Quantitative assessment of the troCarWash™ system for automated laparoscopic camera cleaning.

BACKGROUND: Soilage of the surgical endoscope occurs frequently during minimally invasive surgery. The resultant impairment of visualization of the surgical field compromises patient safety, prolongs operative times, and frustrates surgeons. The standard practice for cleaning the surgical camera involves a disruption in the conduct of surgery by completely removing the endoscope from the field, manually cleaning its lens, treating it with a surfactant, and reinserting it into the patient; after which the surgeon resumes the procedure. METHODS: We developed an automated solution for in vivo endoscope cleaning in minimally invasive surgery- a port that detects the position of the endoscope in its distal lumen, and precisely and automatically delivers a pressurized mist of cleaning solution to the lens of the camera. No additions to the scope and minimal user interaction with the port are required. We tested the efficacy of this troCarWash™ device in a porcine model of laparoscopy. Four board-certified general surgeons were instructed to soil and then clean the laparoscope using the device. Representative pre- and post-clean images were exported from the surgical video and clarity was graded (1) digitally by a canny edge detection algorithm, and (2) subjectively by 3 blinded, unbiased observers using a semi-quantitative scale. RESULTS: We observed statistically significant improvements in clarity by each method and for each surgeon, and we noted significant correlation between digital and subjective scores. CONCLUSION: Based on these data, we conclude that the troCarWash™ effectively restored impaired visualization in a large animal model of laparoscopy.

Patterns and predictors of antidepressant prescribing among adults with cancer and depression in ambulatory care settings in the United States.

OBJECTIVE: Despite depression being a common comorbidity among adults with cancer, limited literature is available regarding pharmacologic depression treatment patterns and predictors in this population. This study aims to examine patterns and predictors of antidepressant prescribing among adults with cancer and depression in ambulatory care settings in the United States (US). METHODS: This retrospective, cross-sectional study utilized data collected from the 2014 to 2015 National Ambulatory Medical Care Survey (NAMCS). The study sample consisted of adults (age ≥ 18 years) with cancer and depression (unweighted N = 539; weighted N = 11,361,000). A multivariable logistic regression analysis was used to adjust for individual-level factors to identify predictors of antidepressant prescribing. RESULTS: Most patients were adults aged ≥ 65 years, female, and non-Hispanic whites. Thirty-seven percent of the study sample received antidepressant treatment. Multivariable logistic regression analysis revealed that race/ethnicity, physician specialty, and number of medications were significantly associated with receiving antidepressant(s). For example, non-Hispanic whites were two-and-half times more likely to receive an antidepressant [OR 2.43, 95% confidence interval 1.13-5.23] compared to other race/ethnic groups. Every unit increase in the number of prescribed medications increased the likelihood of receiving an antidepressant by 6% (OR 1.06, 95% CI: 1.01-1.11). CONCLUSION: Among adults with a comorbid cancer and depression diagnosis and a recorded U.S. ambulatory care visit in 2014-2015, 37% received antidepressant treatment. This suggests most patients with cancer and depression do not receive pharmacologic treatment for depression. Future studies are needed to investigate the impact of antidepressant treatment on health outcomes in this patient population.

Periarticular infiltration used in total joint replacements: an update and review article.

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

The Incidence of Rectal Neuroendocrine Tumors Is Increasing in Younger Adults in the US, 2001-2020.

Prior non-comparative data showed increasing incidence of rectal neuroendocrine tumors (RNET) in the US. We aimed to evaluate age-specific RNET incidence rates and time-trends in demographic- and tumor-specific populations. The RNET age-adjusted incidence rates were calculated from the United States Cancer Statistics (USCS) database between 2001 and 2020. The population was stratified by age into older (≥55 years) and younger adults (<55 years), as well as by sex and race. The tumors were categorized by their stage at diagnosis into early and late. The annual percentage change (APC) and average APC (AAPC) were estimated using joinpoint regression and Monte Carlo permutation analysis. Pairwise comparison assessed for parallelism and coincidence. There were 59,846 patients diagnosed with RNET between 2001 and 2020 (50.3% women). Overall, the RNET incidence rates during this period were increasing in younger but not older adults (AAPC = 3.12 vs. -1.10; AAPC difference = 4.22, p < 0.001), with non-identical non-parallel data (p-values < 0.001). While similar results were seen in men, a greater age-specific difference was noted in women (AAPC = 3.31 vs. -1.10; AAPC difference = 4.41, p = 0.003). The difference between younger and older adults was seen in non-Hispanic White (AAPC-difference = 4.89; p < 0.001) and non-Hispanic Black (AAPC-difference = 3.33; p = 0.03) patients, and, in most years, among Hispanic and Non-Hispanic Asian/Pacific Islander patients, and it was mostly driven by early-stage tumors (AAPC-difference = 3.93; p < 0.001). The nationwide data show a significantly increasing RNET incidence in younger adults, most notably in younger women and in early-stage tumors, seen in various races. Future studies should evaluate RNET risk factors and outcomes in demographic-specific populations.

Pancreatic Cancer Biopsy Modalities: Comparing Insurance Status, Length of Stay, and Hospital Complications Based on Percutaneous, Endoscopic, and Surgical Biopsy Methods.

BACKGROUND: Pancreatic cancer is diagnosed histologically through percutaneous biopsy (PB), endoscopic biopsy (EB), or surgical biopsy (SB). Factors and outcomes associated with method type are not clearly understood. We aimed to evaluate the relationship between insurance status, length of hospital stay (LOS), complications, and different pancreatic biopsy modalities. STUDY: The 2001-2013 database from the National (Nationwide) Inpatient Sample (NIS) was queried for those with pancreatic cancer who underwent biopsies using International Classification of Diseases, Ninth Revision (ICD-9) codes. Data regarding insurance status, hospital stay, demographics, and complications were analyzed using chi-square and multivariate analysis with α < 0.001. RESULTS: A total of 824,162 patients with pancreatic cancer were identified. Uninsured and Medicaid patients were more likely to get PB compared to SB. Patients were more likely to have acute renal failure (ARF) with an EB compared to SB. Patients were more likely to have a urinary tract infection (UTI) with EB or PB compared to SB. All biopsy types were less likely to have pneumonia; pancreatitis was more prevalent in EB compared to PB and SB. CONCLUSIONS: Uninsured and Medicaid patients were most likely to have a PB compared to EB despite unclear indications which may represent an underlying discrepancy in healthcare utilization. EB patients had the shortest LOS while SB patients stayed three more days; those who underwent a combination of biopsies had the greatest LOS. Patients with EB were more likely to develop ARF, UTI, and pancreatitis than SB, possibly attributed to the advanced nature of endoscopic ultrasound. It is important to establish appropriate algorithm contributors to guide decision-making.

Familial CCM Genes Might Not Be Main Drivers for Pathogenesis of Sporadic CCMs-Genetic Similarity between Cancers and Vascular Malformations.

Cerebral cavernous malformations (CCMs) are abnormally dilated intracranial capillaries that form cerebrovascular lesions with a high risk of hemorrhagic stroke. Recently, several somatic "activating" gain-of-function (GOF) point mutations in PIK3CA (phosphatidylinositol-4, 5-bisphosphate 3-kinase catalytic subunit p110α) were discovered as a dominant mutation in the lesions of sporadic forms of cerebral cavernous malformation (sCCM), raising the possibility that CCMs, like other types of vascular malformations, fall in the PIK3CA-related overgrowth spectrum (PROS). However, this possibility has been challenged with different interpretations. In this review, we will continue our efforts to expound the phenomenon of the coexistence of gain-of-function (GOF) point mutations in the PIK3CA gene and loss-of-function (LOF) mutations in CCM genes in the CCM lesions of sCCM and try to delineate the relationship between mutagenic events with CCM lesions in a temporospatial manner. Since GOF PIK3CA point mutations have been well studied in reproductive cancers, especially breast cancer as a driver oncogene, we will perform a comparative meta-analysis for GOF PIK3CA point mutations in an attempt to demonstrate the genetic similarities shared by both cancers and vascular anomalies.

Differential Rates of Lower Gastrointestinal Bleeding and Other Outcomes in Colorectal Cancer Patients With Aortic Stenosis.

Background Aortic stenosis (AS) has been established as a precipitating factor in the development of colonic angiodysplasia, resulting in lower gastrointestinal bleeding (LGIB). While the association between AS and LGIB, termed "Heyde syndrome," has been examined extensively, few studies assess the impact of comorbid AS on rates of LGIB in patients with colorectal cancer (CRC). Our goal is to examine this association.  Methods Patients hospitalized from 2001 to 2013 diagnosed with CRC were identified via ICD-9 codes, further stratified by a diagnosis of AS. Continuous and categorical variables were analyzed by independent sample t-tests and chi-squared analyses respectively. Assessed outcomes included mortality, length of stay (LOS), hospital costs, rates of LGIB, colonic obstruction, colonic perforation, iron-deficiency anemia (IDA), and colectomy. Multivariate analysis via binary logistic regression was utilized to control confounding variables. Results Patients with CRC and AS had higher rates of mortality, lower gastrointestinal bleeding, iron deficiency anemia, and colectomy, while those without AS had higher rates of colonic obstruction. Length of stay and total hospital charges were higher in patients with AS.  Discussion CRC outcomes were worse in patients with AS. This could be due to higher rates of LGIB secondary to the prevalence of angiodysplasia among AS patients. More retrospective studies are required to assess the impact of comorbid AS in patients with CRC.

Intraductal Papillary Neoplasm of the Bile Duct: A Rare Disease and Presentation.

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease that occurs anywhere along the bile duct. The disease predominantly occurs in Far East Asia and is very rarely diagnosed and documented in western countries. IPNB presents similarly to obstructive biliary pathology; however, patients can be asymptomatic. Surgical resection of IPNB lesions is crucial for patient survival because IPNB is precancerous and can transform into cholangiocarcinoma. Although potentially curative by excision with negative margins, patients who are diagnosed with IPNB need close monitoring for de novo recurrence of IPNB or other pancreatic-biliary neoplasms. In this case, we present an asymptomatic non-Hispanic Caucasian male who was diagnosed with IPNB.

Key Members of the CmPn as Biomarkers Distinguish Histological and Immune Subtypes of Hepatic Cancers.

Liver cancer, comprising hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), is a leading cause of cancer-related deaths worldwide. The liver is a primary metabolic organ for progesterone (PRG) and PRG exerts its effects through classic nuclear PRG receptors (nPRs) and non-classic membrane PRG receptors (mPRs) or a combination of both. Previous studies have shown that the CCM signaling complex (CSC) couples both nPRs and mPRs to form the CmPn (CSC-mPR-PRG-nPR) signaling network, which is involved in multiple cellular signaling pathways, including tumorigenesis of various cancers. Despite advances in treatment, 5-year survival rates for liver cancer patients remain low, largely due to the chemoresistant nature of HCCs. The lack of sensitive and specific biomarkers for liver cancer diagnosis and prognosis emphasizes the need for identifying new potential biomarkers. We propose the potential use of CmPn members' expression data as prognostic biomarkers or biomarker signatures for the major types of hepatic cancer, including HCCs and CCAs, as well as rare subtypes such as undifferentiated pleomorphic sarcoma (UPS) and hepatic angiosarcoma (HAS). In this study, we investigated the CmPn network through RNAseq data and immunofluorescence techniques to measure alterations to key cancer pathways during liver tumorigenesis. Our findings reveal significant differential expression of multiple CmPn members, including CCM1, PAQR7, PGRMC1, and nPRs, in both HCCs and CCAs, highlighting the crucial roles of mPRs, nPRs, and CSC signaling during liver tumorigenesis. These key members of the CmPn network may serve as potential biomarkers for the diagnosis and prognosis of liver cancer subtypes, including rare subtypes.

Social Determinants of Health, Cardiovascular Risk Factors, and Atherosclerotic Cardiovascular Disease in Individuals of Vietnamese Origin.

In 2022, the Vietnamese population in the United States (US) comprises 2.2 million individuals, and Vietnam ranks as the sixth most frequent country of origin among immigrants in the US. The American Heart Association and the National Institutes of Health have called for research to define the burden of cardiovascular risk factors, cardiovascular disease, and their determinants across Asian American subgroups, including Vietnamese Americans. Despite these calls, Vietnamese Americans remain remarkably overlooked in cardiovascular research in the US. Studies in Vietnam, small cross-sectional surveys in the US, and research using US mortality data point to a high prevalence of hypertension and tobacco use among men and a high incidence of gestational diabetes among women. Moreover, Vietnamese Americans have one of the highest rates of cerebrovascular mortality in the country. Adverse social determinants of health-including frequent language barriers, limited health literacy, and low average income-have been suggested as important factors that contribute to cardiovascular risk in this group. In this narrative review, we summarize the existing knowledge in this space, highlight the distinct characteristics of cardiac risk in both Vietnamese and Vietnamese American individuals, discuss upstream determinants, and identify key knowledge gaps. We then outline several proposed interventions and emphasize the need for further studies in this underrepresented population. Our aim is to increase awareness of the significant burden of risk factors and cardiovascular disease shouldered by this large-but thus far overlooked-population in the US, boost research in this space, and help inform tailored, effective preventive interventions.

mPR-Specific Actions Influence Maintenance of the Blood-Brain Barrier (BBB).

Cerebral cavernous malformations (CCMs) are characterized by abnormally dilated intracranial microvascular sinusoids that result in increased susceptibility to hemorrhagic stroke. It has been demonstrated that three CCM proteins (CCM1, CCM2, and CCM3) form the CCM signaling complex (CSC) to mediate angiogenic signaling. Disruption of the CSC will result in hemorrhagic CCMs, a consequence of compromised blood-brain barrier (BBB) integrity. Due to their characteristically incomplete penetrance, the majority of CCM mutation carriers (presumed CCM patients) are largely asymptomatic, but when symptoms occur, the disease has typically reached a clinical stage of focal hemorrhage with irreversible brain damage. We recently reported that the CSC couples both classic (nuclear; nPRs) and nonclassic (membrane; mPRs) progesterone (PRG)-receptors-mediated signaling within the CSC-mPRs-PRG (CmP) signaling network in nPR(-) breast cancer cells. In this report, we demonstrate that depletion of any of the three CCM genes or treatment with mPR-specific PRG actions (PRG/mifepristone) results in the disruption of the CmP signaling network, leading to increased permeability in the nPR(-) endothelial cells (ECs) monolayer in vitro. Finally, utilizing our in vivo hemizygous Ccm mutant mice models, we demonstrate that depletion of any of the three CCM genes, in combination with mPR-specific PRG actions, is also capable of leading to defective homeostasis of PRG in vivo and subsequent BBB disruption, allowing us to identify a specific panel of etiological blood biomarkers associated with BBB disruption. To our knowledge, this is the first report detailing the etiology to predict the occurrence of a disrupted BBB, an indication of early hemorrhagic events.

Comprehensive assessment during palliative radiotherapy consultation optimizes supportive care for patients with advanced breast cancer.

PURPOSE: Palliative radiotherapy (PRT) in advanced cancer improves symptom control and quality of life. PRT consultations take place in various clinical settings, including through dedicated rapid access clinics. We examined holistic assessment and PRT delivery by consultation setting. METHODS: We analyzed patients with breast cancer who died (01/04/2013-31/03/2014), after at least one lifetime PRT consultation. Data abstracted included Karnofsky Performance Status (KPS), Edmonton Symptom Assessment System Revised (ESAS-r) ratings, and PRT timelines. Descriptive statistics, t tests of proportions, independent t tests, and chi-square tests were calculated. RESULTS: One hundred thirty patients were assessed for PRT over 224 consults, 28/224 (12.5%) in the rapid access clinic. In non-rapid access versus rapid access visits, KPS was documented in 30.1% versus 89.3%, and medication history in 53.6% versus 96.4%, respectively (both p < 0.0001). Baseline ESAS-r scores were available for 67.9% of rapid access visits, versus no non-rapid access visit. Rapid access consults had a higher proportion of subsequent supportive care referrals (46.4% versus 8.2%; p < 0.0001). Same day PRT start occurred in 37% of rapid access versus 23.4% of non-rapid access visits (p = 0.13). CONCLUSIONS: Assessment for PRT by a dedicated multidisciplinary team provides a comprehensive picture of patient needs and streamlines PRT delivery, essential to personalizing supportive care.

Hospital Utilization, Treatment Modalities, and Mortality Using Different Biopsy Methods in Infants With Biliary Atresia.

Objectives To present a nationwide retrospective analysis of the sequelae and aftereffects of different liver biopsy methods in the care of pediatric patients with biliary atresia. Methods The National Inpatient Sample 2001-2013 database was queried for a primary diagnosis of biliary atresia and stratified based on biopsy type including percutaneous, surgical, laparoscopic, and transjugular. Patient demographics, length of stay, hospital costs, type of treatment, and mortality were compared by biopsy type. One-way analysis of variance test and multivariable logistic regression were used for analysis with α < 0.05. Results A total of 4,306 patients with biliary atresia were identified, of whom 2,293 underwent no biopsy, and 723 and 1,080 underwent a percutaneous or surgical biopsy, respectively. Significant differences in socio-demographics were demonstrated between the biopsy types. The length of stay and hospital charges were statistically significantly different between the biopsy types where patients without biopsies had the smallest length compared to percutaneous, surgical, and combination of biopsies. Overall, the Kasai procedure was done more frequently compared to direct liver transplantation, and compared to other biopsy types, undergoing a combination of biopsies had the highest odds of undergoing either procedure. Conclusions When comparing different biopsy methods, surgical biopsies of the liver outperformed percutaneous biopsies in hospital utilization and progression to definitive treatments with the Kasai procedure. Our research indicated that vulnerable populations such as minorities or the indigent may undergo inferior treatments or infrequently undergo definitive treatment. The need for definitive diagnostic guidelines is understated in patients with biliary atresia.

CmP signaling network unveils novel biomarkers for triple negative breast cancer in African American women.

Breast cancer is the most diagnosed cancer worldwide and remains the second leading cause of cancer death. While breast cancer mortality has steadily declined over the past decades through medical advances, an alarming disparity in breast cancer mortality has emerged between African American women (AAW) and Caucasian American women (CAW). New evidence suggests more aggressive behavior of triple-negative breast cancer (TNBC) in AAW may contribute to racial differences in tumor biology and mortality. Progesterone (PRG) can exert its cellular effects through either its classic, non-classic, or combined responses through binding to either classic nuclear PRG receptors (nPRs) or non-classic membrane PRG receptors (mPRs), warranting both pathways equally important in PRG-mediated signaling. In our previous report, we demonstrated that the CCM signaling complex (CSC) consisting of CCM1, CCM2, and CCM3 can couple both nPRs and mPRs signaling cascades to form a CSC-mPRs-PRG-nPRs (CmPn) signaling network in nPR positive(+) breast cancer cells. In this report, we furthered our research by establishing the CSC-mPRs-PRG (CmP) signaling network in nPR(-) breast cancer cells, demonstrating that a common core mechanism exists, regardless of nPR(+⁣/⁣-) status. This is the first report stating that inducible expression patterns exist between CCMs and major mPRs in TNBC cells. Furthermore, we firstly show mPRs in TNBC cells are localized in the nucleus and participate in nucleocytoplasmic shuttling in a coordinately synchronized fashion with CCMs under steroid actions, following the same cellular distribution as other well-defined steroid hormone receptors. Finally, for the first time, we deconvoluted the CmP signalosome by using systems biology and TNBC clinical data, which helped us understand key factors within the CmP network and identify 6 specific biomarkers with potential clinical applications associated with AAW-TNBC tumorigenesis. These novel biomarkers could have immediate clinical implications to dramatically improve health disparities among AAW-TNBCs.

Palliative radiotherapy delivery by a dedicated multidisciplinary team facilitates early integration of palliative care: A secondary analysis of routinely collected health data.

BACKGROUND: Early integration of Specialist Palliative Care (SPC) with oncological care improves quality of life (QOL) of patients with advanced cancer; however, patients tend to access SPC late in their disease trajectory, if at all. Routine referral of all patients to SPC would quickly overwhelm available resources, suggesting a need for widespread accessibility of generalist PC competencies. This has been increasingly facilitated by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at the Cross Cancer Institute (CCI). Our objectives were to estimate the proportion of patients dying with breast cancer seen in consultation for PRT, and the interaction between PRT delivery and SPC referral. METHODS: This secondary analysis of routinely collected health data examined female adults with breast cancer who died between 04/01/2013 and 03/31/2014, and had advanced disease while under the care of a CCI oncologist. Alberta Cancer Registry, electronic medical records, and Edmonton Zone Palliative Care Program data were linked. During the study period, referrals for SPC, and setting of assessment for PRT, were at the attending physicians' discretion. Clinical data were abstracted including summaries of intervals between PRT and SPC consultations, as well as from consults to death. Kaplan-Meier survival estimates, independent samples median tests, t tests of proportions, independent t tests and Chi-square tests compared groups. RESULTS: Of 194 patients, median age at cancer diagnosis was 59 years (range 24-95yrs), median one-way distance from the CCI was 18.8km, and overall median survival (MS) was 4.4 years. 130/194 (67.0%) and 110/194 (56.7%) were assessed for PRT and by SPC respectively; 22/194 (11.3%) saw neither prior to death. Median time between first PRT consultation and death was 11.7 months (interquartile range 3.7-22.2 mos). Median time between first SPC consult and death was 2.9 mos (IQR 1-6.2 mos). 65.6% of those who never had PRT ultimately required SPC involvement, versus 52.3% of those receiving PRT. Of the 68/130 who had both, 91.2% were seen for PRT first, a median of 7.9 mos prior to seeing SPC. Patients who had SPC consultation without previous PRT were seen by PC a median 1.5 mos prior to death (IQR 0.6-4.9 mos). Patients seen for PRT outside of the PRO clinic had SPC consultation a median of 3.3 mos before death (IQR 1.2-6.2 mos), versus those seen by the PRO clinic team, who were referred a median of 6.2 mos prior (IQR 2.4-8.1 mos). CONCLUSIONS: Fewer advanced breast cancer patients who received PRT ultimately required SPC consultation, but those who did were referred earlier in their disease course, especially if PRT assessment and delivery had taken place in the setting of a dedicated multidisciplinary team.

Impact of Fellow Participation During Colonoscopy on Adenoma Detection Rates.

BACKGROUND: An endoscopist's adenoma detection rate (ADR) is inversely related to interval colorectal cancer risk and cancer mortality. Previous studies evaluating the impact of gastroenterology fellow participation in colonoscopy on ADR have generated conflicting results. AIMS: We aimed to determine the impact of fellow participation, duration of fellowship training, and physician sex on ADR and advanced ADR (AADR). METHODS: We retrospectively analyzed average-risk patients undergoing screening colonoscopy at Veterans Affairs New York Harbor Healthcare System Brooklyn Campus and Kings County Hospital Center. Review of colonoscopy and pathology reports were performed to obtain adenoma-specific details, including the presence of advanced adenoma and adenoma location (right vs. left colon). RESULTS: There were 893 colonoscopies performed by attending only and 502 performed with fellow participation. Fellow participation improved overall ADR (44.6% vs. 35.4%, p < 0.001), right-sided ADR (34.1% vs. 25.2%, p < 0.001), and AADR (15.3% vs. 8.3%, p < 0.001); however, these findings were institution-specific. Year of fellowship training did not impact overall ADR or overall AADR, but did significantly improve right-sided AADR (p-value for trend 0.03). Female attending physicians were associated with increased ADR (47.1% vs. 37.0%, p = 0.0037). Fellow sex did not impact ADR. CONCLUSIONS: Fellow participation in colonoscopy improved overall ADR and AADR, and female attending physicians were associated with improved ADR. Year of fellowship training did not impact overall ADR or AADR.

Primary Cutaneous Anaplastic Large Cell Lymphoma With Gastric Metastasis.

Primary cutaneous anaplastic large cell lymphoma (PCALCL) is a subtype of non-Hodgkin lymphoma (NHL) that is localized to the skin. Disseminated disease is rare, and visceral organ involvement is even more so. We report a unique case of PCALCL with gastric metastasis. A 75-year-old man with a history of cutaneous left lower extremity PCALCL status post radiation therapy initially presented with abdominal pain and was found to have diffuse celiac axis and retroperitoneal lymphadenopathy. Endoscopy, initially done to biopsy an involved lymph node (LN), demonstrated a friable gastric nodular lesion with telangiectasias. Biopsy of the lesion and LN revealed anaplastic large cell lymphoma, identical in pathology to the known skin lesion. The patient was treated with systemic chemotherapy with a good response. PCALCL has been thought of as a localized malignancy with a good prognosis and low potential for extracutaneous spread. To our knowledge, this is the first instance of metastatic PCALCL involving the stomach.

OR and ICU teams 'running in parallel' at the end of cardiothoracic surgery improves perceptions of handoff safety.

The transfer of a cardiac surgery patient from the operating room (OR) to the intensive care unit (ICU) is both a challenging process and a critical period for outcomes. Information transferred between these two teams-known as the 'handoff'-has been a focus of efforts to improve patient safety. At our institution, staff have poor perceptions of handoff safety, as measured by low positive response rates to questions found in the Agency for Health Care Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS). In this quality improvement project, we developed a novel handoff protocol after cardiac surgery where we invited the ICU nurse and intensivist into the OR to receive a face-to-face handoff from the circulating nurse, observe the final 30 min of the case, and participate in the end-of-case debrief discussions. Our aim was to increase the positive response rates to handoff safety questions to meet or surpass the reported AHRQ national averages. We used plan, do, study, act cycles over the course of 123 surgical cases to test how our handoff protocol was leading to changes in perceptions of safety. After a 10-month period, we achieved our aim for four out of the five HSOPS questions assessing safety of handoff. Our results suggest that having an ICU team 'run in parallel' with the cardiac surgical team positively impacts safety culture.

Liposome-induced immunosuppression and tumor growth is mediated by macrophages and mitigated by liposome-encapsulated alendronate.

Liposomal nanoparticles are the most commonly used drug nano-delivery platforms. However, recent reports show that certain pegylated liposomal nanoparticles (PLNs) and polymeric nanoparticles have the potential to enhance tumor growth and inhibit antitumor immunity in murine cancer models. We sought herein to identify the mechanisms and determine whether PLN-associated immunosuppression and tumor growth can be reversed using alendronate, an immune modulatory drug. By conducting in vivo and ex vivo experiments with the immunocompetent TC-1 murine tumor model, we found that macrophages were the primary cells that internalized PLN in the tumor microenvironment and that PLN-induced tumor growth was dependent on macrophages. Treatment with PLN increased immunosuppression as evidenced by increased expression of arginase-1 in CD11b+Gr1+ cells, diminished M1 functionality in macrophages, and globally suppressed T-cell cytokine production. Encapsulating alendronate in PLN reversed these effects on myeloid cells and shifted the profile of multi-cytokine producing T-cells towards an IFNγ+ perforin+ response, suggesting increased cytotoxic functionality. Importantly, we also found that PLN-encapsulated alendronate (PLN-alen), but not free alendronate, abrogated PLN-induced tumor growth and increased progression-free survival. In summary, we have identified a novel mechanism of PLN-induced tumor growth through macrophage polarization and immunosuppression that can be targeted and inactivated to improve the anticancer efficacy of PLN-delivered drugs. Importantly, we also determined that PLN-alen not only reversed protumoral effects of the PLN carrier, but also had moderate antitumor activity. Our findings strongly support the inclusion of immune-responsive tumor models and in-depth immune functional studies in the preclinical drug development paradigm for cancer nanomedicines, and the further development of chemo-immunotherapy strategies to co-deliver alendronate and chemotherapy for the treatment of cancer.

Diagnosis of Normal-Pressure Hydrocephalus: Use of Traditional Measures in the Era of Volumetric MR Imaging.

Purpose To assess the diagnostic performance of the callosal angle (CA) and Evans index (EI) measures and to determine their role versus automated volumetric methods in clinical radiology. Materials and Methods Magnetic resonance (MR) examinations performed before surgery (within 1-5 months of the MR examination) in 36 shunt-responsive patients with normal-pressure hydrocephalus (NPH; mean age, 75 years; age range, 58-87 years; 26 men, 10 women) and MR examinations of age- and sex-matched patients with Alzheimer disease (n = 34) and healthy control volunteers (n = 36) were studied. Three blinded observers independently measured EI and CA for each patient. Volumetric segmentation of global gray matter, white matter, ventricles, and hippocampi was performed by using software. These measures were tested by using multivariable logistic regression models to determine which combination of metrics is most accurate in diagnosis. Results The model that used CA and EI demonstrated 89.6%-93.4% accuracy and average area under the curve of 0.96 in differentiating patients with NPH from patients without NPH (ie, Alzheimer disease and healthy control). The regression model that used volumetric predictors of gray matter and white matter was 94.3% accurate. Conclusion CA and EI may serve as a screening tool to help the radiologist differentiate patients with NPH from patients without NPH, which would allow for designation of patients for further volumetric assessment. © RSNA, 2017.