Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes.

BACKGROUND: Nipple-sparing mastectomy (NSM) outcomes in the elderly have not been well characterized. The goal of this study was to evaluate NSM outcomes in patients over age 60. PATIENTS AND METHODS: A single-institution retrospective cohort study was performed for NSM patients over the age of 60 from January 2004 to January 2022. Demographic, intraoperative, and postoperative variables were collected. RESULTS: We identified 136 women who underwent a total of 200 NSMs at a mean age 65.2 years and with mean body mass index of 25. Most (56%) had invasive breast cancer, requiring neoadjuvant chemotherapy in 15%, and 17.5% had radiation prior to NSM. A total of 91% had immediate tissue expander placement. The infection rate was 19%, with 11.5% requiring expander explantation in the follow-up period. In binomial logistic regression analysis, prior radiation increased the odds of any complication by 2.9 (OR 2.93, CI 1.30-6.58, p = 0.009) and increased the odds of infection by 5.7 (OR 5.70, CI 1.95-16.66, p = 0.001), but no associations were seen for other covariates including age, comorbidities, prior chemotherapy, or presence of invasive disease. Diabetes increased the odds of wound breakdown specifically by 9.0 (OR 8.97, CI 2.01-39.92, p = 0.004). Local recurrence was 3% in mean 3.4-year follow-up. CONCLUSIONS: Our data support NSM in patients over the age of 60 years with acceptable outcomes within the standard of care. Locoregional recurrence was within the cited range of 0-5%, and only diabetes and prior radiation were associated with reconstructive complications. NSM should thus be offered when appropriate regardless of increased age to achieve oncologic and reconstructive goals.

Simultaneous High-Strength and Deformable Nanolaminates With Thick Biphase Interfaces.

Two-phase nanolaminates are known for their high strength, yet they suffer from loss of ductility. Here, we show that broadening heterophase interfaces into "3D interfaces" as thick as the individual layers breaks this strength-ductility trade-off. In this work, we use micropillar compression and transmission electron microscopy to examine the processes underlying this breakthrough mechanical performance. The analysis shows that the 3D interfaces stifle flow instability via shear band formation through their interaction with dislocation pileups. To explain this observation, we use phase field dislocation dynamics (PFDD) simulations to study the interaction between a pileup and a 3D interface. Results show that when dislocation pileups fall below a characteristic size relative to the 3D interface thickness, transmission across interfaces becomes significantly frustrated. Our work demonstrates that 3D interfaces attenuate pileup-induced stress concentrations, preventing shear localization and offering an alternative way to enhanced mechanical performance.

The positivity principle: do positive instructors improve learning from video lectures?

The positivity principle states that people learn better from instructors who display positive emotions rather than negative emotions. In two experiments, students viewed a short video lecture on a statistics topic in which an instructor stood next to a series of slides as she lectured and then they took either an immediate test (Experiment 1) or a delayed test (Experiment 2). In a between-subjects design, students saw an instructor who used her voice, body movement, gesture, facial expression, and eye gaze to display one of four emotions while lecturing: happy (positive/active), content (positive/passive), frustrated (negative/active), or bored (negative/passive). First, learners were able to recognize the emotional tone of the instructor in an instructional video lecture, particularly by more strongly rating a positive instructor as displaying positive emotions and a negative instructor as displaying negative emotions (in Experiments 1 and 2). Second, concerning building a social connection during learning, learners rated a positive instructor as more likely to facilitate learning, more credible, and more engaging than a negative instructor (in Experiments 1 and 2). Third, concerning cognitive engagement during learning, learners reported paying more attention during learning for a positive instructor than a negative instructor (in Experiments 1 and 2). Finally, concerning learning outcome, learners who had a positive instructor scored higher than learners who had a negative instructor on a delayed posttest (Experiment 2) but not an immediate posttest (Experiment 1). Overall, there is evidence for the positivity principle and the cognitive-affective model of e-learning from which it is derived.

Bilateral Breast Reduction Without Opioid Analgesics: A Comparative Study.

BACKGROUND: Breast reduction has traditionally been performed under general anesthesia with adjunct opioid use. However, opioids are associated with a wide variety of adverse effects, including nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction. OBJECTIVES: This study compares bilateral breast reduction using a multimodal opioid-free pain management regimen vs traditional general anesthesia with adjunct opioids. METHODS: A total of 83 female patients were enrolled in this study. Group 1 includes a retrospective series of 39 patients that underwent breast reduction via general anesthesia with adjunct opioid use. This series was compared to 2 prospective groups of patients who did not receive opioids either preoperatively or intraoperatively. In group 2, twenty-six patients underwent surgery under intravenous sedation and local anesthesia. In group 3, eighteen patients underwent surgery with general anesthesia. All patients in groups 2 and 3 received preoperative gabapentin and celecoxib along with infiltration of local anesthetics during the operation and prior to discharge to the Post-Anesthesia Care Unit (PACU). Primary outcome measures included the duration of surgery, time from end of operation to discharge home, postoperative opioid and antiemetic use, and unplanned postoperative hospitalizations. RESULTS: When compared to group 1, groups 2 and 3 experienced a shorter time from end of operation to discharge home (P < 0.05), fewer unplanned hospital admissions (P < 0.05), and highly significant decrease in postoperative opioid use (P < 0.001). CONCLUSIONS: This multimodal approach allows patients to safely undergo opioid-free bilateral breast reduction either under local or general anesthesia as an outpatient. This method resulted in significantly less morbidity, use of opioids postoperatively, as well as unplanned hospital admissions compared to "traditional" breast reduction under general anesthesia with the use of opioids. LEVEL OF EVIDENCE: 3.

Nicotinic Acetylcholine Receptors Sensitize a MAPK-linked Toxicity Pathway on Prolonged Exposure to ß-Amyloid.

Among putative downstream synaptic targets of ß-amyloid (Aß) are signaling molecules involved in synaptic function, memory formation and cognition, such as the MAP kinases, MKPs, CaMKII, CREB, Fyn, and Tau. Here, we assessed the activation and interaction of signaling pathways upon prolonged exposure to Aß in model nerve cells expressing nicotinic acetylcholine receptors (nAChRs). Our goal was to characterize the steps underlying sensitization of the nerve cells to neurotoxicity when Aß-target receptors are present. Of particular focus was the connection of the activated signaling molecules to oxidative stress. Differentiated neuroblastoma cells expressing mouse α4ß2-nAChRs were exposed to Aß1-42 for intervals from 30 min to 3 days. The cells and cell-derived protein extracts were then probed for activation of signaling pathway molecules (ERK, JNK, CaMKII, CREB, MARCKS, Fyn, tau). Our results show substantial, progressive activation of ERK in response to nanomolar Aß exposure, starting at the earliest time point. Increased ERK activation was followed by JNK activation as well as an increased expression of PHF-tau, paralleled by increased levels of reactive oxygen species (ROS). The impact of prolonged Aß on the levels of pERK, pJNK, and ROS was attenuated by MEK-selective and JNK-selective inhibitors. In addition, the MEK inhibitor as well as a JNK inhibitor attenuated Aß-induced nuclear fragmentation, which followed the changes in ROS levels. These results demonstrate that the presence of nAChRs sensitizes neurons to the neurotoxic action of Aß through the timed activation of discrete intracellular signaling molecules, suggesting pathways involved in the early stages of Alzheimer disease.

Associations of appendicular lean mass and abdominal adiposity with insulin resistance in older adults: A cross-sectional study.

Loss of lean muscle mass and accumulation of adipose tissue are changes associated with aging. Previous studies have documented various components of body composition as predictors for insulin resistance. The objective of this study was to investigate whether components of body composition-appendicular lean mass (ALM) and/or abdominal fat mass (AFM)-correlate with insulin resistance in older men and women. This was a cross-sectional study of 92 older men and women. Weight was classified according to body mass index (BMI)-normal (BMI <25), overweight (BMI 25-30), and obese (BMI >30). All body composition data was determined by dual energy x-ray absorptiometry (DEXA), and insulin resistance was assessed by the homeostatic model assessment of insulin resistance (HOMA-IR). Multivariable regression models with two-way interaction terms were employed to assess whether the associations between components of body composition and log HOMA varied by BMI categories. Adjusted regression showed that log HOMA was significantly associated with AFM (estimate ± standard error: 0.055 ± 0.026) and ALM (0.057 ± 0.029) for the overweight participants (p-values <0.05). Additionally, the adjusted associations between log HOMA and ALM were significantly greater for participants who were either obese or overweight compared to those with a normal BMI (p<0.002). Less consistent relationships were observed between insulin resistance and abdominal fat mass across BMI categories, whereas more consistent associations were observed between insulin resistance and appendicular lean mass in individuals with greater BMI. Further research is needed to clarify if lipid deposition within muscle tissue promotes muscle dysfunction and thereby increases risk for insulin resistance.

Serpentine supravenous hyperpigmentation induced by chemotherapy: a systematic review.

Serpentine supravenous hyperpigmentation (SSH) describes increased skin pigmentation that develops in the area immediately overlying the vessels through which chemotherapeutic drugs are administered. While SSH can be cosmetically distressing and there are no definitive management options, the literature is severely limited and the variations in clinical presentation, risk factors, and histopathology of SSH across patients are not well understood. We aimed to systematically summarize characteristics from current available data, and thus improve SSH awareness and management. A literature search was conducted in PubMed using specific eligibility criteria through the end of December 2022. Included articles focused on patients who experienced SSH after chemotherapy infusion. Study quality was assessed using a modified Oxford Centre for Evidence-Based Medicine quality rating scheme. Of the 41 articles identified by literature search, 24 met eligibility criteria. Two additional articles were identified through the reference sections of retrieved articles, for 26 articles total. All articles were case reports, representing 28 patients total. Locations of SSH were mostly in the forearm near the site of injection (85%), and the most common associated symptom was erythema. Histopathologic analysis was available for half of cases, the majority of which were inflammatory in nature. The most common inflammatory pattern observed was a vacuolar/lichenoid interface dermatitis. Duration of SSH ranged from days to > 1 year after the chemotherapy was stopped. Six (21%) patients were managed with topical steroids and oral vasodilators, six (21%) patients switched to central venous infusion rather than peripheral infusion, five (18%) patients received only supportive care, three (11%) patients received venous washing with chemotherapy, three (11%) patients stopped chemotherapy, and one (4%) patient reduced the chemotherapy dosage. Ten (36%) patients attained complete resolution, seven (25%) had SSH that was near resolution/fading, and three (11%) had persistent hyperpigmentation. Although SSH often spontaneously resolves once the chemotherapeutic agent is stopped, it can persist in some patients and cause significant distress. As the literature is severely limited and there are no definitive treatments, additional research using more standardized definitions and methods of assessments is necessary to improve characterization of SSH and evaluate potential interventions.

Synchronous metastatic prostate cancer and male breast cancer while on testosterone replacement therapy: Case report.

INTRODUCTION: Testosterone replacement therapy (TRT) can improve quality of life for men with hypogonadism. However, it is generally avoided in patients with a history of prostate cancer or breast cancer as there is uncertainty about risks. This case illustrates an example of synchronous metastatic prostate cancer and male breast cancer following TRT. PRESENTATION OF CASE: A 72-year-old man with previously treated intermediate-risk prostate adenocarcinoma experienced a gradual rise in prostate-specific antigen (PSA) while self-administering testosterone replacement. He was later found to have recurrent metastatic prostate cancer and prior to initiating androgen deprivation therapy (ADT), he was also diagnosed with male breast cancer. His treatment has consisted of continued ADT for metastatic castration-sensitive prostate cancer (mCSPC) as well as surgical resection of his breast cancer. DISCUSSION: ADT plays a role in treatment of male breast cancer and prostate cancer. TRT remains relatively contraindicated in patients with a history of these malignancies, but the evidence supporting this recommendation is somewhat limited. CONCLUSION: This case highlights the potential risk for synchronous recurrent prostate and new male breast cancer following TRT. Further studies are needed to better elucidate the increased risks of these malignancies with TRT.

Assessment of valve regurgitation severity via contrastive learning and multi-view video integration.

Objective. This paper presents a novel approach for addressing the intricate task of diagnosing aortic valve regurgitation (AR), a valvular disease characterized by blood leakage due to incompetence of the valve closure. Conventional diagnostic techniques require detailed evaluations of multi-modal clinical data, frequently resulting in labor-intensive and time-consuming procedures that are vulnerable to varying subjective assessment of regurgitation severity.Approach. In our research, we introduce the multi-view video contrastive network, designed to leverage multiple color Doppler imaging inputs for multi-view video processing. We leverage supervised contrastive learning as a strategic approach to tackle class imbalance and enhance the effectiveness of our feature representation learning. Specifically, we introduce a contrastive learning framework to enhance representation learning within the embedding space through inter-patient and intra-patient contrastive loss terms.Main results. We conducted extensive experiments using an in-house dataset comprising 250 echocardiography video series. Our results exhibit a substantial improvement in diagnostic accuracy for AR compared to state-of-the-art methods in terms of accuracy by 9.60%, precision by 8.67%, recall by 9.01%, andF1-score by 8.92%. These results emphasize the capacity of our approach to provide a more precise and efficient method for evaluating the severity of AR.Significance. The proposed model could quickly and accurately make decisions about the severity of AR, potentially serving as a useful prescreening tool.

The biophysical mechanisms of altered hyaluronan concentration in synovial fluid after anterior cruciate ligament transection.

OBJECTIVE: The residence time of hyaluronan (HA) in knee joint synovial fluid (SF) was investigated using a rabbit anterior cruciate ligament transection (ACLT) model. The aims of this study were to assess, at 7 and 28 days after surgery, the 1) HA concentration and molecular mass (M(r) ) distribution in the SF, 2) endogenous replenishment of HA after saline washout, 3) HA residence times in the SF, and 4) synovium and subsynovium cellularity of the knee joints of rabbits subjected to ACLT, compared to sham-operated and nonoperated control joints. METHODS: Adult NZW rabbits underwent ACLT or sham surgery on one hind limb, while each contralateral limb was the nonoperated control. On day 7 or 28 after surgery, the joints were aspirated for SF, lavaged with saline, and injected with saline or polydisperse HA, and samples were obtained for analysis at set time points up to 8 hours after injection. Joint fluid samples were analyzed for the concentration and M(r) distribution of HA to calculate the HA residence time constant. RESULTS: Analysis of HA concentrations and M(r) distributions showed 1) loss of high-M(r) HA in the SF on day 7 and a shift toward a lower-M(r) distribution on day 28, 2) endogenous replenishment of high-M(r) HA after washout, and 3) M(r) -dependent loss of HA from the knee joints after ACLT, particularly on day 7 postsurgery. The HA residence time decreased with decreasing HA M(r) (residence time ∼27 hours with an M(r) load of 7,000-2,500 kd, to ∼7 hours with an M(r) load of 250-50 kd). HA residence time also decreased (by ∼70%) in the knee joints on day 7 after ACLT. The subsynovium of the joints subjected to ACLT displayed increased cellularity and neovascularization on days 7 and 28 postsurgery. CONCLUSION: The residence time of HA in the SF is transiently decreased after ACLT, suggesting that a biophysical transport mechanism is responsible for the altered composition of the SF after joint injury or during inflammation.

Assessment of an embedded primary care-derived electronic health record (EHR) frailty index (eFI) in older adults with acute myeloid leukemia.

INTRODUCTION: Assessing frailty is integral to treatment decision-making for older adults with acute myeloid leukemia (AML). Prior electronic frailty indices (eFI) derive from an accumulated-deficit model and are associated with mortality in older primary care populations. We evaluated use of an embedded eFI in AML by describing baseline eFI categories by treatment type and exploring associations between eFI categories, survival, and treatment received. MATERIALS AND METHODS: This was a retrospective study of subjects ≥60 years old with new AML treated at an academic medical center from 1/2018-10/2020. The eFI requires ≥2 ambulatory visits over two years and uses demographics, vitals, ICD-10 codes, outpatient labs, and available functional information from Medicare Annual Wellness Visits. Frailty was defined as fit (eFI ≤ 0.10), pre-frail (0.10 < eFI ≤ 0.21), and frail (eFI > 0.21). Chemotherapy was intensive (anthracycline-based) or less-intensive (hypomethylating agent, low dose cytarabine +/- venetoclax). Therapy type, pre-treatment characteristics, and chemotherapy cycles were compared by eFI category using chi-square and Fisher's exact tests and ANOVA. Median survival was compared by eFI category using log-rank tests stratified by therapy type. RESULTS: Among 166 older adults treated for AML (mean age 74 years, 61% male, 85% Caucasian), only 79 (48%) had a calculable eFI score before treatment. Of these, baseline eFI category was associated with treatment received (fit (n = 31): 68% intensive, 32% less intensive; pre-frail (n = 38): 37% intensive, 63% less intensive; frail (n = 10): 0% intensive, 100% less intensive; not calculable (n = 87): 48% intensive, 52% less-intensive; p < 0.01). The prevalence of congestive heart failure and secondary AML differed by frailty status (p < 0.01). Median survival did not differ between eFI categories for intensively (p = 0.48) or less-intensively (p = 0.09) treated patients. For those with less-intensive therapy who lived ≥6 months, eFI category was not associated with the number of chemotherapy cycles received (p = 0.97). The main reason for an incalculable eFI was a lack of outpatient visits in our health system prior to AML diagnosis. DISCUSSION: A primary care-derived eFI was incalculable for half of older adults with AML at an academic medical center. Frailty was associated with chemotherapy intensity but not survival or treatment duration. Next steps include testing adaptations of the eFI to the AML setting.

Carotid artery stenting for asymptomatic stenosis is associated with decreased 30-day readmission at very high volume centers.

Endovascular carotid artery stenting (CAS) is a common treatment for carotid artery stenosis and stroke prevention. Previous studies have shown that high procedural volume centers are associated with improved patient outcomes. Unplanned 30-day readmissions, which are associated with significant expenses, are increasingly used as a metric of patient outcome. Despite prior studies evaluating associations between procedural volume and multiple outcomes, the association between very high CAS volume and short-term (30-day) readmission has not yet been evaluated in a large multicenter study. The National Readmissions Database (NRD) was analyzed retrospectively from 2010 to 2015 to evaluate the association between hospital procedural volume and patient outcomes in asymptomatic and symptomatic CAS patients. Very high volume centers (VHVC) were defined as the top 10% hospitals in terms of procedural volume, performing >= 79 procedures a year. Univariate and multivariate analyses of patient and hospital characteristics evaluated associations with short-term (30-day) readmissions (SR), long-term (90-day) readmissions (LR), index mortality, discharge disposition, major complications, and neurological complications. A total of 36,128 asymptomatic patients and 8,390 symptomatic patients who underwent CAS were identified. Asymptomatic CAS patients treated at VHVCs were associated with decreased likelihood of SR (OR 0.88, 95% CI 0.80-0.95, p = 0.003) and LR (OR 0.91, 95% CI 0.85-0.99, p = 0.037) compared to asymptomatic patients at non-VHVCs. There was no significant difference in SR or LR between symptomatic CAS patients treated at a VHVC vs. non-VHVC. Our findings provide additional evidence to support the role of experience in improved CAS treatment outcomes.

Wireless physical activity monitor use among adults living with HIV in a community-based exercise intervention study: a quantitative, longitudinal, observational study.

OBJECTIVES: Our aim was to examine wireless physical activity monitor (WPAM) use and its associations with contextual factors (age, highest education level, social support and mental health) among adults living with HIV engaged in a community-based exercise (CBE) intervention. DESIGN: Quantitative, longitudinal, observational study. SETTING: Toronto YMCA, Ontario, Canada. PARTICIPANTS: Eighty adults living with HIV who initiated the CBE intervention. INTERVENTION: Participants received a WPAM to track physical activity during a 25-week CBE intervention involving thrice-weekly exercise, supervised weekly (phase 1) and a 32-week follow-up involving thrice-weekly exercise with no supervision (phase 2), completed in December 2018. OUTCOME MEASURES: Uptake was measured as participants who consented to WPAM use at initation of the intervention. Usage was defined as the proportion of days each participant had greater than 0 steps out of the total number of days in the study. We measured contextual factors using a baseline demographic questionnaire (age, highest education level), and median scores from the bimonthly administered Medical Outcomes Study-Social Support Scale and Patient Health Questionnaire (mental health), where higher scores indicated greater social support and mental health concerns, respectively. We calculated Spearman correlations between WPAM usage and contextual factors. RESULTS: Seventy-six of 80 participants (95%) consented to WPAM use. In phase 1, 66% of participants (n=76) and in phase 2, 61% of participants (n=64) used the WPAM at least 1 day. In phase 1, median WPAM usage was 50% (25th, 75th percentile: 0%, 87%; n=76) of days enrolled and in phase 2, 23% (0%, 76%; n=64) of days. Correlation coefficients with WPAM usage ranged from weak for age (ρ=0.26) and mental health scores (ρ=-0.25) to no correlation (highest education level, social support). CONCLUSIONS: Most adults living with HIV consented to WPAM use, however, usage declined over time from phase 1 to phase 2. Future implementation of WPAMs should consider factors to promote sustained usage by adults living with HIV. TRIAL REGISTRATION NUMBER: NCT02794415.

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec.

OBJECTIVES: Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec. DESIGN: Population-based birth cohort study through administrative health data linkage. SETTING AND PARTICIPANTS: Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec. RESULTS: Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities. CONCLUSIONS: The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

Botulinum toxin as an adjunct for severe Dupuytren's contracture treated with collagenase injections.

Even with Dupuytren's proximal interphalangeal joint (PIPJ) contractures successfully released, volar flexor muscle memory can contribute to persistent contracture. We report using botulinum toxin (BoNTA) to the flexor digitorum superficialis muscle (FDS) to reduce flexor tone during recovery. Case Description. Two Collagenase clostridium histolyticum (CCH) injections were given to a patient with a -90° (PIPJ) contracture and a -35° degree distal interphalangeal joint (DIPJ) contracture. At the first CCH injection, 20 µ total of the Botulinum toxin was placed into the FDS muscle. Manipulation occurred at one week. A second injection of CCH followed by manipulation one week later occurred at two months, but no additional BoNTA was given. The final follow-up measurements at 53 months showed a PIPJ of -30° and a DIPJ of 0°. Total active motion improved from 140° to 240°. Outcomes of any treatment for severe Dupuytren's PIPJ contractures of the little finger are unpredictable and are often considered for staged external expansion or even salvage procedures. BoNTA injections weaken flexor tone in tendon repairs and for treating hypertonic muscles after strokes. Conclusion. We hypothesized that BoNTA injection could enhance the outcomes of DC treatment by inhibiting volar flexion forces during the recovery phase. The following case illustrates that using a BoNTA injection may have helped treat a severe PIPJ contracture. BoNTA injections need further research and controlled clinical trials to discover their proper role in Dupuytren's contractures treated via CCH injections, fasciotomies, and fasciectomies.

Non-operative management of pneumoperitoneum following cardiopulmonary resuscitation.

Spontaneous pneumoperitoneum in a patient with a tracheostomy tube following cardiopulmonary resuscitation is exceedingly rare, with little experimental nor observational data to guide evidence-based management. We present the case of a 75-year-old woman with a tracheostomy tube who developed pneumoperitoneum following CPR. The patient experienced pulseless electrical activity arrest requiring nine rounds of chest compressions to return to spontaneous circulation. Computerized tomography demonstrated pneumothoraces, subcutaneous emphysema and extensive intraperitoneal, extraperitoneal and retroperitoneal free air without evidence of visceral perforation. The patient's abdomen was distended without tenderness, guarding or rebound. She had a white blood cell count mildly elevated from her baseline levels. The management plan of serial abdominal exams without operative intervention was chosen given the absence of clinical and laboratory signs of peritonitis. This case highlights the importance of developing a standardized management algorithm for patients with pneumoperitoneum in the setting of tracheostomy tubes without evidence of perforation.

Polypharmacy in Oncology.

Polypharmacy, defined as taking five medications or more, is a common geriatric syndrome. It is especially prevalent in older adults with cancer. For older patients with breast, lung, prostate, and colorectal cancer and chronic lymphocytic leukemia, polypharmacy has numerous adverse effects, including interactions with medications prescribed for other comorbidities. Polypharmacy is influenced by drug-drug interactions and can reduce the efficacy of systemic cancer therapeutics. It is also associated with worse progression-free and overall survival for some cancers such as lung and colorectal cancer. This highlights the need for a judicious review of all medications and the role of interventions in improving quality of life and survival.

Metastatic Alveolar Rhabdomyosarcoma with Extensive Bone Marrow Replacement in an Older Adult.

Rhabdomyosarcoma is extremely rare in adults. Metastatic rhabdomyosarcoma can resemble other malignancies, which can delay diagnosis and prompt treatment. This case illustrates an example of metastatic alveolar rhabdomyosarcoma with concurrent bone marrow infiltration. A 67-year-old woman presented with epistaxis and diffuse bone pain. She developed progressive thrombocytopenia requiring platelet transfusions. The patient was initially thought to have leukemia. She was found to have a large sinonasal mass with extensive metastatic disease and bone marrow infiltration. The patient was ultimately diagnosed with metastatic alveolar rhabdomyosarcoma. She was started on chemotherapy with vincristine, actinomycin, and cyclophosphamide. Unfortunately, she died prior to discharge home. Alveolar rhabdomyosarcoma can resemble a primary bone marrow malignancy when it infiltrates the bone marrow. Further investigation is needed to clarify its clinical behavior and expedite diagnosis and treatment.