Immunobiology of spinal cord injuries and potential therapeutic approaches.

The incidence of spinal cord injuries (SCI) is high every year. As the spinal cord is the highway that allows for the brain to control the rest of the body, spinal cord injuries greatly impact the quality of life of the patients. The SCI include the primary response consisting of the initial accident-induced damage and the secondary response that is characterized by damage due to inflammation and biological responses. Astrocytes are the first to act at the site of the injury, forming a glial scar and attracting immune cells. The immune system plays a role in cleaning out the debris caused by the injury, as well as preventing neurons to grow and heal. The secondary injury caused by the inflammatory response is the major target to combat SCI. This article critically reviews the key players in the inflammatory SCI response and potential therapies, specifically targeting astrocytes, neutrophils, and macrophages. These cells are both beneficial and detrimental following SCI, depending on the released molecules and the types of cells infiltrated to the site of injury. Indeed, depending on the subtype of macrophages, M1 or M2, beneficial or detrimental response could be incited. Therapeutic strategies to regulate and manipulate the immune cells via increasing or decreasing their recruitment to the site of injury could be developed together with upregulating and downregulating the release of certain chemicals from the infiltrated cells.

Association between electrodiagnosis and neuromuscular ultrasound in the diagnosis and assessment of severity of carpal tunnel syndrome.

BACKGROUND: Neuromuscular ultrasound plays an increasing role in diagnosing carpal tunnel syndrome (CTS). There are limited data supporting the correlation between the electrodiagnostic studies and ultrasound measurements in CTS. OBJECTIVE: To assess the association between different electrodiagnostic severities and ultrasound measurements of the median nerve in CTS. DESIGN: A retrospective cohort study. SETTING: An academic tertiary care center. PATIENTS: Patients 18 years or older evaluated with upper limb electrodiagnostic studies and neuromuscular ultrasound. MAIN OUTCOME MEASUREMENT: Ultrasound measurements of the median nerve cross-sectional area (CSA) at the wrist and the calculated wrist-to-forearm ratio (WFR) were compared with the electrodiagnostic severity (normal, mild, moderate, and severe). Mean analysis and analysis of variance test (α = 0.05) were performed to assess the association. RESULTS: A total of 1359 limbs were identified. There was a statistically significant association between electrodiagnostic severity of CTS and median nerve CSA at the wrist (p < .001), as well as the WFR (p < .001). The mean median nerve CSA at the wrist and WFR were 7.01 ± 2.06 mm2 (95% CI: 6.80-7.20) and 1.24 ± 0.36 (95% CI: 1.16-1.24) in electrodiagnostically normal median nerves, 10.47 ± 2.82 mm2 (95% CI: 10.25-10.75) and 2.06 ± 0.67 (95% CI: 2.04-2.16) in electrodiagnostically mild CTS, 12.95 ± 4.74 mm2 (95% CI: 12.41-13.59) and 2.49 ± 1.04 (95% CI: 2.37, 2.63) in electrodiagnostically moderate CTS, and 14.69 ± 5.38 mm2 (95% CI: 13.95-15.44) and 2.71 ± 1.02 (95% CI: 2.56-2.84) in electrodiagnostically severe CTS, respectively. CONCLUSION: This study suggests a direct association between electrodiagnostic severity and ultrasound measurements of the median nerve in patients with suspected CTS.

Breast reconstruction using the Latissimus Dorsi Flap and Immediate Fat Transfer (LIFT): A systematic review and meta-analysis.

BACKGROUND: Despite several efforts have been made to increase the volume of the latissimus dorsi (LD) flap, few studies have reported the outcomes of LD flap and immediate fat transfer (LIFT) to restore a natural native breast appearance during the initial reconstructive procedure. The aim of this study was to report the different surgical techniques used when implementing LIFT for breast reconstruction and evaluate the postoperative outcomes. METHODS: A systematic search was conducted across PubMed, Embase, Web of Science, Ovid MEDLINE®, and Scopus. We included articles reporting postoperative outcomes of patients who underwent breast reconstruction with LIFT. RESULTS: We included nineteen studies reporting outcomes of 704 breast reconstructions with LIFT (57.09%). The average age and BMI of patients were 51 years and 26.01 kg/m2. The pooled rate of patients requiring additional fat grafting following LIFT was 64.9% (95% CI 43.3%-86.5%). The overall pooled incidence of total flap loss was 3% (95% CI <0%-7.2%), wound-related complications was 14.5% (95% CI 7.3%-21.7%), seroma was 18.2% (95% CI 5.1%-31.2%), and fat necrosis was 14.5% (95% CI 4.5%-24.4%). When compared with abdominal free flaps, we found a significantly lower risk difference of developing wound-related complications favoring LIFT (RD, 0.066; 95%CI 0.004-0.129; p = 0.038). CONCLUSIONS: LIFT offers a totally autologous, less morbid type of reconstruction in breast cancer patients who are not ideal candidates for reconstruction with free tissue transfer. However, immediate fat transfer during reconstruction with the LD flap does not eliminate the need for further fat grafting.

Patient Perception of Medical Student Professionalism: Does Attire Matter?

INTRODUCTION: Patient compliance and outcomes have been shown to be influenced by the quality of the doctor-patient relationship. In addition, the effect of physician attire on the patient's perception of the physician has been long appreciated. Data shows that professional attire is preferred by patients. Whereas treating physicians are the backbone of patient management, medical students are often a patient's first encounter in a teaching clinic. Patient perception of the student may impact their rating of the attending physician. Despite this, medical students are often dressed wearing scrubs in surgery clinic. The purpose of this study was to determine if patient perception of medical students would be affected by the students' attire. METHODS: A 7-item, validated professionalism scale was used to survey surgery clinic patients whose initial examinations were performed by a medical student. Students were blinded and randomly assigned to wear professional attire versus scrubs. Patients' responses of 'strongly agree' were compared to lower ratings for each item. RESULTS: One hundred twenty-three patients completed our survey, 63 (51.2%) wearing scrubs and 60 (48.8%) in professional attire. The average age was 49.7 ± 15.8 years. In the professional attire group, there was no significant association for any of the 7 items. However, in the scrubs group, all 7 items were significant such that a higher proportion of patients under the age of 60 rated medical students wearing scrubs higher than did patients aged 60 and above. CONCLUSION: Students in scrubs were perceived to be less knowledgeable, competent, and professional by older patients. In contrast, younger patients seemed unaffected by the dress of medical students in clinic. Older patients may judge the medical community's growing acceptance of more casual attire in the workplace as less professional, potentially affecting patient satisfaction. Surgical educators should require a standard of professional attire for students in clinic.

Association Between Primary Payer Status and Survival in Patients With Stage III Colon Cancer: An National Cancer Database Analysis.

BACKGROUND: Colon cancer is the third most frequent cancer diagnosis, and primary payer status has been shown to be associated with treatment modalities and survival in cancer patients. The goal of our study was to determine the between-insurance differences in survival in patients with clinical stage III colon cancer using data from the National Cancer Database (NCDB). MATERIALS AND METHODS: We identified 130,998 patients with clinical stage III colon cancer in the NCDB diagnosed from 2004 to 2012. Kaplan-Meier curves and multivariable Cox regression models were used to determine the association between insurance status and survival. RESULTS: Patients with private insurance plans were 28%, 30%, and 16% less likely to die than were uninsured patients, Medicaid recipients, and Medicare beneficiaries, respectively. Medicare patients were 14% were less likely to die compared with uninsured patients. Patients receiving chemotherapy were, on average, 65% less likely to die compared with the patients not receiving chemotherapy. CONCLUSION: Private insurance and a greater socioeconomic status were associated with increased patient survival compared with other insurance plans or the lack of insurance. Future research should continue to unravel how socioeconomic status and insurance status contribute to the quality of care and survival of oncologic patients.

Impact of siltuximab on patient-related outcomes in multicentric Castleman's disease.

Multicentric Castleman's disease (MCD) is a rare, widespread lymphoproliferative disorder and a life-threatening disease involving hyperactivity of the immune system, excessive proinflammatory cytokine release, immune cell proliferation, and organ system dysfunction. Interleukin-6 (IL-6) is a cytokine that plays a key role in the pathogenesis of MCD, as it is involved in the synthesis of acute-phase reactants and aids in the induction of B-cell proliferation. Siltuximab is an anti-IL-6 chimeric monoclonal antibody that acts as a novel treatment modality to bind to IL-6 with high affinity, thus neutralizing the cytokine bioactivity and inhibiting B-cell proliferation. Clinical trials with siltuximab have shown early clinical promise for patients with MCD for many years, leading to recent US Food and Drug Administration approval as a novel agent for the treatment of MCD. Here, a systematic review was conducted to include 171 cases of MCD patients treated with siltuximab. While traditional treatment methods were able to achieve a 5-year survival rate of only 55%-77%, results of siltuximab treatment demonstrated 5-year survival rates of nearly 96.4% (only 2 deaths reported out of 55 patients with follow-up data). Ultimately, the results from multiple clinical trials have demonstrated that siltuximab is extremely efficacious in alleviating disease symptoms (fatigue, pain, and lymphadenopathy) while simultaneously achieving disease remission, thus extending progression-free survival for years longer than the average 5-year survival rates for MCD.

Socioeconomic status and survival for patients with melanoma in the United States: an NCDB analysis.

BACKGROUND: The importance of socioeconomic factors and healthcare treatment and outcomes for lower income patients is tremendous, affecting not only those afflicted by poverty and decreased quality of care but also physicians, healthcare professionals, and society at large. METHODS: The National Cancer Database was used to identify 80,907 patients with stage 0-4 melanoma and analyze variables to track patterns in survival and outcome. RESULTS: This study demonstrates that disparities in income, insurance status, and education affects treatment and survival rates across all stages of melanoma and seeks to establish further understanding surrounding socioeconomic factors and quality of healthcare in America. CONCLUSION: Through investigation and analysis, the goal of this study is to highlight how the existing socioeconomic gap in America impacts the quality of treatment and survival in patients diagnosed with melanoma.

Factors Affecting Adjuvant Therapy in Stage III Pancreatic Cancer-Analysis of the National Cancer Database.

BACKGROUND: Adjuvant therapy after curative resection is associated with survival benefit in stage III pancreatic cancer. We analyzed the factors affecting the outcome of adjuvant therapy in stage III pancreatic cancer and compared overall survival with different modalities of adjuvant treatment. METHODS: This is a retrospective study of patients with stage III pancreatic cancer listed in the National Cancer Database (NCDB) who were diagnosed between 2004 and 2012. Patients were stratified based on adjuvant therapy they received. Unadjusted Kaplan-Meier and multivariable Cox regression analysis were performed. RESULTS: We analyzed a cohort included 1731 patients who were recipients of adjuvant therapy for stage III pancreatic cancer within the limits of our database. Patients who received adjuvant chemoradiation had the longest postdiagnosis survival time, followed by patients who received adjuvant chemotherapy, and finally patients who received no adjuvant therapy. On multivariate analysis, advancing age and patients with Medicaid had worse survival, whereas Spanish origin and lower Charlson comorbidity score had better survival. CONCLUSIONS: Our study is the largest trial using the NCDB addressing the effects of adjuvant therapy specifically in stage III pancreatic cancer. Within the limits of our study, survival benefit with adjuvant therapy was more apparent with longer duration from date of diagnosis.