Progress in the Treatment of Small Intestine Cancer.

OPINION STATEMENT: Small intestine cancer is rare, accounting for approximately 3% of all gastrointestinal malignancies. The most common histological subtypes include adenocarcinoma, neuroendocrine tumours (NETs) and gastrointestinal stromal tumours (GISTs). In localised disease, surgery remains the mainstay of treatment and the best approach to improve survival. Current treatment for small intestine adenocarcinoma (SIA) is extrapolated from small studies and data from colorectal cancer (CRC). There is limited evidence to guide therapy in the adjuvant setting. However, there are small phase II studies in the advanced setting providing evidence for the role of chemotherapy and immunotherapy. There is also limited evidence assessing the efficacy of targeted therapies. Small intestine NETs are rare, with evidence for somatostatin analogue therapy, particularly in the low to intermediate-grade well-differentiated tumours. Poorly differentiated NETs are generally managed with chemotherapy but have worse outcomes compared with well-differentiated NETs. The management of small intestine GISTs is largely targeting KIT mutations with imatinib. Recent trials have provided evidence for effective therapies in imatinib-resistant tumours and the potential role of immunotherapy. The aim of this article was to review the evidence for the current management and recent advances in the management of small intestine adenocarcinoma, NETs and GISTs.

Principlist approach to multiple heart valve replacements for patients with intravenous drug use-induced endocarditis.

Medical professionals often deny patients who inject opioids a second or third heart valve replacement, even if such a surgery is medically indicated. However, such a position is not well defended. As this paper demonstrates, the ethical literature on the topic too often fails to develop and apply an ethical lens to analyse the issue of multiple valve replacements. This paper addresses this lacuna by analysing the case of Mr Walsh, a composite case which protects the identity of any one patient, through the principlist approach of Beauchamp and Childress. It argues that the hospital should offer Mr Walsh, a second valve replacement because the procedure is: medically indicated, autonomously requested, non-maleficent, beneficent and does not violate a formal account of justice. The paper concludes with clinical ethical guidelines for valve surgery for patients with opioid use disorder.

A Case of Multiple Posterior Intercostal Artery Common Trunks in Conjunction with Additional Arterial Variations.

Several thoracic vasculature variations were observed in an 81-year-old male cadaver during routine dissection. These included 5 common trunks of posterior intercostal arteries, a descending branch of the right vertebral artery, and atypical neurovascular relationships within intercostal spaces. On the right side, two common trunks of posterior intercostal arteries were observed supplying the 4th-7th intercostal spaces and 9th-11th intercostal spaces, respectively. There was also a small accessary branch supplying the 9th intercostal space. The first three posterior intercostal spaces on the right were supplied by a descending branch of the vertebral artery. On the left side, three common trunks of posterior intercostal arteries were encountered, supplying intercostal spaces 3-5, 6-7, and 11 plus the subcostal space. An atypical neurovascular relationship was observed in the right 6th intercostal space, as well as the left 2nd, 3rd, and 6th intercostal spaces. This is the first case report that presents 5 common trunks of posterior intercostal arteries, as well as common trunks in conjunction with other arterial variation in the posterior thoracic wall. These variations carry a high level of clinical significance and may be helpful in guiding decision-making related to surgical procedures related to the posterior thoracic cavity and spine.

How to perform transcystic stenting in the COVID-19 pandemic: an approach to biliary stenting without specialized endobiliary stenting equipment.

Management options for common bile duct stones found at laparoscopic cholecystectomy (LC) includes concurrent transcystic biliary stenting, effectively providing a conduit for common bile duct drainage and improving the success of subsequent endoscopic retrograde cholangiopancreatography. In the unprecedented COVID-19 pandemic however, potential disruptions to the medical supply chain have been far reaching, including the distribution of specialised biliary stent sets. To overcome this, we devised an innovative method at our centre to substitute traditional procedural stent sets by employing standard, universally accessible open-ended ureteral catheters, jagwires and pancreatic or biliary stents with similar procedural success.

A Case of Left Retroexternal Iliac Artery Megaureter Associated with Additional Renal and Vascular Congenital Anomalies.

Introduction. A number of rare anatomical anomalies, including retroexternal iliac ureter, extrarenal calyces (ERCs), and vascular anomalies, were observed in a 96-year-old female cadaver during a routine dissection. Description. A markedly dilated left extrarenal pelvis (ERP) with a diameter of 3.15 cm was noticed. Three major calyces were found outside of the normal-sized left kidney. The abdominal aorta (AA), instead of normal bifurcation, branched to the right common, left external, and left internal iliac arteries. The median sacral artery was a direct branch from the right common iliac artery. No hydronephrosis was observed on the affected side, and no urinary tract anomalies were observed on the right side. Significance. The retroiliac megaureter is a rare congenital anomaly, with fewer than 25 cases reported to date. Additionally, the ERCs are amongst the rarest anomalies of the renal collecting system. Further, the current case is one of few reported cases where the particular branching pattern of the AA was observed. The combination of such anatomical anomalies is rare, and the relationship between them is unclear. Common clinical manifestations of retroiliac ureters are the results of ureteric obstruction, hydronephrosis, and secondary infection. Precise knowledge of anomalies of the kidney and urinary tract can help radiologists and surgeons make a definitive diagnosis and prevent inadvertent injury during surgery.

Approach-Related Complications of Anterior Lumbar Interbody Fusion: Results of a Combined Spine and Vascular Surgical Team.

Study Design Retrospective analysis of prospectively collected cohort data. Objective Anterior lumbar interbody fusion (ALIF) is a commonly performed procedure for the treatment of degenerative diseases of the lumbar spine. Detailed and comprehensive descriptions of intra- and postoperative complications of ALIF are surprisingly limited in the literature. In this report, we describe our experience with a team model for ALIF and report all complications occurring in our patient series. Methods Patients were prospectively enrolled between January 2009 and January 2013 by a combined spine surgeon and vascular surgeon team. All patients underwent an open ALIF using an anterior approach to the lumbosacral spine. Results From the 227 ALIF cases, mean operative blood loss was 103 mL, ranging from 30 to 900 mL. Mean operative time was 78 minutes. The average length of stay was 5.2 days. Intraoperative vascular injury requiring primary repair with suturing occurred in 15 patients (6.6%). There were 2 cases of postoperative retroperitoneal hematoma. Three patients (1.3%) had incisional hernia requiring revision surgery; 7 (3.1%) patients had prolonged ileus (>7 days) managed conservatively. Four patients described retrograde ejaculation. Sympathetic dysfunction occurred in 15 (6.6%) patients. There were 5 (2.2%) cases of superficial wound infection treated with oral antibiotics, with no deep wound infections requiring reoperation or intravenous therapy. There were no mortalities in this series. Conclusions ALIF is a safe procedure when performed by a combined vascular surgeon and spine surgeon team with acceptably low complication rates. Our series confirms that the team approach results in short operative times and length of stay, with rapid control of intraoperative vessel injury and low overall blood loss.

Assessment of fatigue thresholds in 50-m all-out swimming.

CONTEXT: It is essential to determine swimmers' anaerobic potential and better plan training, understanding physiological effects of the fatigue. PURPOSE: To study changes in the characteristics of the intracyclic velocity variation during an all-out 50-m swim and to observe differences in speed and stroking parameters between these changes. METHODS: 28 competitive swimmers performed a 50-m front-crawl all-out test while attached to a speedometer. The velocity-time (v[t]) curve off all stroke cycles was analyzed per individual using a routine that included a wavelet procedure, allowing the determination of the fatigue thresholds that divide effort in time intervals. RESULTS: One or 2 fatigue thresholds were observed at individual level on the v(t) curve. In males, when 1 fatigue threshold was identified, the mean velocity and the stroke index dropped (P < .05) in the second time interval (1.7 ± 0.0 vs 1.6 ± 0.0 m/s and 3.0 ± 0.2 vs 2.8 ± 0.3 m/s, respectively). When 2 fatigue thresholds were identified, the mean velocity of the first time interval was higher than that of the third time interval (P < .05), for both male (1.7 ± 0.0 vs 1.6 ± 0.1 m/s) and female (1.5 ± 0.1 vs 1.3 ± 0.1 m/s) swimmers. CONCLUSION: One or 2 fatigue thresholds were found in the intracyclic velocity-variation patterns. Concurrently, changes in velocity and stroke parameters were also observed between time intervals. This information could allow coaches to obtain new insights into delaying the degenerative effects of fatigue and maintain stable stroke-cycle characteristics over a 50-m event.

Evolution of cardiorespiratory fitness after stroke: a 1-year follow-up study. Influence of prestroke patients' characteristics and stroke-related factors.

OBJECTIVES: To examine changes in cardiorespiratory fitness over the first year poststroke and explore the effect of prestroke patients' characteristics and stroke-related factors on this evolution. DESIGN: Descriptive, longitudinal study with repeated measures of exercise capacity at 3, 6, and 12 months poststroke. SETTING: Rehabilitation center and exercise testing laboratory. PARTICIPANTS: Consecutive sample of patients with stroke (N=33; mean age ± SD, 59.0±11.3 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak oxygen consumption (VO(2)peak) and oxygen uptake efficiency slope (OUES) were determined during a symptom-limited graded cycle ergometer test at 3, 6, and 12 months poststroke. Age, sex, premorbid physical activity level, clinical history (smoking, diabetes mellitus, chronic pulmonary diseases, cardiovascular diseases, overweight, and hypertension), stroke type and area, side of lesion, and assessments of stroke severity were evaluated at intake. RESULTS: Mean VO(2)peak ± SD was 18.1±6.6 mL·kg(-1)·min(-1), 19.8±8.0 mL·kg(-1)·min(-1), and 19.7±8.4 mL·kg(-1)·min(-1) at 3, 6, and 12 months poststroke. Values for OUES were 1575.3±638.3, 1710.7±710.3, and 1687.2±777.5, respectively. Mixed models showed no significant difference over time for VO(2)peak (P=.10), nor for the logarithm of OUES (P=.09). Stroke survivors at risk of deconditioning were premorbidly less active at work or in sport activities, diabetic, or initially more severely impaired. Combination of factors revealed that older patients with stroke and diabetes were less likely to improve on VO(2)peak and that older, women, diabetic nonsmokers improved less on log OUES. CONCLUSIONS: Cardiorespiratory fitness was reduced from 3 to 12 months poststroke and on average did not significantly change over time. Further studies should elucidate methods of increasing cardiorespiratory fitness during stay in the rehabilitation center and how community-based aerobic exercise training postrehabilitation can be organized.