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A Rare Case of Colorectal Cancer With Delayed Metastasis to the Duodenum.
No full textColorectal cancer (CRC) continues to be a significant global health issue contributing to a high mortality rate. Despite advancements in treatment, the risk of recurrence remains due to inherent mutations and the rapid turnover of intestinal mucosa. We present an exceptionally rare case of CRC metastasis to the duodenum in a 42-year-old female who has been compliant with postsurgical surveillance. Despite previous negative surveillance results, elevated CEA levels and a 3-cm mesenteric mass were detected, raising concerns for carcinoma, which was later confirmed by biopsy. The tumor board deemed her ineligible for surgery due to vascular involvement, leading to palliative care and an attempt at neoadjuvant therapy. Vigilant monitoring is crucial for early detection and intervention
SWOG S1815: A Phase III Randomized Trial of Gemcitabine, Cisplatin, and Nab-Paclitaxel Versus Gemcitabine and Cisplatin in Newly Diagnosed, Advanced Biliary Tract Cancers.
No full textPURPOSE: SWOG S1815 was a randomized, open label phase III trial, evaluating gemcitabine, nab-paclitaxel, and cisplatin (GAP) versus gemcitabine and cisplatin (GC) in patients with newly diagnosed advanced biliary tract cancers (BTCs).
METHODS: Patients with newly diagnosed locally advanced unresectable or metastatic BTC, including intrahepatic cholangiocarcinoma (ICC) and extrahepatic cholangiocarcinoma (ECC) and gallbladder carcinoma (GBC), were randomly assigned 2:1 to either GAP (gemcitabine 800 mg/m(2), cisplatin 25 mg/m(2), and nab-paclitaxel 100 mg/m(2) intravenously once per day on days 1 and 8 of a 21-day cycle) or GC (gemcitabine 1,000 mg/m(2) and cisplatin 25 mg/m(2) intravenously once per day on days 1 and 8 of a 21-day cycle).
RESULTS: Among 452 randomly assigned participants, 441 were eligible and analyzable, 67% with ICC, 16% with GBC, and 17% with ECC. There was no significant difference in overall survival (OS) between GAP versus GC. Median OS with GAP was 14.0 months (95% CI, 12.4 to 16.1) and 13.6 months with GC (95% CI, 9.7 to 16.6); hazard ratio (HR), 0.91 (95% CI, 0.72 to 1.14); P = .41. Median progression-free survival (PFS) was similar between groups with median PFS for GAP being 7.5 months (95% CI, 6.4 to 8.5) versus 6.3 months for GC (95% CI, 4.4 to 8.2); HR, 0.89 (95% CI, 0.71 to 1.12); P = .32. In exploratory subset analyses, the OS and PFS benefits of GAP versus GC treatment were greater in locally advanced disease compared with metastatic disease, although not statistically significant (interaction P = .14 for OS and P = .17 for PFS). Moreover, GAP versus GC showed greater improvement in PFS among participants with GBC than those with ICC or ECC (interaction P = .01), but not OS (interaction P = .28).
CONCLUSION: The addition of a taxane in the GAP regimen to the standard gemcitabine-cisplatin regimen did not improve OS in newly diagnosed BTC. More toxicity was encountered with GAP versus GC
Physicians\u27 knowledge, attitudes, and beliefs regarding practices of male and female surgical sterilization procedures in Lebanon
No full textOBJECTIVE: Surgical sterilization, including vasectomy in males and tubal ligation in females, is a highly effective but underutilized contraception method. Adoption rates vary globally mostly due to misconceptions by both the general public and practicing physicians. Our survey aims to explore physicians\u27 knowledge, attitudes and beliefs about surgical sterilization techniques in Lebanon.
STUDY DESIGN: A web-based survey was sent to residents and attending physicians of different specialties in Lebanon between April 2022 and April 2023. The survey included 21 multiple-choice questions divided in four parts (demographics, knowledge, attitudes and beliefs) and required around 8 min to complete. Data was analyzed using IBM SPSS Statistics. A descriptive analysis was performed using the chi-square test for categorical variables and ANOVA for continuous variables.
RESULTS: One hundred eighty-three physicians specialized in Urology, OB/GYN, Family medicine and Internal medicine filled the survey. The majority were resident physicians (79%), male (57%), single (72%) and did not receive training in family planning (73%). Knowledge assessment showed an average score of 5/7. After setting this as a passing score, 60.7% of participants passed the assessment with higher likelihood of passing among attending physicians (84.6%), OB/GYN physicians (94.4%), married participants (80.8%), and physicians who received training in family planning (91.8%). Lower likelihood of passing was among Family Medicine (60%), and Internal Medicine (72.5%) physicians. Recommendations varied among specialties. Most physicians perceived the general public preferring tubal ligation as a sterilization method (98%).
CONCLUSION: Lebanese primary care physicians have a lower level of knowledge of surgical sterilization procedures compared to specialists. This, coupled with low levels of family planning training and negative perception of patient beliefs may impact attitudes and recommendations. Ongoing education and family planning training is needed to increase awareness among physicians, especially primary care physicians, to allow them to provide more adequate counseling to patients
Maresin-1 promotes neuroprotection and modulates metabolic and inflammatory responses in disease-associated cell types in preclinical models of Multiple Sclerosis
No full textMultiple sclerosis (MS) is a prevalent inflammatory neurodegenerative disease in young people, causing neurological abnormalities and impairment. To investigate a novel therapeutic agent for MS, we observed the impact of maresin 1 (MaR1) on disease progression in a well-known, relapsing-remitting experimental autoimmune encephalomyelitis (RR-EAE) mouse model. Treatment with MaR1 accelerated inflammation resolution, reduced neurological impairment, and delayed disease development by reducing immune cell infiltration (CD4+IL-17+ and CD4+IFNγ+) into the central nervous system (CNS). Furthermore, MaR1 administration enhanced IL-10 production, primarily in macrophages and CD4+ cells. However, neutralizing IL-10 with an anti-IL-10 antibody eliminated the protective impact by MaR1 in RR-EAE model, implying the significance of IL-10 in MaR1 treatment. Metabolism has been recognized as a critical mediator of effector activity in many types of immune cells. In our investigation, MaR1 administration significantly repaired metabolic dysregulation in CD4+ cells, macrophages, and microglia in EAE mice. Furthermore, MaR1 treatment restored defective efferocytosis in treated macrophages and microglia. MaR1 also preserved myelin in EAE mice and regulated O4+ oligodendrocyte metabolism by reversing metabolic dysregulation via increased mitochondrial activity and decreased glycolysis. Overall, in a preclinical MS animal model, MaR1 therapy has anti-inflammatory and neuroprotective properties. It also induced metabolic reprogramming in disease-associated cell types, increased efferocytosis, and maintained myelination. Moreover, our data on patient-derived PBMCs substantiated the protective role of MaR1, expanding the therapeutic spectrum of SPMs. Altogether, these findings suggest the potential of MaR1 as a novel therapeutic agent for MS and other autoimmune diseases
Robert Wartenberg and the Hallervorden Affair, 1953: A Clash Between Medical Ethics and Cold War Politics
No full textRobert Wartenberg was an emigrant from Nazi Germany and an iconic pioneer in neurology, describing eponyms and helping to found and nurture the American Academy of Neurology. However, in 1953, ironically, he became embroiled in a controversial event regarding the German neuroscientist and Nazi collaborator Julius Hallervorden. Wartenberg attempted to convince the Dutch delegation to attend the International Neurological Congress in Lisbon from which they had withdrawn in response to Hallervorden\u27s inclusion as a speaker. In addition, he rallied neuroscientists worldwide to help convince the Dutch, largely ignoring and burying their concerns about Hallervorden\u27s ethical transgressions. In numerous letters, Wartenberg wanted to both ignore and exonerate Hallervorden of ethical violations in collecting 700 brains from patients murdered in the Nazi euthanasia program. Wartenberg\u27s unexpected defense of Hallervorden, despite not knowing him professionally, purportedly was to reintegrate German neuroscience to the international community and to create Western unity against communism. However, Wartenberg\u27s efforts and the lack of international censure against Hallervorden prevented proper attention to the victims\u27 brains that remained in Hallervorden\u27s collection for decades and the use of these brains in scientific publications. Those who stood against Hallervorden have been vindicated by history, but work remains to uncover all brain specimens in German collections. Wartenberg\u27s misguided and shortsighted involvement in this affair serves as a lesson for future generations of neurologists in the consequences of ignoring ethical concerns for expediency and politics
Symptom management in isocitrate dehydrogenase mutant glioma
No full textAccording to the 2021 World Health Organization classification of CNS tumors, gliomas harboring a mutation in isocitrate dehydrogenase (mIDH) are considered a distinct disease entity, typically presenting in adult patients before the age of 50 years. Given their multiyear survival, patients with mIDH glioma are affected by tumor and treatment-related symptoms that can have a large impact on the daily life of both patients and their caregivers for an extended period of time. Selective oral inhibitors of mIDH enzymes have recently joined existing anticancer treatments, including resection, radiotherapy, and chemotherapy, as an additional targeted treatment modality. With new treatments that improve progression-free and possibly overall survival, preventing and addressing daily symptoms becomes even more clinically relevant. In this review we discuss the management of the most prevalent symptoms, including tumor-related epilepsy, cognitive dysfunction, mood disorders, and fatigue, in patients with mIDH glioma, and issues regarding patient\u27s health-related quality of life and caregiver needs in the era of mIDH inhibitors. We provide recommendations for practicing healthcare professionals caring for patients who are eligible for treatment with mIDH inhibitors
Enhancing the Use of 5-Aminolevulinic Acid in Fluorescence-guided Surgery for High-grade Glioma: An Expert Nurse Practitioner Opinion-based Approach
No full textPURPOSE: This report details the recommendations of a Nursing Best Practice Working Group, which aims to advance best practice in the use of 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery (FGS) in patients with high-grade glioma (HGG).
DESIGN: Quality Improvement Project.
METHODS: These recommendations were gathered during a meeting of a Nursing Best Practice Working Group comprising expert nurses and practice administrators from five US centers of excellence in the management of HGG. Ahead of the meeting, a survey was taken to evaluate the views of each expert and surgical teams, patients and institutions on current benefits, challenges and practices associated with the use of 5-ALA FGS in HGG. The Nursing Best Practice Working Group then met to share their experiences, explore where consensus exists, and identify opportunities for enhanced patient management.
FINDINGS: The advisors made recommendations to support improvements across a range of areas associated with multidisciplinary team delivery of 5-ALA FGS. These included specific issues surrounding the administration of 5-ALA, photosensitivity and low-light precautions, and key aspects relating to protocol development, content features, format and accessibility, and updates and education of both the multidisciplinary team and patients. Guidance was also gathered on a flowchart to support the practical delivery of patient care and detail roles, responsibilities, and timings.
CONCLUSIONS: This guidance provides direction for the development of practical, evidence-based protocols and educational approaches for multidisciplinary teams and patients. Such approaches can improve best practice in 5-ALA FGS in all institutes, irrespective of size, and when developed collaboratively provide the means to share best practice across institutes and reach consensus on patient care
Ipsilateral Nasoseptal Flaps in a Transpterygoid Approach: Technical Pearls and Reconstruction Outcomes
No full textBackground: Transpterygoid approaches to the skull base require dissection of the sphenopalatine artery, potentially compromising the option to harvest an ipsilateral nasoseptal flap (NSF) for reconstruction. In cases where other reconstructive options are limited, it may be necessary to utilize a NSF ipsilateral to the transpterygoid approach. Here, we describe the technique of NSF pedicle preservation with reconstruction outcomes.
Methods: This was a retrospective single-institution review of all expanded endonasal skull base cases utilizing a NSF ipsilateral to a transpterygoid approach. Reconstruction outcomes collected include intraoperative fluorescence with indocyanine green (ICG), postoperative magnetic resonance imaging (MRI) gadolinium enhancement, endoscopic assessment, and reconstruction-related complications.
Results: Twenty-one cases were included in this study (mean age 51.0 ± 20.6 years, 61.9% female). Indications for NSF ipsilateral to the transpterygoid approach included: bilateral transpterygoid approach (52.4%), revision reconstruction (23.8%), or significant septal deviation (19.0%). Twelve of 14 (85.7%) flaps demonstrated intraoperative perfusion with ICG, 15 of 15 (100%) enhanced on postoperative MRI, and 21 of 21 (100%) flaps had a healthy, viable appearance on postoperative endoscopy. There were no instances of flap necrosis or postoperative cerebrospinal fluid leaks. Technical keys to optimize mobilization of the pedicle include wide decompression of the sphenopalatine foramen and release of neurovascular tethering points of the pterygopalatine fossa. These steps allow for wide skull base exposure with preservation of the sphenopalatine artery.
Conclusion: With this technique, the transpterygoid approach can be performed in a manner that preserves the pedicle for an ipsilateral NSF and achieve an excellent reconstructive outcome
Textural and geometric measures derived from digital tomosynthesis discriminate women with and without vertebral fracture
No full textVertebral fractures are a common and debilitating consequence of osteoporosis. Bone mineral density (BMD), measured by dual energy x-ray absorptiometry (DXA), is the clinical standard for assessing overall bone quantity but falls short in accurately predicting vertebral fracture. Fracture risk prediction may be improved by incorporating metrics of microstructural organization from an appropriate imaging modality. Digital tomosynthesis (DTS)-derived textural and microstructural parameters have been previously correlated to vertebral bone strength in vitro, but the in vivo utility has not been explored. Therefore, the current study sought to establish the extent to which DTS-derived measurements of vertebral microstructure and size discriminate patients with and without vertebral fracture. In a cohort of 93 postmenopausal women with or without history of vertebral fracture, DTS-derived microstructural parameters and vertebral width were calculated for T12 and L1 vertebrae, as well as lumbar spine BMD and trabecular bone score (TBS) from DXA images. Fracture patients had lower BMD and TBS, while DTS-derived degree of anisotropy and vertebral width were higher, compared to nonfracture (p \u3c 0.02 to p \u3c 0.003) patients. The addition of DTS-derived parameters (fractal dimension, lacunarity, degree of anisotropy and vertebral width) improved discriminative capability for models of fracture status (AUC = 0.79) compared to BMD alone (AUC = 0.67). For twelve additional participants who were imaged twice, in vivo repeatability errors for DTS parameters were low (0.2 % - 7.3 %). The current results support the complementary use of DTS imaging for assessing bone quality and improving the accuracy of fracture risk assessment beyond that achievable by DXA alone
Incidence of surgical infection in cefazolin 3 g versus 2 g for colorectal surgery in obese patients
No full textOBJECTIVE: To compare the incidence of surgical site infection (SSI) between cefazolin 3 g and 2 g surgical prophylaxis in patients weighing ≥120 kg that undergo elective colorectal surgery.
METHODS: A multicenter, retrospective cohort study was performed utilizing a validated database of elective colorectal surgeries in Michigan acute care hospitals. Adults weighing ≥120 kg who received cefazolin and metronidazole for surgical prophylaxis between 7/2012 and 6/2021 were included. The primary outcome was SSI, which was defined as an infection diagnosed within 30 days following the principal operative procedure. Multivariable logistic regression was used to identify variables associated with SSI; the exposure of interest was cefazolin 3 g surgical prophylaxis.
RESULTS: A total of 581 patients were included; of these, 367 (63.1%) received cefazolin 3 g, while 214 (36.8%) received 2 g. Patients who received cefazolin 3 g had less optimal antibiotic timing (324 [88.3%] vs 200 [93.5%]; P = .043) and a higher receipt of at least 1 of the prophylaxis antibiotics after incision (22 [6%] vs 5 [2.3%]; P = .043). There was no SSI difference between cefazolin 3 g and 2 g cohorts (23 [6.3%] vs 16 [7.5%], P = .574). When accounting for age, smoking status, and surgical duration, cefazolin 3 g was not associated with a reduction in SSI (adjOR, .64; 95%CI, .32-1.29).
CONCLUSIONS: Surgical prophylaxis with cefazolin 3 g, in combination with metronidazole, was not associated with decreased SSI compared to 2 g dosing in obese patients undergoing elective colorectal surgery