Serratus Plane Block in Breast Cancer Surgery: A Systematic Review and Meta-Analysis

The serratus plane block is a regional anesthesia technique awaiting efficacy and safety evaluation in breast cancer surgery, but evidence is unclear. This meta-analysis evaluates the analgesic effectiveness of serratus plane block vis-à-vis general anesthesia and paravertebral block for breast cancer surgery. We searched for randomized controlled trials in PubMed, the Cochrane Library, and Web of Science with no language limitation, comparing the serratus plane block with multimodal analgesia or the thoracic paravertebral block in breast cancer surgery. The Hartung-Knapp-Sidik-Jonkman method in combination with a random-effects model was used to pool data. We included 12 randomized controlled trials (799 patients). Compared with multimodal analgesia, pooled outcomes favored the use of serratus plane block for effectively alleviating acute postoperative pain severity at multiple time points. The serratus plane block also resulted in decreased postoperative analgesic consumption of 28.81mg (95% confidence interval [CI]: ?51.20, ?6.43), decreased intraoperative fentanyl consumption of ?56.46 mg (95% CI: ?79.61, ?33.30), increased duration of postoperative anesthesia of 243.85 min (95% CI: 104.38, 383.31), and reduced postoperative nausea and vomiting with a log relative risk of ?1.07 (95% CI: ?1.90, ?0.24). Compared with the thoracic paravertebral block, the serratus plane block was not statically worse for all of the outcomes assessed. No adverse effects were reported. The serratus plane block effectively alleviates acute postoperative pain, reduces the rate of postoperative nausea and vomiting, and improves perioperative anesthesia outcomes in breast cancer surgery, and it may represent an alternative to thoracic paravertebral block.     

Early Toxicity and Patient-Reported Cosmetic Outcomes in Patients Treated With Adjuvant Proton-Based Radiotherapy After Breast-Conserving Surgery

IntroductionTo evaluate the dosimetric data, early toxicity, and patient-reported cosmetic outcomes in breast cancer patients treated with adjuvant proton-based radiotherapy (RT) after breast-conserving surgery.Materials and MethodsWe performed a retrospective review of our institutional database to identify breast cancer patients treated with breast-conserving surgery followed by proton-based RT from 2015 to 2020. Patient-reported cosmetic outcomes were graded as excellent, good, fair, or poor. Early toxicity outcomes were graded by the treating physician during treatment. Dose-volume histograms were reviewed to obtain dosimetry data.ResultsWe identified 21 patients treated with adjuvant proton-based RT. Median whole breast dose delivered was 46.8 Gy (range, 40.0-50.4 Gy). Target volumes included the regional lymph nodes in 17 patients (81%). Seventeen patients (81%) received a lumpectomy boost. The median planning target volume V95 was 94% (range, 77%-100%), V100 71% (range, 60%-97%), V110 2% (range 0%-18%), and median max point dose was 115% (range, 105%-120%). The median ipsilateral breast V105 was 367.3 cc (range, 0-1172 cc) and V110 was 24.1 cc (range, 0-321.3 cc). Grade 2 and 3 dermatitis occurred in 62% and 14% of patients, respectively. Grade 2 and 3 pain was reported by 33% and 10% of patients, respectively. Median follow-up at the time of cosmetic evaluation was 27 months (range, 5-42 months). Four patients (21%) reported fair cosmetic outcome and 15 patients (79%) reported good or excellent cosmetic outcome. No poor cosmesis was reported.ConclusionAdjuvant proton-based radiotherapy after breast-conserving surgery is well tolerated with acceptable rates of acute toxicities and a high rate of good-to-excellent patient-reported cosmetic outcomes.     

Institution-Level Evolution of Lung Cancer Resection Quality With Implementation of a Lymph Node Specimen Collection Kit

IntroductionLung cancer surgery with a lymph node kit improves patient-level outcomes, but institution-level impact is unproven.MethodsUsing an institutional stepped-wedge implementation study design, we compared lung cancer resection quality between institutions in preimplementation and postimplementation phases of kit deployment and, within implementing institutions, resections without versus with the kit. Benchmarks included rates of nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and attainment of American College of Surgeons Operative Standard 5.8. We report institution-level adjusted ORs (aORs) for attaining quality benchmarks.ResultsFrom 2009 to 2020, three preimplementing hospitals had 953 resections; 11 implementing hospitals had 4013 resections, 58% without and 42% with the kit. Quality was better in implementing institutions and with kit cases. Compared with preimplementing institutions, the aOR for nonexamination of lymph nodes was 0.62 (0.49–0.8, p = 0.002), nonexamination of mediastinal lymph nodes was 0.56 (0.47–0.68, p < 0.0001), and attainment of Operative Standard 5.8 was 7.3 (5.6–9.4, p < 0.0001); aORs for kit cases were 0.01 (0.001–0.06), 0.08 (0.06–0.11), and 11.6 (9.9–13.7), respectively (p < 0.0001 for all). Surgical quality was persistently poor in preimplementing institutions but sequentially improved in implementing institutions in parallel with kit adoption. In implementing institutions, resections with the kit had a uniformly high level of quality, whereas nonkit cases had a low level of quality, approximating that of preimplementing institutions. Within implementing institutions, 5-year overall survival was 61% versus 51% after surgery with versus without the kit (p < 0.001).ConclusionsSurgery with a lymph node specimen collection kit improved institution-level quality of curative-intent lung cancer resection.     

Inverted U-Shaped Associations between Glycemic Indices and Serum Uric Acid Levels in the General Chinese Population: Findings from the China Cardiometabolic Disease and Cancer Cohort (4C) Study

Objective The relationship between serum uric acid(SUA)levels and glycemic indices,including plasma glucose(FPG),2-hour postload glucose(2 h-PG),and glycated hemoglobin(HbA1 c),remains inconclusive.We aimed to explore the associations between glycemic indices and SUA levels in the general Chinese population.Methods The current study was a cross-sectional analysis using the first follow-up survey data from The China Cardiometabolic Disease and Cancer Cohort Study.A total of 105,922 community-dwelling adults aged≥40 years underwent the oral glucose tolerance test and uric acid assessment.The nonlinear relationships between glycemic indices and SUA levels were explored using generalized additive models.Results A total of 30,941 men and 62,361 women were eligible for the current analysis.Generalized additive models verified the inverted U-shaped association between glycemic indices and SUA levels,but with different inflection points in men and women.The thresholds for FPG,2 h-PG,and HbA1 c for men and women were 6.5/8.0 mmol/L,11.0/14.0 mmol/L,and 6.1/6.5,respectively(SUA levels increased with increasing glycemic indices before the inflection points and then eventually decreased with further increases in the glycemic indices).Conclusion An inverted U-shaped association was observed between major glycemic indices and uric acid levels in both sexes,while the inflection points were reached earlier in men than in women.     

β2-微球蛋白对新型冠状病毒肺炎患者肾功能评估的临床价值

目的 探讨血清β2-微球蛋白（β2-MG）对新型冠状病毒肺炎（COVID-19）患者肾功能评估的临床价值。方法回顾性分析收治的23例COVID-19患者的血清肌酐（Cr）、胱抑素C（Cys C）、β2-MG、α1微球蛋白（α1-MG）水平。结果COVID-19轻型和普通型患者治疗后的血清β2-MG水平较治疗前下降,差异均有统计学意义（P<0.05）。普通型患者血清β2-MG水平高于轻型患者,而差异无统计学意义（P>0.05）。COVID-19患者中,Cys C与Cr、β2-MG呈正相关（r分别为0.478、0.423,P<0.05）。结论COVID-19患者出现血清β2-MG升高,或可作为评估肾功能损伤的早期生物标志物。     

A descriptive pharmacokinetic/pharmacodynamic analysis of continuous infusion ceftazidime-avibactam in a case series of critically ill renal patients treated for documented carbapenem-resistant Gram-negative bloodstream infections and/or ventilator-associated pneumonia

ObjectivesTo describe the pharmacokinetic/pharmacodynamic (PK/PD) behaviour of continuous infusion (CI) ceftazidime-avibactam and the microbiological outcome in a case series of critically ill renal patients treated for documented carbapenem-resistant Gram-negative (CR-GN) bloodstream infections (BSI) and/or ventilator-associated pneumonia (VAP).MethodsCritically ill patients with different degrees of renal function who were treated with CI ceftazidime-avibactam for documented CR-GN infections, and who underwent therapeutic drug monitoring from April 2021 to March 2022, were retrospectively assessed. Ceftazidime and avibactam concentrations were determined at steady-state, and the free fraction (fC_ss) was calculated. The joint PK/PD target of ceftazidime-avibactam was considered as optimal when both C_ss/MIC ratio for ceftazidime ≥4 (equivalent to 100%fT>_4xMIC) and C_ss/C_T ratio for avibactam >1 (equivalent to 100% fT>C_T of 4.0 mg/L) were simultaneously achieved (quasi-optimal if only one of the two was achieved, and suboptimal if neither of the two was achieved). The relationship between ceftazidime-avibactam PK/PD targets and microbiological outcome was assessed.ResultsTen patients with documented CR-GN infections (5 BSIs, 4 VAP, 1 BSI+VAP) were retrieved. The joint PK/PD targets of ceftazidime-avibactam were optimal and quasi-optimal in eight and two cases, respectively. Microbiological failure occurred in two patients (one with VAP, one with BSI+VAP), one of whom developed ceftazidime-avibactam resistance. Both underwent renal replacement therapy, and failed despite attaining optimal joint PK/PD target and receiving fosfomycin co-treatment.ConclusionCI administration may enable optimal joint PK/PD targets of ceftazidime-avibactam to be achieved in most critical renal patients with CR-GN infections, and may help to minimize the risk of microbiological failure.     

Three siblings of fatal infantile encephalopathy with olivopontocerebellar hypoplasia and microcephaly

We report three male siblings born with fatal encephalopathy comprising microcephaly, myoclonus and muscle hypertonia. All three patients died during infancy. Postmortem examination on the brain revealed that all infants had neuronal loss in the cerebellar cortex, inferior olivary and pontine nuclei, which were more pronounced in the older subject than the younger ones. In addition, they were associated with polymicrogyria in the cerebral cortex of the insula, olivary and dentate nuclear dysplasia, and a hypoplastic corticospinal tract. The clinical and neuropathological findings in our cases were identical to those in fatal infantile encephalopathy with olivopontocerebellar hypoplasia and microencephaly [Albrecht et al., Acta Neuropathol 1993;85:394–399], but an association of malformations suggests a new genetic factor in pathogenesis of olivopontocerebellar hypoplasia.     

Histopathologic analysis of hyaluronic acid composite solution following intravascular injection: Variability and safety

Background

Although a composite solution of non-crosslinked hyaluronic acid is generally considered safe, few studies have investigated its safety after intravascular injection.

Methods

Male Sprague–Dawley rats were administered 0.05 mL of a non-crosslinked hyaluronic acid composite solution via intravascular injection into bilateral inferior epigastric arteries (IEA). Artery samples were obtained at multiple time points for histopathologic analysis. Bilateral abdominal flaps supplied by the IEA were lifted and the same dose of solution was injected into the artery, and flap survival was analyzed.

Results

Histopathologic analysis showed that the non-crosslinked hyaluronic acid composite solution remained temporarily in the artery lumen following intravascular injection. With continuous blood flow, the filler gradually disintegrated and the artery became recanalized. At 24 h, no filler remained in the lumen. At 7 days after the filler was injected into the IEA feeding the flap, there was no significant difference between the experimental and control groups with respect to flap survival rate.

Conclusions

Non-crosslinked hyaluronic acid composite solution is relatively safe when a minimal volume is administered by intravascular injection. The filler will remain in the vessel for a short time, after which the vessel recanalizes.     

Traitement de la pseudo-occlusion colique aiguë (syndrome d'Ogilvie) par le cisapride

A case is reported of a 68-year-old woman admitted in the ICU for acute exacerbation of a chronic obstructive respiratory disease. The trachea was intubated and the lungs ventilated mechanically. She received sedation including midazolam and phenoperidine 1 mg · h⁻¹. On the 6th day, she experienced a massive colonic dilation (caecal diameter of 10 cm at X-ray examination). A colonoscopy was performed which showed the absence of obstruction, confirmed the diagnosis of pseudo-obstruction of the colon and allowed a decompression which was unefficient. A new colonoscopic decompression was performed on the 8th day, without prolonged effect. At that time, the patient was given cisapride in her gastric tube (80 mg). This treatment restarted the bowel movements within 48 hours and the caecal diameter decreased immediately to 7 cm. Cisapride was maintained for 10 days and mechanical ventilation for 30 days. No further dilation occurred during this time and the patient was discharged from the ICU. Few cases of Olgivie's syndrome successfully treated with cisapride have been reported in the literature. The efficacy of this agent for the treatment of Ogilvie's syndrome remains to be assessed in a controlled study.