Substernal Chest Pain and Dyspnea in a Female Patient

A 76-year-old female patient presented to the emergency department with substernal chest pain and dyspnea symptoms. She reported that the symptoms started 2 days earlier. These symptoms can arise from both cardiac and noncardiac conditions. It is difficult to ascribe chest pain and dyspnea symptoms to a single cause. Recognizing these symptoms is critical for inpatient cardiac and primary care nurse practitioners to choose the correct diagnosis and facilitate more effective treatment planning.     

Efficacy of a Fibrin Sealant (Tissucol Duo) for the Preventionof Lymphocele after Laparoscopic Pelvic Lymphadenectomy:A Randomized Controlled Trial

Study ObjectiveTo assess the efficacy of Tissucol Duo (Baxter AG, Vienna, Austria) fibrin sealant in decreasing the incidence of lymphocele (LC) after pelvic laparoscopic lymph node dissection using harmonic shears.DesignRandomized controlled trial (Canadian Task Force classification level I).SettingTertiary referral and educational center.PatientsSeventy-four patients randomized to the use of sealant per hemipelvis.InterventionFibrin sealant.Measurements and Main ResultsAfter bilateral pelvic lymphadenectomy a fibrin sealant was used in 1 hemipelvis but not the other, applied in 41 patients (55.4%) to the left and 33 patients (44.6%) to the right hemipelvis. The primary outcome was the incidence of LC after surgery in symptomatic and asymptomatic patients. Imaging (ultrasound, computed tomography, and magnetic resonance) was performed to detect LC at 3, 6, and 12 months after surgery. Overall, 26 patients (35.1%) developed LC, and 4 were symptomatic (5.4%). Allowing patients to serve as their own treatment group and control, the hemipelvis treated with Tissucol Duo corresponding to the treatment group and that not treated to the control group, LCs were found in 17 (23%) and 14 (19%) cases, respectively, but the difference was not significant. The mean initial LC maximum diameter was 27.1 mm (standard deviaiotn, 35.2), and LCs tended to decrease in size during the first year to a mean of 8.7 mm.ConclusionApplication of Tissucol Duo fibrin sealant after laparoscopic pelvic lymphadenectomy using ultrasonic shears does not decrease the occurrence of symptomatic or asymptomatic LC.     

原发癌灶定位与甲状腺微小癌颈侧区淋巴结转移关系研究

目的 探究原发灶定位与甲状腺乳头状微小癌（PTMC）颈侧区淋巴结转移的关系，评估超声检查预测颈侧区淋巴结转移的准确率。方法 回顾性分析2014年1月至2015年12月天津医科大学肿瘤医院收治的134例PTMC病人的临床资料，均行中央区淋巴结清扫+改良颈侧区淋巴结清扫。依据超声定位分组，分析癌灶位置与颈侧区淋巴结转移的关系。结果 颈侧各分区淋巴结转移发生率分别为：Ⅱ区30.6%、Ⅲ区50.7%、Ⅳ区57.5%、Ⅴ区11.3%。癌灶位于中上极者颈侧区淋巴结转移发生率高于癌灶位于下极者（89.7% vs. 75.7%，P=0.038），靠近外侧者较内侧者更易出现颈侧区淋巴结转移（93.7% vs. 81.4%，P=0.049）。超声检查判定Ⅱ、Ⅲ、Ⅳ、Ⅴ区淋巴结转移的敏感度分别为43.9%、85.3%、85.7%、14.3%；特异度为91.4%、57.6%、35.1%、99.1%。超声预测Ⅲ、Ⅳ区淋巴结转移敏感度较高，Ⅱ、Ⅴ区淋巴结转移特异度较高。结论 癌灶位置与甲状腺微小癌颈侧区淋巴结转移密切相关，超声可为临床确定颈侧区淋巴结的清扫范围提供依据。     

Outcome of sentinel lymph node biopsy in early-stage squamous cell carcinoma of the oral cavity with methylene blue dye alone: a prospective validation study

Our aim was to evaluate the feasibility and role of sentinel lymph node (SLN) biopsy using methylene blue dye alone in identifying occult lymph node metastases in early oral cancer (cT1, T2, and cN0). The study was done from 2013–15 in 94 patients in a large cancer centre. The blue nodes were dissected and sent for frozen section, routine histopathological examination, and immunohistochemical testing for cytokeratin, and was followed by elective neck dissection in all patients. The identification rate was 93.61%. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for frozen section and haematoxylin and eosin (H&E) staining were 84.6%, 100%, 100%, 93.9% and 95.5%, respectively. Occult lymph node metastasis was seen in 27.6% cases. Biopsy of SLN with blue dye alone might be used successfully with good sensitivity and negative predictive value in countries with limited resources in the developing world. Immunohistochemistry contributes to it by increasing the sensitivity and NPV, and thereby improves the diagnostic value.     

Cost-effectiveness of Osimertinib as a Second-line Treatment in Patients With EGFR-mutated Advanced Non–Small Cell Lung Cancer in China

PurposeTo assess the cost-effectiveness of osimertinib used as a second-line treatment after failure of epidermal growth factor receptor tyrosine kinase inhibitor therapy for advanced non–small cell lung cancer (NSCLC) in China.MethodsFrom the perspective of China's health care system, a Markov model was used for estimating the costs and health outcomes of osimertinib and 4 platinum-based chemotherapies, including pemetrexed + platinum (PP), gemcitabine + platinum (GP), docetaxel + platinum (DP), and paclitaxel + platinum (TP). Two scenarios were considered, one in all confirmed patients with T790M-positive disease (scenario 1) and the other in all patients whose disease progressed after epidermal growth factor receptor tyrosine kinase inhibitor therapy, which consisted of patients with T790M-positive or T790M-negative NSCLC (scenario 2). Clinical data for transition probabilities and treatment effects were obtained from published clinical trials. Health care resource utilization and costs were derived from local administrative databases and published literature. Deterministic and probabilistic sensitivity analyses were conducted to assess the uncertainty of the results.FindingsIn the base-case analysis, compared with the 4 platinum-based chemotherapies, osimertinib yielded an additional 0.671 to 0.846 quality-adjusted life-year (QALY), with incremental costs of 15,943 to 20,299 USD in scenario 1, and an additional 0.376 to 0.808 QALY with incremental costs of 9710 to 15,407 USD in scenario 2. In the probabilistic sensitivity analysis, the probabilities that osimertinib would be cost-effective were 57.7% in scenario 1 and 58.4% in scenario 2 if the willingness-to-pay threshold were 30,000 USD/QALY, and probabilities would be more than 75 % in both scenarios if the willingness-to-pay threshold were 50,000 USD/QALY.ImplicationsOsimertinib is likely to be cost-effective when used as a second-line treatment of advanced NSCLC in China based on the latest reimbursement price of osimertinib through National Reimbursement Drug List negotiation.     

Outcomes after neoadjuvant or adjuvant chemotherapy for cT2-4N0-1 non–small cell lung cancer: A propensity-matched analysis

Objective

Comparative survival between neoadjuvant chemotherapy and adjuvant chemotherapy for patients with cT2-4N0-1M0 non–small cell lung cancer has not been extensively studied.

Slow atrioventricular nodal pathway affecting fast pathway conduction

A 15‐year‐old girl with a history of paroxysmal supraventricular tachycardia underwent an electrophysiology study (EPS) for diagnosis and ablation. Her baseline electrocardiogram and echocardiogram were normal. At EPS, she had dual atrioventricular nodal (AVN) conduction, but isoproterenol was needed to initiate the slow‐fast form of AVN reentry. Before ablation without any isoproterenol, she began to have a spontaneous block in the fast pathway with continuous conduction over the slow pathway. After ablation of the slow pathway, all complexes conducted over the fast pathway during a 25‐year follow‐up. Possible electrotonic interaction between the slow and fast pathways is proposed as the mechanism for this phenomenon.