in 41 T2DM patients who underwent bariatric surgery. Anthropometric measures and biochemical variables, including insulin sensitivity indices (HOMA2), were assessed at baseline and at 1 and 3 years after surgery.

RESULTS

At baseline, patients who experienced T2DM remission had increased waist circumference, body weight and BMI, and higher serum OPN, compared with non-remitters. Patients with and without T2DM remission improved their lipid and glucose profiles, although insulin resistance indices were only improved in the T2DM remission group. In the overall cohort of both T2DM remission and non-remission patients, baseline circulating levels of OPN significantly correlated with reductions of body weight and BMI over time, and insulin sensitivity improved as well. However, only the HOMA2-%S remained independently associated with serum OPN on multivariate linear regression analysis (B: 0.227, 95% CI: 0.067-0.387, β = 0.831; P = 0.010). Baseline values of OPN predicted 3-year T2DM remission independently of body weight loss, lower BMI and duration of diabetes (OR: 1.046, 95% CI: 1.004-1.090; P = 0.033).

CONCLUSION

Although larger studies are still needed to confirm our preliminary results, pre-operative OPN serum levels might be useful for predicting 3-year T2DM remission independently of weight loss in patients undergoing bariatric surgery.

High serum levels of C-reactive protein (CRP) predict beneficial decrease of visceral fat in obese females after sleeve gastrectomy

BACKGROUND & AIMS

Gender-related differences represent an emerging investigation field to better understand obesity heterogeneity and paradoxically associated cardiovascular (CV) risk. Here, we investigated if high-sensitivity C-reactive protein (hs-CRP) might differently affect adiposity and predict the clinical response to bariatric surgery in obese males and females.

METHODS AND RESULTS

In 110 morbidly obese patients undergoing laparoscopic sleeve gastrectomy, hs-CRP as well as anthropometric assessment of adiposity, completed by electric bioimpedance and ultrasonography quantification of visceral fat area (VFA), were measured before and one year after surgery. As compared to males, obese female showed less severe overweight and prevalent subcutaneous fat deposition, but higher circulating hs-CRP. In obese females, hs-CRP was associated with VFA at baseline, independently of body mass index (BMI) and visceral adiposity index (OR 1.022 [95% CI 1.001-1.044]; p = 0.039). Based on decreases and increases in hs-CRP levels after surgery, two distinct subgroups of females were identified. Post-surgery decreases in hs-CRP was predominantly observed in patients with higher baseline levels of hs-CRP and associated with greater reduction of weight, BMI, fat and lean mass, VFA and visceral to subcutaneous fat ratio. Finally, we observed that high baseline values of hs-CRP were able to predict VFA reduction one-year after surgery, independently of BMI and visceral adiposity index (VAI) loss (OR 1.031 [95% CI 1.009-1.053]; p = 0.005).

CONCLUSION

In obese females, hs-CRP levels might be a promising biomarker of visceral fat amount and dysfunction, in addition to predict the effectiveness of bariatric surgery in terms of loss of VFA one-year after surgery.

The effect of sildenafil on gastric motility and satiation in healthy controls

Sildenafil induces relaxation of smooth muscle cells by blocking PDE5. Dyspepsia is one of sildenafil's most frequently reported adverse events, suggesting its effect on gastric motility. Our aim was to study the effect of sildenafil on gastric accommodation (GA) and gastric emptying (GE) in healthy volunteers (HVs).

Methods

Sildenafil (50 mg) or placebo was randomly administered to 16 blinded HVs. After a manometry probe and an infusion catheter were positioned in the proximal stomach, the intragastric pressure (IGP) was measured before and during nutrient drink infusion (ND, 60 ml/min). HVs were asked to score their hunger, satiation and six epigastric symptoms at five-minute intervals. The experiment ended when the HVs scored maximal satiation during ND infusion at one-minute intervals. To assess GE, breath samples were collected every 15 minutes for six hours after the meal (244 kcal).

Results

ND infusion induced a drop in proximal stomach IGP, which was suppressed by sildenafil (average area under the curve for sildenafil: -33.6 ± 8.8 mmHg; placebo: -60.8 ± 11.3 mmHg, p = 0.005). Sildenafil-treated volunteers reached earlier maximal satiation compared to placebo (678 ± 70 ml vs. 836 ± 82.6 ml, p = 0.019). Finally, GE was significantly slower after sildenafil (90.6 ± 5.9 min vs. 76.6 ± 7.1 min, p = 0.04).

Conclusion

Sildenafil inhibits GA, leading to significantly decreased nutrient tolerance, and slightly delays the GE rate in humans.

Laser-Induced Skyrmion Writing and Erasing in an Ultrafast Cryo-Lorentz Transmission Electron Microscope

We demonstrate that light-induced heat pulses of different duration and energy can write Skyrmions in a broad range of temperatures and magnetic field in FeGe. Using a combination of camera-rate and pump-probe cryo-Lorentz transmission electron microscopy, we directly resolve the spatiotemporal evolution of the magnetization ensuing optical excitation. The Skyrmion lattice was found to maintain its structural properties during the laser-induced demagnetization, and its recovery to the initial state happened in the sub-μs to μs range, depending on the cooling rate of the system.

The superstatistical nature and interoccurrence time of atmospheric mercury concentration fluctuations

The probability density function (PDF) of the time intervals between subsequent extreme events in atmospheric Hg⁰ concentration data series from different latitudes has been investigated. The Hg⁰ dynamic possesses a long-term memory autocorrelation function. Above a fixed threshold Q in the data, the PDFs of the interoccurrence time of the Hg⁰ data are well described by a Tsallis q-Exponential function. This PDF behavior has been explained in the framework of superstatistics, where the competition between multiple mesoscopic processes affects the macroscopic dynamics. An extensive parameter μ, encompassing all possible fluctuations related to mesoscopic phenomena, has been identified. It follows a χ ²-distribution, indicative of the superstatistical nature of the overall process. Shuffling the data series destroys the long-term memory, the distributions become independent of Q, and the PDFs collapse on to the same exponential distribution. The possible central role of atmospheric turbulence on extreme events in the Hg⁰ data is highlighted.

The effect of mirtazapine on gastric accommodation, gastric sensitivity to distention, and nutrient tolerance in healthy subjects

BACKGROUND

Disturbances of gastric motor function of functional dyspepsia (FD) have been implicated in the pathogenesis of the symptoms, and hence, motility modifying agents are considered for its treatment. Mirtazapine was recently shown to improve symptoms and increase nutrient tolerance in FD patients with weight loss. We aim to evaluate the effect of mirtazapine on gastric sensorimotor function in healthy volunteers (HV).

METHODS

Thirty-one HV underwent an intragastric pressure (IGP) and barostat measurements on separate days before and after 3 weeks of placebo or mirtazapine (15 mg). Gastric compliance, sensitivity and accommodation (GA) measured by the barostat. GA was quantitated as the difference (delta) in intra-balloon volume before and after ingestion of 200 mL of a nutrient drink (ND). GA measured by IGP was quantitated as the drop of IGP from baseline during the intragastric infusion of ND until maximal satiation.

KEY RESULTS

Mirtazapine significantly increased the bodyweight of subjects (67.8±3.7 to 69.1±3.7 kg; P=.01). Barostat results showed no effect on gastric compliance, sensitivity, and GA. Nutrient tolerance was not affected after treatment (1170±129.4 vs 1104±133.6 kcal; P=.4), and mirtazapine was associated with lower symptom ratings. The IGP drop during meal ingestion was significantly suppressed (area under the curve: -43.3±4.5 mm Hg vs -28.9±3.1 mm Hg; P=.005).

CONCLUSIONS & INFERENCES

In HVs, the occurrence of weight gain and decreased meal-induced symptoms in spite of a suppressed meal-induced IGP drop, point towards a central mode of action. Mirtazapine does not display changes in gastric sensorimotor function that could explain its beneficial effects on symptoms and nutrient tolerance in FD.

Watching ultrafast responses of structure and magnetism in condensed matter with momentum-resolved probes

We present a non-comprehensive review of some representative experimental studies in crystalline condensed matter systems where the effects of intense ultrashort light pulses are probed using x-ray diffraction and photoelectron spectroscopy. On an ultrafast (sub-picosecond) time scale, conventional concepts derived from the assumption of thermodynamic equilibrium must often be modified in order to adequately describe the time-dependent changes in material properties. There are several commonly adopted approaches to this modification, appropriate in different experimental circumstances. One approach is to treat the material as a collection of quasi-thermal subsystems in thermal contact with each other in the so-called "N-temperature" models. On the other extreme, one can also treat the time-dependent changes as fully coherent dynamics of a sometimes complex network of excitations. Here, we present examples of experiments that fall into each of these categories, as well as experiments that partake of both models. We conclude with a discussion of the limitations and future potential of these concepts.

Real-Time Observation of Phonon-Mediated σ-π Interband Scattering in MgB_{2}

In systems having an anisotropic electronic structure, such as the layered materials graphite, graphene, and cuprates, impulsive light excitation can coherently stimulate specific bosonic modes, with exotic consequences for the emergent electronic properties. Here we show that the population of E_{2g} phonons in the multiband superconductor MgB_{2} can be selectively enhanced by femtosecond laser pulses, leading to a transient control of the number of carriers in the σ-electronic subsystem. The nonequilibrium evolution of the material optical constants is followed in the spectral region sensitive to both the a- and c-axis plasma frequencies and modeled theoretically, revealing the details of the σ-π interband scattering mechanism in MgB_{2}.

Rome III functional dyspepsia symptoms classification: Severity vs frequency

BACKGROUND

The Rome III criteria subdivide functional dyspepsia (FD) in the epigastric pain syndrome (EPS) and the postprandial distress syndrome (PDS) based on the frequency of the symptoms to optimize the diagnostic and therapeutic approach. However, it is unclear to which extent the frequency of the symptoms is related to their severity. Our aim was to explore the frequency and severity of dyspeptic symptoms and their relationship in FD patients.

METHODS

Functional dyspepsia patients fulfilling the Rome III diagnostic completed a questionnaire that evaluated the frequency and severity of FD symptoms. The concordance between the severity and frequency categories was analyzed by means of spearman correlation and the concordance correlation coefficient (ρ_c ).

KEY RESULTS

In the entire patient cohort (n=421), the classification of symptoms severity and frequency showed good concordance for all symptoms. In the EPS subgroup (n=….), the symptom severity and frequency score of epigastric pain showed a poor correlation (r=.28; ρ_c =0.07). The PDS subgroup (n=…) showed a good correlation for most of the symptoms. Due to its limited occurrence in this group, the correlation of the severity and frequency scores for epigastric pain is of little relevance (r=.79; ρ_c =0.58). The overlap EPS-PDS group showed good correlation for most of the symptoms, except for epigastric pain (pain r=.24; ρ_c =0.09).

CONCLUSIONS & INFERENCES

We conclude that the information given by the assessment of frequency and severity of PDS symptoms is comparable and hence one of the scores sufficiently identifies symptom pattern in PDS patients. In EPS patients, both the symptom frequency and severity should be taken into account as two separate entities.

High baseline C-reactive protein levels predict partial type 2 diabetes mellitus remission after biliopancreatic diversion

BACKGROUND AND AIMS

Several studies demonstrated that surgery can improve inflammation parameters, such as C-reactive protein (CRP). Few biomarkers have been investigated to potentially predict type 2 diabetes mellitus (T2DM) remission. We aimed at determining whether pre-surgery serum CRP levels could predict T2DM remission after 3 years in patients undergoing bariatric surgery, especially biliopancreatic diversion (BPD).

METHODS AND RESULTS

This study was conducted from 2007 to 2009 at the Surgical Department of the University of Genoa, Italy. Forty-four patients with T2DM undergoing BPD (n = 38) or Roux-en-Y gastric bypass (n = 6) were enrolled. The primary endpoint was to evaluate whether pre-surgery CRP levels could predict T2DM partial remission at 3-year follow-up. Secondary endpoints were to assess whether glycaemic, lipid, and inflammatory parameters modified during the follow-up. At baseline, patients with T2DM ranged from overweight to morbid obesity, had mild dyslipidaemia, and a low-grade inflammation. Bariatric surgery improved body weight, lipid and glycaemic profile both at 1- and 3-year follow-up. Pre-surgery CRP levels progressively decreased at 1- and 3-year follow-up. Among inflammatory pre-surgery parameters, only high CRP levels were shown to predict T2DM partial remission after 3 years. Multivariate analysis confirmed the predictive value of pre-surgery CRP levels independently of age, gender, type of surgery, and body mass index.

CONCLUSION

Bariatric surgery, in particular BPD, improved both metabolic and inflammatory biomarkers at 1- and 3-year follow-up. Pre-surgery high CRP levels predicted 3-year T2DM partial remission, indicating a promising target population to be especially treated with BPD.

Pathophysiological Abnormalities in Functional Dyspepsia Subgroups According to the Rome III Criteria

OBJECTIVES

The Rome III criteria proposed to subdivide functional dyspepsia (FD) into a postprandial distress syndrome (PDS) group, characterized by the presence of postprandial fullness and/or early satiety, and an epigastric pain syndrome (EPS) group, characterized by the presence of epigastric pain and/or epigastric burning. It has been suggested that different pathophysiological mechanisms underlie the symptom presentations in these subgroups that might determine treatment choices. The aim of this study was to investigate the prevalence of gastric sensorimotor dysfunction in the PDS, EPS, and overlap groups and to evaluate potential differential associations with dyspeptic symptom scores.

METHODS

Consecutive FD patients fulfilling Rome III criteria were recruited and they scored frequency of dyspeptic symptoms (postprandial fullness, early satiety, nausea, bloating, epigastric pain, and epigastric burning) over the past 3 months (0-5; 1=once a month or less, 2=two or three times a month, 3=once a week, 4=several times a week, 5=every day). The cumulative symptom score was calculated by adding up the score of these dyspeptic symptoms. Based on these symptom scores, the patients were subdivided into subgroups according to the Rome III consensus: (i) PDS, characterized by postprandial fullness and/or early satiety at least several times a week, (ii) EPS, characterized by epigastric pain and/or epigastric burning at least once a week, and (iii) overlap, fulfilling the criteria for both PDS and EPS. Gastric sensitivity and gastric accommodation were measured using barostat testing, and solid gastric emptying was determined using the [¹⁴C]octanoate breath test.

RESULTS

A total of 560 FD patients (165 men, age 41.8±0.7 years) were classified into PDS (n=131), EPS (n=50), and overlap (n=379) groups. The prevalence of gastric hypersensitivity, impaired gastric accommodation, and delayed gastric emptying were 37%, 37%, and 23%, respectively, without any differential distribution in Rome III subgroups (P=0.16, P=0.27, and P=0.39 respectively). Comparing the physiological parameters for these gastric sensorimotor functions, there was only a significant difference in the gastric half emptying time between subgroups, with the overlap group having a higher t_1/2 (P<0.05) compared with the EPS group. In the overlap group, gastric hypersensitivity was associated with the severity of PDS symptoms (P=0.03), EPS symptoms (P=0.02), and the cumulative symptom score (P=0.02), whereas delayed gastric emptying was associated with nausea (P=0.02) and the cumulative symptom score (P=0.02).

CONCLUSIONS

Except for gastric emptying in the overlap group, FD subgroups as defined by the Rome III criteria are not differentially associated with putative pathophysiological mechanisms. These observations question the utility of this classification for guiding therapeutic choices in clinical practice.

Validation of the Leuven Postprandial Distress Scale, a questionnaire for symptom assessment in the functional dyspepsia/postprandial distress syndrome

BACKGROUND

A validated patient-reported outcome instrument is lacking for the functional dyspepsia/postprandial distress syndrome.

AIM

To validate the Leuven Postprandial Distress Scale (LPDS).

METHODS

The LPDS diary, comprising eight symptoms with verbal descriptors rated for severity (0-4), was derived from focus groups and cognitive debriefing. It was used in a 2-week run-in, 8-week double-blind placebo-controlled trial of itopride 100 mg t.d.s. Results in 60 patients, with concealed treatment allocation, were used to analyse LPDS content validity, consistency, reliability and responsiveness. Patients also filled out Patient Assessment of Gastrointestinal Symptoms (PAGI-SYM), Nepean Dyspepsia Index, overall treatment evaluation and overall symptom severity questionnaires. Construct validity was evaluated by known-group analyses and by correlating LPDS with these additional questionnaires. Minimum Clinically Important Difference was determined from threshold changes in anchor questionnaires.

RESULTS

Symptom patterns and factor analysis identified three cardinal symptoms of postprandial distress syndrome (early satiation, postprandial fullness, upper abdominal bloating), whose mean intensities generate weekly LPDS scores. Known-groups analysis showed large-effect-size differences in LPDS scores (Cohen's d = 2.16). Strong correlations (r > 0.57) between LPDS scores and relevant anchors at baseline indicate good convergent validity. Internal consistency of LPDS was good (α > 0.85) with high inter-item correlations (0.67-0.76), and test-retest reliability (r = 0.85). Changes in LPDS scores were highly convergent with changes in overall treatment evaluation, overall symptom severity and PAGI-SYM (r > 0.52). minimum clinically important difference analysis generated thresholds of 0.4-0.6.

CONCLUSIONS

The Leuven Postprandial Distress Scale, which is supported by the European Medicines Agency, is a sensitive and reliable patient-reported outcome instrument to assess symptoms in the functional dyspepsia/postprandial distress syndrome.

Imaging and controlling plasmonic interference fields at buried interfaces

Capturing and controlling plasmons at buried interfaces with nanometre and femtosecond resolution has yet to be achieved and is critical for next generation plasmonic devices. Here we use light to excite plasmonic interference patterns at a buried metal–dielectric interface in a nanostructured thin film. Plasmons are launched from a photoexcited array of nanocavities and their propagation is followed via photon-induced near-field electron microscopy (PINEM). The resulting movie directly captures the plasmon dynamics, allowing quantification of their group velocity at ∼0.3 times the speed of light, consistent with our theoretical predictions. Furthermore, we show that the light polarization and nanocavity design can be tailored to shape transient plasmonic gratings at the nanoscale. This work, demonstrating dynamical imaging with PINEM, paves the way for the femtosecond and nanometre visualization and control of plasmonic fields in advanced heterostructures based on novel two-dimensional materials such as graphene, MoS₂, and ultrathin metal films.

Visualizing surface plasmon polaritons at buried interfaces has remained elusive. Here, the authors develop a methodology to study the spatiotemporal evolution of buried near-fields within complex heterostructures, enabling the characterization of the next generation of plasmonic devices.

Sphenofrontal distance on three-dimensional ultrasound in euploid and trisomy-21 fetuses at 16-24 weeks' gestation

OBJECTIVE

To compare the distance between the sphenoid and frontal bones on three-dimensional (3D) ultrasound in euploid and trisomy-21 fetuses at 16-24 weeks' gestation.

METHODS

We acquired 3D volumes of the fetal profile from 80 normal and 30 trisomy-21 fetuses at 16-24 weeks' gestation. We used the multiplanar mode to obtain the mid-sagittal plane and measured the sphenofrontal distance as the shortest distance between the most anterior edge of the sphenoid bone and the lowest edge of the frontal bone.

RESULTS

In normal fetuses, the sphenofrontal distance increased linearly with gestational age, from 15.1 mm at 16 weeks to 18.2 mm at 24 weeks. In fetuses with trisomy 21, the mean sphenofrontal distance delta value was significantly smaller than in normal cases (-3.447 mm (95% CI, -5.684 to -1.211 mm); P < 0.01). The sphenofrontal distance was below the 5(th) and 1(st) percentiles of the normal range in 29 (96.7%) and 27 (90.0%) trisomy-21 fetuses, respectively.

CONCLUSIONS

The sphenofrontal distance is shorter at 16-24 weeks' gestation in fetuses with trisomy 21 than in normal fetuses. A reduction in the growth of the anterior cranial base contributes to the mid-facial hypoplasia observed in fetuses with trisomy 21. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.