Impact of pancreas transection site on incidence of pancreatic fistula after distal pancreatectomy: a propensity score matched study.

BACKGROUND: Distal pancreatectomy (DP) is performed for lesions in the body and tail of the pancreas. The morbidity profile is considerable, mainly due to clinically relevant postoperative pancreatic fistula (CR-POPF). This study aims to investigate potential differences in CR-POPF related to transection site. METHODS: An observational cohort study from a prospectively maintained database was performed. Subtotal distal pancreatectomy (SDP) was defined as transection over the superior mesenteric vein, and DP was defined as transection lateral to this point. Propensity score matching (PSM) in 1:1 fashion was applied based on demographical and perioperative variables. RESULTS: Six hundred and six patients were included in the analysis (1997-2020). Four hundred twenty (69.3%) underwent DP, while 186 (30.7%) underwent SDP. The rate of CR-POPF was 19.3% after DP and 20.4% after SDP (p = 0.74). SDP was associated with older age (63.1 vs 60.1 years, p = 0.016), higher occurrence of ductal adenocarcinoma (37.1 vs 17.6%, p = 0.001) and more frequent use of neoadjuvant chemotherapy (3.8 vs 0.7%, p = 0.012). After PSM, 155 patients were left in each group. The difference in CR-POPF between DP and SDP remained statistically non-significant (20.6 vs 18.7%, p = 0.67). CONCLUSION: This study found no difference in CR-POPF related to transection site during distal pancreatectomy.

Benign breast tumors may arise on different immunological backgrounds.

Benign breast tumors are a nonthreatening condition defined as abnormal cell growth within the breast without the ability to invade nearby tissue. However, benign lesions hold valuable biological information that can lead us toward better understanding of tumor biology. In this study, we have used two pathway analysis algorithms, Pathifier and gene set variation analysis (GSVA), to identify biological differences between normal breast tissue, benign tumors and malignant tumors in our clinical dataset. Our results revealed that one-third of all pathways that were significantly different between benign and malignant tumors were immune-related pathways, and 227 of them were validated by both methods and in the METABRIC dataset. Furthermore, five of these pathways (all including genes involved in cytokine and interferon signaling) were related to overall survival in cancer patients in both datasets. The cellular moieties that contribute to immune differences in malignant and benign tumors were analyzed using the deconvolution tool, CIBERSORT. The results showed that levels of some immune cells were specifically higher in benign than in malignant tumors, and this was especially the case for resting dendritic cells and follicular T-helper cells. Understanding the distinct immune profiles of benign and malignant breast tumors may aid in developing noninvasive diagnostic methods to differentiate between them in the future.

Whole blood RNA signatures in tuberculosis patients receiving H56:IC31 vaccine as adjunctive therapy.

Introduction: Therapeutic vaccination in tuberculosis (TB) represents a Host Directed Therapy strategy which enhances immune responses in order to improve clinical outcomes and shorten TB treatment. Previously, we have shown that the subunit H56:IC31 vaccine induced both humoral and cellular immune responses when administered to TB patients adjunctive to standard TB treatment (TBCOX2 study, NCT02503839). Here we present the longitudinal whole blood gene expression patterns in H56:IC31 vaccinated TB patients compared to controls receiving standard TB treatment only. Methods: The H56:IC31 group (N=11) and Control group (N=7) underwent first-line TB treatment for 182 days. The H56:IC31 group received 5 micrograms of the H56:IC31 vaccine (Statens Serum Institut; SSI, Valneva Austria GmbH) intramuscularly at day 84 and day 140. Total RNA was extracted from whole blood samples collected in PAXgene tubes on days 0, 84, 98, 140, 154, 182 and 238. The expression level of 183 immune-related genes was measured by high-throughput microfluidic qPCR (Biomark HD system, Standard BioTools). Results: The targeted gene expression profiling unveiled the upregulation of modules such as interferon (IFN) signalling genes, pattern recognition receptors and small nucleotide guanosine triphosphate (GTP)-ases in the vaccinated group compared to controls two weeks after administration of the first H56:IC31 vaccine. Additionally, the longitudinal analysis of the Adolescent Cohort Study-Correlation of Risk (ACS-COR) signature showed a progressive downregulation in both study arms towards the end of TB treatment, in congruence with reported treatment responses and clinical improvements. Still, two months after the end of TB treatment, vaccinated patients, and especially those developing both cellular and humoral vaccine responses, showed a lower expression of the ACS-COR genes compared to controls. Discussion: Our data report gene expression patterns following H56:IC31 vaccination which might be interpreted as a lower risk of relapse in therapeutically vaccinated patients. Further studies are needed to conclude if these gene expression patterns could be used as prognostic biosignatures for therapeutic TB vaccine responses.

Billroth-I anastomosis in distal subtotal gastrectomy for non-early gastric adenocarcinoma.

BACKGROUND: Billroth-I (B-I) anastomosis is known as a simple and physiological reconstruction method after distal subtotal gastrectomy for early gastric cancer. Yet its role and oncological validity in non-early gastric adenocarcinoma (NEGA) remain unclear. PATIENTS AND METHODS: Patients with NEGA without distant metastases operated between May 2004 and December 2020 were included. Surgical and oncologic outcomes of distal subtotal gastrectomy were studied in patients with B-I and Billroth II (B-II) anastomoses. Propensity score matching (PSM) was used to adjust for age, gender, tumor size, location, resection type, pT and pN stages. RESULTS: A total number of 332 patients underwent distal subtotal gastrectomy for NEGA followed by B-I and B-II anastomoses in 165 (49.7%) and 167 (50.3%) cases, respectively. B-I was applied in patients with smaller tumor size, less advanced pT stage and tumor location in the gastric antrum. The former was also associated with lower proportion of multiorgan resections and shorter operative time. After PSM, these differences became statistically non-significant, except operative time. Postoperative outcomes were similar before and after PSM. Greater lymph node yield was observed in patients with B-I anastomosis. The incidence of recurrence, specifically local recurrence was lower in patients with B-I anastomosis. However, this association was not statistically significant in the multivariable model. Median overall survival was 38 months, without significant differences between the groups. CONCLUSIONS: The use of B-I anastomosis after distal subtotal gastrectomy for NEGA is associated with satisfactory surgical and oncologic outcomes. B-I anastomosis should be considered as a valid reconstruction method in these patients.

Laparoscopic vs open repair for primary midline ventral hernia: a prospective cohort study.

BACKGROUND: The optimal operative treatment for umbilical and epigastric hernia, i.e., primary midline ventral hernia (PMVH), is debatable. The most common techniques are the primary suture and open repair with mesh, while laparoscopic approach using intraperitoneally placed onlay mesh (IPOM) is less frequent. The aim of this study was to examine the outcomes of IPOM in PMVH. Perioperative results, recurrence, pain, and functional status were studied. METHODS: This single-center prospective cohort study included consecutive patients with PMVH operated between September 2006 and December 2015. Systematic follow-up was conducted 6 months and 2 and 5 years postoperatively. RESULTS: Seven hundred fifty-four patients underwent PMVH repair. Open repair without mesh, open repair with mesh, and IPOM were performed in 251 (34.9%), 273 (38%), and 195 (27.1%) patients, respectively. In the unmatched cohort, the incidence of postoperative complications was similar except postoperative seroma, which was more frequent after IPOM. The latter was also associated with longer length of stay. Open repair with mesh was associated with significantly lower recurrence compared with open repair without mesh and IPOM (5.2 vs 18.2 vs 13.8%, p=0.001, respectively). No differences were seen between the groups in terms of visual analog scale used for registering postoperative pain. These observations persisted after applying propensity score matching. In the multivariable analysis, open repair without mesh and IPOM significantly correlated with recurrence. CONCLUSIONS: In PMVH, open repair with mesh is associated with lower recurrence compared with open repair without mesh and IPOM. Pain, postoperative complications (except for seroma), and functional status are similar.

Assessing nuclear versus mitochondrial cell-free DNA (cfDNA) by qRT-PCR and droplet digital PCR using a piglet model of perinatal asphyxia.

BACKGROUND: Since the discovery more than half a century ago, cell-free DNA (cfDNA) has become an attractive objective in multiple diagnostic, prognostic, and monitoring settings. However, despite the increasing number of cfDNA applications in liquid biopsies, we still lack a comprehensive understanding of the nature of cfDNA including optimal assessment. In the presented study, we continued testing and validation of common techniques for cfDNA extraction and quantification (qRT-PCR or droplet digital PCR) of nuclear- and mitochondrial cfDNA (ncfDNA and mtcfDNA) in blood, using a piglet model of perinatal asphyxia to determine potential temporal and quantitative changes at the levels of cfDNA. METHODS AND RESULTS: Newborn piglets (n = 19) were either exposed to hypoxia (n = 11) or were part of the sham-operated control group (n = 8). Blood samples were collected at baseline (= start) and at the end of hypoxia or at 40-45 min for the sham-operated control group. Applying the qRT-PCR method, ncfDNA concentrations in piglets exposed to hypoxia revealed an increasing trend from 7.1 ng/ml to 9.5 ng/ml for HK2 (hexokinase 2) and from 4.6 ng/ml to 7.9 ng/ml for ß-globulin, respectively, whereas the control animals showed a more balanced profile. Furthermore, median levels of mtcfDNA were much higher in comparison to ncfDNA, but without significant differences between intervention versus the control group. CONCLUSIONS: Both, qRT-PCR and the droplet digital PCR technique identified overall similar patterns for the concentration changes of cfDNA; but, the more sensitive digital PCR methodology might be required to identify minimal responses.

Change in Ocular Surface Staining during Eyelid Warming Is Related to Tear Cytokine Levels.

Purpose: To investigate the changes in the tear cytokine profile of patients with meibomian gland dysfunction (MGD) treated with eyelid warming and to correlate these changes with clinical parameters for dry eye disease (DED). Methods: Seventy patients with MGD were included and treated with the warming of eyelids. Of these, 61 still used the treatment three months after baseline, while 48 completed the whole treatment period of six months. The concentrations of 39 cytokines in the tear fluid were measured at baseline and after three and six months of treatment. All participants were examined with tests for DED, including tear film break-up time (TBUT), ocular surface staining (OSS), and the self-reporting Ocular Surface Disease Index (OSDI). Changes in cytokine concentrations were assessed from baseline to three months, from three to six months, and from baseline to six months. Correlation analyses were performed between changes in the cytokine concentrations and changes in TBUT, OSS, and OSDI during the same time intervals. Results: No significant changes were found in the concentrations of the 39 cytokines during any of the three treatment intervals. However, several correlations were detected between changes in the level of cytokines and OSS from baseline to three months of treatment. Decreasing concentrations of granulocyte chemotactic protein 2 (GCP-2/CXCL6, mean effect 2.36, p=0.042), interleukin 10 (IL-10, mean effect 1.04, p=0.045), and IL-16 (mean effect 1.36, p=0.035) were associated with decreasing OSS. Decreasing concentrations of granulocyte macrophage colony-stimulating factor (GM-CSF, mean effect -2.98, p=0.024), IL-8 (IL-8/CXCL8, mean effect -1.35, p=0.026), and macrophage migration inhibitory factor (MIF, mean effect -2.44, p=0.033) were related to increasing OSS. Conclusions: Warming of eyelids did not change the concentration of cytokines in the tear fluid of patients with MGD significantly. However, alterations in the level of several cytokines were associated with changes in the OSS. This finding indicates a close connection between tear cytokines and OSS in MGD patients treated with eyelid warming.

The relationship between ocular and oral dryness in a cohort from the 65-year-old population in Norway.

In the present study, the relationship between dry eyes and dry mouth was explored in 150 65-year-old subjects randomly selected from the general population in Oslo, Norway. The number of drugs, including xerogenic drugs, and current and previous systemic diseases were recorded. Ocular parameters recorded were the McMonnies Dry Eye Questionnaire, the Ocular Surface Disease Index, the Schirmer I Test, tear film break-up time and ocular surface staining. The oral parameters were xerostomia frequency, Summated Xerostomia Inventory, Clinical Oral Dryness Score, and unstimulated and stimulated whole saliva. The participants with current or previous systemic diseases had significantly more ocular and oral symptoms and significantly more oral clinical findings than the participants without a history of disease. Moreover, correlation and factor analyses demonstrated an association between subjective ocular and oral parameters. A significant correlation between the total number of drugs and the presence of ocular and oral symptoms was also noted. When the participants were categorized based on their ocular symptoms, poorer values were found for the oral parameters among the participants more troubled with dry eyes. The results in the present study call for increased awareness and an interdisciplinary approach in matters related to dry eyes and dry mouth.

A scalable solver for a stochastic, hybrid cellular automaton model of personalized breast cancer therapy.

Mathematical modeling and simulation is a promising approach to personalized cancer medicine. Yet, the complexity, heterogeneity and multi-scale nature of cancer pose significant computational challenges. Coupling discrete cell-based models with continuous models using hybrid cellular automata (CA) is a powerful approach for mimicking biological complexity and describing the dynamical exchange of information across different scales. However, when clinically relevant cancer portions are taken into account, such models become computationally very expensive. While efficient parallelization techniques for continuous models exist, their coupling with discrete models, particularly CA, necessitates more elaborate solutions. Building upon FEniCS, a popular and powerful scientific computing platform for solving partial differential equations, we developed parallel algorithms to link stochastic CA with differential equations (https://bitbucket.org/HTasken/cansim). The algorithms minimize the communication between processes that share CA neighborhood values while also allowing for reproducibility during stochastic updates. We demonstrated the potential of our solution on a complex hybrid cellular automaton model of breast cancer treated with combination chemotherapy. On a single-core processor, we obtained nearly linear scaling with an increasing problem size, whereas weak parallel scaling showed moderate growth in solving time relative to increase in problem size. Finally, we applied the algorithm to a problem that is 500 times larger than previous work, allowing us to run personalized therapy simulations based on heterogeneous cell density and tumor perfusion conditions estimated from magnetic resonance imaging data on an unprecedented scale.

TheraPearl Eye Mask and Blephasteam for the treatment of meibomian gland dysfunction: a randomized, comparative clinical trial.

Meibomian gland dysfunction (MGD) is the most common cause of dry eye disease (DED). In this study, we aimed to compare the effects of eyelid warming treatment using either TheraPearl Eye Mask (Bausch & Lomb Inc., New York, USA) or Blephasteam (Spectrum Thea Pharmaceuticals LTD, Macclesfield, UK) in a Norwegian population with mild to moderate MGD-related DED. An open label, randomized comparative trial with seventy patients (49 females, 21 males; mean age 53.6 years). Patients were randomly assigned to treatment with Blephasteam (n = 37) or TheraPearl (n = 33). All received a hyaluronic acid based artificial tear substitute (Hylo-Comod, Ursapharm, Saarbrücken, Germany). Patients were examined at baseline, and at three and six months initiation of treatment. Treatment efficacy was primarily evaluated by fluorescein breakup time (FBUT) and Ocular Surface Disease Index (OSDI) scores. Other outcome measures included ocular surface staining (OSS), Schirmer's test, and meibomian quality and expressibility. Baseline parameter values did not differ between the groups. After six months of treatment, Blephasteam improved FBUT by 3.9 s (p < 0.01) and OSDI by 13.7 (p < 0.01), TheraPearl improved FBUT by 2.6 s (p < 0.01) and OSDI by 12.6 (p < 0.01). No difference between treatments was detected at 6 months (p = 0.11 for FBUT and p = 0.71 for OSDI), nor were there differences in the other tested parameters between the treatment groups. Blephasteam and TheraPearl are equally effective in treating mild to moderate MGD in a Norwegian population after 6-months of treatment.Clinicaltrials.gov ID: NCT03318874; Protocol ID: 2014/1983; First registration: 24/10/2017.

Toward Personalized Computer Simulation of Breast Cancer Treatment: A Multiscale Pharmacokinetic and Pharmacodynamic Model Informed by Multitype Patient Data.

The usefulness of mechanistic models to disentangle complex multiscale cancer processes, such as treatment response, has been widely acknowledged. However, a major barrier for multiscale models to predict treatment outcomes in individual patients lies in their initialization and parametrization, which needs to reflect individual cancer characteristics accurately. In this study, we use multitype measurements acquired routinely on a single breast tumor, including histopathology, MRI, and molecular profiling, to personalize parts of a complex multiscale model of breast cancer treated with chemotherapeutic and antiangiogenic agents. The model accounts for drug pharmacokinetics and pharmacodynamics. We developed an open-source computer program that simulates cross-sections of tumors under 12-week therapy regimens and used it to individually reproduce and elucidate treatment outcomes of 4 patients. Two of the tumors did not respond to therapy, and model simulations were used to suggest alternative regimens with improved outcomes dependent on the tumor's individual characteristics. It was determined that more frequent and lower doses of chemotherapy reduce tumor burden in a low proliferative tumor while lower doses of antiangiogenic agents improve drug penetration in a poorly perfused tumor. Furthermore, using this model, we were able to correctly predict the outcome in another patient after 12 weeks of treatment. In summary, our model bridges multitype clinical data to shed light on individual treatment outcomes. SIGNIFICANCE: Mathematical modeling is used to validate possible mechanisms of tumor growth, resistance, and treatment outcome.

Ocular findings and ocular graft-versus-host disease after allogeneic stem cell transplantation without total body irradiation.

Patients treated with allogeneic stem cell transplantation (allo-SCT) often develop ocular complications. To investigate the ocular findings in young long-term survivors after allo-SCT without TBI, we examined 96 patients more than 5 years after transplantation. All patients were under 30 years of age at transplantation. The mean follow-up time was 16.8 years (range 6.0-26.1 years). The study was a part of the Norwegian Allo Survivorship Study investigating health impairments in young survivors after allo-SCT. Ophthalmological examination included visual acuity, tear break-up time, corneal fluorescein staining, Schirmer I test, tear film osmolarity, biomicroscopy and dilated ophthalmoscopy. In patients with known systemic chronic GVHD (cGVHD), ocular GVHD (oGVHD) diagnosed by clinical examination was compared with diagnosis using National Institutes of Health (NIH) or International Chronic Ocular Graft-vs-Host-Disease (ICCGVHD) Consensus Group criteria. We diagnosed dry eye disease (DED) in 52 patients (54%), cataract in 3 patients (3%) and retinopathy in 1 patient (1%). Systemic cGVHD was a risk factor for DED (OR 4.40, CI 1.33-14.56, p = 0.02). Comparison of diagnostic criteria suggests that the more stringent ICCGVHD criteria can better differentiate DED from oGVHD after allo-SCT as compared with the NIH criteria.

Impact of obesity on surgical outcomes of laparoscopic distal pancreatectomy: A Norwegian single-center study.

BACKGROUND: Obesity is known as a risk factor for intra- and postoperative complications in pancreatic operation. However, the operative outcomes in obese patients undergoing laparoscopic distal pancreatectomy remain unclear. METHODS: A total number of 423 patients underwent laparoscopic distal pancreatectomy at Oslo University Hospital-Rikshospitalet from April 1997 to December 2015. Patients were categorized into 3 groups based on the body mass index: normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2). After excluding underweight patients, 402 patients were enrolled in this study. RESULTS: Obese patients had significantly longer operative time and increased blood loss compared with overweight and normal weight patients (190 [61-480] minutes vs 158 [56-520] minutes vs 153 [29-374] minutes, P = .009 and 200 [0-2,800] mL vs 50 [0-6250] mL vs 90 [0-2,000] mL, P = .01, respectively). A multiple linear regression analysis identified obesity as predictive of prolonged operative time and increased blood loss during laparoscopic distal pancreatectomy. The rates of clinically relevant pancreatic fistula and severe complications (≥grade III by Accordion classification) were comparable in the 3 groups (P = .23 and P = .37, respectively). A multivariate logistic regression model did not demonstrate an association between obesity and postoperative morbidity (P = .09). The duration of hospital stay was comparable in the 3 groups (P = .13). CONCLUSION: In spite of longer operative time and greater blood loss, laparoscopic distal pancreatectomy in obese patients is associated with satisfactory postoperative outcomes, similar to those in normal weight and overweight patients. Hence, laparoscopic distal pancreatectomy should be equally considered both in obese and nonobese patients.