SR Group Research Articles

Second-line treatment of pediatric patients with relapsed rhabdomyosarcoma adapted to initial risk stratification: Data of the European Soft Tissue Sarcoma Registry (SoTiSaR).

Outcome of relapsed disease of localized rhabdomyosarcoma remains poor. An individual treatment approach considering the initial systemic treatment and risk group was included in the Cooperative Weichteilsarkom Studiengruppe (CWS) Guidance. Second-line chemotherapy (sCHT) ACCTTIVE based on anthracyclines (adriamycin, carboplatin, cyclophosphamide, topotecan, vincristine, etoposide) was recommended for patients with initial low- (LR), standard- (SR), and high-risk (HR) group after initial treatment without anthracyclines. TECC (topotecan, etoposide, carboplatin, cyclophosphamide) was recommended after initial anthracycline-based regimen in the very high-risk (VHR) group. Data of patients with relapse (n=68) registered in the European Soft Tissue Sarcoma Registry SoTiSaR (2009-2018) were retrospectively analyzed. Patients of initial LR (n=2), SR (n=16), HR (n=41), and VHR (n=9) group relapsed. sCHT consisted of ACCTTIVE (n=36), TECC (n=12), or other (n=15). Resection was performed in 40/68 (59%) patients and/or radiotherapy in 47/68 (69%). Initial risk stratification, pattern/time to relapse, and achievement of second complete remission were significant prognostic factors. Microscopically incomplete resection with additional radiotherapy was not inferior to microscopically complete resection (p=.17). The 5-year event-free survival (EFS) and overall survival (OS) were 26% (±12%) and 31% (±14%). The 5-year OS of patients with relapse of SR, HR, and VHR groups was 80% (±21%), 20% (±16%), and 13% (±23%, p=.008), respectively. Adapted systemic treatment of relapsed disease considering the initial risk group and initial treatment is reasonable. New treatment options are needed for patients of initial HR and VHR groups.

‘Triple clear’: a systematic and comprehensive surgical process for Campanacci grades II and III giant cell tumors of the bone, with or without pathological fracture and slight joint invasion

BackgroundIn recent years, researchers have proposed a number of adjuvant methods for extended curettage of giant cell tumors of the bone. However, various schemes have significant differences in efficacy and safety. Therefore, this article will describe an empirical expanded curettage protocol, ‘triple clear’, in detail to show the effect of the efficient surgical protocol.MethodPatients with Campanacci grades II and III primary GCTB who were treated with either SR (n = 39) or TC (n = 41) were included. Various perioperative clinical indicators, including the therapy modality, operation time, Campanacci grade, and filling material were recorded and compared. The pain level was determined by the visual analog scale. Limb function was determined by the Musculoskeletal Tumour Society (MSTS) score. Follow-up time, recurrence rates, reoperation rates, and complication rates were also recorded and compared.ResultThe operation time was 135.7 ± 38.4 min in the TC group and 174.2 ± 43.0 min in the SR group (P < 0.05). The recurrence rates were 7.3% in the TC group and 8.3% in the SR group (P = 0.37). The MSTS scores at three months after surgery were 19.8 ± 1.5 in the TC group and 18.8 ± 1.3 in the SR group. The MSTS scores at two years were 26.2 ± 1.2 in the TC group and 24.3 ± 1.4 in the SR group (P < 0.05).ConclusionTC is recommended for patients with Campanacci grade II–III GCTB and for those with a pathological fracture or slight joint invasion. Bone grafts may be more suitable than bone cement in the long term.

A simple procedure to identify children with B‐lineage acute lymphoblastic leukemia who can be successfully treated with low or moderate intensity: Sequential versus single‐point minimal residual disease measurement

Sequential monitoring of minimal residual disease (MRD) by molecular techniques or multicolor flow cytometry (MFC) has emerged over the past two decades as the primary tool to optimize treatment in pediatric B-cell precursor acute lymphoblastic leukemia (BCP-ALL). The aim of our study was to compare the prognostic power of repeated MFC-MRD measurement with single-point MRD assessment in children with BCP-ALL treated with the reduced-intensity protocol ALL-MB 2008. Data from consecutive MFC-MRD at day 15 and day 36 (end of induction, EOI) were available for 507 children with Philadelphia-negative BCP-ALL. They were stratified into standard risk (SR, n=265), intermediate risk (ImR, n=211), and high risk (HR, n=31) according to the initial clinical characteristics defined in the ALL-MB 2008 protocol. Quantitative (relative to quantitative thresholds) and kinetic (logarithmic reduction) assessments of MFC-MRD at both time points effectively separated patients into three groups with different risk of recurrence. On the other hand, starting with low (for the SR group) and moderate (for the ImR group) induction therapy, a single MFC-MRD measurement at EOI proved sufficient to unequivocally identify patients in whom this therapy is highly effective and distinguish them from those who cannot be successfully treated with such therapy. Therefore, initiating treatment with low or moderate treatment from the start, together with careful consideration of initial clinical risk factors and just one EOI-MFC-MRD measurement is simple, inexpensive, and entirely sufficient for treatment optimization. Furthermore, for a large proportion of patients, this approach allows better adjustment, in particular also reduction of therapy intensity than sequential MRD measurements.

Surgical approach affecting long-term urinary continence status after robot-assisted laparoscopic prostatectomy prospectively evaluated using self-reported functional status (Expanded Prostate Cancer Index Composite, EPIC-26).

The aim of the study was to examine the influence of the surgical approach for robot-assisted laparoscopic prostatectomy (RALP) on long-term urinary continence status in the era of self-reported functional status measures using the Expanded Prostate Cancer Index Composite 26. This is a prospective evaluation of 232 patients undergoing RALP between September, 2019 and September, 2020. Urinary continence status and postoperative incontinence (pad usage) were evaluated 12 months after RALP using Expanded Prostate Cancer Index Composite 26 questionnaires. Patients were categorized according to their surgical approach and outcome into the following groups: successful nerve sparing (NS), primarily without nerve sparing (prim. NNS), and no nerve sparing by secondary resection (NNS by SR). The median levels of their questionnaire outcomes were evaluated and compared using the Wilcoxon rank sum test with continuity correction. Urinary continence status 12 months after RALP differed significantly between the NS and prim. NNS (p = 0.0071) and the NS and NNS by SR (p = 0.0076) groups. There was no significant difference between the prim. NNS and NNS by SR (p = 0.53) groups. Pad usage 12 months after RALP had no significant difference with regard to SR of the neurovascular bundle (p = 0.14). Patient-reported outcomes of long-term urinary continence status seem to show no difference in postoperative continence, regardless of whether a non-nerve-sparing result was planned or reached through SR. Instead, preservation of neurovascular bundle seems to lead to better long-term continence rates.

Change in Long Non-Coding RNA Expression Profile Related to the Antagonistic Effect of Clostridium perfringens Type C on Piglet Spleen.

LncRNAs play important roles in resisting bacterial infection via host immune and inflammation responses. Clostridium perfringens (C. perfringens) type C is one of the main bacteria causing piglet diarrhea diseases, leading to major economic losses in the pig industry worldwide. In our previous studies, piglets resistant (SR) and susceptible (SS) to C. perfringens type C were identified based on differences in host immune capacity and total diarrhea scores. In this paper, the RNA-Seq data of the spleen were comprehensively reanalyzed to investigate antagonistic lncRNAs. Thus, 14 lncRNAs and 89 mRNAs were differentially expressed (DE) between the SR and SS groups compared to the control (SC) group. GO term enrichment, KEGG pathway enrichment and lncRNA-mRNA interactions were analyzed to identify four key lncRNA targeted genes via MAPK and NF-κB pathways to regulate cytokine genes (such as TNF-α and IL-6) against C. perfringens type C infection. The RT-qPCR results for six selected DE lncRNAs and mRNAs are consistent with the RNA-Seq data. This study analyzed the expression profiling of lncRNAs in the spleen of antagonistic and sensitive piglets and found four key lncRNAs against C. perfringens type C infection. The identification of antagonistic lncRNAs can facilitate investigations into the molecular mechanisms underlying resistance to diarrhea in piglets.

Is there any difference in the therapeutic effects of Levosimendan on advanced HFrEF patients with sinus rhythm or atrial fibrillation?

Patients with advanced heart failure have a high incidence of atrial fibrillation (AF) and develop into heart failure with reduced ejection fraction (HFrEF), and require higher doses of inotropes. However, it is uncertain about the differences in the effects of levosimendan in HFrEF patients with sinus rhythm or AF. A total of 63 advanced HFrEF subjects (ejection fraction < 40%) were divided into sinus rhythm (SR, n = 34) and atrial fibrillation (AF, n = 29) cohorts. All patients received six cycles of intermittent repeated levosimendan infusion. After 3 months of treatment, B-type natriuretic peptide (BNP), estimated glomerular filtration rate, resting heart rate (rHR), creatinine, left ventricle ejection fraction (LVEF), left ventricular end diastolic diameter and blood pressure body weight, NYHA classification were measured. After completing the course of treatment, LVEF, BNP, and rHR were significantly decreased (p < 0.0.5), and no significant differences between the two groups were observed (p > 0.05). The NYHA classification improved in the SR group but not in the AF group. There was no significant difference between patients with different rHRs (≤70 bpm vs. >70 bpm) in the SR group (p > 0.05) or in the AF group (rHR ≤ 90 bpm vs. rHR >90 bpm) (p > 0.05). This study showed no difference in the therapeutic effect of intermittent repeated levosimendan infusion on advanced HFrEF with different heart rhythms (SR or AF); Advanced HFrEF patients receive levosimendan treatment without taking the inference of heart rhythm.

Short and long-term oncologic outcomes of patients with colon cancer of the splenic flexure

BackgroundThere is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA). MethodsPatients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR). ResultsOne-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01–1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7–5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76–20.82, p < 0.001) were predictive of mortality. ConclusionsShort and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.

Clinical Comparative Analyses of Thymectomy Between Subxiphoid and Subcostal Arch Thoracoscopic Resection and Median Sternotomy for the Treatment of Thymoma With Myasthenia Gravis in Chinese Patients

IntroductionThis study aims to retrospectively compare the efficacy and safety of subxiphoid and subcostal arch thoracoscopic resection (SR) and the median sternotomy (MS) for thymoma with myasthenia gravis (MG) via propensity-matched analysis. MethodsWe retrospectively analyzed 502 patients with thymoma and MG in Tangdu Hospital of the Fourth Military Medical University from December 2012 to December 2017. The patients were allocated to SR group (n = 424) and MS group (n = 78). Perioperative outcomes were compared between SR group and MS group by using propensity-matched analysis. ResultsAll SR and MS operations were accomplished successfully. Most postoperative outcomes between the two groups showed no significant difference such as remission of MG and postoperative complication (P > 0.05). There were statistically significant differences between MS group and SR group in operation time [(116.3 ± 33.7) min versus (52.2 ± 31.3) min], intraoperative blood loss [(145.2 ± 26.7) mL versus (51.2 ± 10.3) mL], chest drainage duration (3.4 d versus 0 d), days of hospital-stay (5.2 d versus 2.7 d), patient satisfaction score (5.9 ± 2.3 versus 8.7 ± 1.2), the incidence of complications and pain scores, with all P values < 0.05. ConclusionsThis study suggests that subxiphoid and subcostal arch thoracoscopic resection is a less invasive procedure with good safety and feasibility as compared with median sternotomy for thymoma with myasthenia gravis.

Impact of atrial fibrillation on the cognitive decline in Alzheimer’s disease

BackgroundAtrial fibrillation (AF) is a strong risk factor for Alzheimer’s disease (AD) independent of ischemic stroke. However, the clinicopathological impact of AF on the severity of AD has not been well elucidated. We aimed to investigate the clinical differences between dementia patients with AF and those without AF by means of imaging data.MethodsFollowing approval from the institutional ethics committee, patients with newly diagnosed AD or amnestic mild cognitive impairment (aMCI) were retrospectively screened (n = 170, 79.5 ± 7.4 years old). Cognitive function was assessed using the Mini-Mental State Examination (MMSE). Based on the MRI data, the cerebral volume, cerebral microbleeds (CMBs), periventricular white matter lesions (WMLs), and deep WMLs were evaluated. The regional cerebral blood flow (rCBF) was measured using 123I-IMP SPECT.ResultsOf the patients, 14 (8.2%) and 156 (91.8%) had AF (AF group) and sinus rhythm (SR group), respectively. The AF group had significantly lower MMSE scores than the SR group (average [standard deviation (SD)]: 19.4 [4.4] and 22.0 [4.4], respectively; p = 0.0347). Cerebral volume and CMBs did not differ between the two groups. The periventricular WMLs, but not the deep WMLs, were significantly larger in the AF group than in the SR group (mean [SD] mL: 6.85 [3.78] and 4.37 [3.21], respectively; p = 0.0070). However, there was no significant difference in rCBF in the areas related to AD pathology between the two groups.ConclusionAD and aMCI patients with AF showed worse cognitive decline along with larger periventricular WMLs compared to those with SR, although the reduction of rCBF was not different between patients with AF and SR. The white matter lesions may be a more important pathology than the impairment of cerebral blood flow in dementia patients with AF. A larger study is needed to confirm our findings in the future.

Psychosocial characteristics pattern correlated with HIV-related risky sexual behavior among HIV-negative men who have sex with men: a latent profile analysis

Men who have sex with men (MSM) have become a high risk population of HIV infection due to their risky sexual behaviors. The latent pattern of psychosocial characteristics plays an important effect in HIV-related risky behaviors among HIV-negative MSM. Participants were recruited from Wuhan, Nanchang, and Changsha city from September 2017 to January 2018. Social support was assessed by the multidimensional scale of social support, Connor-Davidson Resilience scale-10 items for reliance, the assessment of Stigma towards Homosexuality for sexual minority stigma, the Likert subscale of nondisclosure for identity concealment, the ACE questionnaire-Kaiser-CDC for adverse childhood experience, the Centers for Epidemiological Studies Depression Scale for depression. Latent profile analysis (LPA) and multivariate regression were used to analyze the data. Three psychosocial characteristic patterns were revealed by the LPA. "Social support and resilience group" (SR group), "Identity concealment group" (IC group) and "Adverse childhood experience" (ACE group) were identified, respectively. In comparison with "SR group", "IC group" have a higher likelihood of one-night male partners (AOR = 2.74, 95%CI = [1.54, 4.90]), both fixed and one-night male partners (AOR = 2.01, 95%CI = [1.34, 3.01]) and HIV-unsure male partner (AOR = 2.12, 95%CI = [1.44, 3.13]). Similarly, "ACE group" were more likely having inconsistent condom use (AOR = 2.58, 95%CI = [1.41, 4.73]), and having sex with HIV-positive male partner (AOR = 4.90, 95%CI = [1.95, 12.30]) with comparison of "SR group". In addition, we further revealed that "ACE group" had a higher ratio (90.0%) of inconsistent condom use among MSM whose male partners were HIV-positive. Six important psychosocial factors were divided into three latent pattern classes. Compared with "SR group", "IC group" and "ACE group" were more likely to engage in HIV-related risky sexual behaviors. Further research may pay more attention to "IC group" and "ACE group" for targeted intervention.

Expression of PDGFR-&amp;lt;i&amp;gt;α&amp;lt;/i&amp;gt; in Patients with Valvular Atrial Fibrillation

Objective: To investigate the expression of Platelet-derived growth factor receptor alpha (PDGFR-α) in patients who have valvular atrial fibrillation. Methods: In this research, eighty-four patients with rheumatic heart disease who were going to undertake cardiac surgery were included. The subjects were divided into two groups: the AF group and the sinus rhythm group, the quantities are 39 and 45 respectively. Before the surgery, baseline demographics, physical examination, routine laboratory testing, echocardiography, echocardiographic data and additional clinical data were available for all patients. The right atrial tissue of the subjects was separated during surgery, with an area of approximately 0.3 - 0.5 mm3. Immunofluorescence staining was used to analyze the distribution of PDGFR-α of atrial tissue. mRNA of PDGFR-α in atrial tissue were determined by real-time quantitative PCR (Polymerase Chain Reaction); Western-Blot technique was used to measure the protein of PDGFR-α in atrial tissue. Results: There were no significant differences (P > 0.05) in sex ratio, age, blood pressure, blood biochemistry, and other aspects of medical history between the two groups. However, the right and left atrium diameters in the AF group were markedly larger than those in the SR group (P α from right atrial tissue were obviously higher in the AF group than that in the SR group (P α in the right atrial tissue of patients with atrial fibrillation was found to be significantly higher.

Effects of soy milk ingestion immediately after resistance training on muscular-related biomarkers in older men: a randomized controlled trial.

We evaluated the effects of soy milk ingestion on changes in body composition, strength, power, and muscular-related biomarkers following 12 weeks of resistance training in older men. Thirty healthy older men (age = 65.63 ± 3.16 years; body mass = 62.63 ± 3.86 kg) were randomly assigned to one of two groups: soy milk + resistance training (SR) or placebo + resistance training (PR). Participants in the SR group received 240 ml of vanilla-flavoured non-dairy soy milk immediately after every training session and at the same time on non-training days. Differences in muscle mass, upper limb body strength (UBS), lower limb aerobic power (LAP), activin A, and GDF15 were significantly greater in the SR group vs. the PR group (P < 0.05). Both intervention groups experienced a significant (p < 0.05) reduction in body mass (PR = -3.9 kg; SR = -3.2 kg), body fat % (PR = -0.8%; SR = -1.2%), activin A (PR = -5.1 pg/ml; SR = -12.8 pg/ml), GDF15 (PR = -8.1 pg/ml; SR = -14.7 pg/ml), TGFβ1 (PR = -0.43 pg/ml; SR = -0.41 pg/ml), and increase in muscle mass (PR = 0.81 kg; SR = 2.5 kg), UBS (PR = 3.4 kg; SR = 6.7 kg), lower limb body strength (PR = 2.8 kg; SR = 5.2 kg), upper limb aerobic power (PR = 34.3 W; SR = 38.6 W), LAP (PR = 23.2 W; SR = 45.2 W), BDNF (PR = 8.3 ng/ml; SR = 12.7 ng/ml), and irisin (PR = 1.5 ng/ml; SR = 2.9 ng/ml) compared to baseline. The ingestion of soy milk during 12 weeks of resistance training augmented lean mass, strength, and power, and altered serum concentrations of skeletal muscle regulatory markers in older men.

Randomized clinical trial of tissue equivalent bolus prescription in postmastectomy radiotherapy stratified by skin involvement status

PurposeTo assess the impact and optimize the prescription of tissue-equivalent bolus in postmastectomy radiotherapy (PMRT), we compared the use of different bolus regimens tailored by skin involvement status. MethodsPatients with breast cancer who required PMRT were recruited (NCT01925651) and classified into two groups: standard-risk (SR, without skin involvement) and high-risk (HR, with skin involvement). SR was randomized between no bolus or 5 mm-bolus on alternate days and HR between 5 mm-bolus on alternate days or daily. Conventional fractionation (50.4 Gy; 1.8 Gy/daily) was used. Acute skin toxicity was evaluated blindly and the radiodermatitis-specific toxicity index [rads-TI] calculated. Subsequently, patients were followed up to assess oncologic outcomes, focusing on chest wall (CW) local control. ResultsFifty-eight patients were enrolled (34 SR and 24 HR). Baseline characteristics were similar between arms within the same risk group. Overall, maximal radiodermatitis rates were 29.4 % (G2) and 15.7 % (G3). In the SR group, no difference existed in G2 radiodermatitis incidence between the subgroups (p = 0.70) and no G3 events occurred. In the HR group, incidences of G2 (100 % vs 44.5 %, p = 0.01) and G3 radiodermatitis (70 % vs 11.1 %, p = 0.02) were higher with daily bolus. After adjusting for confounders, the daily bolus had a higher incidence of G2 (p = 0.03), G3 radiodermatitis (p = 0.04), and worse rads-TI (p < 0.01). After a median follow-up of 6.2 years, the 5-year local control was 95.8 % (95 %CI: 88.2 %–100 %) in the SR and 91.7 % (95 %CI: 77.3 %–100 %) in the HR groups. Per risk group, there was no difference in local control between the SR (p = 0.90) or the HR bolus regimens (p = 0.70). ConclusionDaily 5 mm bolus prescription significantly increased the overall toxicity burden. In this preliminary study, within the same risk group, no detriment in CW local control was detected with less intense bolus regimens (SR: no bolus; HR: alternate-days bolus). Additionally, the rads-TI was able to distinguish overall radiodermatitis burden.

Interactive Effects of Swimming High-Intensity Interval Training and Resveratrol Supplementation Improve Mitochondrial Protein Levels in the Hippocampus of Aged Rats.

Mitochondrial dysfunction and increased oxidative stress cause damage to cells which can lead to the aging process and age-related diseases. Antioxidants such as resveratrol and high-intensity exercise can benefit oxidative damage prevention. This study is aimed at evaluating the effects of swimming high-intensity interval training and resveratrol on mitochondrial metabolism key proteins, SIRT5, SOD1, and PDH-E1α, and the level of NAD+ as a cofactor in the deacetylation process in aged rat hippocampus. Forty-five male Wistar rats, aged 20 months, were randomly divided into five groups: control (C), Swimming High-Intensity Interval Training (HIIT) (S-HIIT), Swimming HIIT with resveratrol supplementation (S-HIIT-R), resveratrol supplementation (R), and solvent of resveratrol supplementation (SR). S-HIIT and resveratrol groups performed the exercise and received resveratrol (10 mg/kg/day, gavage) for six weeks. Western blot analysis was performed to determine the protein level in the hippocampus. The amount of SIRT5 and SOD1 proteins in the hippocampus increased. S-HIIT with resveratrol or resveratrol alone increased the PDH-E1α level significantly. The amount of NAD+ was analyzed by assay kit that was reduced in S-HIIT, S-HIIT-R, and SR groups compared to controls. The results showed that resveratrol and S-HIIT attenuated the age-related brain changes by increasing the expression of SOD1 and SIRT5 and reducing the level of NAD+ in the hippocampus. Considering these findings, S-HIIT and resveratrol supplementation could be proposed as strategies to attenuate age-related brain changes. Resveratrol alone and exercise through the regulation of crucial proteins and cofactors can influence mitochondrial metabolism and oxidative stress in the hippocampus of aged rats.

Safety and Efficacy of Simultaneous Resection of Gastric Carcinoma and Synchronous Liver Metastasis-A Western Center Experience.

Background and objectives: Gastric cancer (GC) is often diagnosed in the metastatic stage. Palliative systemic therapy is still considered the gold standard, even for patients with resectable oligometastatic disease. The aim of the current study is to assess the potential benefit of up-front gastric and liver resection in patients with synchronous resectable liver-only metastases from GC (LMGC) in a Western population. Materials and Methods: All patients with GC and synchronous LMGC who underwent gastric resection with or without simultaneous resection of LMs between January 1997 and December 2016 were selected from the institutional records. Those with T4b primary tumors or with unresectable or more than three LMs were excluded from the analysis. All patients who underwent emergency surgery for hemorrhagic shock or gastric perforation were also excluded. Results: Out of 28 patients fulfilling the inclusion criteria, 16 underwent simultaneous gastric and liver resection (SR group), while 12 underwent palliative gastric resection (GR group). The median overall survival (OS) of the entire cohort was of 18.81 months, with 1-, 3- and 5-year OS rates of 71.4%, 17.9% and 14.3%, respectively. The 1-, 3- and 5-year OS rates in SR group (75%, 31.3% and 25%, respectively) were significantly higher than those achieved in GR group (66.7%, 0% and 0%, respectively; p = 0.004). Multivariate analysis of the entire cohort revealed that the only independent prognostic factor associated with better OS was liver resection (HR = 3.954, 95% CI: 1.542-10.139; p = 0.004). Conclusions: In a Western cohort, simultaneous resection of GC and LMGC significantly improved OS compared to patients who underwent palliative gastric resection.

Perioperative Reflection: An Understudied Yet Common Practice Among Surgical Residents

Directed reflection, a descriptive, analytical, and critical reasoning process, has been implemented in several professional fields as a method of developing expertise. In surgery, investigation of reflection has been limited. To date, we are unaware of any study that has sought to define or characterize the independent reflective practices of surgical trainees. In this small pilot study, we characterize the independent operative reflection activities among surgical residents at a single academic institution. An unvalidated survey was developed through cognitive interviews and pilot testing to assess 5 aspects of operative reflection. An IRB approved electronic survey was developed and distributed to all general surgery residents at an academic institution. Responses were divided by post-graduate year into junior residents (JR; PGY 1-3) and senior residents (SR; PGY 4-5). A response rate of 46% (23/50) was attained. All respondents self-identified as operative reflectors. Three primary methods of reflection were identified: mental, written, and oral. Mental reflection was the primary reflection method of 75% of our respondents as identified by step-by-step mental rehearsal, internal narration, and question series. Reflection was practiced everyday by 42% of respondents. Topics of reflection focused on weaknesses (50%), self-improvement (35%) and judgment (15%). Several respondents (57%) indicated that reflection-based learning tools would be useful. No statistically significant changes in the method or frequency were established between junior and senior residents (p = 0.378, p = 0.464, respectively). Variation in mental reflection activities among JR and SR groups were found (p = 0.029, p = 0.00004, respectively). The enduring role of reflection in experiential learning has been established in many professional fields but remains under-utilized in surgical education. Our study suggests surgical residents reflect independently of curriculum in individual and categorizable ways. Further investigation is required to adequately characterize reflective habits of the surgical resident and evaluate its impact on competency.

Myeloperoxidase Levels in Pericardial Fluid Is Independently Associated with Postoperative Atrial Fibrillation after Isolated Coronary Artery Bypass Surgery

Postoperative atrial fibrillation (POAF) is the most common complication after surgery for atherosclerotic cardiovascular disease (ASCVD) and leads to extended hospital stays and increased mortality. Myeloperoxidase (MPO) in postoperative pericardial drainage fluid is associated with an increased risk of POAF; however, the correlations between MPO in intraoperative pericardial fluid and POAF remain largely unknown. The aim of the study was to evaluate whether MPO is associated with POAF. A total of 97 patients with no history of atrial arrhythmia who had undergone coronary artery bypass surgery (CABG) were identified. We prospectively measured the levels of MPO in intraoperative pericardial fluid and blood using the human magnetic Luminex assay. Then, the occurrence of atrial fibrillation was continuously observed by postoperative ECG and telemetry strips until discharge. Our data showed that POAF occurred in 24 of 97 patients (24.74%). MPO levels in blood were higher in the POAF group than the SR group (p = 0.064). Patients with POAF had significantly higher intraoperative pericardial fluid MPO levels than patients who remained in SR (p = 0.021). There was no significant correlation between pericardial fluid MPO levels and blood MPO levels (r = -0.47, p = 0.770). In a multivariable logistic regression model, pericardial fluid MPO levels were significantly associated with a higher risk of POAF (odds ratio = 1.016, 95% confidence interval, 1.001-1.031; p = 0.031). Higher intraoperative pericardial fluid MPO levels are linked with POAF in patients undergoing CABG. This finding provides insight into a possible mechanism of MPO in pericardial fluid increase susceptibility to developing POAF in patients undergoing CABG.

On the Mechanism of Anti-galvanic Metal Displacement Reaction between [Au25(SR)18]- and Metal-Thiolate Complex.

Metal displacement reaction is widely used for preparing alloy nanomaterials. In this study, the mechanism of anti-galvanic metal displacement reaction between the atomic precision [Au25(SC2H4Ph)18]- cluster and the metal-thiolate complexes SR-M-SR (M = Ag, Cd, and Hg) is studied based on dispersion correction density functional theory (DFT-D) calculations. The present study reveals that the metal displacement reaction of the Au25 cluster is carried out through two-stage metal diffusion including the rapid diffusion of the metal heteroatom from metal thiolate to the ligand layer of Au25 cluster and then gradual diffusion of the metal heteroatom into the icosahedral 13-atom core. The atomic charge analysis confirms that the SR group plays a crucial role. Due to the partial reducibility of SR group, it can nucleophilic attack Au atom to result in the fracture of the Au-S bond in the ligand layer and the formation of atomic vacancy on the surface of the metal core, which facilitates the metal heteroatom diffusion from the metal-SR complex to the ligand layer of gold cluster and then to the surface of gold core.

Evaluation of High-Dose Cytarabine Induction Therapy and Flow Cytometric Measurable Residual Disease Monitoring for Children with De Novo Acute Myeloid Leukemia: A Report from the JPLSG-AML-12 Trial

Background: High-dose cytarabine (HDAC) in initial induction therapy has been tested in several clinical trials both in children and adults with acute myeloid leukemia (AML), however, the trial results are conflicting. In addition, there is growing evidence on significance of measurable residual disease (MRD) monitoring to predict subsequent relapse, but MRD in AML is still challenging in terms of methodology and quality control. In the nationwide clinical trial AML-12 by the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG), the hematological malignancy subgroup of the Japan Children's Cancer Group (JCCG), a role of HDAC in initial induction and feasibility and efficacy of central reference laboratory-based flow cytometric MRD (FCM-MRD) monitoring were evaluated in children with AML. Patients & Methods: JPLSG-AML-12 trial (registered as jRCTs041180128) was designed as a seamless phase II/III trial; because of a safety concern in HDAC induction, children (0-18 years old) with newly diagnosed de novo AML (excluding acute promyelocytic leukemia and AML in Down syndrome patients) registered in selected institutions were randomized to receive either standard ECM (etoposide, standard-dose cytarabine, and mitoxantrone) or experimental HD-ECM (etoposide, HDAC, and mitoxantrone) induction, while patients registered in non-selected institutions were non-randomly allocated to receive standard ECM; in the following phase III part, all the patients were randomized. FCM-MRD were measured at two time points [end of Induction-1 (EOI-1) and end of Induction-2 (EOI-2)] at either of the two central reference laboratories (Mie University or Kyoto University) but was not used to guide subsequent therapies. Following complete remission (CR) evaluation at EOI-2, patients achieving CR were allocated to either of the 3 risk groups and received post-remission chemotherapies; core-binding-factor standard risk (CBF SR), non-CBF SR, or high risk (HR) group. Only HR patients were allocated to receive allogeneic hematopoietic stem cell transplantation in first CR. Primary endpoints of the trial were 3-year EFS and positive FCM-MRD (≥0.1%) rate at EOI-1. Results: Total 359 eligible patients were registered at 102 institutions between 2014-2018. CR, 3-year EFS, and 3-year OS rates of all patients were 94.0%, 63.1% (95%CI, 57.9-67.9%), and 80.3% (95%CI, 75.8-84.1%), respectively. Among all, 324 patients were randomized (ECM, n=168; HD-ECM, n=156). Median follow-up period of these patients was 50.9 months (range, 0.2 - 84.7 months). No significant difference in outcomes were observed between the 2 arms; CR rates were 94.2% vs. 93.8% (p=0.998), 3-year EFS rates were 64.3% (95%CI, 56.5-71.0%) vs. 61.2% (53.1-68.4%) (p=0.551), 3-year OS rates were 84.4% (95%CI, 78.0-89.1%) vs. 75.3% (95%CI, 67.7-81.4%) (p=0.053), 3-year cumulative incidence of relapse were 28.6% (95%CI, 21.5-36.0%) vs. 30.9% (95%CI, 23.3-38.8%) (p=0.585), and 3-year non-relapse mortality rates were 0.9% (95%CI, 0.1-6.4%) vs. 1.8% (95%CI, 0.4-7.1%) (p=0.832). These outcome parameters were not different within each risk groups as well. FCM-MRD at EOI-1 was evaluated in 135 patients (80.4%) in the ECM arm and 127 patients (81.4%) in the HD-ECM arm; the positive FCM-MRD rates were 21.5% vs. 25.2% (p=0.575). Regarding grade 3 or higher adverse events (AEs) evaluated by CTCAE version 4 during Induction-1, disseminated intravascular coagulation was more frequent in the HD-ECM arm (1.8% vs. 6.4%, p=0.046), but no significant difference was observed for other AEs. Univariable Cox regression analysis for baseline characteristics revealed that the intermediate-risk cytogenetics and positive FLT3-ITD were significantly associated with decreased EFS rate. However, in multivariable analyses for EFS after EOI-1 and EOI-2, FCM-MRD was the sole poor prognostic factor; hazard ratios were 5.24 (95%CI, 3.19-8.63) (p<0.001) at EOI-1 and 5.56 (95%CI, 2.93-10.54) (p<0.001) at EOI-2. Conclusions: Although HDAC in initial induction did not improve the outcome of children with AML, overall outcomes were comparable to the recently completed pediatric AML trials worldwide. Central reference laboratory-based FCM-MRD measurement was feasible and MRD at both EOI-1 and EOI-2 were the most powerful prognostic factors to predict outcome of children with AML. Therefore, FCM-MRD should be included in future risk stratification for children with AML. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 13131: Three-Dimensional Echocardiography Left Atrial Appendage Dimensions is a Reflect of Cardiac Rhythm at Mid-Term Follow-Up in Atrial Fibrillation Patients

Introduction: Few studies have described the characteristics of the left atrial appendage (LAA) using three dimensional (3D) transesophageal echocardiography (TEE) in atrial fibrillation (AF). Hypothesis: We hypothesized that 3D characteristics of the LAA could further characterize patients in AF. Methods: We prospectively evaluated 156 patients hospitalized for AF with two-dimensional (2D) transthoracic and 3D TEE of the LAA within 24 hours of admission. 3D parameters were off-line analysed with Tomtec software (4D Cardio-View, Generic Volume, Philips) (Figure 1A). Patients were divided into two groups according to the cardiac rhythm at 2 years of follow up: restoration of sinus rhythm (SR group, 107 patients) or persistence of atrial fibrillation (AF group, 49 patients). Results: The mean age of the population was 66±11 years and 95 (61%) patients were male. At admission using 2D transthoracic echocardiography, AF group had in comparison with SR group higher left atrial end-systolic volume indexed (respectively 48.0 (38.7-57.0) versus 41.8 (35.0-51.5) ml/m 2 , p=0.0096), higher E velocity (respectively 0.90 (0.78-1.00) versus 0.76 (0.62-0.91) m/s, p= 0.0001) and higher pulmonary arterial pressure (respectively 31 (25-38) versus 28 (23-33) mmHg, p=0.0142). There were no significant differences in left ventricle ejection fraction and right atrial end-systolic volume indexed. At admission using 2D TEE, AF group had in comparison with SR group lower emptying flow velocity (29 (20-38) versus 38 (26-53) cm/s, p=0.002) and filling flow velocity (29 (20-39) versus 40 (29-56) cm/s, p=0.001) of the LAA. In 3D TEE, AF group had higher 3D end-systolic and end-diastolic LAA volumes (non-indexed and indexed) and no significant differences in LAA ostium in comparison with SR group (Figure 1B). Conclusions: 3D evaluation of the LAA reflects a degree of cardiac cavities remodeling in AF and seems to be associated with the evolution of cardiac rhythm at two-years follow-up.