One- versus two-stage partial hepatectomy for large resectable solitary hepatocellular carcinomas determined preoperatively to have a narrow resection margin: a propensity score matching analysis

BackgroundFor patients with a large but resectable solitary hepatocellular carcinoma (HCC) of >5 cm in diameter, it is often difficult to achieve a sufficient resection margin. There is still no study on whether a two-stage hepatectomy to increase a narrow resection margin would be beneficial.MethodsFrom August 2014 to February 2017, patients with a large but resectable solitary HCC of >5 cm and a preoperative estimated resection margin of <1.0 cm were retrospectively studied. They were divided into one- and two-stage resection groups. A retrospective analysis was performed, followed by propensity score matching (PSM) analysis. Disease recurrence, survival, intraoperative and postoperative data were compared.ResultsBefore PSM, the 1-, 2-, 3-and 4-year recurrence-free survival rates for the one- and two-stage groups were 44.3%, 31.7%, 24.3%, 19.2% versus 60.6%, 45.4%, 43.5%, 32.3%, respectively (P=0.007). The corresponding OS rates were 61.0%, 45.2%, 43.8%, 38.4% versus 69.6%, 62.5%, 60.7%, 57.3%, respectively (P=0.029). After PSM, the 1-, 2-, 3-and 4-year recurrence-free survival rates for the one- and two-stage groups were 44.0%, 31.5%, 27.3%, 21.0% versus 60.6%, 45.4%, 43.5%, 32.3%, respectively (P=0.013). The corresponding OS rates were 62.5%, 41.1%, 41.1%, 37.5% versus 69.6%, 62.5%, 60.7%, 57.3%, respectively (P=0.038). Differences in the resection margins between the one- and two-stage groups before [0.3 (0–0.5) versus 1.2 (0.8–2.2) cm] and after [0.2 (0–0.5) versus 1.2 (0.8–2.2) cm] PSM were also significant.ConclusionsTwo-stage hepatectomy allowed a wider resection margin for patients with a resectable but solitary HCC of >5 cm, and resulted in significantly better long-term survival outcomes after partial hepatectomy.     

A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year

Background contextEffective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role.PurposeThe purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR – replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration).Study design/settingA retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital.Patient sampleAnalysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208.Outcome measuresSelf-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery.MethodsThe implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success.ResultsAt 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF.ConclusionsHere we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.     

Adherence to antiretroviral therapy for HIV in sub‐Saharan Africa and Asia: a comparative analysis of two regional cohorts

Introduction : Our understanding of how to achieve optimal long‐term adherence to antiretroviral therapy (ART) in settings where the burden of HIV disease is highest remains limited. We compared levels and determinants of adherence over time between HIV‐positive persons receiving ART who were enrolled in a bi‐regional cohort in sub‐Saharan Africa and Asia. Methods : This multicentre prospective study of adults starting first‐line ART assessed patient‐reported adherence at follow‐up clinic visits using a 30‐day visual analogue scale. Determinants of suboptimal adherence (<95%) were assessed for six‐month intervals, using generalized estimating equations multivariable logistic regression with multiple imputations. Region of residence (Africa vs. Asia) was assessed as a potential effect modifier. Results : Of 13,001 adherence assessments in 3934 participants during the first 24 months of ART, 6.4% (837) were suboptimal, with 7.3% (619/8484) in the African cohort versus 4.8% (218/4517) in the Asian cohort (p < 0.001). In the African cohort, determinants of suboptimal adherence were male sex (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.06–1.53; p = 0.009), younger age (OR 0.8 per 10 year increase; 0.8–0.9; p = 0.003), use of concomitant medication (OR 1.8, 1.0–3.2; p = 0.044) and attending a public facility (OR 1.3, 95% CI 1.1–1.7; p = 0.004). In the Asian cohort, adherence was higher in men who have sex with men (OR for suboptimal adherence 0.6, 95% CI 0.4–0.9; p = 0.029) and lower in injecting drug users (OR for suboptimal adherence 1.6, 95% CI 0.9–2.6; p = 0.075), compared to heterosexuals. Risk of suboptimal adherence decreased with longer ART duration in both regions. Participants in low‐ and lower‐middle‐income countries had a higher risk of suboptimal adherence (OR 1.6, 1.3–2.0; p < 0.001), compared to those in upper‐middle or high‐income countries. Suboptimal adherence was strongly associated with virological failure, in Africa (OR 5.8, 95% CI 4.3–7.7; p < 0.001) and Asia (OR 9.0, 95% CI 5.0–16.2; p < 0.001). Patient‐reported adherence barriers among African participants included scheduling demands, drug stockouts, forgetfulness, sickness or adverse events, stigma or depression, regimen complexity and pill burden. Conclusions : Psychosocial factors and health system resources may explain regional differences. Adherence‐enhancing interventions should address patient‐reported barriers tailored to local settings, prioritizing the first years of ART.     

Robotic-assisted vs. open radical prostatectomy: A machine learning framework for intelligent analysis of patient-reported outcomes from online cancer support groups

Background

The advantages of Robot-assisted laparoscopic prostatectomy (RARP) over open radical prostatectomy (ORP) in Prostate cancer perioperatively are well-established, but quality of life is more contentious. Increasingly, patients are utilising online cancer support groups (OCSG) to express themselves. Currently there is no method of analysis of these sophisticated data sources. We have used the PRIME-2 (Patient Reported Information Multidimensional Exploration version 2) framework for automated identification and intelligent analysis of decision-making, functional and emotional outcomes in men undergoing ORP vs. RARP from OCSG discussions.

A biomechanical study of two postoperative prostheses for transtibial amputees: a custom-molded and a prefabricated adjustable pneumatic prosthesis

We evaluated an adjustable pneumatic prefabricated prosthesis and a rigid custom-molded prosthesis for immediate postoperative use. Twelve transtibial amputations were performed on cadaver limbs. Differential variable reluctance transducers were placed subcutaneously across the wound edge medially and laterally. The limbs were then placed in either the pneumatic prosthesis (five limbs) or the rigid prosthesis (seven limbs). The specimens underwent static and cyclic loading to simulate weight bearing. The strain readings for static and cyclic loading were greater in the rigid prosthetic group. Only the mean medial strain measurement after cyclic loading was statistically significant. The results demonstrate that the pneumatic prosthesis places less strain across the wound than a rigid prosthesis.     

The value of a wound score for diabetic foot infections in predicting treatment outcome: A prospective analysis from the SIDESTEP trial

Scoring the severity of a diabetic foot wound infection may help assess the severity, determine the type and urgency of antibiotic and surgical treatment needed, and predict clinical outcomes. We developed a 10-item diabetic foot infection wound score (results could range from 3 to 49 [least to most severe]) incorporating semi-quantitative grading of both wound measurements and various infection parameters. Using data from a prospective diabetic foot infection antibiotic trial (SIDESTEP), we evaluated the score's accuracy in predicting outcome, analyzed its components and tested it for consistency, construct, and validity. Wound scores for 371 patients significantly correlated with the clinical response; it was favorable at the follow-up assessment in 94.8% with a baseline score ≤12 compared with 77.0% with a score >19. Scores demonstrated good internal consistency (Cronbach's α >0.70 to <0.95). Patients with more severe wounds had higher scores, supporting construct validity. Excluding scores for wound discharge (purulent and nonpurulent), leaving an eight-item score, provided better measurement statistics. This easily performed wound score appears to be a reliable, valid, and useful tool for predicting clinical outcomes. Further validation studies in different patient populations should refine the items included.     

两种球囊扩张器于PKP术后并发椎体高度丢失风险的时间相关性临床对比研究

[目的]对比研究两种球囊扩张器(普霖及Kyphon Balloon)行PKP治疗骨质疏松性椎体压缩性骨折术后,随时间推移在手术椎体高度丢失并发症上的异同,及其对疼痛症状改善的可能影响。[方法]2012年12月30日~2014年6月11日纳入新鲜骨质疏松性压缩骨折患者72例,多中心随机单盲条件下分为均等2组,分别使用普霖球囊扩张器及Kyphon Balloon行PKP手术。术前及术后3、30、90 d随访并测量患椎压缩高度及Cobb角,使用VAS评分评估患者术后疼痛缓解程度,分析比较二组术后即时至终末随访时椎体高度丢失程度及症状反复情况。[结果]两组手术前后椎体高度差在FAS(P=0.076 4)、PPS(P=0.329 0)结果上差异无统计学意义,手术前后Cobb角差异在FAS(P=0.253 1)、PPS(P=0.248 1)结果上差异无统计学意义,二者随时间推移均有先下降后上升的趋势;两组手术后疼痛改善率差异无统计学意义FAS(P=0.393 9)、PPS(P=0.541 2),随时间推移趋势下降。排除手术椎体再骨折及椎体前缘高度丢失在国产球囊参与的单盲试验中可能出现的试验者偏倚影响,术后椎体高度丢失及疼痛缓解在随访时间线上曲线变化不一致,随时间推移二组手术椎均在术后早期存在普遍的塌陷现象。[结论]普霖PKP球囊扩张器与Kyphon Balloon术后手术椎均存在相似的塌陷风险,该风险发生时间或较相邻椎体退变或再骨折更为普遍和早期,但该风险与疼痛症状并未发现明显正相关性。     

Metabolic syndrome and upper tract urothelial carcinoma: A retrospective analysis from a large Chinese cohort

Background

Metabolic syndrome (MetS) has been reported to be associated with adverse outcomes in cancer patients. However, the relationship between MetS and upper tract urothelial carcinoma (UTUC) has yet to be explored.

A comparison of two designs of postoperative shoe for hallux valgus surgery: A biomechanical study in a cadaveric model

BackgroundHallux Valgus Surgery success depends not only on the operative technique, but also on the care of the foot during the postoperative period. Orthopedic shoes have been developed to decrease the weight load on the first ray, an excess of which might lead to a loss of fixation or pseudoarthrosis.The goal of this study was to determine how the load distribution changed as the forced applied to the foot increased, with and without an orthopedic shoe. Also, we compared to different shoe models.MethodsPressure sensors were placed under the first metatarsal head and the heel of twenty specimens of fresh cadaveric adult feet. Two orthopedic shoes were chosen, a double padded (MS) and a reverse camber shoe (RCS). 10 kg loads were progressively applied, up to 60 kg. We first compared three instances: no shoe, MS and RCS. A secondary analysis comparing barefoot versus shoes was performed. A mean comparison was performed (ANOVA/T-student).ResultsThe mean pressure of the heed and the first metatarsal showed that there were significant differences between groups (P < .005). The secondary analysis (no shoe vs orthopedic shoes) showed that the pressure without shoe was significantly higher than with any orthopedic shoe (P < .005). There were no statistically significant differences between models of shoes (P = .402).ConclusionAfter a surgical procedure for hallux valgus fixation, postoperative shoes should be indicated to decrease the pressure on the first metatarsal head and heel in order to avoid an overload of the postoperative area.Level of evidenceCadaveric study. Level V.     

One-stage versus staged laparoscopic-assisted anorectoplasty for high-and intermediate anorectal malformations: Medium-term outcomes from a propensity score matching analysis

BackgroundThe timing of anorectoplasty for anorectal malformations (ARMs) is controversial and essential for long-term bowel function. The advantages of laparoscopy make primary anoplasty possible for neonates. This study aims to report the medium-term results of the one-stage laparoscopic-assisted anorectoplasty (LAARP) and compare them with the staged LAARP.MethodsThis study included 242 boys who underwent LAARP between June 2013 and December 2018 in our center. Forty-five neonatal patients successfully underwent the one-stage LAARP, and the remaining 197 patients who had already undergone colostomy received staged procedures. The complications and bowel function were compared between the two groups after 1:1 propensity score matching (PSM).ResultsBefore matching, age at assessment and classification were significantly different between the two groups (P < 0.05). After PSM, 42 patients were included in each of the two groups, and the patients were well balanced. The overall occurrence of postoperative complications in the one-stage group was significantly lower than in the staged group (P < 0.05). The median follow-up periods were 55.0 and 54.5 months, respectively. The mean value of BFS was similar in the two groups. After medical management, a second evaluation was conducted to distinguish overflow pseudo-incontinence from patients with no bowel control potential. The functional outcome in the two groups is comparable (P = 0.307).ConclusionsOne-stage LAARP is safe and feasible for neonates with high-and intermediate-type ARMs. Compared with staged LAARP, one-stage LAARP has fewer complications and comparable functional outcomes. The authors recommend these procedures to be performed in dedicated centers with sufficient expertise.Level of evidenceLevel III.     

Needlestick injuries among anesthesia providers from a large US academic center: A 10-year retrospective analysis

Study objectiveAnesthesiologists are at high risk for needlestick injury. Such injuries pose a serious health threat from exposure to bloodborne pathogens. This retrospective analysis aimed to examine needlestick injury rate among anesthesia providers between 2010 and 2020 at the University of California Los Angeles, Department of Anesthesiology and Perioperative Medicine to determine specialty-specific factors associated with these injuries.DesignRetrospective analysis.SettingAcademic Anesthesiology Department.Patients and interventionsNone.MeasurementsAll reported incidents of needlestick injuries to employees are sent to the Injury and Illness Prevention Committee. We included all anesthesia residents, fellows, nurse anesthetists, solo anesthesiologists, and supervising anesthesiologists.Main resultsThe overall rate of reported needlestick injuries was 5.3%. The rates for anesthesia residents were 2.1%, 13.5%, 7.9%, and 6.7% for post graduate year 1–4 (PGY 1–4) residents. The rates were 14.3%, 4.7%, 2.1%, and 6.9% for fellows, nurse anesthetists, supervising anesthesiologists, and solo anesthesiologists, respectively. We found that PGY2 residents had a higher injury rate than PGY1 residents (p-value<0.001). When grouping PGY2, PGY3, and PGY4 residents together, they had a collective rate of 9.4%. Furthermore, residents had a higher needlestick injury rate than supervising anesthesiologists (p-value <0.001).ConclusionsPGY2 residents and fellows had the highest rate of needlestick injury. Our study highlights the trend of increasing sharps injuries after PGY1 while supervising anesthesiologists had the lowest rate. Proposed mechanisms for the increased sharps injuries include residents' transition from medicine-based internship to the operating room environment with increased exposure to potentially injurious equipment, overnight call, and increased work-related and cognitive stress. Improving understanding of institution-specific prevention programs, raising awareness during their initial high-intensity training period with one-to-one supervision when habits are formed, and reducing exposure to sharps using a needleless system are some steps toward reducing the incidence of sharps injuries in a field where the risk remains high.     

A novel surgical technique for implanting a new electrostimulation system for treating female overactive bladder: a preliminary report

OBJECTIVE: To assess the results of peripheral electrostimulation of pelvic floor muscles in patients with overactive bladder (OAB) symptoms, and to describe a novel surgical technique for inserting a specially designed implantable electrostimulator which can deliver different forms of muscle stimulation through a para-urethral electrode. PATIENTS AND METHODS: The study included seven women with OAB (mean age 59 years) who had frequency (including nocturia), urgency and urge incontinence for > or = 1 year, and in whom conventional treatment failed. The antepubic technique was used to implant the electrostimulator and a para-urethral electrode. The patients' urinary symptoms and quality of life (King's College Hospital incontinence questionnaire) were compared before and after surgery, and possible complications monitored. RESULTS: The mean (range) follow-up was 14.5 (13-17) months in six and 10 months in the seventh patient (stimulator removed because of infection). The mean (range) frequency of 15 (13-23) voids/24 h before surgery decreased to 9 voids/24 h (i.e. by 40%) afterward. All patients had leakage episodes because of urgency (4-15 times/day) before surgery, which ceased in five afterward; these patients used no further pads. In the remaining two patients urgency incontinence continued after surgery, but with significantly fewer leakage episodes, from 15 and 12 per day before to 6.7 and 4 afterward, respectively. The mean degree of urgency (graded 0-3) decreased from 2 to 1.4 after surgery, and quality of life improved significantly. Urodynamic studies showed a greater mean maximum detrusor capacity, from 135 mL before to 189 mL after implanting the stimulator. CONCLUSIONS: The good results (over a follow-up of 1 year) in patients with OAB symptoms treated by the present electrostimulator should encourage further clinical studies in such patients. A trial to evaluate the efficacy of pelvic floor muscle electrostimulation in a broad spectrum of diseases of the lower urinary tract causing symptoms similar to OAB has been started.