Worsened oncologic outcomes for women of lower socio-economic status (SES) treated for locally advanced breast cancer (LABC) in Pakistan

Two hundred and thirty-seven women, undergoing multimodality treatment for locally advanced breast cancer (LABC), were retrospectively analyzed for age, menopausal status, socio-economic status (SES), tumor size, nodal involvement, tumor grade, estrogen and progesterone receptor (ER, PR) status and tumor stage. Primary purpose was to assess outcomes of these patients treated in a low-income country as defined by the World Bank and using limited-level treatment resources as defined by Breast Health Global Initiative (BHGI) guidelines. Secondary objectives included correlation of predictive and prognostic features with event-free survival (EFS) and overall survival (OS) at 5 years.Predictors of decreased EFS or OS included lower SES [P = 0.05 (95%CI 0.34–1.0) and P = 0.1 (CI 0.29–1.14)], larger tumor size [P = 0.01 (95%CI 1.06–1.59) and P = 0.3 (CI 0.86–1.50)] and positive lymph node status [P = 0.04 (95% CI 1.0–1.55) and P < 0.0001 (CI 1.37–2.64).In women diagnosed with LABC in Pakistan, patients with lower SES had larger, more aggressive tumors with worsened survival outcomes. Optimal breast cancer care warrants consideration for health care policies that address access to diagnostic and treatment services for financially disadvantaged women.     

Pre-transplant soluble CD30 level as a predictor of not only acute rejection and graft loss but pneumonia in renal transplant recipients

Pre-transplant sera of 586 renal graft recipients were tested to investigate whether soluble CD30 (sCD30) is a useful predictor of some severe clinical episodes post-transplant. Correlation analysis showed sCD30 level was significantly correlated with acute rejection (AR) (r = 0.242, P < 0.001), graft loss (r = 0.162, P < 0.001), and pneumonia (r = − 0.147, P < 0.001). Higher sCD30 levels were observed in patients with AR than the others (180.0 ± 89.1 vs. 135.3 ± 72.7 U/ml, P < 0.001). And patients with pneumonia had significantly lower pre-transplant sCD30 level than the others (123.2 ± 75.5 vs. 150.7 ± 79.6 U/ml, P = 0.003). Based on statistical results, 120 and 240 U/ml were selected as the optimal couple of cut-off value to divide patients into three groups: Group High (H), Group Intermedial (I) and Group Low (L). The lowest AR rate of 17.4% was observed in Group L (P < 0.001). Significant difference of AR rate was also observed between Group I (29.2%) and H (42.9%) (P < 0.001). There were much more patients suffering pneumonia in Group L (P = 0.001). Significantly lower 5-year patient survival rate (79.4%) was observed in Group H (P = 0.016). These data showed that elevated pre-transplant sCD30 level of renal allograft recipients may reflect an immune state detrimental for renal allograft survival. But sCD30 level lower than < 120 U/ml may be associated with a high risk of pneumonia. Pre-transplant sCD30 level is an independent predictor of acute rejection, lung infection, even graft survival. Suitable immunosuppression protocol should be selected according to pre-transplant sCD30 level in an attempt to promote patient and graft survival.     

Valor pronóstico de la invasión microvascular en la predicción de la supervivencia en el carcinoma de células renales

ObjectiveTo assess microvascular tumor invasion and other clinical and histological parameters as potential prognostic factors in surgically treated renal cell carcinoma.Materials and methodsSurgical specimens from 238 consecutive patients who underwent radical or partial surgery between 1990 and 2006 were retrospectively evaluated. The series included clinically localized or metastatic renal cell carcinoma (pT1-4; N0-1; M0-1). Disease-free and cancer-specific survival assessments were the end points with median follow-up of 75 months (range 1-189 months). Variables studied included: age, sex, tumor size, TNM 2010 classification, Fuhrman grade, histological subtype and microvascular tumor invasion.ResultsMicrovascular tumor invasion was observed in 79 patients (33,2%) and was significantly associated with age (P = .010), tumor size (P = .000), Fuhrman grade (P = .000), pT stage 2010 (P = .000), N stage 2010 (P = .000) and M stage 2010 (P = .000). Multivariate analyses determined that sex, Fuhrman grade, pT stage 2010 and histological subtipe were independent prognostic factors of disease-free survival, while sex, Fuhrman grade, pT stage 2010, M stage 2010, histological subtype and microvascular invasion were prognostic factors for cancer-specific survival.ConclusionsOur study shows that microvascular tumor invasion is an independent prognostic factor for cancer-specific survival in surgically treated patients with renal cell carcinoma.     

Dexmedetomidine as supplement to low-dose levobupivacaine spinal anesthesia for knee arthroscopy

AimTo evaluate efficiency of dexmedetomidine compared to fentanyl as supplements to low-dose levobupivacaine spinal anesthesia in patients undergoing knee arthroscopy.Materials and methodsSixty adult patients (ASA I or II) scheduled for knee arthroscopy were randomized to receive plain levobupivacaine (4 mg) plus dexmedetomidine (3 μg) in group D or fentanyl (10 μg) in group F.ResultsDexmedetomidine shortened time to surgery (P = 0.002), time to highest sensory level (P = 0.001), and time to highest Bromage score (P < 0.001). The highest sensory level was comparable in both groups (P = 0.969), but the duration of sensory block was significantly longer in group D (P = 0.009). The highest Bromage score was 2 in both groups. This score was attained in significant higher number of patients in group D (P = 0.038) that showed better muscular relaxation (P = 0.035). At the end of surgery, a residual motor block (Bromage score 1) was observed in significant higher number of patients (P = 0.033) and time to ambulation was significantly longer in group D (P = 0.001). There was no difference in the number of patients bypassed post-anesthesia care unit (PACU) (P = 0.761) or time to hospital discharge (P = 0.357) between groups. The pain free period was more prolonged (P < 0.001), and the visual analog scale (VAS) for pain was lower at the 2nd, 4th, 6th, and 8th postoperative hours (P < 0.001, <0.001, 0.013, 0.030 respectively) in group D.ConclusionDexmedetomidine is a good alternative to fentanyl for supplementation of low-dose levobupivacaine spinal anesthesia for knee arthroscopy.     

Chest wall resection for internal mammary lymph node metastases of breast cancer

Evaluation of morbidity, mortality and oncologic outcome of patients treated with a chest wall resection for isolated breast cancer recurrences in the Internal Mammary Chain. Retrospectively we retrieved data from 29 patients. Multivariate analysis was performed to identify prognostic factors for (disease-free) survival. There were no postoperative deaths. Complications occurred in 11 patients. The median follow-up after CWR for all 16 patients still alive at the end of this study is 18.4 months. Nine patients were free of cancer. The 3-year overall and disease-free survival is 59.2% and 8.6%. The median survival is 40.7 months. After multivariate analysis for each of the four endpoints studied, only one prognostic factor remains significant for survival: systemic therapy before CRW (p = 0.004). For local recurrence-free survival a first CRW recurrence (p < 0.00001) and for disease-free survival radicality of the resection (p = 0.008) are independent prognostic factors. Chest wall resection is a safe and effective treatment for isolated breast cancer recurrences in the IMC. Surgically treated patients have a fair survival and some of them are even cured.     

Evaluation of an acetated Ringer-based contrast material mixture for postmortem computed tomography angiography

PurposeThe purpose of this study was to compare an established postmortem contrast medium mixture based on polyethylene glycol (PEG) to an isotonic crystalloid with acetated Ringer solution (AR) as the base, both mixed with water-soluble iodinated contrast medium for postmortem computed tomography angiography (PMCTA) with the aim to avoid alterations of the corpse during autopsy.Materials and methodsThe study included 20 cadavers; 10 had PMCTA with AR and 10 with PEG. PMCTA images were analyzed with respect to image quality, vascular contrast patterns and artifacts. Autopsy was evaluated for visual, organ, vessel and haptic alterations. The Wilcoxon rank sum test was used to search for differences in image quality between the two groups. Statistical significance was set at P < 0.05.ResultsAR provided excellent contrast within the right coronary artery (P < 0.001) but a lack of contrast within the left coronary artery (P = 0.008) whereas PEG showed the opposite. A better image quality was observed in the PEG group by comparison with the AR group for right common carotid artery (P = 0.03), left common carotid artery (P = 0.01) and left coronary artery (P = 0.008). No differences were found for ascending aorta (P = 0.65), aortic arch (P = 0.09), right circle of Willis (P = 0.17), left circle of Willis (P = 0.08), inferior vena cava (P = 0.07) and abdominal aorta (P = 0.08). Severe extravasation occurred in all (10/10; 100%) cadavers in the AR group but in none (0/10; 0%) in the PEG group (P < 0.001). At autopsy, visual alteration with lilac discoloration of the face was observed in 4/10 cadavers (40%) in the AR group and in 9/10 cadavers (90%) in the PEG group (P = 0.057). Haptic alterations were observed in 3/10 cadavers (30%) in the AR group and 10/10 cadavers (100%) in the PEG group (P = 0.003).ConclusionAR results in contrast medium mixture extravasation in all cadavers, but PEG altered the autopsy more severely. Both carrier substances result in specific substance-related artifacts and dependent opacification of the coronary arteries, but PEG is recommended for PMCTA exclusively with regard to diagnostic imaging.     

Interaction of TNFi and conventional synthetic DMARD in SARS-CoV-2 vaccine response in axial spondyloarthritis and psoriatic arthritis

ObjectivesTo evaluate humoral responses to three doses of the inactivated SARS-CoV-2 vaccine (CoronaVac) in patients with spondyloarthritis (SpA) and the effect of therapy, compared with a control group (CG).MethodsProspective cohort of axial SpA/psoriatic arthritis patients and age/sex-balanced CG from the CoronavRheum phase 4 trial (NCT04754698). CoronaVac was given in two doses (28-days interval) with a booster at day 210. Blood samples were collected in the days 0/28 (D28)/69 (D69) and 240 (D240) to evaluate anti-SARS-CoV-2 IgG seropositivity (SP) and neutralising antibodies (NAb).ResultsOne hundred and ninety-four SpA patients were enrolled and 183 patients were age/sex-balanced with 183 CG. At D69, SpA patients showed a high SP (80.2% vs. 95.7%, P < 0.001) and moderate NAb positivity (61.6% vs. 82.7%, P < 0.001), but lower than CG. In patients, older age   prednisone (P < 0.001), methotrexate (MTX) (P < 0.001) and TNF inhibitors (TNFi) (P < 0.001) were independently associated with lower SP, while Caucasian ethnicity (P < 0.05) and prednisone (P < 0.01) were associated with diminished NAb. In contrast, sulfasalazine (SSZ) use was associated with NAb presence (P < 0.05). In monotherapy, only TNFi was also associated with absence of SP (P < 0.05). Further comparison with CG revealed that TNFi and/or MTX negatively impacted SP/NAb (P < 0.05). In contrast, patients under SSZ monotherapy achieved 100% SP (P > 0.999) and 83.3% NAb positivity (P > 0.999). SSZ + TNFi combination resulted in a similar response than CG [SP (P = 0.153) and NAb (P = 0.715)]. After third dose (D69–D240), a major increment occurred for SP (81.3% to 93.1%, P < 0.001) and NAb (63.2% to 86.1%, P < 0.001), but still lower than CG (P < 0.05), and only TNFi impaired both SP (P = 0.016)/NAb (P = 0.002).ConclusionsWe provided novel data demonstrating that TNFi attenuates immunogenicity in SpA patients while SSZ has a positive impact on vaccine antibody production. We also confirmed that MTX in combination with TNFi had a major negative impact in vaccine humoral response (CoronavRheum clinicaltrials.gov #NCT04754698).     

Comparison of hepatic epithelioid angiomyolipoma and non-hepatitis B,non-hepatitis C hepatocellular carcinoma on contrast-enhanced ultrasound

PurposeThe purpose of this study was to retrospectively compare the imaging features of hepatic epithelioid angiomyolipoma (HEAML) to those of hepatocellular carcinoma negative for hepatitis B surface antigen and hepatitis C antibody (NBNC-HCC) on contrast-enhanced ultrasound (CEUS) with sulphur hexafluoride microbubbles.Material and methodsTwenty-two patients (4 men, 18 women) with a mean age of 42.6 ± 10.2 (SD) years (range: 22–63 years) with histopathologically confirmed HEMAL were included in the study. Forty-four patients (30 men, 14 women) with a mean age of 57.3 ± 15.9 years (range: 19-85 years) with histopathologically confirmed NBNC-HCC were randomly selected from our institution's database as a control group. The CEUS characteristics of the two groups were compared.ResultsOn conventional ultrasound, significant differences in tumor diameter were found between HEAML (4.0 ± 2.0 [SD] cm; range: 1.3–8.9 cm) and NBNC-HCC (8.4 ± 4.4 [SD] cm; range: 1.6-18 cm) (P < 0.001) as well as in degrees of enhancement during the portal (P = 0.001) and late phases (P = 0.003), contrast distribution (P < 0.001) and absence of pseudocaspule (P < 0.001). On CEUS, hyperenhancement during the arterial phase was observed in 21/22 (95.5%) HEAMLs and in 43/44 (97.7%) NBNC-HCCs (P > 0.999). Homogeneous enhancement was more frequent in HEAMLs (20/22; 90.9%) than in NBNC-HCCs (13/44; 29.6%) (P < 0.001). Pseudocapsule was observed in 0/22 HEAMLs (0.0%) and in 36/44 NBNC-HCCs (81.8%) (P = 0.017). A prolonged enhancement was observed in 5/22 HEAMLs (22.7%) and in 0/44 NBNC-HCCs (0.0%) (P < 0.001) during the late phase.ConclusionCEUS with sulphur hexafluoride microbubbles is helpful in discriminating between HEAML and NBNC-HCC. Homogeneous enhancement and lack of pseudocapsule are suggestive features for the diagnosis of HEAML.     

Does perceived injustice correlate with pain intensity and disability in orthopaedic trauma patients?

IntroductionIndividuals who experience musculoskeletal trauma may construe the experience as unjust and themselves as victims. Perceived injustice is a cognitive construct comprised by negative appraisals of the severity of loss as a consequence of injury, blame, injury-related loss, and unfairness. It has been associated with worse physical and psychological outcomes in the context of chronic health conditions. The purpose of this study is to explore the association of perceived injustice to pain intensity and physical function in patients with orthopaedic trauma.MethodsA total of 124 orthopaedic trauma patients completed the Injustice Experience Questionnaire (IEQ), the PROMIS Physical Function Computer Adaptive Testing (CAT), the PROMIS Pain Intensity instruments, the short form Patient Health Questionnaire for depression (PHQ-2), the short form Pain Self-Efficacy Questionnaire (PSEQ-2), and the short form Pain Catastrophizing Scale (PCS-4) on a tablet computer. A stepwise linear regression model was used to identify the best combination of predictors explaining variance in PROMIS Physical Function and PROMIS Pain Intensity.ResultsThe IEQ was associated with PROMIS Physical Function (r = −0.36; P < 0.001) and PROMIS Pain Intensity (r = 0.43; P < 0.001). In multivariable analysis, however, Caucasian race (β = 5.1, SE: 2.0, P = 0.013, 95% CI: 1.1–9.2), employed work status (β = 5.1, SE: 1.5, P = 0.001, 95% CI: 2.1–8.2), any cause of injury other than sports, mvc, or fall (β = 7.7, SE: 2.1, P < 0.001, 95% CI: 3.5–12), and higher self-efficacy (PSEQ-2; β = 0.93, SE: 0.23, P < 0.001, 95% CI: 0.48–1.4) were selected as part of the best model predicting variance in PROMIS Physical Function. Only a higher degree of catastrophic thinking (PCS-4; β = 1.2, SE: 0.12, P < 0.001, 95% CI: 0.99 to 1.5) was selected as important in predicting higher PROMIS Pain Intensity.ConclusionPerceived injustice was associated with both physical function and pain intensity in bivariate correlations, but was not deemed as an important predictor when assessed along with other demographic and psychosocial variables in multivariable analysis. This study confirms prior research on the pivotal role of catastrophic thinking and self-efficacy in reports of pain intensity and physical function in patients with acute traumatic musculoskeletal pain.     

Resección transuretral en bloque vs. resección transuretral convencional para el cáncer de vejiga primario no músculo-infiltrante: metaanálisis

IntroductionWe performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer.MethodsA systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models.ResultsEn-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50-0.78; P < 0.001), catheterization-time (MD: –0.66; 95%CI: –1.02-[–0.29]; P < 0.001), length of hospital stay (MD: –0.95; 95%CI: –1.55-[–0.34]; P = 0.002), postoperative bladder irrigation duration (MD: –6.06; 95%CI: –9.45-[–2.67]; P < 0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02-0.34; P = 0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06-0.36: P < 0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61-1.04; P = 0.09), the operation time (MD: 0.67; 95%CI: –1.92-3.25; P = 0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14-1.47; P = 0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects.ConclusionsEn-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.     

Safety and efficacy of adipose-derived mesenchymal stem cells for knee osteoarthritis: A systematic review and m-analysis

ObjectiveThis research aimed to study the safety and efficacy of adipose-derived mesenchymal stem cells (ADMSCs) for knee osteoarthritis (OA).MethodsWe used six databases to search for records and then screened them for eligibility. In both randomized and non-randomized studies, the risk of bias was assessed. The data were then retrieved and used in single-arm and double-arm analyses using Comprehensive Meta-Analysis (CMA) Version 3.0 and RevMan Version 5.3, respectively.ResultsBased on the study's inclusion criteria, we included 15 studies with a total of 463 patients. According to our single-arm analyses, there was a significant improvement in quality of life (QOL) among the three dose subgroups (high, medium, and low doses), as measured by SF-36 scores after a year of follow-up [low dose: mean (M) = ?23.99; 95% confidence interval (CI) [?31.49 to ?16.49]; P < 0.001; medium dose: M = ?15.96; 95% CI [?23.5 to ? 8.42]; P < 0.001; high dose: M = ?19.31; 95% CI [?28.02 to ?10.59], P < 0.001] and the knee injury and osteoarthritis outcome score (KOOS) QOL sub-score after six months following ADMSCs injection in the low-dose group (M = 24.9; 95% CI [4.3 to 45.6]; P < 0.05). Moreover, after three months of follow-up, we detected significant pain reduction as measured by the numeric pain rating scale (NPRS), with no significant difference between the low and medium doses (low dose: M = ?3.12; 95% CI [?5.09 to ?1.14]; P < 0.01; medium dose; M = ?2.17; 95% CI [?3.13 to ?1.21]; P < 0.001). However, after a year, the results were no longer significant. Despite finding no significant difference between them after 6 and 12 months post-treatment in the Visual Analogue scale (VAS) scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, double-arm analyses revealed significant pain reduction in the ADMSCs group over the control after 12 months as estimated by the WOMAC pain sub-score (mean difference (MD) = ?1.85, 95% CI [?3.55, ?0.15], P < 0.05). After six months, the low dosage group's knee functions and activity levels improved significantly, as determined by the WOMAC physical function and stiffness subscales (M = ?23.79; 95% CI [?38.43 to ?9.16]; P = 0.001; M = ?10.25; 95% CI [?17.31 to ?2.59]; P < 0.01, respectively), as well as the KOOS scores after a year (P < 0.01 for all KOOS subscales). In the ADMSCs injections group, there were no serious adverse effects [event rate (ER) = 0.11; 95% CI [0.03–0.3]; P = 0.001].ConclusionIn the present single-arm meta-analysis, ADMSCs were associated with significant reduction in pain and improvement in QOL and knee functions in patients with knee OA. However, double arm analyses did not confirm these positive findings, which may be returned to the small sample size of included patients. Therefore, to introduce ADMSCs into clinical practice and establish guidelines for their use, more randomized controlled clinical trials with large sample sizes and long-term follow-ups are needed.     

Sarcoidosis presenting with and without Löfgren's syndrome: Clinical,radiological and behavioral differences observed in a group of 691 patients

ObjectivesJust a few series of Löfgren's syndrome have been reported. Our aim was to describe the epidemiology and clinical profile of sarcoidosis patients presenting with Löfgren's syndrome vs. non-Löfgren's syndrome.MethodsRetrospective cohort study of 691 consecutive patients with sarcoidosis diagnosed at the Bellvitge University Hospital in Barcelona, Spain, between 1976 and 2018.ResultsThree hundred and nine patients (44.7%) were diagnosed with Löfgren's syndrome and 382 with non-Löfgren's syndrome (55.3%). The mean age at diagnosis was 39.8 years-old (SD 11.7) vs. 46.6 (SD 14.5) (P < 0.001). 249 patients (80.6%) vs. 218 (57.1%) were female (P < 0.001), and mostly Caucasians (304, 98.4% vs. 351, 91.9%, P = 0.002). Out of the total 309, Löfgren's syndrome patients developed more frequently fever and articular involvement, and 45 (14.6%) presented with isolated periarticular ankle inflammation. When compared, radiological stages at diagnosis were more advanced in non-Löfgren's syndrome patients: stage 0 (2.9% vs. 14.7%), stage I (82.5% vs. 41.4%), stage II (14.6% vs. 29.3%), and stage III/IV (0 vs. 14.7%) (P < 0.001). Chronic trend > 2 years was more prevalent in non-Löfgren's syndrome (66, 22.6% vs. 233, 67.4%; P < 0.001), as well as the proportion of patients in whom treatment was needed (58, 18.8% vs. 224, 58.6%; P < 0.001). Risk factors related to chronic trend > 2 years were older age, stage II at diagnosis and the need of treatment.ConclusionsLöfgren's syndrome is a well-differentiated form of sarcoidosis with persuasive different epidemiological, clinical, radiological and prognostic features.     

Rheumatoid arthritis risk in periodontitis patients: A systematic review and meta-analysis

ObjectiveMany clinical studies have been carried out to investigate the relationship between periodontitis and rheumatoid arthritis (RA). Owing to limited evidence and inconsistent findings among these studies, it is unclear whether periodontitis would increase the risk for RA. This meta-analysis was performed to evaluate whether periodontitis represents a risk factor for RA.MethodsPubMed, Cochrane Library, Embase, Web of Science, and Wanfang were searched for eligible studies that compared periodontitis patients with controls. A pooled odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the association between periodontitis and RA.ResultsThirteen studies including a total of 706611 periodontitis patients and 349983 control subjects were included. The pooled OR of RA risk between periodontitis and controls was (OR: 1.69; 95% CI: 1.31–2.17; P < 0.0001), indicating that the patients in periodontitis group had a 69% greater risk for RA than people in control group. When stratified by disease type, the pooled results showed periodontitis represents a risk factor for incident RA (OR = 1.70, 95%CI: 0.75–3.85, P < 0.001) and mixed RA (OR = 1.61, 95%CI: 1.26–2.06; P < 0.001). When stratified by disease duration, the pooled results showed periodontitis represents a risk factor for RA disease duration > 5 years (OR = 2.88, 95%CI: 0.66–12.62, P = 0.018), disease duration < 5 years (OR = 2.59, 95%CI: 0.83–8.11, P < 0.001), mixed disease duration (OR = 1.53; 95%CI: 1.05–2.22, P < 0.001).ConclusionOur meta-analysis revealed an increased risk of RA in patients with periodontitis compared to healthy controls. Moreover, when stratified by disease type, there was a higher risk between incident RA and periodontitis. When stratified by disease duration, the patients with periodontitis might be more closely associated with the RA patients with disease duration >5 years.     

COVID-19: A qualitative chest CT model to identify severe form of the disease

PurposeThe purpose of this study was to identify clinical and chest computed tomography (CT) features associated with a severe form of coronavirus disease 2019 (COVID-19) and to propose a quick and easy to use model to identify patients at risk of a severe form.Materials and methodsA total of 158 patients with biologically confirmed COVID-19 who underwent a chest CT after the onset of the symptoms were included. There were 84 men and 74 women with a mean age of 68 ± 14 (SD) years (range: 24–96 years). There were 100 non-severe and 58 severe cases. Their clinical data were recorded and the first chest CT examination was reviewed using a computerized standardized report. Univariate and multivariate analyses were performed in order to identify the risk factors associated with disease severity. Two models were built: one was based only on qualitative CT features and the other one included a semi-quantitative total CT score to replace the variable representing the extent of the disease. Areas under the ROC curves (AUC) of the two models were compared with DeLong's method.ResultsCentral involvement of lung parenchyma (P < 0.001), area of consolidation (P < 0.008), air bronchogram sign (P < 0.001), bronchiectasis (P < 0.001), traction bronchiectasis (P < 0.011), pleural effusion (P < 0.026), large involvement of either one of the upper lobes or of the middle lobe (P < 0.001) and total CT score ≥ 15 (P < 0.001) were more often observed in the severe group than in the non-severe group. No significant differences were found between the qualitative model (large involvement of either upper lobes or middle lobe [odd ratio (OR) = 2.473], central involvement [OR = 2.760], pleural effusion [OR = 2.699]) and the semi-quantitative model (total CT score ≥ 15 [OR = 3.342], central involvement [OR = 2.344], pleural effusion [OR = 2.754]) with AUC of 0.722 (95% CI: 0.638–0.806) vs. 0.739 (95% CI: 0.656–0.823), respectively (P = 0.209).ConclusionWe have developed a new qualitative chest CT-based multivariate model that provides independent risk factors associated with severe form of COVID-19.     

The relationship between kinesiophobia and health-related quality of life in patients with rheumatoid arthritis: A controlled cross-sectional study

ObjectivesTo evaluate the kinesiophobia and kinesiophobia-related factors in patients with rheumatoid arthritis (RA) and provide a better perspective on the relationship between kinesiophobia and patients’ health-related quality of life (HRQoL).MethodsA total of 88 patients (67 females, 21 males) with RA and 93 healthy volunteers (67 females, 26 males) were included in the study between March 2020 and July 2020. Kinesiophobia was evaluated using the Tampa Scale of Kinesiophobia (TSK) and HRQoL was evaluated using the 36-item Short-Form Health Survey (SF-36). The Fatigue Severity Scale (FSS), Beck Depression Inventory (BDI), Health Assessment Questionnaire Disability Index (HAQ-DI), International Physical Activity Questionnaire (IPAQ) (Short Form) were completed by all participants.ResultsThe median age was 52.0 (IQR, 45.0-58.0) years in the RA group and 50.0 (IQR, 41.5-56.0) years in the control group. Age and sex were not significantly different between the groups. The median TSK score was 45.0 (IQR, 39.0-49.75) in the RA group, 39.0 (IQR, 37.0-43.0) in the control group (P < 0.001). The median FSS, BDI, and HAQ-DI scores were higher and the median HRQoL domains were lower in the RA group than in the control group (P < 0.05). Multivariate linear regression analysis including age, sex, education level, body mass index (BMI), morning stiffness duration, Disease Activity Score in 28 joints, FSS, BDI, visual analog scale and IPAQ scores variables showed that FSS scores (B = 1.07, P < 0.05), BDI scores (B = 0.24, P < 0.05), and BMI (B = 0.22, P < 0.05) were independent variables for kinesiophobia in patients with RA (R² = 0.32). TSK was a predictive variable for HAQ-DI (B = 0.03, P < 0.001), the physical functioning domain of the HRQoL (B = -1.18, P < 0.001), the bodily pain domain of the HRQoL (B = -0.78, P < 0.05), respectively.ConclusionPhysicians should have awareness of kinesiophobia in patients with RA. Educating patients about kinesiophobia, developing strategies for avoiding kinesiophobia, and specific treatment strategies with a multidisciplinary approach may improve HRQoL and disability.     

Breast cancer in women under 40 years of age: A series of 57 cases from Northern Ireland

BackgroundThere are few studies examining breast cancer in women under the age of 40 years, particularly in western European populations. Such tumours are reported to be more aggressive, possibly due to a different pathophysiology compared to older patients.MethodsWe performed a retrospective review of all women less than 40 years of age, diagnosed or treated with breast cancer, from June 2001 to June 2007 to assess pathophysiological factors that may influence clinical outcome and prognosis including patient demographics, clinical presentation, pre-operative investigations, surgical and pathological findings, treatment and outcome.ResultsFifty-eight women (mean age 34.9 years, range 27–39 years) were identified. One patient was excluded due to incomplete data; 98.2% (n = 56) patients presented directly to our symptomatic clinic; 89.5% (n = 51) patients had a palpable lump; 71.9% (n = 41) patients had no family history. Mammography was less sensitive than ultrasound (64.3% vs. 82.4%) while fine needle aspiration cytology was 92.5% sensitive for malignancy. Twenty-nine (50.9%) patients underwent breast-conserving surgery (BCS) of which 7 proceeded subsequently to completion mastectomy due to involved margins. Twenty-six (45.6%) patients required total mastectomy primarily while 2 (3.5%) patients were treated palliatively due to metastatic disease. The mean tumour size (nearest resection margin) was 2.13 cm (2.58 mm) for BCS and 3.95 cm (6.38 mm) for mastectomy. From a total of 55 primary resections, 85.5% (n = 47) of tumours were invasive ductal carcinoma; 57.4% (n = 31) and 40.7% (n = 22) were grade II and III tumours respectively. Lymphovascular invasion was identified in 50.9% (n = 28) while 40.0% (n = 22) were lymph node positive for metastatic disease. 76.8% (n = 43), 39.3% (n = 22) and 30.2% (n = 16) were oestrogen, progesterone and human epidermal growth factor receptor-2 positive respectively. The mean Nottingham prognostic index was 4.37 (range 2.2–8.4). Neo-adjuvant and adjuvant chemotherapy was administered to 9.3% (n = 5) and 80.0% (n = 44) of surgically treated patients respectively while 76.4% (n = 42) patients received adjuvant radiotherapy. 76.4% (n = 42) of patients were treated with tamoxifen. Four patients received Herceptin® therapy. Statistically significant univariate factors adversely associated with overall survival were time from referral to out-patient department attendance (p = 0.038), administration of neo-adjuvant treatment (p = 0.019), surgical intervention (p < 0.001), progesterone receptor positivity (p = 0.018) and tumour recurrence (p < 0.001). 86.0% (n = 49) patients were alive at mean follow-up of 52 months; 82.5% (n = 47) remain disease free.ConclusionOur study reports a low familial trait rate combined with a high proportion of hormonally active tumours less than grade III which suggests that breast cancer in this series of young women from Northern Ireland may be less aggressive and more hormonally responsive than anticipated.     

Accès veineux périphériques au bloc opératoire : caractéristiques et facteurs prédictifs de difficulté

PurposeTo investigate of predictor's factors of difficult venous access device in the operating room in elective surgery.MethodsIn a prospective study in central operating room, were included all patients scheduled for a surgical or diagnostic intervention. Were excluded all patients admitted with functional venous access. For each, were recorded patient's demographic characteristics (age, gender, ASA class, BMI), history (chemotherapy, prolonged ICU stay, hospitalization for more than five days), data from the clinical examination (presence of skin lesions, arteriovenous fistulas, burns, neurological deficits) and the type of operator (trainee, nurse, resident, senior). The difficulty was judged on the number of attempts required for successful venous access. Puncture was considered easier for a number of attempts to one to two and difficult if the number of attempts was greater than two. Predictor's factors were identified after univariate and multivariate analysis.ResultsDuring one year (March 2008 to February 2009), form returns in 1500 were met, 1325 were usable. Venous catheterization was successful in 50.9% at the first attempt in 24.2% of patients at the second attempt and after three attempts in 18% of patients. Only 6.8% of patients required more than three attempts. A central venous catheter was required in seven patients. In multivariate analysis, chemotherapy (OR = 4.54, 95% CI [2.92 to 7.03]; P < 0.001), a nurse in training (OR = 2.27, 95% CI [1.40 to 3.63]; P = 0.001), a resident in training (OR = 2.14, 95% CI [1.29 to 3.58]; P = 0.003) and the presence of burns (OR = 3.59, 95% CI [2.44 to 5.27]; P < 0.001) were identified as independent predictors of difficulty of peripheral venous access.DiscussionThe optimization of venous access devices in the operating room through the search for predictors of difficulty.     

Residual neuromuscular block as a risk factor for critical respiratory events in the post anesthesia care unit

ObjectiveResidual neuromuscular block is an important postoperative complication associated to the use of neuromuscular blocking drugs. The purpose of this study was to access the incidence of residual neuromuscular block in a post-anesthesia care unit and to evaluate its association with critical respiratory events.Material and methodsProspective cohort study was conducted in a Post Anesthetic Care Unit (PACU) for a period of 3 weeks. Two hundred two adult patients who submitted to scheduled non-cardiac and non-intracranial surgery were eligible to the study. The primary outcome variable was residual neuromuscular block after arrival to PACU that was defined as train-of-four ratio <0.9 and objectively quantified using acceleromyography. Demographic data, perioperative variables, lengths of hospital and recovery room stay and critical respiratory events were recorded. Inadequate emergence was classified in its different forms according to the Richmond agitation and sedation scale 10 min after admission to the recovery room.ResultsResidual neuromuscular block incidence in the post-anesthesia care unit was 29.7% (95% confidence interval: 23.4, 36.1). Patients with residual neuromuscular block had more frequently overall critical respiratory events (51% versus 16%, P < 0.001), airway obstruction (10% versus 2%, P = 0.029), mild-moderate hypoxemia (23% versus 4%, P < 0.001), severe hypoxemia (7% versus 1%, P = 0.033), respiratory failure (8% versus 1%, P = 0.031), inability to breathe deeply (38% versus 12%, P < 0.001) and muscular weakness (16% versus 1%, P < 0.001). Residual neuromuscular block was more common after high-risk surgery (53% versus 33%, P = 0.011) and was more often associated with post-operative hypoactive emergence as defined by the Richmond Agitation and Sedation Scale (21% versus 6%, P = 0.001).ConclusionsThis study suggests that residual neuromuscular block is common in the PACU and is associated with more frequent critical respiratory events.     

Postural change from lateral to supine is an important mechanism enhancing cephalic spread after injection of intrathecal 0.5% plain bupivacaine for cesarean section

BackgroundSpinal anesthesia is widely used for cesarean section, but the factors that affect the spread of the block in pregnant patients are still not fully explained. This study was designed to investigate the effect of postural changes on sensory block level.MethodsThirty patients scheduled for elective cesarean section under combined spinal–epidural anesthesia were randomly allocated into three groups. After intrathecal injection of 0.5% plain bupivacaine 7.5 mg, patients in group S were immediately placed in the supine position with left tilt, patients in group L5 were kept lateral for 5 min and then turned to the supine position with left tilt, and patients in group L10 were kept lateral for 10 min and then turned to the supine position with left tilt.ResultsAt 5 min, median cephalad level of sensory block was lower in groups L5 and L10 compared with group S (corrected P<0.001); at 10 min, median cephalad sensory block level was lower in group L10 compared with group S (corrected P<0.001) and group L5 (corrected P<0.001), and lower in group L5 compared with group S (corrected P=0.033); at 15 min, median cephalad level of sensory block was lower in group L10 compared with group S (corrected P=0.003) and group L5 (corrected P=0.015).ConclusionsIn our population, using 0.5% plain bupivacaine 7.5 mg, postural change from the lateral position to the supine position is an important mechanism enhancing cephalic spread of spinal anesthesia during late pregnancy.