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The impact of virtual reality on patient experience during wide-awake surgery: a randomized controlled trial
No full textThis study aimed to establish whether virtual reality can reduce patient anxiety and improve surgical satisfaction during wide-awake local anaesthetic no tourniquet hand procedures. Previously validated questionnaires were used to assess subjective anxiety and patient satisfaction. Objective anxiety was determined using patient blood pressure and heart rate measured four times during the procedure. The median difference in intra-operative minus pre-operative diastolic blood pressure was significantly lower in the virtual reality group compared with the control group (p = 0.003). There was a significant decrease in heart rate from pre-operative to post-operative within the virtual reality group (p \u3c 0.001). No differences were observed in subjective anxiety or surgical satisfaction between the groups. Virtual reality can benefit wide-awake patients during hand procedures, particularly where patient preference exists.
Level of evidence: Level I, Randomized Controlled Trial
Editorial Commentary: Evaluation and Treatment of Mental Health Status Can Improve Surgical Patient Outcomes
No full textThere has been a growing concern over the impact of mental health on patient outcomes in the field of orthopaedic surgery. However, it is uniquely difficult to investigate the impact of depression on surgical outcomes for several reasons: (1) Patients who do not formally seek help for mental health issues often go undiagnosed. (2) Prospectively administered depression screening forms provide limited data. (3) Debilitating pain and function may be the cause-not effect-of mental health issues. The recent literature on patients undergoing arthroscopic rotator cuff repair suggests an association between depression and increased utilization of health care resources. There is also evidence that patients with a recent acute depressive episode shortly before surgery are more likely to require more opioids, sedatives, and antidepressants after surgery. Consideration of surgical patients\u27 mental health status can result in timely intervention to improve outcomes
The GATA-3-dependent transcriptome and tumor microenvironment are regulated by eIF4E and XPO1 in T-cell lymphomas
No full textThe transcription factor GATA-binding protein 3 (GATA-3) and the transcriptional program it regulates have emerged as oncogenic drivers across diverse T-cell lymphomas (TCLs), many of which are resistant to conventional chemotherapeutic agents and characterized by recurrent losses of key tumor suppressor genes, including TP53 and PTEN, both of which are clients of the nuclear export protein XPO1. Here, we demonstrated that XPO1 is highly expressed by malignant T cells expressing GATA-3 and by lymphoma-associated macrophages (LAMs) within their tumor microenvironment (TME). Using complementary genetically engineered mouse models, we demonstrated that TP53- and/or phosphate and tensin homolog (PTEN)-deficient TCLs, and LAMs within their TME, are sensitive to the selective exportin-1 (XPO1) antagonist selinexor. In an effort to identify TP53- and PTEN-independent mechanisms, we used complementary and orthogonal approaches to investigate the role of eIF4E and XPO1-dependent messenger RNA nuclear export in these TCLs. We identified a novel role for eIF4E/XPO1 in exporting GATA-3 and GATA-3-dependent transcripts from the nucleus in TCLs, and in the export of therapeutically relevant transcripts, including colony-stimulating factor-1 receptor, from LAMs. Therefore, XPO1 antagonism, by impairing oncogenic transcriptional programs in TCLs and depleting LAMs from their TME, is a novel approach to target 2 independent dependencies in a group of therapeutically challenging TCLs
Fluoroscopic radiation-induced skin reactions: radiation dermatitis and radiation-induced morphea
No full textMucosal Schwann Cell Hamartoma of the Appendix: Expanding the Differential for Gastrointestinal Bleeding
No full textMucosal Schwann cell hamartomas (MSCH) are rare benign tumors typically found in the colorectal region. We present the case of an 87-year-old man with a history of mucosa-associated lymphoid tissue lymphoma who developed symptomatic gastrointestinal bleeding due to an appendiceal MSCH. The patient\u27s ongoing melena and anemia led to further evaluation. Subsequent colonoscopy revealed active bleeding from the appendiceal orifice with hemostasis achieved using epinephrine injection. A laparoscopic appendectomy confirmed MSCH through histopathology and immunohistochemical staining. Given its rarity, this case underscores the importance of considering MSCH in unexplained gastrointestinal bleeding and demonstrates its potential to be a symptomatically significant entity
Cold snare endoscopic resection for large colon polyps: a randomised trial
No full textBACKGROUND: Complications of endoscopic mucosal resection (EMR) of large colorectal polyps remain a concern.
OBJECTIVE: We aimed to compare safety and efficacy of cold EMR (without electrocautery) to hot EMR (with electrocautery) of large colorectal polyps.
DESIGN: In this multicentre randomised trial, patients with any large (≥20 mm) non-pedunculated colon polyp were assigned to cold or hot EMR (primary intervention), and to submucosal injection with a viscous or non-viscous solution (secondary intervention) following a 2×2 design. The primary outcome was the rate of severe adverse events (SAEs). The secondary outcome was polyp recurrence. In this study, we report results of the primary intervention.
RESULTS: 660 patients were randomised and analysed. An SAE was observed in 2.1% of patients in the cold EMR group and in 4.3% in the hot EMR group (p=0.10) (per protocol analysis 1.4 vs 5.0%, p=0.017) with fewer perforations following cold EMR (0%) compared with hot EMR (1.6%, p=0.028). Postprocedure bleeding did not differ (1.5% vs 2.2%, p=0.57). The effect of cold resection was independent of the type of submucosal injection solution, polyp size or antithrombotic medications. Recurrence was detected in 27.6% and 13.6% in the cold and hot EMR groups, respectively (p\u3c 0.001). Recurrence was not significantly different for 20-29 mm polyps (18.6% vs 13.4%, p=0.24) and for sessile serrated polyps (14.1% vs 8.5%, p=0.33).
CONCLUSION: Universal application of cold EMR did not significantly lower SAEs (unless cold EMR could be completed) and doubled the recurrence rate compared with hot EMR.
TRIAL REGISTRATION DETAILS: ClinicalTrials.gov, number: NCT03865537
Comorbid sleep disorders among individuals with spinal cord injury
No full textSTUDY OBJECTIVES: To determine the rate of sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI). and its types (central and obstructive, and combined (COSA) and to assess the response to treatment using positive airway pressure (PAP) (defined as an apnea-hypopnea index (AHI) of less than 5 events per hour on initial PAP titration) in individuals with SCI.
METHODS: Individuals with SCI who underwent a full night of diagnostic polysomnography (PSG) from to 2010-2024 to determine the type of SDB and its severity using the AHI and central apnea index (CAI). The inclusion criteria were individuals with chronic SCI at low cervical or thoracic (at C4-T6 levels). who are not mechanically ventilated or had tracheostomies. Central sleep apnea (CSA) is diagnosed with an AHI of 5+ events/h and a CAI of at least 50% of the AHI. Obstructive sleep apnea (OSA) only is identified by an AHI of 5+ events/h and a CAI of less than 5 events/h. COSA is characterized by an AHI of 5+ events/h, with a CAI over 5 events/h but under 50% of the total AHI. The positive response to PAP therapy was based on the AHI level of less than 5 events/h after initiating PAP treatment and based on remote monitoring data.
RESULTS: Among the 81 individuals who met the inclusion criteria, 12 patients (15%) were diagnosed with COSA, 4 patients (5%) presented with CSA only, 56 patients (69%) had OSA, and 8 patients (10%) exhibited no SDB. In a subset of participants (N=51) hypopneas were classified as obstructive or central events based on American Academy of Sleep Medicine (AASM) definition and revealed that approximately one-third (32%) had central or COSA, 63% had OSA, and 6% did not have SDB on PSG. A total of 35 (47%) individuals diagnosed with SDB underwent PAP titration and were prescribed PAP. Twenty (27%) individuals received PAP treatment, and only 17 (23%) continued their use for the initial three months. Only 11 patients (15%) demonstrated responsiveness to PAP on day 90 (AHI\u3c 5 during therapy).
CONCLUSIONS: SDB is extremely common in individuals with SCI. The efficacy of PAP therapy is suboptimal, and adherence rates decline significantly over time
Humor me with calcium: a case report of humoral hypercalcemia of malignancy secondary to cholangiocarcinoma
No full textBACKGROUND: Humoral hypercalcemia of malignancy (HHM) is a rare presentation of cholangiocarcinoma, with few reports in prior literature. HHM is due to the production of parathyroid hormone related peptide (PTHrP) from malignant tissues leading to hypercalcemia, often hard to control. Currently, HHM due to cholangiocarcinoma has been associated with poor prognosis and therapies utilized to manage HHM have not been shown to increase survival. Furthermore, biomarkers such as cytokeratin-7 (CK7) have been shown to correlate with worse prognosis in cholangiocarcinoma. While surgical treatment can be curative for cholangiocarcinoma, current nonsurgical treatment options for HHM due to cholangiocarcinoma have not been associated with improved prognosis.
CASE DESCRIPTION: We present a rare case of HHM secondary to cholangiocarcinoma. This case presents a rare case of HHM due to cholangiocarcinoma with an atypical presentation in a 55-year-old female. This patient presented with abdominal swelling and severe hypercalcemia prompting evaluation for a possible gastrointestinal source and was found to have HHM due to cholangiocarcinoma. She was treated for her hypercalcemia medically, however due to the extent of her disease she was unable to undergo surgery. Chemotherapy was not considered during her initial presentation as she originally had a malignancy of unknown primary. Ultimately, shortly after her initial presentation, the patient passed at another hospitalization 36 days after her initial presentation.
CONCLUSIONS: HHM rarely presents in cholangiocarcinoma, and of the reported cases, it is often associated with poor prognosis. Given the complexity of these cases, a multi-disciplinary approach is necessary for optimal management of these patients. The ability to risk-stratify patients with unique presentations such as this is crucial for accurate diagnosis and potential treatment. HHM in cholangiocarcinoma is poorly studied due to its rarity; however, given the prognosis of this syndrome, further research is essential for earlier detection and better treatments
Manual vs robotic patellofemoral arthroplasty outcomes: A Michigan arthroplasty registry collaborative quality initiative-based study.
No full textBACKGROUND: Historically, all patellofemoral arthroplasty (PFA) was performed manually. Recently, robotic-assisted PFA has gained popularity. The purpose of this study was to determine whether a robotic-assisted technique influenced outcomes and revision rates. We hypothesized that robotic-assisted PFA would have improved 90-day complication and revision rates.
METHODS: A single center\u27s data from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) was queried for all primary PFAs from January 2014 to December 2022. Manual and robotic cohorts were compared for revisions and 90-day complications, including emergency visits, readmissions, and returns to the operating room (OR). Chi-square and Fisher\u27s exact tests were used for categorical data and t-tests for continuous data.
RESULTS: Among 75 PFAs (mean age 53.0 ± 12.9 years, 78% women), 19 were manual and 56 robotic. Manual PFA experienced more 90-day complications (31% vs 10%, p = 0.0321) and a longer mean length of stay (30.9 ± 14.4 vs 20.6 ± 17.7 h, p = 0.03). No significant differences existed in age, BMI, gender, race, surgical time, 30-day complications, or revision rate. Manual PFA had no revisions, while 5% of robotic PFAs were revised for osteoarthritis progression, with a mean conversion time of 4.5 ± 2.7 years. Five-year cumulative percent revision (CPR) for all PFAs was 7.37%. Logistical regression showed manual PFA patients were more likely to experience 90-day complications (OR 3.84, p = 0.04).
CONCLUSIONS: Manual PFA were prone to more 90-day complications and longer hospital stays compared to robotic PFA, which may minimize complications without affecting revision rates. Importantly, the PFA revision rate herein exceeded MARCQI-reported rates for unicompartmental and total knee arthroplasty
In Vivo Cell Migration and Growth Within Electrospun Porous Nanofibrous Scaffolds with Different Pore Sizes in a Mouse Pouch Model.
No full textCellular infiltration into traditional electrospun nanofibers (NFs) is limited due to their dense structures. We were able to obtain polycaprolactone (PCL) NFs with variable and defined pore sizes and thicknesses by using a customized programmed NF collector that controls the moving speed during electrospinning. NFs obtained by this method were tested in vitro and have shown better cell proliferation within the NFs with larger pore sizes. This study investigated in vivo host cell migration and neovascularization within implanted porous PCL NF discs using a mouse pouch model. Four types of PCL NFs were prepared and classified based on the electrospinning speed: NF-zero (static control), NF-low (0.085 mm/min), NF-mid (0.158 mm/min) and NF-high (0.232 mm/min) groups. With the increase in the speed, we observed an increase in the pore area; NF-zero (11.6 ± 6.2 μm(2)), NF-low (37.4 ± 28.6 μm(2)), NF-mid (67.6 ± 54.8 μm(2)), and NF-high (292.3 ± 286.5 μm(2)) groups. The NFs were implanted into air pouches of BALB/cJ mice. Mice without NFs served as control. Animals were sacrificed at 7 and 28 days after the implantation. Pouch tissues with implanted NFs were collected for histology (n = three per group and time point). The efficiency of the tissue penetration into PCL NF sheets was closely linked to the pore size and area. NFs with the highest pore area had more efficient tissue migration and new blood vessel formation compared to those with a smaller pore area. No newly formed blood vessels were observed in NF-zero sheets up to 28 days. We believe that a porous NF scaffold with a controllable pore size and thickness has great potential for tissue repair/regeneration and for other healthcare applications