Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.     

Loss of skeletal muscle density during neoadjuvant chemotherapy in older women with advanced stage ovarian cancer is associated with postoperative complications

ObjectiveTo assess the association between loss of lumbar skeletal muscle mass and density during neoadjuvant chemotherapy (NACT) and postoperative complications after interval cytoreductive surgery (CRS) in older patients with ovarian cancer.Materials and methodsThis multicenter, retrospective cohort study included patients aged 70 years and older with primary advanced stage ovarian cancer (International Federation of Gynecology and Obstetrics stage III-IV), treated with NACT and interval CRS. Skeletal muscle mass and density were retrospectively assessed using Skeletal Muscle Index (SMI) and Muscle Attenuation (MA) on routinely made Computed Tomography scans before and after NACT. Loss of skeletal muscle mass or density was defined as >2% decrease per 100 days in SMI or MA during NACT.ResultsIn total, 111 patients were included. Loss of skeletal muscle density during NACT was associated with developing any postoperative complication ≤30 days after interval CRS both in univariable (Odds Ratio (OR) 3.69; 95% Confidence Interval (CI) 1.57–8.68) and in multivariable analysis adjusted for functional impairment and WHO performance status (OR 3.62; 95%CI 1.27–10.25). Loss of skeletal muscle density was also associated with infectious complications (OR 3.67; 95%CI 1.42–9.52) and unintended discontinuation of adjuvant chemotherapy (OR 5.07; 95%CI 1.41–18.19). Unlike loss of skeletal muscle density, loss of skeletal muscle mass showed no association with postoperative outcomes.ConclusionIn older patients with ovarian cancer, loss of skeletal muscle density during NACT is associated with worse postoperative outcomes. These results could add to perioperative risk assessment, guiding the decision to undergo surgery or the need for perioperative interventions.     

Imaging in neonatal respiratory disease

The purpose of this review is to describe the current state of the art in clinical imaging for NICU patients, divided into major areas that correspond to likely phenotypes of neonatal respiratory disease: airway abnormalities, parenchymal disease, and pulmonary vascular disease. All common imaging modalities (ultrasound, X-ray, CT, and MRI) are discussed, with an emphasis on modalities that are most relevant to the individual underlying aspects of disease. Some promising aspects of dynamic and functional imaging are included, where there may be future clinical applicability.     

Pulmonary Hypertension Registry of Kerala,India (PRO-KERALA): One-year outcomes

BackgroundShort term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India.MethodsWe conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite end-point of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome.ResultsMean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35–2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04–0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28–0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29–2.51) were associated with primary composite outcome at one-year (p < 0.05).ConclusionIn the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptimal in the study population. Quality improvement programmes to improve guideline directed therapy may improve clinical outcomes of PH patients in India.     

基于COSMIN指南对癌症患者支持性照护需求量表的系统评价

背景国内外用于评估癌症患者支持性照护需求的量表较多，但有关此类量表质量的标准化评价研究及不同量表间的横向比较研究较为缺乏，也少有研究者对此类量表的测量特性进行系统的整合与评价。目的评价中文版癌症患者支持性照护需求量表的测量学性能及研究的方法学质量。方法2021年4月检索中国知网、万方数据知识服务平台、维普中文科技期刊全文数据库、中国生物医学文献数据库、PubMed、EmBase、Web of Science、CINAHL Complete数据库，获取有关中文版癌症患者支持性照护需求量表测量学性能评价的研究，检索时限均为建库至2021年3月30日。由两位研究者独立筛选文献、提取资料后，采用健康测量工具遴选标准（COSMIN）系统综述指南，在对量表的测量特性及研究的方法学质量进行评价的基础上，综合评定中文版癌症患者支持性照护需求评估量表各测量特性的证据等级，并形成对于量表的最终推荐意见。采用描述分析法对评价结果进行汇总、分析。结果共纳入15项研究，涉及8个中文版癌症患者支持性照护需求评估量表〔癌症患者支持性照护需求简明问卷中文版（SCNS-SF34）、中文版支持性照护需求筛查工具（SCNS-ST9-C）、癌症患者综合需求评估量表（CNAT）、癌症需求简明问卷（CNQ-SF）、中文版癌症患者未满足需求量表（CaSUN-C）、癌症患者未满足需求简明量表（SF-SUNS）、晚期癌症患者需求评估问卷（ACNQ-41）、晚期癌症患者需求评估表简表（ACNQ-29）〕。就量表的测量特性质量而言，除ACNQ-29的内容效度为"未提及"外，其余7个量表的内容效度均为"不确定"；除CaSUN-C、SF-SUNS的结构效度为"充分"外，其余6个量表的结构效度均为"不确定"；SCNS-SF34、CNQ-SF、CaSUN-C、SF-SUNS的内部一致性为"充分"，ACNQ-41的内部一致性为"不充分"，其余3个量表的内部一致性为"不确定"；CNAT、CNQ-SF、ACNQ-29的假设检验为"未提及"，CaSUN-C、SF-SUNS、ACNQ-41的假设检验为"不确定"，SCNS-SF34、SCNS-ST9-C的假设检验为"充分"；除ACNQ-41的稳定性为"不充分"，SCNS-ST9-C、ACNQ-29的稳定性为"未提及"外，其余5个量表的稳定性均为"充分"；仅SCNS-SF34的跨文化效度为"充分"，其余7个量表的跨文化效度均为"未提及"。8个量表的推荐等级均为B级。结论SCNS-SF34的测量特性得到了最为全面的评价，其具有较好的信效度，且临床应用可行性高，可暂时被推荐使用，但上述结论仍有待更多高质量证据加以支撑。     

Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fraction

BackgroundCoronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and < 55%).MethodsWe analyzed data on isolated CABG patients from the Veterans Affairs national database (2010-2019). We stratified patients into control (normal LVEF and no heart failure), HFmrEF, and heart failure with reduced LVEF (HFrEF) groups. We compared all-cause mortality and heart failure hospitalization rates between groups with a Cox model and recurrent events analysis, respectively.ResultsIn 6533 veterans, HFmrEF and HFrEF was present in 1715 (26.3%) and 566 (8.6%) respectively; the control group had 4252 (65.1%) patients. HFrEF patients were more likely to have diabetes mellitus (59%), insulin therapy (36%), and previous myocardial infarction (31%). Anemia was more prevalent in patients with HFrEF (49%) as was a lower serum albumin (mean, 3.6 mg/dL). Compared with the control group, a higher risk of death was observed in the HFmrEF (hazard ratio [HR], 1.3 [1.2-1.5)] and HFrEF (HR, 1.5 [1.2-1.7]) groups. HFmrEF patients had the higher risk of myocardial infarction (subdistribution HR, 1.2 [1-1.6]; P = .04). Risk of heart failure hospitalization was higher in patients with HFmrEF (HR, 4.1 [3.5-4.7]) and patients with HFrEF (HR, 7.2 [6.2-8.5]).ConclusionsHeart failure with midrange ejection fraction negatively affects survival after CABG. These patients also experience higher rates myocardial infarction and heart failure hospitalization.     

经鼻高流量氧气湿化治疗老年慢性阻塞性肺疾病急性加重合并呼吸衰竭的可行性研究

ObjectiveTo investigate the feasibility of transnasal heated humidified high flow nasal cannula oxygen therapy (HFNC) in the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with respiratory failure in elderly patients. MethodsA total of 176 elderly patients with AECOPD complicated with respiratory failure who were hospitalized at Peking University Shougang Hospital from December 2016 to January 2022 were enrolled, including 82 patients in an HFNC group and 94 patients in an NPPV group. After treatment, pulse oxygen saturation (SPO₂), arterial partial pressure of carbon dioxide (PaCO₂), oxygenation index (OI), respiratory rate (RR), heart rate (HR), mean arterial pressure (MAP), comfort score, discharge rate, rate of endotracheal intubation, rate of transfer to intensive care unit (ICU), and mortality were compared between the two groups. The independent sample t-test was used for comparison between the two groups. Statistical data are expressed in percentage or number of cases and the χ² test was used for their comparisons. ResultsThe SPO₂ values at 30 min, 1 h, and 6 h were significantly higher in the HFNC group than in the NPPV group (t=-2.049,-2.618, and -3.314, P=0.043, 0.010, and 0.001, respectively). SPO₂ before discharge was significantly lower than that of the NPPV group (t=2.162, P=0.033), but OI at each time point and before discharge had no statistical significance (P＞0.05). MAP at 6 h was significantly higher in the HFNC group than in the NPPV group (t=-2.209, P=0.029), but within the normal range. HRs at 2 h and 3 h in the HFNC group were significantly higher than those of the NPPV group (t=-2.199 and -2.336, P=0.030 and 0.021, respectively). There were no significant differences in RR, HR, or MAP between the two groups at other time points and before discharge (P＞0.05). There was no significant difference in PaCO2 between the two groups (P＞0.05). Comfort score in the HFNC group was significantly higher than that of the NPPV group (t=-46.807, P＜0.001). There were no significant differences in discharge rate, ICU transfer rate, endotracheal intubation rate, and mortality between the two groups (P＞0.05). ConclusionHFNC is as effective as NPPV in treating elderly patients with AECOPD complicated with type Ⅰ or mild type Ⅱ respiratory failure, and HFNC is more comfortable than NPPV.     

Home Use Guidance for Aerosol-Generating Procedures During the Coronavirus Disease 2019 Pandemic

From the early days of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, there were concerns that nebulizers used for the treatment of respiratory diseases as aerosol-generating devices could enhance the transmission of SARS-CoV-2. However, given the absence of any compelling data showing that nebulized treatments increase the risk of SARS-CoV-2 infection, it is unnecessary for community-dwelling patients with respiratory diseases to alter their current therapies, including nebulized treatments, to prevent symptom exacerbations. Maintaining current inhaled therapies also minimizes the risk of hospitalization and hospital-acquired infection of SARS-CoV-2.     

Radical radiotherapy in older patients with muscle invasive bladder cancer

Background

Muscle invasive bladder cancer (MIBC) is prevalent in the older patients, who are a vulnerable population with multiple co-morbidities and at increased risk of complications. Radical cystectomy is often not suitable, hence radical radiotherapy (RT) is an alternative option. We reviewed the outcomes of older patients treated with RT with or without concurrent chemotherapy (CRT) at our institution.