Simple Diverting Colostomy for Sacral Pressure Ulcers: Not So Simple After All.

BACKGROUND: Surgeons are often asked to provide a diverting colostomy to enable healing or simplify management of sacral pressure ulcers. However, little evidence exists regarding the safety of a diversion in this often compromised patient population. We hypothesized that malnourished patients with sacral pressure ulcers have poor outcomes with fecal diversion. METHODS: ACS-NSQIP (2012-2018) was used to identify patients who underwent elective diverting colostomy for sacral pressure ulcers. Demographics, comorbidities, and perioperative details were recorded. Postoperative complications and 30-day mortality were compared between patients with moderate/severe hypoalbuminemia (< 2.5 g/dL) vs those with albumin > 2.5 g/dL. RESULTS: We identified a total of 863 patients who underwent elective diverting colostomy for sacral pressure ulcer. Mean age was 57.5 years old. Rate of associated comorbidities was high, with most patients classified as ASA class 3 or 4. Over 40% of patients had a preoperative albumin level < 2.5 g/dL. Thirty-day overall postoperative mortality was 6.7%. This was significantly higher in patients with hypoalbuminemia (11.4% vs. 3.5%, p < 0.001). On multivariable regression analysis, preoperative albumin < 2.5 g/dL was independently associated with mortality (OR 1.92, p = 0.039). Other factors associated with mortality included increased age (OR 1.04 per year, p < 0.001), preoperative sepsis (OR 1.66, p = 0.003), and Black race (OR 2.2, p = 0.01). CONCLUSIONS: Diverting colostomy performed for patients with sacral pressure ulcers is associated with a substantial risk of postoperative death. Surgeons should carefully consider risks of diversion in this patient population, especially in malnourished patients with hypoalbuminemia.

Nocardiosis of the Central Nervous System: A rare complication of COVID management?

This case report examines a previously immunocompetent male that was treated with a prolonged course of corticosteroids for COVID pneumonia. He then returned with worsening headaches followed by flaccid paralysis of extremities due to cerebral and spinal cord abscesses secondary to Nocardia farcinica. A review of the literature on the mechanism of immunosuppression with COVID infection and corticosteroids is provided.

Clinical Factors Associated With Long-Term Benefit in Patients With Metastatic Renal Cell Carcinoma Treated With Axitinib: Real-World AXILONG Study.

BACKGROUND: Axitinib monotherapy obtained approval in pre-treated mRCC patients and recently in combination with pembrolizumab or avelumab in the first-line setting. However, patient profiles that may obtain increased benefit from this drug and its combinations still need to be identified. PATIENTS AND METHODS: Retrospective multicentre analysis describing clinical characteristics associated with axitinib long-responder (LR) population by comparing two extreme-response sub-groups (progression-free survival [PFS] ≥9 months vs. disease progression/refractory patients [RP]). A multivariate logistic-regression model was used to analyse clinical factors. Efficacy and safety were also analysed. RESULTS: In total, 157 patients who received axitinib in second or subsequent line were evaluated (91 LR and 66 RP). Older age at start of axitinib and haemoglobin levels > LLN were independent predictive factors for LR in multivariate analyses. In LR patients, median (m) PFS was 18.1 months, median overall survival was 36.0 months and objective response rate (ORR) was 45.5%. In 59 LR patients receiving axitinib in second-line, mPFS was 18.7 months, mOS was 44.8 months and ORR was 43.9%. mOS was significantly longer in second line compared to subsequent lines (44.8 vs. 26.5 months; P = .009). In LR vs. RP, mPFS with sunitinib in first-line was correlated with mPFS with axitinib in second-line (27.2 vs. 10.9 months P < .001). The safety profile was manageable and consistent with known data. CONCLUSIONS: This study confirms the long-term benefits of axitinib in a selected population, helping clinicians to select the best sequential approach and patients who could obtain a greater benefit from axitinib.

CCR2/CCL2 and CMKLR1/RvE1 chemokines system levels are associated with insulin resistance in rheumatoid arthritis.

Rheumatoid arthritis (RA) has been associated with insulin resistance (IR). Due to an excess in storage of white adipose tissue, IR has an inflammatory process that overlaps with RA. This is performed by the activation/migration of monocytes carried out by the CCR2/CCL2 and CMKLR1/RvE1 chemokines systems. Furthermore, these can potentiate chronic inflammation which is the central axis in the immunopathogenesis of RA. We evaluated the association between the relative expression of CCR2 and CMKLR1 and the serum levels of their ligands CCL2 and RvE1, in the context of adiposity status with IR as a comorbidity in RA. We studied 138 controls and 138 RA-patients classified with and without IR. We evaluated adiposity, RA activity, IR status and immunometabolic profiles by routine methods. Insulin, CCL2 and RvE1 serum levels were determined by ELISA. Relative expression of CCR2, CMKLR1 and RPS28 as constitutive gene by SYBR green RT-qPCR and 2-ΔΔCT method. Increased measurements were observed of body adiposity and metabolic status as follows: RA with IR>control group with IR>RA without IR> control group without IR. CCR2 and CMKLR1 relative expression was increased in RA without IR versus control without IR. CCR2: 2.3- and 1.3-fold increase and CMKLR1: 3.5- and 2.7-fold increase, respectively. Whereas, CCR2 expression correlates with CMKLR1 expression (rho = 0.331) and IR status (rho = 0.497 to 0.548). CMKLR1 expression correlates with inflammation markers (rho = 0.224 to 0.418). CCL2 levels were increased in the RA groups but levels of RvE1 were increased in RA without IR. We conclude that in RA with IR, the chemokine receptors expression pattern showed a parallel increase with their respective ligands. RA and IR in conjunction with the pathological distribution of body fat mass might exacerbate chronic inflammation. These results suggest that high CCL2 levels and compensatory RvE1 levels might not be enough to resolve the inflammation by themselves.

The Montreal Cognitive Assessment Test: A Useful Tool in Screening of Cognitive Impairment in Patients With Systemic Lupus Erythematosus.

BACKGROUND/OBJECTIVE: Systemic lupus erythematosus (SLE) is an inflammatory, chronic, and multisystemic disease, which may be associated with a wide range of neuropsychiatric manifestations, including cognitive impairment. Cognitive evaluations based on screening tests might identify early SLE-related cognitive alterations. The aim of this study was to evaluate and to compare the efficacy of three screening tests (Montreal Cognitive Assessment [MoCA], Mini Mental State Examination [MMSE], Cognitive Symptom Inventory [CSI]) against the gold standard (neuropsychological battery), in order to identify the most efficient screening test for cognitive impairment in patients with SLE. METHODS: This observational cross-sectional study recruited 44 patients, from August to December 2017, who were diagnosed with SLE according to the Systemic Lupus International Collaborating Clinics (SLICC) Criteria 2012, and had no medical or psychiatric comorbidities. The patients were evaluated using the MoCA, MMSE, CSI, and the gold standard. Spearman's correlation and area under the curve analysis were performed; p < 0.05 was considered significant. RESULTS: The MoCA test showed the highest correspondence with the gold standard (AUC = 99.4%, p < 0.001), sensitivity (84%), and specificity (100%). This was followed by the MMSE (AUC = 92.6%, p < 0.001; sensitivity, 54.8%; specificity, 100%) and the CSI (AUC = 30.6%, p < 0.05; sensitivity, 54.8%; specificity, 30.76%). CONCLUSION: The MoCA is a brief, easily applied screening test that is highly effective for detecting cognitive impairment in SLE patients. It could be useful in clinical follow-up as a tool for early detection of cognitive alterations.

MicroRNA let-7 Downregulates Ligand-Independent Estrogen Receptor-mediated Male-Predominant Pulmonary Fibrosis.

Rationale: The relevance of hormones in idiopathic pulmonary fibrosis (IPF), a predominantly male lung disease, is unknown.Objectives: To determine whether the ER (estrogen receptor) facilitates the development of pulmonary fibrosis and is mediated in part through microRNA regulation of ERα and ERα-activated profibrotic pathways.Methods: ER expression in male lung tissue and myofibroblasts from control subjects (n = 6) and patients with IPF (n = 6), aging bleomycin (BLM)-treated mice (n = 7), and BLM-treated AF2ERKI mice (n = 7) was determined. MicroRNAs that regulate ER and fibrotic pathways were assessed. Transfections with a reporter plasmid containing the 3' untranslated region of the gene encoding ERα (ESR1) with and without miRNA let-7 mimics or inhibitors or an estrogen response element-driven reporter construct (ERE) construct were conducted.Measurements and Main Results: ERα expression increased in IPF lung tissue, myofibroblasts, or BLM mice. In vitro treatment with let-7 mimic transfections in human myofibroblasts reduced ERα expression and associated fibrotic pathways. AF2ERKI mice developed BLM-induced lung fibrosis, suggesting a role for growth factors in stimulating ER and fibrosis. IGF-1 (insulin-like growth factor 1) expression was increased and induced a fourfold increase of an ERE construct.Conclusions: Our data show 1) a critical role for ER and let-7 in lung fibrosis, and 2) that IGF may stimulate ER in an E2-independent manner. These results underscore the role of sex steroid hormones and their receptors in diseases that demonstrate a sex prevalence, such as IPF.

The Challenge of Managing Bladder Cancer and Upper Tract Urothelial Carcinoma: A Review with Treatment Recommendations from the Spanish Oncology Genitourinary Group (SOGUG).

Bladder cancer is the fourth most common cancer in men and the ninth most common in women in the Western world. The management of bladder carcinoma requires a multidisciplinary approach. Optimal treatment depends on several factors, including histology, stage, patient status, and possible comorbidities. Here we review recent findings on the treatment of muscle-invasive bladder carcinoma, advanced urothelial carcinoma, upper tract urothelial carcinoma, non-urothelial carcinoma, and urologic complications arising from the disease or treatment. In addition, we present the recommendations of the Spanish Oncology Genitourinary Group for the treatment of these diseases, based on a focused analysis of clinical management and the potential of current research, including recent findings on the potential benefit of immunotherapy. In recent years, whole-genome approaches have provided new predictive biomarkers and promising molecular targets that could lead to precision medicine in bladder cancer. Moreover, the involvement of other specialists in addition to urologists will ensure not only appropriate therapeutic decisions but also adequate follow-up for response evaluation and management of complications. It is crucial, however, to apply recent molecular findings and implement clinical guidelines as soon as possible in order to maximize therapeutic gains and improve patient prognosis.

Predicting Factors Associated with Postoperative Hypotension following Carotid Artery Stenting.

BACKGROUND: Prolonged hemodynamic instability after carotid artery stenting (CAS) has been associated with increased incidence of stroke and other major adverse events. The objective of this study is to determine the factors associated with hypotension following CAS. In particular, this study evaluates whether involvement of the carotid bifurcation/bulb and degree of calcification can predict postoperative hypotension. METHODS: A retrospective review of 90 CASs performed in 88 patients at a single tertiary center was completed. In patients with proximal internal carotid stenosis involving the carotid bifurcation, the extent of bifurcation/bulb calcification on preoperative computed tomography angiography was assessed using a scoring system. Calcium scores were assigned based on the percent of circumferential calcification of carotid bifurcation as follows: grade 1, <10%; grade 2, 10-50%; grade 3, 50-90%; and grade 4, >90%. Perioperative factors associated with prolonged postoperative hypotension requiring vasopressor infusion were analyzed. RESULTS: Overall, postoperative hypotension requiring vasopressors occurred in 26 (28.9%) of CAS. There were no differences in baseline demographics, comorbidities, or CAS indication between patients who required postoperative vasopressors for hypotension and those who did not. The majority of patients (64.4%) were on 2 or more antihypertensive medications preoperatively. Stenosis involved carotid bifurcation in 64 (71.1%) cases. Of these, 27 (42.2%) were grade 1, 19 (29.7%) were grade 2, 10 (15.6%) were grade 3, and 8 (12.5%) were grade 4 based on our calcium scoring system. On risk-adjusted analysis, carotid bifurcation/bulb involvement (adjusted odds ratio [aOR] 4.5, 95% confidence interval [CI] 1.1-18.5) and preoperative regimen of 2 or more antihypertensives (aOR 4.2, 95% CI 1.1-16.0) were independent predictors of hypotension requiring vasopressors following CAS. Among patients with carotid bifurcation involvement, severity of calcium score was not a significant predictor of postoperative hypotension. CONCLUSIONS: CAS for carotid stenosis involving the carotid bifurcation/bulb is associated with a higher risk for postoperative hypotension requiring vasopressors. Patients with preoperative hypertension requiring 2 or more antihypertensive medications are also at increased risk. However, severity of carotid bifurcation calcification is not a significant predictor of need for postoperative vasopressors.

Subclinical parameters of arterial stiffness and arteriosclerosis correlate with QRISK3 in systemic lupus erythematosus.

It is well known that cardiovascular diseases (CVD) are a major contributor of death in systemic lupus erythematosus (SLE) as well in other rheumatic illness. In the last decades, there has been a growing development of different methodologies with the purpose of early detection of CVD. OBJECTIVE: The aim of this study is to correlate the usefulness of subclinical parameters of vascular aging and QRISK 3-2017 score for early detection of CVD in SLE. METHODS: Clinical assessment including systemic lupus erythematosus disease activity index (SLEDAI) and systemic lupus international collaborating clinics / american college of rheumatology damage index (SLICC/ACR DI), laboratory measurements, carotid ultrasound examination, carotid intima media thickness (cIMT) measurement, carotid distention and diameter analysis, arterial stiffness measurement measured by tonometry and QRISK 3-2017 were done. All results were analyzed by SPSS 24 software. RESULTS: We observed correlation between QRISK3 and mean cIMT (rs = 0.534, P < 0.001), PWV (rs = 0.474, P < 0.001), cfPWV (rs = 0.569, P < 0.001) and distensibility (rs = -0.420, P = 0.006). Consistent with above, SLE patients in middle and high risk QRISK 3-2017 showed increased arterial stiffness versus low risk group. CONCLUSIONS: We encourage to the rheumatology community to assess cardiovascular risk in SLE patients with QRISK 3-2017 risk calculator as an alternative method at the outpatient clinic along a complete cardiovascular evaluation when appropriate.

Prevalencia de trastornos temporomandibulares en pacientes psicógenos: presentación de caso clínico / Prevalence of temporomandibular disorders in psychogenic patients: clinical case presentation

Antecedentes: Los trastornos temporomandibulares (TTM), según estudios realizados a nivel mundial, son un problema muy frecuente, aproximadamente entre el 70 y 90% de la población general tiene al menos un signo clínico, mientras que entre el 5 y 13% muestran sintomatología clínicamente signifi cativa; los TTM son considerados una patología presente en la ajetreada sociedad industrial de la actualidad, son una enfermedad de la sociedad moderna. Laskin, en 1969, comenzó a defender la etiología de los TTM, otorgando especial relevancia al estrés y al estado psicológico. Más de 340 millones de personas sufren actualmente de algún tipo de depresión clínica, con base en datos reportados por la Organización Mundial de la Salud (OMS, 2008). Según estudios en el 2012 en la Universidad de Greifswald en Alemania, se ha propuesto que los síntomas de depresión y ansiedad deberían ser considerados como factores de riesgo en los TTM. Material y métodos: Se acudió al Servicio de Psicología de la Unidad de Medicina Familiar (UMF) Núm. 26, Monterrey (Mty), Nuevo León (NL), donde se buscaron y evaluaron, en conjunto con la licenciada en psicología, pacientes sin antecedentes de traumatismos o lesiones cervicales. Se les aplicó una encuesta, se elaboró una fi cha epidemiológica y la valoración clínica, se seleccionó un caso para su presentación. Resultados: La paciente acude después de haber realizado una terapia miorrelajante, refi riendo mejoría a la apertura oral. Conclusiones: Es necesario el trabajo interdisciplinario por parte del estomatólogo, cirujano maxilofacial y psicólogo en la atención de las personas con trastornos temporomandibulares y una fi sioterapia en casa que incluya estrategias de autocuidado, educación del paciente, modifi caciones del estilo de vida. El tratamiento que incluye enfoques odontológicos y psicológicos al mismo tiempo parece ser más efectivo y se obtienen mejores resultados. Los pacientes deberían estar conscientes de que los hábitos no cambian solos y son éstos los responsables de estos cambios de comportamiento. La corrección de un hábito puede lograrse haciendo al paciente conocedor de que ese hábito existe, cómo debe corregirlo y por qué debe hacerlo (AU)

Background: Temporomandibular disorders (TMD), according to worldwide studies, are a very frequent problem, approximately between 70-90% of the general population has at least one clinical sign. While between 5-13% show significant symptomatology clinically; TMD is a pathology considered present in the busy industrial society of today, the disease of modern society. Laskin in 1969 began to defend the etiology of the TMD, giving special importance to stress and psychological state. More than 340 million people currently suff er from some type of clinical depression, based on data reported by the World Health Organization (WHO 2008). According to studies in 2012, the University of Greifswald, in Germany, has proposed that the symptoms of depression and anxiety should be considered as risk factors in TMD. Material and methods: We went to the Psychology Service of the Family Medicine Unit (FMU) No. 26 in Monterrey, Nuevo Leon (NL). And in conjunction with the psychologist, were researched patients without a history of trauma or cervical injuries and were assessed. A survey was applied, an epidemiological record was drawn up, a clinical assessment was made and a case was selected for its presentation. Results: The patient comes to monthly checks after myorelaxing therapy, referring improvement to oral opening. Conclusions: The stomatologist, maxillofacial surgeon, and psychologist in the care of people with TMD require interdisciplinary work; included home physiotherapy with self-care strategies, patient education, and lifestyle modifi cations. Treatment with dental and psychological approaches at the same time seems to be more eff ective and obtains better results. Patients should be aware that habits do not change on their own and they are responsible for these behavioral changes. The correction of a habit can be achieved by making the patient aware that this habit exists, how he should correct it and why he should do it (AU)

Incidence and outcomes of pediatric extremity melanoma: A propensity score matched SEER study.

BACKGROUND: There is a paucity of literature on treatment of melanoma in children with surgical management extrapolated from adult experience. The incidence and clinical outcomes of pediatric extremity melanoma were studied. METHODS: SEER registry was analyzed between 1973 and 2010 for patients <20years old with extremity melanoma. Multivariate and propensity-score matched analyses were performed to identify independent predictors of survival. RESULTS: Overall, 917 patients were identified with an age-adjusted incidence of 0.2/100,000 persons, annual percent change 0.96. Most had localized disease (77%), histology revealing melanoma-not otherwise specified (52%). Surgical procedures performed included wide local excision (50%), excisional biopsy (32%), lymphadenectomy (LA) (28%), and sentinel lymph node biopsy (SLNB) (15%). Overall, 30-year disease specific mortality was 7% with lower survival for extremity melanoma (90%), males (89%), nodular histology (69%), and distant disease (36%) (all P<0.05). Post-treatment multivariate analysis revealed localized disease (HR 9.76; P=0.006) as an independent prognosticator of survival; earlier diagnostic years 1988-1999 (HR 2.606; P=0.017) were a negative prognosticator of survival. Propensity-score matched analysis found no difference in survival between SLNB/LA vs no sampling for regional/distant disease. CONCLUSIONS: Pediatric extremity melanoma in SEER demonstrate no survival advantage between children undergoing sampling procedures vs no sampling for regional/distant disease. TYPE OF STUDY: Retrospective, prognostic study. LEVEL OF EVIDENCE: III.

Results of the FLAC European Database of Metastatic Castration-Resistant Prostate Cancer Patients Treated With Docetaxel, Cabazitaxel, and Androgen Receptor-Targeted Agents.

BACKGROUND: Several agents have demonstrated an overall survival (OS) benefit in patients with metastatic castration-resistant prostate cancer (mCRPC); however, the optimal sequencing of these therapies is unknown as a result of a lack of prospective randomized controlled trials. This retrospective study aimed to identify clinical factors influencing outcomes and to determine optimal treatment sequencing in patients with mCRPC treated with cabazitaxel (CABA) and/or androgen receptor-targeted agents (ART) after androgen-deprivation therapy (ADT) and docetaxel (DOC). PATIENTS AND METHODS: Records of 574 consecutive patients treated (2012-2016) at 44 centers in 6 countries were retrospectively examined. RESULTS: A total of 267 patients received ADT → DOC → CABA (group 1), 183 patients ADT → DOC → ART → CABA (group 2), and 124 patients ADT → DOC → CABA → ART (group 3), with respective median OS from diagnosis of mCRPC of 38.3, 44.45, and 53.9 months (P = .012 for group 3 vs. group 1). Multivariate analysis showed response to first ADT ≤ 12 months, Gleason score of 8 to 10, clinical progression, and high prostate-specific antigen levels at mCRPC diagnosis were associated with worse OS. Prior receipt of ART did not influence activity of CABA. CONCLUSION: OS appeared to increase with the number of life-extending therapies, with a sequence including DOC, CABA, and an ART providing the greatest OS benefit.

Panniculectomy Outcomes in Patients with End-Stage Renal Disease in Preparation for Renal Transplant.

PURPOSE: End-stage renal disease (ESRD) is associated with increased cardiovascular risk factors, electrolyte imbalances, and iron deficiency anemia. These factors may increase the risk of adverse outcomes in patients undergoing panniculectomy. There is a paucity of data regarding outcomes in patients with ESRD undergoing panniculectomy. The purpose of this study is to investigate whether ESRD is associated with increased rate of complications following a panniculectomy. METHOD: The Nationwide Inpatient Sample database (2006-2011) was used to identify patients who underwent a panniculectomy. Among this cohort, patients diagnosed with end-stage renal disease were identified. Patients excluded from the study were emergency admissions, pregnant women, patients less than 18 years old, and patients with concurrent nephrectomy or kidney transplants. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-squared and risk-adjusted multivariate logistic regression analyses were performed to determine whether end-stage renal disease was associated with increased rate of postoperative complications. RESULTS: A total of 34,779 panniculectomies were performed during the study period. Of these, 613 (1.8%) were diagnosed with ESRD. Patients with ESRD were older (mean age 58.9 vs. 49.3, p < 0.01) and more likely to have Medicare (63.5 vs. 18.4%, p < 0.01). They had higher rates of comorbidities, including diabetes, hypertension, congestive heart failure, chronic lung disease, chronic anemia, liver disease, peripheral artery disease, obesity, and coagulopathies (p < 0.01). The procedure was more likely to occur at a large, teaching hospital (p < 0.01). Postoperatively, patients with ESRD had a higher rate of death (3.3 vs. 0.2%, p < 0.01), wound complications (10.6 vs. 6.2%, p < 0.01), venous thromboembolism (4.9 vs. 0.8%, p < 0.01), blood transfusions (25.3% vs. 7.0%, p < 0.01), non-renal major medical complications (40.0% vs. 8.4%), and longer hospital stay (9.2 vs. 3.8 days, p < 0.01). Multivariate logistic regression analysis controlling for age, race, sex, hospital location/teaching hospital, payer, and all comorbidities demonstrated that ESRD was independently associated with increased venous thromboembolisms (OR 2.38, 95% CI 1.48-3.83) and non-renal major medical complications (OR 1.51, 95% CI 1.19-1.91). ESRD was not independently associated with increased rate of wound complications or transfusions. CONCLUSION: Patients with ESRD are at increased risk of VTE and non-renal major medical complications following panniculectomy. Moreover, patients with ESRD have longer hospital stays and higher rates of mortality. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mesenchymal stromal cells prevent bleomycin-induced lung and skin fibrosis in aged mice and restore wound healing.

Fibrosis can develop in nearly any tissue leading to a wide range of chronic fibrotic diseases. However, current treatment options are limited. In this study, we utilized an established aged mouse model of bleomycin-induced lung fibrosis (BLM) to test our hypothesis that fibrosis may develop simultaneously in multiple organs by evaluating skin fibrosis and wound healing. Fibrosis was induced in lung in aged (18-22-month-old) C57BL/6 male mice by intratracheal BLM administration. Allogeneic adipose-derived mesenchymal stromal cells (ASCs) or saline were injected intravenously 24 hr after BLM administration. Full thickness 8-mm punch wounds were performed 7 days later to study potential systemic anti-fibrotic and wound healing effects of intravenously delivered ASCs. Mice developed lung and skin fibrosis as well as delayed wound closure. Moreover, we observed similar changes in the expression of known pro-fibrotic factors in both lung and skin wound tissue, including miR-199 and protein expression of its corresponding target, caveolin-1, as well as phosphorylation of protein kinase B. Importantly, ASC-treated mice exhibited attenuation of BLM-induced lung and skin fibrosis and accelerated wound healing, suggesting that ASCs may prime injured tissues and prevent end-organ fibrosis.

Abdominal Contouring Outcomes in Class III Obesity: Analysis of the ACS-NSQIP Database.

BACKGROUND: Obesity may increase the risk of complications following abdominal contouring. The aim of this study is to evaluate panniculectomy outcomes in patients with class III obesity (BMI > 40 kg/m2). METHODS: The American College of Surgeon's National Surgical Quality Improvement Program ACS-NSQIP (2010-2014) was used to identify patients who underwent panniculectomy. Class III obesity patients were identified. Demographics, comorbidities and postoperative outcomes were evaluated. Risk-adjusted multivariate logistic regression analyses were performed to assess impact of class III obesity on panniculectomy outcomes. RESULTS: A total of 4497 panniculectomies were identified. Of these, 545 (12.1%) were performed in patients with class III obesity. This group was older (mean age 50.3 vs. 45.9, p < 0.01) with a higher proportion of men (23.4 vs. 12.4%, p < 0.01). Class III obesity group also had higher rates of comorbidities (p < 0.01). Postoperatively, class III obesity patients experienced much higher rates of wound complications (17.8 vs. 6.8%), sepsis (3.3 vs. 0.8%), venous thromboembolism (1.5 vs. 0.7%) and medical complications (6.4 vs. 1.8%), p < 0.05. Additionally, this group had higher rates of unplanned reoperation (9.2 vs. 3.7%) and 30-day readmissions (3.5 vs. 1.0%), p < 0.01. On risk-adjusted multivariate regression analyses, class III obesity was independently associated with increased risk of wound complications (OR 2.22, p < 0.01), sepsis (OR 3.53, p < 0.01), medical adverse events (OR 1.98, p < 0.05), unplanned reoperation (OR 1.62, p < 0.05) and 30-day readmission (OR 2.30, p < 0.05). CONCLUSION: Class III obesity patients are at significantly increased risk of adverse outcomes following abdominal contouring. Plastic surgeons should consider these risks for counseling and preoperative risk optimization. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Estrogen receptor subtype expression and regulation is altered in papillary thyroid cancer after menopause.

BACKGROUND: Estrogen receptors can regulate growth in papillary thyroid cancer and may affect prognosis after menopause. This study examines changes of estrogen receptor subtype ratio expression in papillary thyroid cancer cell lines derived from pre- and postmenopausal women. METHODS: Cells were harvested from papillary thyroid cancer and non-papillary thyroid cancer thyroid tissue (control) from pre- (n = 9) and postmenopausal women (n = 11). Protein expression of estrogen receptor α, estrogen receptor ß, and phosphorylated extracellular signal-regulated kinase and protein kinase B were analyzed. Matrix metalloproteinase-2 activity was determined as a measure of tumor invasiveness. Mitochondrial retrograde signaling was altered with ethidium bromide to determine its effect on estrogen receptor α protein expression. RESULTS: Estrogen receptor α expression was increased in postmenopausal papillary thyroid cancer cells compared with controls but was unchanged in premenopausal papillary thyroid cancer. Estrogen receptor ß expression did not change in either group. Increased matrix metalloproteinase-2 activity was observed only in postmenopausal papillary thyroid cancer. Premenopausal papillary thyroid cancer cells demonstrated increased extracellular signal-regulated kinase and unchanged protein kinase B activation. Conversely, postmenopausal papillary thyroid cancer cells had decreased extracellular signal-regulated kinase and increased protein kinase B activation. Ethidium bromide treatment resulted in increased estrogen receptor α protein expression only in premenopausal papillary thyroid cancer cells. CONCLUSION: Increased estrogen receptor α expression may be involved in papillary thyroid cancer aggressiveness after menopause. This process may be regulated by differential activation of intracellular pathways and differing sensitivities to mitochondrial signaling regulation.