Nonsurgical Cases Research Articles

P01.02 High Risk Factors and Benefit of Adjuvant Chemotherapy in Surgically Resected Stage IB Non–Small Cell Lung Cancer

Lung cancer remains the leading cause of cancer deaths worldwide. Although Stage IB disease is usually managed with upfront resection, consideration for adjuvant chemotherapy treatment is dependent on the presence or absence of high risk factors. The prognostic value of these factors and survival outcomes for these patients as reported by a national database have not been clearly elucidated. Patients with diagnosed NSCLC Stage IB (pT2aN0) per AJCC 7th edition between 2010 and 2016 from the NCDB were included. Non-surgical cases and cases that received radiotherapy were excluded. Univariate analyses comparing the clinico-demographic and pathologic features of those managed with surgery and observation (obs) versus surgery and adjuvant chemotherapy (CT) was performed. Multivariate analyses identified factors that influence survival and the likelihood of receiving CT. Kaplan-Meier method was performed to compare median OS. A total of 10,669 cases (84.2% obs, 15.8% CT) were identified. The obs cohort were primarily over age 70 (50.4%); those managed with CT were primarily 50-70 years (69.3%). Cases with tumors 4-5cm (OR, 0.388, P<0.0001), pleural invasion (OR, 0.598, P<.0001), and poor tumor differentiation (OR, 0.332, P<.0001) had a decreased likelihood of receiving obs versus CT. Age over 70 (HR, 1.801, P<.0001), Medicare insurance (HR, 1.246, P<.0001), and poor tumor differentiation (HR, 1.741, p<.0001) were adverse predictors of OS for those receiving obs versus CT. Five-year survival was higher for CT (63.6%) versus obs (57.1%), median OS was 88 months versus 75 months (p<0.0001) respectively. Those with moderately differentiated tumors achieved a survival benefit of 23 months when managed with CT (Table 1). Median OS increased by 19 months (65 versus 84 months) for poorly differentiated tumors managed with CT (p<.0001). When visceral pleural invasion was present, median OS was 60 months (obs) and greater than 75 months (CT) (p=0.0006). Cases with tumors 4-5cm in size had a median OS of 88 months when CT was received versus 67 months when managed with obs (p<.0001). Cases managed with lobectomy experienced a survival benefit of 92 months (CT) and 76 months (obs) (p<.0001).Tabled 1Surgery and Observation (reference)Surgery and ChemotherapyOS Benefit (Mos)P-valueMedian OS (Mos)95% CI Lower Limit95% CI Upper LimitMedian OS (Mos)95% CI Lower Limit95% CI Upper LimitOverall7571778883NEa13<.0001No pleural involvement7875839284NE140.0026Visceral Pleural Invasion605671NE75 bNE-0.0006< lobectomy5851655243NE- 60.8810lobectomy7673789287NE16<.00013-4cm7976868774NE80.05894-5cm6762718883NE21<.0001Moderately Diff6966759292NE23<.0001Poorly Diff6560708477NE19<.0001aNE= Not estimate, small sample/sparse data bMedian OS >75 months for CT; Mos=Months CI=Confidence Interval Diff=differentiation Open table in a new tab aNE= Not estimate, small sample/sparse data bMedian OS >75 months for CT; Mos=Months CI=Confidence Interval Diff=differentiation Overall, stage IB (pT2aN0) NSCLCs managed with CT, experienced an increased median OS of 13 months when compared to the obs cohort. Cases with pleural invasion, tumors 4-5cm in size with poor differentiation might experience a survival benefit in excess of 20 months, when CT is given versus obs.

Skin Necrosis Following Rhinoplasty: A Review and Proposed Strategy on Identifying High-Risk Patients.

Vascular compromise leading to cutaneous loss following surgical rhinoplasty is a devastating complication. The objective of this review is to identify all reported cases in literature published in English and summarize the current evidence to identify the patients at risk of this complication following surgery. A comprehensive literature review using Medline and Embase databases was performed to capture all reported cases of cutaneous vascular compromise following rhinoplasty from database inception through September 2020. Nonsurgical rhinoplasty cases were excluded. We identified eight studies that featured vascular cutaneous compromise following surgical rhinoplasty. A total of 18 patients were included in the analysis. The majority of the patients were females with a mean age of 30.9. Risk factors included smoking in 23.5% patients and revision setting. Extensive tip thinning, tight splinting and taping with dorsal onlay grafting, or combining extended alar base excision with revision open rhinoplasty were among surgical techniques associated with vascular compromise. The most commonly affected aesthetic nasal subunit in our review was the dorsum followed by the nasal tip. Conservative management primarily was utilized in 72.2% of patients, allowing the defect to heal by secondary intention. Studies reporting on cutaneous vascular compromise following surgical rhinoplasty are of low level of evidence. This review is the largest summary reporting on this complication to date, aiming to caution surgeons about associated techniques and management options. We also share an expert opinion on preoperative assessment of nasal skin to guide surgeons to potentially avoid rhinoplasty surgery in this subset of patients.

Sustainment of a patient flow intervention in an intensive care unit in a regional hospital in Australia: a mixed-method, 5-year follow-up study

ObjectiveIn 2014, an escalation plan and morning handover meetings were implemented in an intensive care unit (ICU) to reduce access block for post-operative care. In this study, the improvement intervention...

Diagnostic performance and radiation dose of reduced vs. standard scan range abdominopelvic CT for evaluation of appendicitis.

To compare the diagnostic performance and radiation dose of reduced vs. standard scan range CT in diagnosing appendicitis. We retrospectively evaluated 531 consecutive adults who underwent emergency contrast-enhanced CT for abdominal pain or suspected appendicitis between July 2018 and March 2019. One hundred eighty-one young adults (mean age, 26 ± 6 years) were imaged from L2 to thesymphysis pubis (reduced protocol). A total of 350 older patients (mean age, 55 ± 17 years) and those with a wider differential diagnosis were imaged from thediaphragm to theischium (standard protocol). The reference standard was histopathology (surgical cases) or 3 months of medical record follow-up (nonsurgical cases). Sensitivity, specificity, and accuracy were calculated. Mean dose-length products (DLP) were compared (t-test). Using an anthropomorphic phantom, organ doses were measured on CT scanners with (scanner 1) and without (scanner 2) automatic voltage selection; effective radiation doses were calculated. The frequency of appendicitis was 57/181 (31.5%) and 80/350 (22.9%) in the reduced and standard groups, respectively. Results of the reduced and standard protocols respectively were as follows (95% CI in parentheses): sensitivity, 98.2% (90.4-99.9%) and 100.0 (95.3-100.0%); specificity, 99.2% (95.6-100.0%) and 99.6% (97.9-100.0%); accuracy, 97.8% and 97.4%; mean DLPs, 363 ± 191mGy∙cm and 633 ± 591mGy∙cm (p < 0.0001). Phantom-based measurements of effective dose were 47% lower on scanner 1 (4.64 vs. 2.48 mSv) and 26% lower on scanner 2 (4.68 vs. 3.45 mSv) with the reduced protocol. For young adults with clinically suspected appendicitis, a reduced scan range CT protocol is as sensitive, specific, and accurate as a standard scan range CT and imparts significantly less radiation dose. • A reduced scan range CT protocol in young adults with high suspicion of appendicitis demonstrates similar diagnostic performance as a full-range abdominopelvic CT in undifferentiated adult patients. • The reduced scan range CT protocol imparts significantly less radiation dose: 57% based on dose-length product data and 26-47% based on anthropomorphic phantom data.

The Emerging Landscapes to Drug Delivery Systems for the Treatment of Pancreatic Cancer.

Pancreatic Ductal Adenocarcinoma (PDA) is a highly metastatic tumor, and the liver is its first target, which restricts the use of medications. PDA is considered one of the most aggressive types of cancer in the world, with an extremely short survival time, depending on the stage of diagnosis. In non-surgical cases, chemotherapy alternatives are only effective in 40% to 60% of patients. The low efficiency of treatments occurs mainly due to the complex microenvironment in PDA, leading to chemoresistance to treatments and making it difficult to reach the affected tissue. A very important histological characteristic of PDA is the extremely dense stroma, which leads to low vascularization of tumor tissue. Consequently, the stroma environment causes less drug accumulation in tumor cells, even of selective and/or targeted drugs. Overcoming the stroma's microenvironment is a major challenge for therapies. Moreover, specific genes lead to direct chemoresistance in PDA due to their high progression. In this scenario, nanotechnology appears as an alternative to overcome these clinical challenges concerning two distinct ways: acting on the stroma or/and acting directly on the pancreatic tumor cells. Thus, this review aimed to highlight advances in the application of nanotechnology aiming to open up new landscapes against PDA. There are a huge number of nanoparticles carrying drugs in preclinical and clinical trials for the effective treatment of PDA. These works have been discussed, and based on the current scenario, the future prospects for an efficient treatment of PDA have been proposed.

Perceptions of UK clinicians towards postoperative critical care.

SummaryPostoperative critical care is a finite resource that is recommended for high‐risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk‐stratified in practice; elucidate clinicians’ opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri‐operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real‐world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk‐averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure‐specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri‐operative critical care services, such as an overall lack of capacity, competition for beds with non‐surgical cases and poor flow through the hospital leading to bed ‘blockages’. Critical care is perceived to provide benefit to high‐risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating ‘enhanced care’ units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals.

Feline Pituitary Adenomas: Correlation of Histologic and Immunohistochemical Characteristics With Clinical Findings and Case Outcome.

Pituitary glands from 141 feline autopsy cases were reviewed histologically. Adenoma and hyperplasia were the most common lesions at 13 cases each. Pituitary adenoma was more likely than hyperplasia to be associated with clinical evidence of endocrinopathy or an intracranial mass (P < .001). A histochemical and immunohistochemical panel was applied to 44 autopsy- or hypophysectomy-derived pituitary adenomas in 43 cats from 2 diagnostic laboratories. Adenomas were differentiated from hyperplasia by the presence of disrupted reticulin fibers. One cat had a double (somatotroph and melanotroph) adenoma. Twenty somatotroph adenomas consisted of periodic acid-Schiff (PAS)-negative acidophils that expressed growth hormone; 16/20 had hypersomatotropism; 17/20 had diabetes mellitus. Eleven melanotroph adenomas consisted of PAS-positive basophils or chromophobes that expressed melanocyte-stimulating and adrenocorticotrophic hormones; 5/11 had hypercortisolism; 6/11 had diabetes mellitus. Eleven gonadotroph adenomas consisted of PAS-negative chromophobes that expressed follicle-stimulating and/or luteinizing hormones. Two thyrotroph adenomas consisted of PAS-negative basophils or chromophobes that expressed thyroid-stimulating hormone. Pituitary-dependent disease was not recognized in cats with gonadotroph or thyrotroph adenomas. The Ki-67 proliferation index in hypophysectomy specimens was lower in somatotroph than in melanotroph adenomas. Fourteen cats with hypophysectomy-treated somatotroph or melanotroph adenoma had an 899-day median survival time versus 173 days in 17 nonsurgical cases. After adjusting for age, adenoma size and type, hypophysectomized cats had an overall better survival time than nonsurgical cases (P = .029). The study results underscore the value of hypophysectomy and trophic hormone immunohistochemistry in the treatment and classification of feline pituitary adenomas.

ML-09 The REAL-WORLD of Elderly PCNSL Therapy in Tohoku and Niigata Area According to Retrospective Analysis: A Collaborative Investigation of the Tohoku Brain Tumor Study Group

Introduction: Recently, the number of cases of primary central nervous system lymphoma in elderly patients(EL-PCNSL) has been increasing. However, the treatment may be insufficient because of poor performance status and pre- and posttreatment complications. Therefore, we analyzed the risk factors for EL-PCNSL in the Tohoku and Niigata areas of Japan and clarified the REAL-WORLD of EL-PCNSL therapy. Materials & Methods: We investigated surgical and nonsurgical cases of patients aged 71 years or older from eight facilities during the last 8 years. We analyzed patient information, radiotherapy/chemotherapy or not, PFS, OS, RRs, second-line therapy, pre- and posttreatment complications, outcomes, and risk factors for poor prognosis. The log-rank test was used for univariate analysis, and Cox regression analysis was used for a multivariate analysis of risk factors. Results: Of the 142 cases registered, five differed from PCNSL pathologically, three receiving BSC were excluded, 31 were treated without biopsy, three were treated based on CSF-findings, and 100 were treated with biopsy. Total 134 cases were followed. The median age was 76 years, pretreatment KPS was 50%, and 118 cases(88%) had 217 pretreatment complications. The treatment contents consisted of various combinations depending on the attending physician. The retrospective overall PFS was 16 months and OS was 24 months. In the early treatment phase, out of 16 cases with dropout, four tumor and four complication deaths occurred. There were 77 deaths(58%), 39 internal tumor deaths(51%), and 33 complication deaths(43%). Poor prognostic risk factors were <60% posttreatment KPS, complications involving pretreatment cardiovascular and central nervous system disease, posttreatment pneumonia or severe infection, and absence of radiation or chemotherapy. Conclusions: Pretreatment KPS did not affect poor outcomes, but posttreatment KPS <60% and pre- and posttreatment complications did. Radiotherapy and chemotherapy are reportedly effective, but additional research to clarify the details of these modalities is needed.

Characteristics of NAFLD Based on Hypopituitarism.

Background Hypopituitarism and hypothalamic disorders, which induce central obesity and appetite disorder, are associated with nonalcoholic fatty liver disease (NAFLD). We retrospectively analyzed the clinical features of NAFLD patients with hypopituitarism. Patients. We examined the cases of 15 NAFLD patients with hypopituitarism (mean age, 39.4 years; males/females, 11/4). The causes of hypopituitarism were surgical in eight cases (six with craniopharyngioma and two with prolactinoma) and nonsurgical in seven cases, including unexplained hypopituitarism in five cases, Sheehan syndrome in one case, and one case that occurred after the radiation therapy. Serum adiponectin, soluble tumor necrosis factor receptor-2 (TNFR-2), and leptin levels were measured. Results We compared the cases of the eight patients who underwent cranial surgery due to craniopharyngioma or prolactinoma and seven nonsurgical cases. The body mass index (surgery group, 30.2 ± 4.1; nonsurgery group, 29.2 ± 14.2) and the rate of diabetes (75% in surgery group, 14.3% in nonsurgery group) tended to be higher in the surgery group, and the hepatic fibrosis grade (surgery group, 3.75 ± 0.38; nonsurgery group, 1.64 ± 1.07) was significantly higher in the surgery group. The levels of adipocytokines, serum adiponectin, and serum soluble TNFR-2 showed no correlation with hepatic fibrosis, whereas the serum leptin levels were significantly correlated with liver fibrosis (R = 0.696). Conclusion The hepatic fibrosis grade rapidly progressed in the cranial surgery cases of NAFLD patients with hypopituitarism, possibly in association with BMI, diabetes mellitus, and leptin. In such cranial surgery patients, strong interventions should be considered from the early stage, including diet education, hormone replacement, and more.

A NOVEL TREATMENT APPROACH FOR A RARE TRACHEAL TUMOR

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: The differential diagnosis for tracheal tumors is broad and often requires direct endobronchial evaluation for management. Neoplastic tumors account for 10% of tracheal masses. Herein, we describe a rare adult tracheal tumor that was successfully treated bronchoscopically. CASE PRESENTATION: A 48 year-old non-smoking female with childhood asthma presented to pulmonary clinic with a chronic cough for 4 months despite multiple courses of antibiotics and steroid bursts for suspected bronchitis. Due to persistent symptoms, she ultimately underwent a computed tomography scan of the chest which revealed a 0.9x0.6x0.5 cm polypoid-like density at the tracheal carina. Initial endobronchial biopsies showed inflammatory cells without evidence of malignancy. Due to concern for sampling artifact, she underwent a flexible/rigid bronchoscopy with tumor excision by snare electrocautery, argon plasma coagulation, and cryotherapy. Pathologic examination revealed an inflammatory myofibroblastic tumor (IMT) without an ALK rearrangement. A tumor board recommended curative tracheal resection versus surveillance bronchoscopy and imaging. The patient opted for surveillance as her symptoms had resolved. She has had annual bronchoscopies without any evidence of recurrence, and she remains asymptomatic. DISCUSSION: IMTs are slow growing quasi-neoplastic lesions that mostly affect children under 16 years old and are rarely reported in adults, accounting for 0.04-0.07% of all lung neoplasms. Most commonly affecting the lungs, these tumors can also involve a multitude of different organs. The etiology remains unknown although it is theorized to arise from an inflammatory process like a prior infection, trauma or surgery. However, the ALK rearrangement, which has been noted in 50% of IMTs, suggests a possible neoplastic origin. Classic pathologic features include myxoid spindle myofibroblasts with abundant inflammatory cells of plasma cells, lymphocytes, and eosinophils. Up to 80% of patients are asymptomatic but few may present with symptoms suggestive of, and commonly mistaken for, asthma. IMT treatment typically requires surgical resection via thorascoscopy or thoractomy. Chemotherapy, ALK directed therapies, and/or steroids have been used in nonsurgical cases. Few case reports have described effective bronchoscopic resection. A case series of 7 patients reported successful resection with one recurrence. Unfortunately, due to the tumor’s rarity, no robust studies exist for evaluating bronchoscopic treatment. A bronchoscopic approach offers a minimally invasive and potentially curative option but requires regular follow up for recurrence. CONCLUSIONS: IMTs are rare adult tracheal tumors, and treatment often entails surgical tracheal resection, which carries significant peri-operative risks with prolonged recovery. This case of IMT was successfully treated by bronchoscopic resection with curative effect. Reference #1: Jain S, Chopra P, Agarwal A, et al. Inflammatory myofibroblastic tumor of trachea. J Bronchol Intervent Pulmonol 2013;20:80-83. Reference #2: Oztuna F, Pehlivanlar M, Abul Y, et al. Adult inflammatory myofibroblastic tumor of the trachea: case report and literature review. Respir Care 2013;58:e72-6. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 Added 04/07/2020 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 Added 04/07/2020 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Tao He, source=Web Response No relevant relationships by Leeyen Hsu, source=Web Response No relevant relationships by Scott Oh, source=Web Response

Sonographically Guided Percutaneous Sectioning of the Coracohumeral Ligament for the Treatment of Refractory Adhesive Capsulitis: Proof of Concept.

Treatment options are limited for nonsurgical chronic refractory cases of adhesive capsulitis. We describe a novel percutaneous tenotomy technique for coracohumeral ligament interruption with cadaveric validation. The objective of this study was to describe and validate a novel technique for percutaneous interruption of the coracohumeral ligament. Cadaveric study. Academic tertiary care center. Eight cadavers underwent ultrasound (US)-guided percutaneous incision of the coracohumeral (CHL) ligament. Performance of the procedure requires that the practitioner make oscillatory motions with a needle that uses ultrasound energy to cut through tissue. Each pass removes a pinhead-sized amount of tissue. The number of passes and the cutting time are recorded during the procedure. As a standard for this procedure does not exist, the authors created their own based on the preclinical information presented here. Postprocedure dissection was performed to assess the extent of CHL interruption and injury to surrounding tissue. The average resection time was seven minutes, requiring 500 passes. The technique described in this paper completely interrupted the CHL in all subjects. Cadaveric analysis demonstrated interruption of the CHL with respect to control shoulders requiring an average of seven minutes of cutting time and ∼500 micro-perforations. US-guided percutaneous CHL ligament sectioning is possible with a commercially available ultrasonic probe.

Financial burden of orthopaedic gunshot-related injury management at a major trauma centre.

Violence and injuries are a significant global public health concern, and have a substantial emotional, physical and economic impact on society. In South Africa (SA), the Western Cape Injury Mortality Profile shows that homicides increased from 38 deaths per 100000 in 2010 to 52 deaths per 100 000 in 2016. This increase is directly related to an increase in firearm-related homicides, which doubled from 2010 to 2016. Previous research estimated the average cost per gunshot wound (GSW)-related orthopaedic patient at USD2940. GSW-related patient numbers as well as treatment costs have escalated exponentially over the past few years. To calculate the financial costs involved in managing gunshot-related orthopaedic injuries both surgically and non-surgically at a tertiary centre in SA. After ethics approval, a retrospective review of all GSW patients seen in the emergency unit at Tygerberg Hospital in 2017 was undertaken. Patient records yielded data on the following parameters: injury site and characteristics, imaging modalities, orthopaedic management, hospital admission and duration of hospitalisation, theatre episodes, orthopaedic implants and blood products administered. Cost analysis was performed using this information. A total of 389 patients (360 male and 29 female), average age (range, standard deviation) 28 (3 - 69, 9.50) years, were treated during the study period. Patient records identified a total of 449 orthopaedic injuries. A total of 187 patients were admitted, with 175 requiring surgical fixation. The conservatively calculated cost of managing this patient group was ZAR10 227 503. The average management cost per patient was ZAR26 292, with an average of ZAR46 670 per case requiring surgical management and ZAR8810 for non-surgical cases (the average USD-ZAR exchange rate in 2017 was USD1-ZAR13.30). The total cost of managing 389 patients with gunshot-related orthopaedic injuries at a tertiary hospital was ZAR10227503. Improved understanding of these costs will help the healthcare system better prioritise orthopaedic trauma funding and training and highlights the urgent need for cost-saving measures, specifically primary prevention initiatives.

The clinical features and prognosis of 32 cases of pulmonary actinomycosis

Objectives: To describe the clinical features and prognosis of pulmonary actinomycosis in a tertiary Chinese hospital. Methods: We conducted a retrospective analysis of 32 patients diagnosed with pulmonary actinomycosis between January 2013 and December 2019. General characteristics, clinical manifestations, lab data, chest CT imaging, treatment and follow-up information were reviewed and analyzed. Results: This study consisted of 19 males and 13 females, with a mean age of (58±12) years, ranging from 16 to 76 years. There were 26 cases with co-morbidities. Among them, there were 16 cases with pulmonary co-morbidity. Sixteen cases had a smoking history. Eight cases, 5 men and 3 women, with a mean age of (48±8) years, ranging from 41 to 58 years, received thoracic surgery for diagnosis. The remaining 24 cases who did not receive thoracic surgery consisted of 14 males and 8 females, with a mean age of (54±14)years, ranging from 16 to 76 years. Cough (25cases), expectoration (21 cases) and fever (16 cases) were the common clinical manifestations. The erythrocyte sedimentation rate (ESR) ranged from 2 to 114 mm/1 h, with a mean value of (28±31) mm/1 h. The ESR was elevated (>20 mm/1 h) in 15 cases. The C-reactive protein (CRP) ranged from 1 to 116 mg/L, with a mean value of (28±45) mg/L. The CRP was elevated (>8 mg/L) in 16 cases. Localized air-space consolidation (18 cases), pulmonary mass or nodules (16 cases) were the common chest CT manifestations. When compared with non-surgical cases, fever was the sole characteristic that was less common in cases with thoracic surgery (1 case in surgical group vs 11 cases in non-surgical group, P<0.05). Actinomyces spp. was found in 7 cases (87.5%) who received thoracic surgery, in 16 (61.5%) specimens collected through bronchoscopy and in 10 (55.6%) sputum samples of good quality. All of our enrolled cases were administrated with oral antibiotics, and 14 cases were prescribed with intravenous antibiotics initially. Among them, 27 cases were administrated with more than one antibiotic. Penicillin, ampicillin and amoxillin were prescribed for 25 cases. Finally, 30 cases showed improvement or cure in our hospital. Conclusions: Pulmonary actinomycosis tended to develop in aged patients with co-morbidities. Cough, expectoration, fever and localized air-space consolidation were the common clinical and radiological manifestations, respectively. Actinomyces spp. could be found more easily in the surgically resected tissues than other specimens. The prognosis of our enrolled cases was good after treatment with combined antibiotics.

Clinical Characteristics of Primary Hypophysitis - A Single-Centre Series of 60 Cases.

Clinical data on primary hypophysitis are still scarce. Especially non-surgical cases are underreported. We sought to analyse clinical characteristics of primary hypophysitis, particularly in clinically diagnosed patients. Retrospective single centre study in 60 patients with primary hypophysitis. Symptoms, MRI, histopathological findings, treatment and outcomes were analysed in 12 histopathologically and 48 clinically diagnosed patients. Diagnostic criteria for clinical diagnosis were: a) MRI findings compatible with primary hypophysitis; b) course of disease excluding other differential diagnoses. Mean duration of follow-up was 69 months. Female sex was predominant (73%). Fatigue (52%), headache (38%) and diabetes insipidus (38%) were the most frequent symptoms. 42% had a concomitant autoimmune disease. The corticotropic, thyrotropic, gonadotropic, somatotropic axis was impaired in 67%, 57%, 52%, 20%, respectively. Men had a higher number of impaired hormone axes (p=0.022) with the gonadotropic axis being affected more frequently in men (p=0.001). Infundibular thickening (56%) and space occupying lesions (46%) were typical MRI findings. Pituitary size was frequently enlarged at presentation (37%) but diminished during observation (p=0.029). Histopathologically and clinically diagnosed cases did not differ. The cohort of clinically diagnosed patients did not differ from our histopathologically diagnosed patients or from published cohorts with predominantly surgical patients. Thus, diagnosis of primary hypophysitis using clinical criteria seems feasible.

Propofol Infusion Is a Feasible Bridge to Extubation in General Pediatric Intensive Care Unit.

Objective: The current literature on propofol infusion as a bridge to extubation in critically ill children is limited to children with burns and congenital cardiac disease. We hypothesize that propofol infusion is a feasible bridge to extubation in mechanically ventilated, critically ill children.Design: Retrospective chart review.Setting: Pediatric intensive care unit of a tertiary care teaching hospital.Patients: Children < 21 years, admitted to our Pediatric intensive care unit (PICU), requiring mechanical ventilation (MV) for at least 48 h and at least two sedative infusions and who received propofol infusion for 4 to 24 h during anticipated extubation from January 2014 to May 2017.Interventions: None.Measurements and Main Results: We assessed extubation success as primary outcome. We defined extubation success as no re-intubation within 24 h after extubation. We also assessed for occurrence of adverse effects of propofol infusion (1) hemodynamic instability [more than 10% change from pre-propofol baseline heart rate (HR) and mean arterial pressure (MAP) measured 4 h before and during propofol infusion, need for any inotrope and/or fluid bolus] and (2) occurrence of lactic acidosis in absence of any documented sepsis. We compared hemodynamic parameters before and during infusion using Wilcoxon Rank Sum Test (significant p-value ≤ 0.05). We evaluated 35 critically ill, mechanically ventilated children. The median age, weight and duration of MV were 3.8 (IQR: 1.25–10.5) years, 12 (IQR: 6–16.2) kilograms and 111 (IQR: 78–212) h, respectively. Of the 35 patients, 15 (43%) were post-surgical (10 general and 5 cardiac) and the remaining 20 (57%) were non-surgical respiratory failure cases. The median (IQR) propofol infusion dose and duration were 64.7 (53.2-81.1) mcg/kg/min and 7.8 h respectively. Only one patient got re-intubated within 24 h of extubation and was later diagnosed with vascular ring. During propofol infusion, 7/35 (20%) patients exhibited transient drop in MAP > 10% from baseline, but none had lactic acidosis or required an inotrope or fluid bolus.Conclusions: In critically ill, mechanically ventilated patients, propofol infusion used over a short duration (<12 h) was found to be a feasible bridge to extubation. No patient had significant hypotension or lactic acidosis during the infusion.

Serum-Targeted HILIC-MS Metabolomics-Based Analysis in Infants with Ureteropelvic Junction Obstruction.

Ureteropelvic junction obstruction (UPJO) constitutes the predominant cause of obstructive nephropathy in both neonates and infants. Fundamental questions regarding UPJO's mechanism, assessment, and treatment still remain unanswered. The aim of the present study was to elucidate potential differences through serum metabolic profiling of surgical cases of infants with UPJO compared to both nonsurgical cases and healthy age-matched controls. Early diagnosis of renal dysfunction in this cohort based on highlighted biomarkers was the ultimate goal. Thus, serum samples were collected from 20 patients preoperatively, 19 patients with mild stenosis treated conservatively, and 17 healthy controls. All samples were subjected to targeted metabolomics analysis by hydrophilic interaction liquid chromatography coupled to mass spectrometry (HILIC LC-MS/MS). Both univariate and multivariate statistical analyses were performed. Principal component analysis (PCA) and orthogonal partial least squares-discriminant analysis (OPLS-DA) score plots showed that the studied groups differed significantly, with a panel of metabolites, including creatinine, tryptophan, choline, and aspartate, distinguishing patients who required surgery from those followed by systematical monitoring as well as from healthy controls, showing high performance as indicators of UPJO disease.

Perfusão tecidual pode ser utilizada para predição de mortalidade em unidade de terapia intensiva?

Objetivo: Comparar a acurácia para predição de mortalidade dos indicadores de perfusão tecidual e APACHE II nas primeiras 24 horas de internação em uma unidade de terapia intensiva (UTI) do sul do Brasil. Métodos: coorte prospectiva. Foram avaliados o diagnóstico de internação, idade, sexo, casos cirúrgicos ou não-cirúrgicos, APACHE II, índice de perfusão tecidual (IP), lactato sérico, saturação venosa central de oxigênio (SvcO2) e a diferença venosa-arterial de dióxido de carbono (ΔPCO2) nas primeiras 24 horas de internação. Os participantes foram acompanhados até o desfecho na UTI: alta ou óbito. Resultados: Participaram do estudo 126 indivíduos com média de idade de 62,2±16,8 anos e principal causa de internação cardiovascular (37,3%). As variáveis que estiverem relacionadas ao óbito foram apenas a maior idade (p=0,015), casos não-cirúrgicos (p=0,001), maior pontuação no APACHE II (p=0,001) e maior tempo de internação (p=0,004). O estudo elaborou um modelo de avaliação prognóstica utilizando os casos não-cirúrgicos e a SvcO2&lt;65% que, quando comparado com o APACHE II, se mostrou mais acurado para previsão de mortalidade em UTI (área sob a curva ROC 0,727 (IC 95% 0,616 – 0,838 versus 0,802 (IC 95% 0,701 – 0,904). Conclusão: Os indicadores de perfusão tecidual analisados não apresentaram relevância estatística como preditores de mortalidade nas primeiras 24 horas quando analisados de forma independente no estudo. O escore APACHE II apresentou-se como uma boa forma de avaliação prognostica para os pacientes, assim como o modelo proposto no presente estudo para previsão de mortalidade, que quando comparado ao escore APACHE II, apresentou um índice de confiabilidade e uma área sob a curva ROC mais elevada.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment.

BACKGROUNDHepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.AIMTo establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.METHODSThirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.RESULTSLaparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients’ poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.CONCLUSIONHPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients’ prognoses.

Are We Doing Enough to Reduce Ionizing Radiation Exposure in Children?: An Analysis of Current Approaches to Pediatric Appendicitis Imaging at a Major Urban Medical Center.

The aim of this study was to evaluate current imaging approaches in children with suspected appendicitis (AP) in the pediatric emergency department (ED) of a major urban medical center. Children aged 6 to 18 years who presented to a pediatric ED in 2016 with possible AP were identified by a keyword search. Charts were reviewed for the following: age, sex, time of evaluation, imaging study, results of imaging study, disposition, and outcome. We calculated mean values and SD for continuous data. Initially, 503 charts were identified. Of these 503, 292 children were identified as having possible AP. Mean age was 10.7 years (SD, 2.7); 50.6% presented between 5:00 PM and 8:00 AM the next morning. Of the 287 US studies performed, 114 (39.7%) were definitively positive or negative. Of these, 46 (16.0%) were negative for AP and 68 (23.7%) were positive. There were 173 (60.3%) ultrasounds that were equivocal. Computed tomography scans were performed in 41 (13.9%) of the total 292 patients, and 2 (0.7%) of the 292 received magnetic resonance imaging. Patient dispositions were as follows: discharged home, 163 (55.8%); admitted for appendectomy, 69 (23.6%); admitted for observation, 37 (12.7%); and extended observation in ED, 10 (3.4%). There were 83 (28.4%) total surgical and interventional radiology cases and 209 (71.6%) nonsurgical cases. Of the 81 appendectomies, 79 (97.5%) had an abnormal appendix, and 2 (2.5%) had no AP. Of the 79 abnormal appendices, 22 (27.8%) were perforated, 55 (69.6%) were not, and 2 (2.6%) were unclear. Computed tomography scans were performed in 13.9% of patients with suspected AP. The overall AP rate was 28.4%. We plan to increase the use of magnetic resonance imaging and other modalities to reduce overall computed tomography usage.

Clinical Performance and Concurrent Validity of the Adult Spinal Deformity Surgical Decision-making Score.

Multicenter, retrospective study. The aim of this study was to examine the performance and concurrent validity of the adult spinal deformity surgical decision-making (ASD-SDM) score compared to decision-making factors in the ASD population. The ASD-SDM score, which has been recently proposed, is a scoring system to guide the selection of treatment modality for the ASD population. To secure the justification for its clinical use, it is necessary to verify its clinical performance and concurrent validity. A multicenter prospective ASD database was retrospectively reviewed. The data were analyzed separately in younger (≤40 years) and older (≥41 years) age groups. The discriminating capacity of the ASD-SDM score in cases who selected surgical and nonsurgical management was compared using area under the receiver operator characteristic curves (AUROC). Concurrent validity was examined using Spearman correlation coefficients, comparing factors that are reported to be associated with the decision-making process for ASD, including baseline symptomatology, health-related quality of life measures, and the severity of radiographic spinal deformity. There were 338 patients (mean age: 26.6 years; 80.8% female; 129 surgical and 209 nonsurgical) in the younger age group and 750 patients (mean age: 63.5 years; 84.3% female; 410 surgical and 340 nonsurgical) in the older age group. In both younger and older patients, the ASD-SDM score showed a significantly higher performance for discriminating the surgical and nonsurgical cases (AUROC: 0.767, standard error [SE]: 0.026, P < 0.001, 95% confidence interval [CI]: 0.712-0.813; AUROC: 0.781, SE: 0.017, P < 0.001, 95% CI: 0.747-0.812, respectively) compared to the decision-making factors analyzed. In addition, the ASD-SDM showed significant correlations with multiple decision-making factors. The ASD-SDM score alone can effectively grade the indication for surgical management whilst considering multiple decision-making factors. 3.