The effect of Mozart music on patient satisfaction during caesarean delivery: a randomised controlled trial.

BACKGROUND: Music is a low-cost intervention that can improve patient satisfaction. METHODS: This was a prospective, randomised, controlled trial conducted at an urban tertiary care academic medical centre in the United States. Nulliparous women 18-50 years old with a healthy singleton pregnancy at ≥ 37 weeks gestational age undergoing elective caesarean delivery under neuraxial anaesthesia were randomised to the music group (Mozart sonatas) or control group (no music). Mozart sonatas were broadcast to the music group immediately prior to patient entry and maintained throughout the procedure. The primary outcome was patient satisfaction using the Maternal Satisfaction Scale for Caesarean Section (MSSCS). Secondary outcomes were changes in anxiety pre- and post-operatively and post-operative mean arterial pressure (MAP). Student's t-test, the Wilcoxon rank sum test, and the c2 test were used where appropriate for statistical analyses. RESULTS: 27 parturients were evaluated for participation between 2018 and 2019, and 22 enrolled. The final study subject number was 20 due to two withdrawals. There were no clinically meaningful differences in baseline demographics, vital signs, and anxiety. The mean (SD) total patient satisfaction for music vs. control was 116 (16) vs. 120 (22), mean difference 4 (95% CI: -14.0 to 22.0), P = 0.645. The mean (SD) change in anxiety with music vs. control was 2.7 (2.7) vs. 2.5 (2.6), mean difference -0.4 (95% CI: -4.0 to 3.2), P = 0.827. The median (IQR) post-operative MAP with music vs. control was 77.7 (73.7-85.3) vs. 77.3 (72.0-87.3), P = 0.678. CONCLUSIONS: The use of Mozart sonatas did not result in improvements in patient satis-faction, anxiety or MAP in parturients undergoing elective caesarean delivery.

Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center.

PURPOSE: Fragility fractures are a significant source of morbidity and have high associated mortality. Identifying risk factors for poor outcomes is essential for guiding treatment and for setting expectations for patients and their families. Although fragility hip fractures have been abundantly explored, there is a paucity of information regarding proximal humerus fractures (PHFs). METHODS: We retrospectively review the electronic medical records of 379 patients who presented to a level 1 trauma center with a PHF secondary to a fall. Patient demographics, handedness, comorbidities, treatment, imaging data, follow-up data, and death date (if applicable) were recorded. RESULTS: Our cohort consisted of 279 females and 100 males with an average age of 71.4 years. Distribution of injuries was 178 left, 141 right, and 7 bilateral. Compared with handedness, 179 were ipsilateral, 141 were contralateral, and 59 were unknown. A total of 81.3% of injuries were treated nonoperatively, whereas 18.7% were managed surgically. One-year mortality was 17.4%, and 2-year mortality was 24.0%.Males demonstrated a 2.28 increased risk of 1-year mortality (P = .004). Patients who died within 1 year of fracture had significantly higher Charlson comorbidity index scores (P < .0001) and age (P = .0003). Risk of death was significantly lower in patients who underwent surgery compared with those who were treated nonoperatively (P = .01). Patients who used an assist device before fracture had 4.2 increased risk of 1-year mortality (P < .0001). Patients who presented from nursing homes or assisted living had a 2.1 increased risk of 1-year mortality (P = .02). Patients with severe liver disease had a 5.5 increased risk of 1-year mortality (P < .0001), and those with metastatic cancer had a 13.7 increased risk of 1-year mortality (P < .0001). Bilateral fractures, side of injury in relation to handedness, rehospitalization, Neer classification, and PCP follow-up within 30 days were not associated with increased mortality. CONCLUSIONS: Increased understanding risk factors for mortality after PHF will allow for more informed patient discussions regarding treatment outcomes and risk of death. Our data suggest that mortality at 1 year for fragility PHF is universally high regardless of risk factors. This risk is increased in patients who are older, functionally limited, or who have medical comorbidities. Our data demonstrate the importance of medical optimization of patients with a fragility PHF and underscore the importance of fall prevention in high-risk patients.

Clinical Outcomes of Low-Cost, Anchorless Repair of the Triceps Tendon Using a Proximal Knot Technique.

PURPOSE: To use validated outcome measures to evaluate the clinical results of surgical repair of distal triceps tendon ruptures using transosseous tunnels and high-strength sutures with proximally based knots. METHODS: A consecutive series of traumatic distal triceps tendon ruptures at a single institution was studied. All cases were surgically repaired by 1 surgeon using high-strength suture with a bone tunnel-based repair technique. Repair knots were oriented proximally instead of in the traditional distal position. All patients were evaluated at long-term follow-up with a physical examination performed by the orthopaedic surgeon and the following validated outcome measures: Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and visual analog scale score. RESULTS: Seven male patients with a mean age of 38 years (range, 19-50 years) and mean follow-up period of 4.1 ± 1.2 years underwent distal triceps tendon repair with bone tunnels and high-strength sutures with proximally positioned knots. Of the repairs, 4 involved the dominant arm. At final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 1.3 ± 3.1; the mean Mayo Elbow Performance Score was 99.3 ± 1.9; and the mean visual analog scale score was 0. One additional patient who declined participation in the study had wound dehiscence and infection with an associated partial rerupture. CONCLUSIONS: This case series of triceps tendon repairs using transosseous tunnels and proximally based knots showed favorable postoperative elbow function based on validated outcome measures. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

LNX1 Modulates Notch1 Signaling to Promote Expansion of the Glioma Stem Cell Population during Temozolomide Therapy in Glioblastoma.

Glioblastoma (GBM) is the most common primary brain malignancy in adults, with a 100% recurrence rate and 21-month median survival. Our lab and others have shown that GBM contains a subpopulation of glioma stem cells (GSCs) that expand during chemotherapy and may contribute to therapeutic resistance and recurrence in GBM. To investigate the mechanism behind this expansion, we applied gene set expression analysis (GSEA) to patient-derived xenograft (PDX) cells in response to temozolomide (TMZ), the most commonly used chemotherapy against GBM. Results showed significant enrichment of cancer stem cell and cell cycle pathways (False Discovery Rate (FDR) < 0.25). The ligand of numb protein 1 (LNX1), a known regulator of Notch signaling by targeting negative regulator Numb, is strongly upregulated after TMZ therapy (p < 0.0001) and is negatively correlated with survival of GBM patients. LNX1 is also upregulated after TMZ therapy in multiple PDX lines with concomitant downregulations in Numb and upregulations in intracellular Notch1 (NICD). Overexpression of LNX1 results in Notch1 signaling activation and increased GSC populations. In contrast, knocking down LNX1 reverses these changes, causing a significant downregulation of NICD, reduction in stemness after TMZ therapy, and resulting in more prolonged median survival in a mouse model. Based on this, we propose that during anti-GBM chemotherapy, LNX1-regulated Notch1 signaling promotes stemness and contributes to therapeutic resistance.

Epidural Anesthesia for Cesarean Delivery in a Parturient With Lumboperitoneal Shunt: A Case Report.

A lumboperitoneal shunt facilitates dynamic flow of cerebrospinal fluid into the peritoneum. Consequently, neuraxial technique placement in the parturient with a lumboperitoneal shunt can result in unexpected levels of blockade. We present the case of a parturient with a lumboperitoneal shunt who experienced symptoms consistent with high blockade after epidural administration of 450 mg chloroprocaine. This report emphasizes potential mechanisms for high neuraxial blockade and strategies to decrease risks in this unique patient population.

Cancer Stem Cells: Cellular Plasticity, Niche, and its Clinical Relevance.

Cancer handles an estimated 7.6 million deaths worldwide per annum. A recent theory focuses on the role Cancer Stem Cells (CSCs) in driving tumorigenesis and disease progression. This theory hypothesizes that a population of the tumor cell with similar functional and phenotypic characteristics as normal tissue stem cells are responsible for formation and advancement of many human cancers. The CSCs subpopulation can differentiate into non-CSC tumor cells and promote phenotypic and functional heterogeneity within the tumor. The presence of CSCs has been reported in a number of human cancers including blood, breast, brain, colon, lung, pancreas prostate and liver. Although the origin of CSCs remains a mystery, recent reports suggest that the phenotypic characteristics of CSCs may be plastic and are influenced by the microenvironment specific for the individual tumor. Such factors unique to each tumor preserve the dynamic balance between CSCs to non-CSCs cell fate, as well as maintain the proper equilibrium. Alternating such equilibrium via dedifferentiation can result in aggressiveness, as CSCs are considered to be more resistant to the conventional cancer treatments of chemotherapy and radiation. Understanding how the tumoral microenvironment affects the plasticity driven CSC niche will be critical for developing a more effective treatment for cancer by eliminating its aggressive and recurring nature that now is believed to be perpetuated by CSCs.

Stem Cell-Based Cell Carrier for Targeted Oncolytic Virotherapy: Translational Opportunity and Open Questions.

Oncolytic virotherapy for cancer is an innovative therapeutic option where the ability of a virus to promote cell lysis is harnessed and reprogrammed to selectively destroy cancer cells. Such treatment modalities exhibited antitumor activity in preclinical and clinical settings and appear to be well tolerated when tested in clinical trials. However, the clinical success of oncolytic virotherapy has been significantly hampered due to the inability to target systematic metastasis. This is partly due to the inability of the therapeutic virus to survive in the patient circulation, in order to target tumors at distant sites. An early study from various laboratories demonstrated that cells infected with oncolytic virus can protect the therapeutic payload form the host immune system as well as function as factories for virus production and enhance the therapeutic efficacy of oncolytic virus. While a variety of cell lineages possessed potential as cell carriers, copious investigation has established stem cells as a very attractive cell carrier system in oncolytic virotherapy. The ideal cell carrier desire to be susceptible to viral infection as well as support viral infection, maintain immunosuppressive properties to shield the loaded viruses from the host immune system, and most importantly possess an intrinsic tumor homing ability to deliver loaded viruses directly to the site of the metastasis-all qualities stem cells exhibit. In this review, we summarize the recent work in the development of stem cell-based carrier for oncolytic virotherapy, discuss the advantages and disadvantages of a variety of cell carriers, especially focusing on why stem cells have emerged as the leading candidate, and finally propose a future direction for stem cell-based targeted oncolytic virotherapy that involves its establishment as a viable treatment option for cancer patients in the clinical setting.