Addition of Preoperative Ultrasound-Guided Suprascapular Nerve Block and Axillary Nerve Block to Parecoxib Is More Effective in Early Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Study.

PURPOSE: To prospectively compare pain intensity and patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (ARCR) between patients who received ultrasound-guided suprascapular nerve block (SSNB) and axillary nerve block (ANB) as well as preincisional parecoxib and patients who received preincisional parecoxib only. METHODS: Sixty-one patients receiving ARCR between March 2020 and March 2021 were prospectively enrolled. They were randomly assigned to the peripheral nerve block group (group N, n = 30) or control group (group C, n = 31). Two patients in group C were excluded because of miscommunication. All patients were administered 40 mg of parecoxib intravenously prior to induction of anesthesia. SSNB and ANB were performed after general anesthesia in group N, whereas no nerve block was performed in group C. Pain intensity was compared before surgery, as well as immediately, 24 hours, and 2 weeks after surgery. PROs, including the Oxford Shoulder Score, University of California-Los Angeles shoulder score, and Single Assessment Numeric Evaluation score, were compared before and 6 months after surgery. RESULTS: The numerical rating scale (NRS) score for resting pain was significantly lower in group N (4.9 ± 3.1 vs 7.6 ± 2.5, P < .001) immediately after surgery, but no difference was noted 24 hours after surgery. The resting pain NRS score 2 weeks after surgery was significantly lower in group N (1.4 ± 1.6 vs 2.7 ± 2.7, P = .03), but the scores for movement-evoked pain and night pain were similar. All PROs significantly improved 6 months after surgery in both groups, but there was no difference between the 2 groups. CONCLUSIONS: The addition of preoperative ultrasound-guided SSNB and ANB to parecoxib offered better resting pain control immediately and 2 weeks after ARCR, but there was no benefit for PROs 6 months after surgery. LEVEL OF EVIDENCE: Level II, prospective randomized controlled trial.

Clinical practice consensus for the diagnosis and management of melanoma in Taiwan.

Melanoma is rare in Taiwan. Asian melanoma is distinct from Western melanoma because acral and mucosal melanoma accounts for the majority of melanoma cases, leading to distinct tumor behaviors and genetic profiling. With consideration of the clinical guidelines in Western countries, Taiwanese experts developed a local clinical practice consensus guideline. This consensus includes diagnosis, staging, and surgical and systemic treatment, based only on clinical evidence, local epidemiology, and available resources evaluated by experts in Taiwan. This consensus emphasizes the importance of surgical management, particularly for sentinel lymph node biopsies. In addition, molecular testing for BRAF is mandatory for patients before systemic treatment. Furthermore, immunotherapy and targeted therapy are prioritized for systemic treatment. This consensus aimed to assist clinicians in Taiwan in diagnosing and treating patients according to available evidence.

Environmental factors associated with incidence of developmental dysplasia of the hip: a systematic review and meta-analysis.

BACKGROUND: Established associated factors for DDH include female sex, breech presentation, family history, congenital malformations, oligohydramnios, and maternal hyperthyroidism. However, evidence for environmental factors that may contribute to DDH is limited and inconsistent. METHODS: A systematic review of medical literature was conducted to collect data on environmental factors, including latitude, longitude, average yearly precipitation, average yearly temperature, minimum monthly temperature, and maximum monthly temperature, from all institutions that published articles on DDH. Univariate linear regression analysis was used to examine the correlation between environmental factors and DDH incidence, while multiple regression analysis was conducted to identify significant associated factors for DDH incidence. RESULTS: Data from a total of 93 unique manuscripts were analyzed, revealing a significant negative correlation between DDH incidence and temperature, including average yearly temperature (r = -0.27, p = 0.008), minimum monthly temperature (r = -0.28, p = 0.006), and maximum monthly temperature (r = -0.23, p = 0.029). Additionally, there was a significant positive correlation between DDH incidence and latitude (r = 0.27, p = 0.009), and a significant negative correlation between DDH incidence and average yearly precipitation (r = -0.29, p = 0.004). In the final multiple regression analysis, temperature, including average yearly temperature, minimum monthly temperature, and maximum monthly temperature, were identified as significant associated factors for DDH incidence. CONCLUSION: The findings of this study suggest an association between cold weather and DDH incidence. Further research should explore the link between cold weather and DDH incidence, offering insights into potential interventions for cold climates.

Total intravenous anesthesia for geriatric hip fracture with severe systemic disease.

PURPOSE: Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery. METHODS: We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics. RESULTS: There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates. CONCLUSION: Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).

The posterior capsule is distended in dysplastic hips, but the anterior capsule is not.

PURPOSE: In the setting of acetabular dysplasia, the increased translational motion of the femur may damage the labrum and cartilage, as well as stretch the capsule. The purpose of the study was to investigate the relationship between the acetabular coverage and the capsular stiffness by assessing the distension of anterior and posterior joint recesses on the hip computed tomography arthrography. METHODS: One hundred thirty-three patients (138 hips) with a median age of 36 years (range 18-50 years) who received the computed tomography arthrography for evaluation of nonarthritic hip pain in our institute between 2015 and 2017 were retrospectively reviewed. The maximal distance between the anterior/posterior capsule and the anterior femoral head-neck junction/posterior femoral head on the axial imaging of computed tomography arthrography was defined as the width of anterior/posterior joint recess. The width of anterior/posterior joint recess was adjusted with the diameter of the femoral head and was then compared between acetabular dysplasia (lateral center-edge angle < 25°), normal acetabulum (lateral center-edge angle between 25 and 39°), and deep acetabulum (lateral center-edge angle > 39°). In addition, the standard univariate linear regression analysis was used to investigate the relationship between the adjusted width of anterior/posterior joint recess and anterior/posterior coverage of the hip, determined by the anterior/posterior wall index. RESULTS: The adjusted width of posterior joint recess was significantly greater in the acetabular dysplasia group than the normal acetabulum and deep acetabulum groups (p < 0.01 and p = 0.02, respectively). There was no significant difference of the adjusted width of anterior joint recess between the groups (n.s.). The adjusted width of posterior joint recess had a significant but weak negative correlation with the anterior wall index (r = - 0.25, p < 0.001), and no correlation with the posterior wall index (r = - 0.0004, n.s.). There was no significant correlation between the adjusted width of anterior joint recess and the anterior/posterior wall index (r = 0.05, n.s./r = 0.07, n.s.). CONCLUSIONS: The distension of posterior capsule on the computed tomography arthrography was significantly greater in acetabular dysplasia. In addition, there was a significant but weak negative correlation between the distension of posterior capsule and the anterior coverage of the hip. It indicated a looser posterior capsule was observed in a dysplastic hip. The relevance of posterior capsular laxity to clinical outcomes warrants further investigation. Given the fact that the distension of anterior capsule was not significantly higher in acetabular dysplasia, the need of anterior capsular plication in a dysplastic hip should be carefully evaluated. LEVEL OF EVIDENCE: Level III.

Minimally Invasive Percutaneous Vertebroplasty for Thoracolumbar Instrumented Vertebral Fracture in Patients With Posterior Instrumentation.

BACKGROUND: The traditional treatment for an instrumented vertebral fracture involves removing the loosened pedicle screws and extending the posterior instrumentation cephaladly or caudally. There has been a recent trend of performing minimally invasive fluoroscopy-guided percutaneous vertebroplasty as a salvage procedure. OBJECTIVE: The aim of this study was to compare the outcomes of surgical interventions for instrumented vertebral fracture. STUDY DESIGN: Retrospective assessment. SETTING: All data came from Chang Gung Memorial Hospital, Taiwan. METHODS: We retrospectively reviewed 35 patients with an instrumented vertebral fracture who underwent fluoroscopy-guided percutaneous vertebroplasty (Group I, n = 16) or extension of the posterior instrumentation (Group II, n = 19). Demographic data were recorded. The operating time, amount of intraoperative blood loss, time to postoperative ambulation, and duration of hospital stay were also evaluated. The visual analog scale (VAS) score, kyphotic angle on radiological images, Kirkaldy-Willis functional score, complications, and revision surgery were evaluated at one week and one, 3, 6, and 12 months postoperatively. RESULTS: Group I had a shorter operating time (P < 0.001), less intraoperative blood loss (P < 0.001), earlier postoperative ambulation (P < 0.001), and a shorter hospital stay (P < 0.001). The mean VAS score improved significantly after surgery in both groups (P = 0.001). The postoperative kyphotic angle was better in Group II (P < 0.05). There was no significant between-group difference in the Kirkaldy-Willis functional score at the last follow-up (P = 0.91). There was no significant between-group difference in the need for revision surgery (Group I, n = 4; Group II, n = 5; P = 0.93). LIMITATION: This study is a retrospective cohort. CONCLUSIONS: Minimally invasive fluoroscopy-guided percutaneous vertebroplasty can be used as an alternative to extension of posterior instrumentation for instrumented vertebral fracture. It has several advantages, including a shorter operating time, earlier postoperative ambulation, less blood loss, and a shorter hospital stay. The clinical outcomes of these 2 treatment approaches were similar.

Three Nuclear Medicine diagnostic procedures and breast cancer mortality in women. A population-analysis in Taiwan based upon National Health Insurance database.

OBJECTIVE: To investigate the correlation between the utilization of nuclear medicine diagnostic procedures and the mortality of women with breast cancer. SUBJECTS AND METHODS: Based on the National Health Insurance Research Database (NHIRD), we studied female breast cancer patients in 2012 who underwent whole-body bone scan, lymphoscintigraphy, or fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for possibly managing breast cancer metastases. The mortality of breast cancer was then followed up in 2017. Multiple linear regression analysis was applied to analyze the correlation between the use of any of these three nuclear medicine procedures and the mortality of breast cancer. RESULTS: For patients with early-stage breast cancer, single lymphoscintigraphy was the most frequently performed nuclear medicine procedure, accounting for 36.4% of all three nuclear medicine procedures. For patients with late-stage breast cancer, single whole-body bone scan was the most frequently performed nuclear medicine procedure, accounting for 67.2% of all three nuclear medicine procedures. Mortality of breast cancer significantly increased with the prevalence of late-stage breast cancer (b=2.87, P=0.001) and significantly decreased in cases in which whole-body bone scan was used (b=-4.28, P=0.003). CONCLUSION: The mortality of women with late-stage breast cancer was negatively related to the utilization of whole-body bone scan but not to the utilization of lymphoscintigraphy or the 18F-FDG PET/CT scan. In women with early-stage breast cancer, no significant correlation existed between breast cancer mortality and the utilization of the above three nuclear medicine procedures.

Involvement of increased p53 expression in the decrease of mitochondrial DNA copy number and increase of SUVmax of FDG-PET scan in esophageal squamous cell carcinoma.

We appraised Warburg effect through analysis of mitochondrial DNA (mtDNA) copy number and maximum standard uptake value (SUVmax) of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan and their alterations in esophageal squamous cell carcinoma (ESCC). Later T-status and longer longitudinal tumor length were associated with lower mtDNAESCC copy number (p < .05) but higher SUVmax-ESCC (p < .05), respectively. Lower mtDNAESCC copy number correlated with higher SUVmax-ESCC, reciprocally (p < .05). ESCCs expressing mutant p53 protein had lower mtDNAESCC copy number (p = .056) but higher SUVmax-ESCC (p = .046). We conclude that mutant p53 protein may be involved in the Warburg effect of ESCC.

The Impact of First Complete Remission by PET-CT and Time to Next Treatment on Survival of Follicular Lymphoma Patients.

We retrospectively analyzed the impact of initial positron emission tomography and computed tomography (PET-CT) complete remission (CR) and time to next treatment (TTNT) on patient outcome in follicular lymphoma. Between 2002 and 2014, 150 patients could be evaluated for treatment response and long-term outcome. The CR after first line treatment with either rituximab-cyclophosphamide, oncovin, and prednisolone (R-COP) or rituximab-cyclophosphamide, doxorubicin, oncovin, and prednisolone (R-CHOP) was 89% and partial response (PR) was 7%. The 5- and 10-year survival rates were 86.0% and 62.6%, respectively. In five years, 11% of patients had died of lymphoma and 3% from other causes. Forty-seven patients (31%) underwent a second line of treatment comprising 19 (40%) with a TTNT shorter than 24 months and 28 (60%) longer than 24 months. There was no difference in overall survival (OS) between R-COP (86%) and R-CHOP (77%) at 5 years, but there were more next treatment events in the R-COP compared with the R-CHOP group on longer follow-up (60% versus 35% at 8 years). For PET-CT response, there was a significant OS difference between initial CR and PR patients (88% versus 70%, p < 0.01), and a longer TTNT was seen in initial CR patients. Patients with a TTNT longer than 24 months had better OS compared with patients with a shorter TTNT (93% versus 54% at 5 years, p < 0.01). In conclusion, patients with initial PET-CT CR and TTNT longer than 24 months had better OS compared with those achieving only PR and shorter TTNT. PET-CT CR should be considered the treatment goal during initial treatment, and more aggressive treatment should be considered for patients with a TTNT of less than 24 months.

A General Cutoff Level Combined With Personalized Dynamic Change of Serum Carcinoembryonic Antigen Can Suggest Timely Use of FDG PET for Early Detection of Recurrent Colorectal Cancer.

PURPOSE: FDG PET that has been used is good for diagnosing asymptomatic colorectal cancer (CRC) recurrence in patients with elevated serum carcinoembryonic antigen (CEA) level. However, there is no reference level of CEA rise that would universally suggest the necessity of a PET study. The purpose of this retrospective study was to identify the high-risk group of CRC recurrence through an examination of the dynamics of the CEA level rise as a recurrence indicator. PATIENTS AND METHODS: Between July 2002 and May 2010, 112 patients (59 men, 53 women; age, 18-87 years) had FDG PET for suspicious CRC recurrence indicated by elevated CEA level. We reviewed the PET results and the medical records for recurrence verification and calculated the ratio of increase and the velocity of change in CEA levels for risk stratification. RESULTS: The patient-based sensitivity, specificity, and accuracy of PET are 96.6%, 91.3%, and 95.5%, respectively. The probability of recurrence positively correlated with the CEA level rise and the newly diagnosed disease stage. Carcinoembryonic antigen level greater than 13 ng/mL indicated significantly higher risks of recurrence. In patients with CEA level rise of 13 ng/mL or less, an increase over 3.34 times the individualized baseline also indicated high risks of recurrence. CONCLUSIONS: A posttreatment CEA level rise to greater than 13 ng/mL is suggestive of the optimal use of FDG PET, and so is a mild increase below 13 ng/mL at an increase rate over 3.34.

Secondary oligodendroglioma after postoperative irradiation for medulloblastoma: a case report and review of the literature.

Medulloblastoma, a malignant, invasive embryonal tumor of the cerebellum, occurs most often in children. It has high metastatic potential and is usually treated by aggressive multimodal therapy, including surgery, chemotherapy and craniospinal irradiation. Multiple secondary tumors have been reported following craniospinal irradiation. It is rare with the occurrence of oligodendroglioma after irradiation. In this report, we described a patient with secondary oligodendroglioma after postoperative craniospinal irradiation for medulloblastoma.

Underperformance of gallium-67 scan is greater in relapse than in initial staging, compared with FDG PET.

PURPOSE: The purpose of this study is to evaluate the performance of gallium-67 scan (GS) and F-18 fluorodeoxyglucose (FDG) PET scan in lymphoma staging and recurrence detection by comparing the 2 imaging studies in the same patient. MATERIALS AND METHODS: A total of 42 patients from the period between July 2002 and May 2006 were included in this study. Of the 42 patients, 6 had Hodgkin disease and 36 had non-Hodgkin lymphomas. All of them underwent one or more FDG PET scans and also underwent corresponding GS performed within 7 days of FDG PET, for staging or detection of lymphoma recurrence. Among the non-Hodgkin lymphoma cases, 18 were diffuse large B-cell lymphoma, 10 were follicular center cell lymphoma, and 8 were of other types. Of the total 46 pairs of imaging performed in these 42 patients, 27 were for staging, and 19 for restaging after recurrence. RESULTS: In all these studies, FDG PET detected 230 lesion sites, whereas GS detected 85 lesion sites. All of the lesions detected by GS were noted on FDG PET, whereas GS detected only 37.0% of the lesions detected by FDG PET. Among the 27 studies for staging, FDG PET detected 120 lesions, whereas GS detected 68 lesions (56.7%). In the 19 images taken for relapse, FDG PET detected 110 lesions, whereas GS detected only 17 (15.5%). CONCLUSIONS: FDG PET is superior to GS in staging and detecting all types of lymphoma. The difference is notably more significant in recurrence detection.