Is gastric cancer after bariatric surgery on the rise?Will history repeat itself?

Gastric cancer is the fifth most common cancer and the fourth leading cause of cancer-related death worldwide(1).Despite its decreasing incidence during the last decades,a major concern has been raised in patients submitted to bariatric surgery(2).Morbid obesity incidence has increased worldwide leading to low quality of life expectancy in children。

Advances in surgical techniques for gastric cancer:Indocyanine green and near-infrared fluorescence imaging.Is it ready for prime time?

Surgery is still the primary curative treatment for gastric cancer,which includes resection of the tumor with adequate margins and extended lymphadenectomy.In order to improve the operative results and the quality of life of patients,several endeavors have been made toward precision medicine through image-guided surgery,allowing access to real-time intraoperative anatomy and accurate tumor staging.The goal of the surgeon is to achieve a more precise,individualized,and less invasive surgery without compromising oncological efficiency and safety.In this perspective,we have demonstrated the role of indocyanine green(ICG)and near-infrared(NIR)fluorescence imaging method in gastric cancer surgery.This technique may be used to improve localization of the tumor,detection of sentinel lymph nodes(SLN),real-time lymphatic mapping,and blood flow assessment(anastomosis perfusion).

护理诊断——失眠的相关因素及高危人群的文献分析

目的总结有关成人失眠预测因素的文献证据,并确定其与北美护理诊断学会国际组织(NorthAmerica Nursing Diagnosis Association International,NANDA-I)护理诊断——失眠的诊断指标的一致性。方法检索Pubmed,虚拟健康图书馆和CINAHI数据库,纳入2011—2018年以英语、葡萄牙语或西班牙语发表的48篇文章。分析失眠的预测因素、NANDA-I相关因素之间的一致性。结果本研究发现的预测因素与NANDA-I相关因素具有一致性,但悲伤和白天频繁打盹除外。吸烟、咖啡因摄入,睡眠信念功能失调、肥胖和照顾者角色障碍可能是新的相关因素;慢性病可能也是新的相关因素,婚姻状况变化,经济困难、女性、年龄增长和夜班工作者可能是新的高危人群。结论与NANDA-I诊断要素相一致的失眠预测因素可为护理诊断提供证据基础。本研究发现的与失眠护理诊断相关因素没有对应关系的预测因素可考虑纳入NANDA-I分类,从而为护士和学生的临床应用提供支持。

Prognostic implications of tumor-infiltrating lymphocytes in association with programmed cell death ligand 1 expression in remnant gastric cancer

Objective:Remnant gastric cancer(RGC)is usually associated with a worse prognosis.As they are less common and very heterogeneous tumors,new prognostic and reliable determinants are required to predict patients’clinical course for RGC.This study aimed to investigate the tumor-infiltrating lymphocytes(TILs)and programmed cell death ligand 1(PD-L1)status as prognostic biomarkers in a cohort of patients with RGC to develop an immunerelated score.Methods:Patients with gastric cancer(GC)who underwent curative intent gastrectomy were retrospectively investigated.RGC resections with histological diagnosis of gastric adenocarcinoma were enrolled in the study.The risk score based on immune parameters was developed using binary logistic regression analysis.RGCs were divided into high-risk(HR),intermediate-risk(IR),and low-risk(LR)groups based on their immune score.The markers(CD3+,CD4+/CD8+T cells and PD-L1)were selected for their potential prognostic,therapeutic value,and evaluated by immunohistochemistry(IHC).Results:A total of 42 patients with RGC were enrolled in the study.The score based on immune parameters exhibited an accuracy of 79%[the area under the receiver operating characteristic curve(AUC)=0.79,95%confidence interval(95%CI),0.63-0.94,P=0.002],and the population was divided into 3 prognostic groups:10(23.8%)patients were classified as LR,15(35.7%)as IR,and 17(40.5%)as HR groups.There were no differences in clinicopathological and surgical characteristics between the three groups.In survival analysis,HR and IR groups had worse disease-free survival and overall survival rates compared to the LR group.In the multivariate analysis,lymph node metastasis and the immune score risk groups were independent factors related to worse survival.Conclusions:A scoring system with immune-related markers was able to distinguish prognostic groups of RGC associated with survival.Accordingly,tumor-infiltrating immune lymphocytes and PD-L1 status may serve as a potential prognostic biomarker for patients with RGC.

Use of Initial Modified RECIST Tumor Response Evaluation Criteria for Predicting Survival in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization with Drug-Eluting Beads

Introduction: Transarterial chemoembolization (TACE) reduces tumor growth and increases survival in patients with hepatocellular carcinoma (HCC). Drug-eluting beads (DEB) deliver slow-release chemotherapy and reduce systemic toxicity during TACE. This study correlated initial tumor response according to modified RECIST (mRECIST) criteria and 1-year survival in patients with HCC treated with TACE-DEB, and identified predictors of tumor response. Methods: Fifty-two patients with HCC received TACE-DEB loaded with doxorubicin 75 mg during a 6-month period. Tumor response was evaluated 1 month after the procedure according to mRECIST criteria. Results: Most patients were cirrhotic and etiology of liver disease was hepatitis C in 26/52 (50%). Similar numbers of patients had Barcelona Clinic Liver Cancer (BCLC) A and BCLC B disease. Most patients had one nodule (66%). Complete response (CR) was achieved in 12/52 (23%), partial response in 19/52 (37%), stable disease in 4/52 (8%) and progressive disease in 17/52 (32%). Largest HCC ≤58 mm and BCLC stage A were associated with CR. The 1-year survival was 74%, with survival rates of 95% and 56% in the BCLC A and B groups, respectively. Variables reflecting tumor extension were associated with better survival. CR according to mRECIST criteria was a predictor of better 1-year survival (100% vs. 64%, P < 0.05). Conclusion: BCLC A and CR according to mRECIST criteria predict improved 1-year survival in patients with HCC treated with TACE-DEB. Further studies are needed to evaluate other predictors of survival and to determine if tumor response predicts long-term survival.

Acute pancreatitis complicated with splenic rupture: A case report

Atraumatic splenic rupture is an uncommon complication of acute pancreatitis. This report describes the case of a 30-year-old man with acute pancreatitis and splenic vein thrombosis complicated by splenic rupture. The patient was admitted to the emergency department with pain in the upper abdomen that had been present for six hours and was associated with vomiting and sweating. He was diagnosed with acute pancreatitis of alcoholic etiology. Upon computed tomography(CT) of the abdomen, the pancreatitis was scored as Balthazar C grade, and a suspicious area of necrosis affecting 30% of the pancreas with splenic vein thrombosis was revealed. Seventytwo hours after admission, the patient had significant improvement in symptoms. However, he showed clinical worsening on the sixth day of hospitalization, with increasing abdominal distension and reduced hemoglobin levels. A CT angiography showed a large amount of free fluid in the abdominal cavity, along with a large splenic hematoma and contrast extravasation along the spleen artery. The patient subsequently underwent laparotomy, which showed hemoperitoneum due to rupture of the splenic parenchyma. A splenectomy was then performed, followed by ultrasound-guided percutaneous drainage.

Oral PTCTS (Particulated Transialidase) Removes Serum Microparticles and Decreases Inflammation in Atherosclerotic Plaques of Rabbits

Background: Previous studies showed that atherosclerotic plaque vulnerability was related with microparticles (MPs)-vesicles larger than 100 nm, which released MMP9 collagenase. In our previous study, intramuscular injection of a new drug (PTCTS) normalized oxidized LDL serum levels and reduced rabbit atherosclerosis. Now, we studied administration of oral PTCTS in order to clarify anti-atherosclerotic mechanism of action, analyzing if the treatment removed MPs containing ox-LDL and Mycoplasma pneumoniae antigens and improved the immune response. Methods: We compared two groups of rabbits. Control group (CG, n = 6)—1% cholesterol enriched diet for 12 weeks;Treated group (TG, n = 8)—1% cholesterol enriched diet for 12 weeks with administration of PTCTS (400 μl/day) during the last 6 weeks of diet. The animals had their blood collected, in three different phases of the protocol before being fed with hypercholesterolemic diet, before being treated with water or PTCTS and at the moment of sacrifice. The serum was submitted to immunofluorescence technique to evaluate the quantity of microparticles marked with antibodies against Mycoplasma pneumoniae and ox-LDL. A fragment of aorta was submitted to immunohistochemical detection of antigens from MMP9, ox-LDL, NF-κB and IL-1β. Results: PTCTS showed significant reduction in MMP-9 (P = 0.001) and a tendency of reducing IL-1β (P = 0.09) in the aortic plaques compared with CG. In the serum, PTCTS was able to remove microparticles containing antigen of ox-LDL (P = 0.004) and Mycoplasma pneumoniae (P β and mycoplasma, as well as a better stabilization of the atheromatous plaque by reducing levels of MMP-9, avoiding plaque rupture, without causing mortality or toxicity.

Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial

BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy(POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy,has emerged as a promising minimally invasive technique for the management of this condition.AIM To compare POEM and laparoscopic myotomy and partial fundoplication(LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria(dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis(as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min(on a barium esophagogram), pressure at the LES, the occurrence of adverse events(AEs), length of stay(LOS), and quality of life(QoL).RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up(P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group(P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group(185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min,respectively;P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia,shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

Preoperative and Postoperative Spirometry in Patients Undergoing Lobectomy for Sequelae of Pulmonary Tuberculosis

Objective: To assess preoperative and postoperative spirometry values in patients undergoing lobectomy for sequelae of pulmonary tuberculosis. Method: A total of 20 patients (10 males) with history of treatment for tuberculosis and presenting with symptomatic sequelae (repeat infection or hemoptysis) who sought assistance at the chest surgery outpatient clinic between 11.09.07 and 04.02.10, were selected for the study. Only patients that met theeligibility criteria (symptomatic, submitted to tuberculosis treatment) were included in the study. The age of patients ranged from 15 to 56 years (mean: 35.75 years). The average treatment time for tuberculosis was 6 months and onset of symptoms occurred between 01 and 32 years after treatment. To assess the impact of surgery on the variables VC, FVC, FEV1, FEV1/FVC, FEF and PEF preoperative values were compared with postoperative values at 1st, 3rd, 6th and 12th month using the paired t test. The level of significance (α) applied for all tests was 5% where a value of p 0.05 was considered significant. Results: 11 patients were treated because of recurrent infections and 9 because of haemoptysis. The most common lobectomy was right upper lobectomy (7 patients), followed by left upper lobectomy (6 patients), left lower lobectomy (6 patients), and right middle lobectomy (1 patient). There were no postoperative complications. There was no postoperative mortality. Conclusion: Based on the results of the present study, it can be concluded that, at the 12th postoperative month, spirometric parameters of patients with tuberculosis sequelae submitted to lobectomy had returned to preoperative levels.

Proteomic profile of seminal plasma in adolescents and adults with treated and untreated varicocele

Varicocele, the most important treatable cause of male infertility, is present in 15% of adult males, 35% of men with primary infertility, and 80% of men with secondary infertility. On the other hand, 80% of these men will not present infertility. Therefore, there is a need to differentiate a varicocele that is exerting a deleterious effect that is treatable from a ＂silent＂ varicocele. Despite the growing evidence of the cellular effects of varicocele, its underlying molecular mechanisms are still eluding. Proteomics has become a promising area to determine the reproductive biology of semen as well as to improve diagnosis of male infertility. This review aims to discuss the state-of-art in seminal plasma proteomics in patients with varicocele to discuss the challenges in undertaking these studies, as well as the future outlook derived from the growing body of evidence on the seminal proteome.

Asymptomatic male with grade 3 left varicocele and two children desiring vasectomy with low testosterone

When studying varicocele and infertility, substantial knowledge have been acquired in many important areas, including prevalence, etiology, and pathophysiology to the point that varicocele is considered as the main cause of primary and secondary infertility in adult men. On the other hand, offering surgical treatment of varicoceles to improve androgen levels （without a focus on improving fertile potential） is quite controversial.