Elevated Alkaline Phosphatase Prior to Transarterial Chemoembolization for Neuroendocrine Tumors Predicts Worse Outcomes

Introduction

We hypothesized that an elevated preoperative alkaline phosphatase (AP) predicted worse outcomes for patients undergoing transarterial chemoembolization (TACE) for neuroendocrine tumor (NET) liver metastases.

Methods

We reviewed all patients who underwent TACE for metastatic NET between 2009 and 2013. Survival was evaluated using preprocedure variables.

Results

One hundred and nine patients underwent 210 TACE procedures. The average age was 57.7 years (range 20–78). Primary sites included pancreas (N?=?20), other gastrointestinal (N?=?52), lung (N?=?9), and unknown (N?=?28). The tumor was grade 1 in 68 (62 %), grade 2 in 21 (19 %), and grade 3 in 3 (3 %). Extrahepatic disease was present in 54 (50 %) and greater than 50 % hepatic tumor burden by imaging in 63 (58 %). Elevated bilirubin occurred in 8 (7 %), elevated AP in 22 (20 %), elevated ALT in 21 (19 %), and elevated AST in 41 (38 %). Univariate predictors included tumor grade (43 vs 27 vs 21 months, p?=?0.015), hepatic tumor burden (59 vs 37 months, p?=?0.009), and elevated AP (59 vs 23 months, p?<?0.001). On multivariate analysis, only elevated AP (p?=?0.001) predicted worse survival.

Conclusions

Elevated AP prior to TACE for metastatic NET portends a worse survival outcome, even more so than tumor grade or extent of hepatic disease.

     

Ischaemia-induced sympathoexcitation in spinalyzed rats

Systemic ischaemia increases sympathetic activity via both reflex and direct effects on the nervous system, which include the hypothalamus and brainstem structures that provide excitatory drive to sympathetic pre-ganglionic motoneurones. Using an arterially perfused working heart-brainstem preparation (WHBP), we evaluated the sympathoexcitatory response recorded from the thoracic sympathetic chain (tSC) in response to systemic ischaemia (produced by arresting perfusion for 30 s) before and after transecting consecutively at both the ponto-medullary and medullary-spinal cord junctions. Ischaemia produced a striking increase in tSC activity that persisted after transecting at both the ponto-medullary and medullary-spinal cord levels (intact: 70+/-3%; ponto-medullary: 77+/-7%; medullary-spinal cord: 61+/-6%; n=9). In sino-aortic denervated (SAD) rats (n=4), sympathoexcitatory responses were smaller in both intact and ponto-medullary, but not in medullary-spinal cord transected versus intact rats. Following administration of a ganglionic blocker [hexamethonium (hex), 25 mg/kg] after medullary-spinal cord transection the ischaemia-induced sympathoexcitatory response was reduced (12+/-6% increase relative to control, n=4). In medullary-spinal cord transected preparations, intrathecal injection of N2-saturated saline increased tSC discharge (22+/-3%, n=4), which was attenuated by hex (5+/-1%). We propose that neural mechanisms within the cervical-thoracic segments can make a substantial contribution to the sympathoexcitatory response during systemic ischaemia.     

Identification of an immune-responsive mesolimbocortical serotonergic system: potential role in regulation of emotional behavior

Peripheral immune activation can have profound physiological and behavioral effects including induction of fever and sickness behavior. One mechanism through which immune activation or immunomodulation may affect physiology and behavior is via actions on brainstem neuromodulatory systems, such as serotonergic systems. We have found that peripheral immune activation with antigens derived from the nonpathogenic, saprophytic bacterium, Mycobacterium vaccae, activated a specific subset of serotonergic neurons in the interfascicular part of the dorsal raphe nucleus (DRI) of mice, as measured by quantification of c-Fos expression following intratracheal (12 h) or s.c. (6 h) administration of heat-killed, ultrasonically disrupted M. vaccae, or heat-killed, intact M. vaccae, respectively. These effects were apparent after immune activation by M. vaccae or its components but not by ovalbumin, which induces a qualitatively different immune response. The effects of immune activation were associated with increases in serotonin metabolism within the ventromedial prefrontal cortex, consistent with an effect of immune activation on mesolimbocortical serotonergic systems. The effects of M. vaccae administration on serotonergic systems were temporally associated with reductions in immobility in the forced swim test, consistent with the hypothesis that the stimulation of mesolimbocortical serotonergic systems by peripheral immune activation alters stress-related emotional behavior. These findings suggest that the immune-responsive subpopulation of serotonergic neurons in the DRI is likely to play an important role in the neural mechanisms underlying regulation of the physiological and pathophysiological responses to both acute and chronic immune activation, including regulation of mood during health and disease states. Together with previous studies, these findings also raise the possibility that immune stimulation activates a functionally and anatomically distinct subset of serotonergic neurons, different from the subset of serotonergic neurons activated by anxiogenic stimuli or uncontrollable stressors. Consequently, selective activation of specific subsets of serotonergic neurons may have distinct behavioral outcomes.     

Syringomatous adenoma of the nipple: report of a case

Syringomatous adenoma of the nipple is a rarely encountered neoplasm of the breast with histological features similar to eccrine syringoma of the skin. This tumour which is locally invasive with high potential for recurrence if incompletely excised is considered benign and a complete excision is sufficient. Hence it deserves recognition by pathologists and surgeons for appropriate management. We report a case of syringomatous adenoma of the nipple in a postmenopausal diabetic woman who was incidentally found to have a subareolar mass in her right breast. Clinical examination and mammographic findings indicated malignancy. Histopathological examination showed features of syringomatous adenoma of the nipple. A clinicopathological study and histological differential diagnosis of this unusual tumour is described.     

Relationships in early childhood education – beyond the professional into the personal within the teacher–child dyad: relationships ‘that ripple in the pond’

The dyadic nature of the teacher–child relationship is recognized as a significant factor in young children’s learning experiences. However understandings about how teachers’ own personal and professional identities and experiences influence their construction of teacher–child relationships are under researched. This article extends upon earlier research by exploring the concept of a networked dimension of teachers’ personal relationships and how they inform their perceptions of their relationships with children within a dynamic system. Through the interpretation of four teachers’ life history narratives and utilizing the lens of development systems theory, we present original insights regarding how they understand their personal and professional relationships with children. We illuminate how teachers’ lives are open, networked and overlapping in nature and that there are implications for teachers’ initial education and professional development.     

Patterns of lumbar region movement during trunk lateral bending in 2 subgroups of people with low back pain

BACKGROUND AND PURPOSE: The movement system impairment (MSI) system is one proposed system for classifying low back pain (LBP) problems. Prior clinical data and observations for the MSI system suggest that different LBP subgroups demonstrate different patterns of movement during clinical tests, such as trunk lateral bending (TLB). The purpose of this study, therefore, was to examine the validity of the observation that lumbar region (LR) movement patterns during TLB are different between 2 subgroups of people with LBP: lumbar rotation with extension (Rotation With Extension) and lumbar rotation (Rotation). SUBJECTS: Participants were 44 people (28 men and 16 women; age [X+/-SD], 28.5+/-8.4 years) with chronic or recurrent LBP. METHODS: Each participant's LBP problem was classified with the MSI system. Kinematic variables were measured, and LBP symptoms were recorded during the TLB test. RESULTS: People in the 2 LBP subgroups demonstrated different patterns of LR movement during TLB. People in the Rotation With Extension subgroup displayed an asymmetric (right versus left) pattern of LR movement across the TLB movement, whereas people in the Rotation subgroup displayed a symmetric pattern of LR movement. Equal proportions of people in the 2 subgroups reported an increase in symptoms with the TLB test. DISCUSSION AND CONCLUSION: The patterns of LR movement across the TLB movement were different in 2 subgroups of people with LBP. The difference in the LR movement patterns between subgroups may be an important factor to consider in specifying the details of the interventions for these 2 LBP problems.     

The role of dental hygienists, assistants, and office staff in CAMBRA

The role of the dental team in caries management by risk assessment is critical to successful patient outcomes. Positive patient interactions and communication, proper appointment scheduling, diagnostics and data gathering, as well as implementation of noninvasive or minimally invasive procedures can be the responsibility of all members of the dental team. This article will evaluate the role of the clinical and administrative staff in maintaining a practice with a focus on disease prevention and management..     

Limits of autonomy in nursing's moral discourse

This article critiques the dominance of the discourse of autonomy in nursing ethical conversations, and the ways in which it is linked with nursing's commitment to patient advocacy. In its current discursive form, autonomy is too often used to reinforce the position of those already privileged and exacerbates the challenges faced by those with social vulnerabilities. Nursing's historical identity provides both challenges and resources for developing alternate ethical values. We have allowed narrow understandings of autonomy and advocacy to dominate our ethical discourse and have relied too exclusively on them to resolve conflicts and guide practice.