The prognostic value of intraoperative HRV during anesthesia in patients presenting for non-cardiac surgery.

OBJECTIVE: To examine the prognostic value of HRV measurements during anesthesia for postoperative clinical outcomes prediction using machine learning models. DATA SOURCES: VitalDB, a comprehensive database of 6388 surgical patients admitted to Seoul National University Hospital. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Cases with ECG lead II recording duration of less than one hour were excluded. Cases with more than 20% of missing HRV measurements were also excluded. A total of 5641 cases were eligible for the analyses. METHODS: Six machine learning models including Logistic Regression (LR), Support Vector Machine (SVM), Random Forest (RF), Gradient Boosting Decision Trees (GBT), Extreme Gradient Boosting (XGB), and an ensemble of the five baseline models were developed to predict postoperative clinical outcomes. The prediction models were trained using only clinical information, and using both clinical information and HRV features, respectively. Feature importance based on the SHAP method was used to assess the contribution of the HRV measurements to the outcome predictions. Subgroup analysis was also performed to evaluate the risk association between postoperative ICU stay and various HRV measurements such as heart rate, low-frequency power (LFP), and short-term fluctuation DFA [Formula: see text]. RESULT: The final cohort included 5641 unique cases, among whom 4678 (83.0%) cases had ages over 40, 2877 (51.0%) were male, 1073 (19.0%) stayed in ICU after surgery, 52 (0.9%) suffered in-hospital death, and 3167(56.1%) had a total length of hospital stay longer than 7 days. In the final test set, the highest AUROC performance with only clinical information was 0.79 for postoperative ICU stay, 0.58 for in-hospital mortality, and 0.76 for the total length of hospital stay prediction. Importantly, using both clinical information and HRV features, the AUROC performance was 0.83, 0.70, and 0.76 for the three clinical outcome predictions, respectively. Subgroup analysis found that patients with an average heart rate higher than 70, low-frequency power (LFP) < 33, and short-term fluctuation DFA [Formula: see text] < 0.95 during anesthesia, had a significantly higher risk of entering the ICU after surgery. CONCLUSION: This study suggested that HRV measurements during anesthesia are feasible and effective for predicting postoperative clinical outcomes.

Racial Disparities in Survival of Breast Cancer Patients After Surgery.

Introduction: The racial disparities of opportunity to receive the appropriate intervention and lower insurance coverage may result in survival disparities in different races. This study aims to provide a perspective on racial disparities in the survival of breast cancer patients after surgery. Methods: Through data from the Surveillance, Epidemiology, and End Results (SEER) program, this study estimated the survival of breast cancer patients of different races from 1998 to 2017. Inverse probability weighting (IPW) was utilized to adjust the imbalanced clinicopathological features of patients of different races. Results: This study analyzed 214,965 breast cancer patients after surgery. Among them, 130,746 patients received BCS, and the remaining 84,219 breast cancer patients underwent mastectomy. Although Asian or Pacific Islander (API) patients after surgery showed higher survival benefit than that of white patients in the primary data, after adjusting for age at diagnosis, luminal subtype, grade, T stage, and N stage in different races, white individuals had the longest period of survival was higher than that of the minority groups in BCS group [breast cancer-specific survival (BCSS): HRWhitevs.API = 0.402, HRWhitevs.Black = 0.132; P < 0.001; overall survival (OS): HRWhitevs.API = 0.689, HRWhitevs.Black = 0.254; all P < 0.001] and mastectomy group (BCSS: HRWhitevs.API = 0.325, HRWhitevs.Black = 0.128; P < 0.001; OS: HRWhitevs.API = 0.481, HRWhitevs.Black = 0.206; all P < 0.001). Conclusions: We first identified that the survival benefit of the minority group after surgery was lower than that of white individuals, regardless of tumor chrematistics and surgery types.

Knockdown of eIF3a attenuated cell growth in K1 human thyroid cancer cells.

BACKGROUND: In ribosome establishment and the initiation of translation, eukaryotic translation initiation factor (eIF) 3a is a pivotal functional subunit of the eIF3 complex. In various cancer types, abnormal eIF3a expression plays an important role in tumorigenesis. OBJECTIVE: We aimed to explore the role of eIF3a in human thyroid cancer (TC). MATERIAL AND METHODS: The expression of eIF3a was determined in TC tissues by qRT-PCR and immunohistochemistry (IHC) assay, respectively. In addition, the expression of eIF3a in K1 and BCPAP cells were detected by qRT-PCR. Cell proliferation, cell cycle, and cell apoptosis were assessed after eIF3a knockdown in K1 in cell line. RESULTS: The expression of eIF3a mRNA was high in TC tissues and cancer cell lines. Moreover, eIF3a expression in TC tissues indicated that high eIF3a level was associated with tumor grade. In addition, eIF3a knockdown resulted in a significantly decrease in cell proliferation and increased the apoptosis of K1 cells. Cell cycle was arrested in both the S and G2/M phase. The levels of phosphorylated ERK1/2 and surviving were decreased after eIF3a knockdown. CONCLUSION: Our study suggested that eIF3a contributed to TC cell proliferation. It may be a promising target for gene therapy in human thyroid cancer.

Usefulness of Lateral Thoracic Adipofascial Flaps After Breast-conserving Surgery in Small-to Moderate-sized Breasts.

BACKGROUND: Women with small- to moderate-sized breasts present a specific challenge to performing oncoplastic volume-displacement techniques for reconstructing breast defects after breast-conserving surgery (BCS). In such cases, the lateral thoracic wall region serves as a versatile reconstruction donor site. Therefore, in the present study, we aimed to investigate the effectiveness and feasibility of employing lateral thoracic adipofascial (LTA) flaps to reconstruct breast defects following BCS. PATIENTS AND METHODS: A total of 58 female patients who underwent BCS between February 2016 and April 2017 were analyzed. Of these, 33 patients were reconstructed with LTA flaps, and the other 25 patients received BCS only and were assigned as the control group. All patients were followed up, and we assessed surgery-related complications, breast appearance, and disease recurrence. RESULTS: The mean weight of the resected breast tissue was 65.9 g (range, 35-100 g). The mean volume of LTA flaps was 309.5 cm3 (range, 112.6-588 cm3). This oncoplastic technique was performed with minimal complications in all patients. Two patients exhibited partial adipose liquefaction (6.1%), and 2 patients manifested wound infections. CONCLUSIONS: The LTA flaps were reliable and useful for reconstructing breast defects after BCS when the resected volume was confined to between 50 and 100 g, particularly in patients with small- to moderate-sized breasts. This is optimal for patients with lesions located in the upper-outer quadrant.

Clinical behaviors of rare variants of papillary thyroid carcinoma are associated with survival: a population-level analysis.

OBJECTIVE: This study was to evaluate the risk factors of survival in patients with columnar cell variant (CCV) and encapsulated variant (ECV). MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results database (1988-2013) was used to compare the characteristics of CCV and ECV with those of classic papillary thyroid carcinoma (PTC). Survival was analyzed by the Kaplan-Meier method, the log-rank test, and Cox multivariate regression. Multivariate logistic regression was used to further analyze lymph node metastases and distant metastasis. There were 765 CCV, 529 ECV, and 39,035 PTC patients. ECV tumors were similar to PTC in terms of overall survival, disease-specific survival, age, sex, and distant metastasis. RESULTS: Compared with PTC, CCV tumors tended to be larger, with a higher incidence rate among males and in patients ≥65 years of age. CCV was associated with higher rates of extrathyroidal extension, multifocality, lymph node examinations, and lymph node and distant metastases (p<0.0001). Significant differences were found in 10-year overall survival (97.14% vs 89.15%, p<0.0001) and disease-specific survival (99.08% vs 93.07%, p<0.0001) between PTC and CCV. In CCV, distant metastasis (hazard ratio 5.125, p<0.0001) and lymph nodal metastasis (hazard ratio 2.152, p=0.032) predicted a poor prognosis. After adjustment, distant metastasis was independently associated with age ≥65 years, and lymph nodal metastasis was independently associated with female sex (odds ratio [OR] 0.341 [0.234-0.496]), extrathyroidal extension (OR 2.453 [1.368-4.397]), multifocality (OR 2.168 [1.318-3.569]), size >20 mm, ≤40 mm (OR 1.851 [1.170-2.928]), and size >40 mm (OR 1.847 [1.088-3.136]). CONCLUSION: ECV appears to have a similar prognosis to PTC, while CCV has a worse prognosis than classic PTC. Treatment with external beam radiotherapy and radioactive implants should be conducted carefully in patients with CCV.

Young age increases the risk of lymph node positivity in papillary thyroid cancer patients: a SEER data-based study.

INTRODUCTION: Currently in papillary thyroid cancer (PTC), the correlation between lymph node positivity (LN+) and patient's age at diagnosis is still inconclusive. The aim of this study was to investigate whether younger PTC patients had higher LN+ rates. PATIENTS AND METHODS: From the 1998-2013 Surveillance, Epidemiology, and End Results database, we analyzed PTC patients with at least 1 LN examined. The patients were divided into 5 groups by age separately for each T stage: ≤30; 31-40; 41-50; 51-60; >60 years. RESULTS: A total of 46,077 PTC patients were identified, including 8,386 (18.2%) patients aged ≤30 years, 10,971 (23.8%) patients aged 31-40 years, 11,646 (25.3%) patients aged 41-50 years, 8,596 (18.7%) patients aged 51-60 years, and 6,478 (14.1%) patients aged >60 years. In each T stage, LN+ rates were inversely associated with age at diagnosis, which was validated by multivariate logistic regression analysis (p<0.001). In addition, the subset of patients 30 or younger had the highest lymph node ratio compared with other subsets (p<0.001). CONCLUSION: We identified that younger PTC patients have an increased predisposition for LN+ regardless of T stage. This finding could help surgeons to select the optimal treatment for younger PTC patients.

Iris-Like Acceptor with Most PDI Units for Organic Solar Cells.

Mother Nature is always the best source for scientists to draw inspiration. Herein, a three-dimensional perylene diimide (PDI)-based molecular acceptor was designed and synthesized, in which six PDI units form an "iris-like" structure upon connecting with the hexaphenylbenzene core. Interestingly, this molecule is the nonfullerene acceptor containing most PDI units, which can absorb solar light to exhibit excellent power conversion efficiency, much more efficient than the natural flowers. This contribution presents an interesting example of learning from Mother Nature to design novel materials for applications.

Evaluation of the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems in predicting postoperative mortality and morbidity in gastric cancer patients.

BACKGROUND/OBJECTIVE: Gastric cancer is the fourth most prevalent cancer worldwide. The ability to accurately predict surgery-related morbidity and mortality is critical in deciding both the timing of surgery and choice of surgical procedure. The aim of this study is to compare the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems for predicting surgical morbidity and mortality in Chinese gastric cancer patients, as well as to create new scoring systems to achieve better prediction. METHODS: Data from 612 gastric cancer patients undergoing gastrectomy between January 2007 and December 2011 were included in this study. The predictive abilities of the four scoring systems were compared by examining observed-to-expected (O/E) ratios, the receiver operating characteristic curve, Student t test, and χ2 test results. RESULTS: The observed complication rate of 34% (n = 208) did not differ significantly from the rate of 36.6% (n = 208) predicted by the POSSUM scoring system (O/E ratio = 0.93). The observed mortality rate was 2.9% (n = 18). For predicting mortality, POSSUM had an O/E ratio of 0.34 as compared with p-POSSUM (O/E ratio = 0.91), o-POSSUM (O/E ratio = 1.26), and APACHE II (O/E ratio = 0.28). CONCLUSION: The POSSUM scoring system performed well with respect to predicting morbidity risk following gastric cancer resection. For predicting postoperative mortality, p-POSSUM and o-POSSUM exhibited superior performance relative to POSSUM and APACHE II.

Nomogram predicts survival benefit from preoperative radiotherapy for non-metastatic breast cancer: A SEER-based study.

BACKGROUND: To estimate survival in non-metastatic breast cancer patients who failed to achieve a pathological complete response (pCR) more effectively, we combined the clinicpathological characteristics after preoperative radiation therapy (pRT) and established a novel nomogram. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 2,545 non-metastatic breast cancer patients who underwent pRT between 1998 and 2013. Based on the registries of patients, the primary cohort divided into training set (n = 1,692) and validation set (n = 853). Nomograms were established by training set and validated by validation set. RESULTS: According to the multivariate analysis of training set, nomogram which combined age at diagnosed, marital status, location, grade, ER status, yp-T status, yp-N status and whether received breast conservation surgery (BCS) was developed. Calibration plots of the nomograms showed that the probability of DSS corresponded to actual observation closely. The C-index was 0.78 in validation set, which was significantly higher than that of yp-TNM staging system (0.75, p = 0.004). CONCLUSIONS: The proposed nomogram resulted in more-reliable DSS prediction for non-metastatic breast cancer patients in general population, it would be helpful in individualized survival prediction and better treatment allocation after pRT.

Using a novel T-lymph node ratio model to evaluate the prognosis of nonmetastatic breast cancer patients who received preoperative radiotherapy followed by mastectomy: An observational study.

We aimed to investigate the prognostic value of postpathological characters in nonmetastatic breast cancer (NMBC) patients who received preoperative radiotherapy (PRT) followed by mastectomy (MAST).We conducted retrospective analyses using the data collected from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute. Univariate and multivariate analyses were performed to identify prognostic factors. Disease-specific survival was calculated by the Kaplan-Meier curve and validated by log rank test. The discriminations of independent risk factors and staging systems were compared by the area under receiver operating characteristic curves (AUC) and validated by Harrell concordance index (bootstrapping algorithm). Akaike information criterion (AIC) was applied to compare the difference of model.One thousand three hundred fifty NMBC patients who had received PRT followed by MAST from 1988 to 2013 were included in the study. We found the metastatic lymph node ratio (mLNR) staging was a superior indicator than pN staging. Thus, we proposed a T-lymph node ratio (T-NR) staging system with simplified-T categories (T0-3 and T4) and the mLNR staging. The novel T-NR staging system provided larger AUC (P = .024, .008, respectively) and the smaller AIC (P < .001) value than American Joint Committee on Cancer staging system.The novel T-NR staging system performed more accurate survival prediction and better model fitness for NMBC patients who receive PRT followed by MAST, it may provide a wide applicability in clinical decision-making.

CXCR4/RhoA signaling pathway is involved in miR-128-regulated proliferation and apoptosis of human thyroid cancer cells.

microRNA-128 (miR-128), a kind of short, noncoding RNAs, functioned as a tumor marker. However, the underlying function and mechanism of miR-128 in human thyroid cancer were uncertain. Therefore, in the present study, the effects of miR-128 on the proliferation and apoptosis of cultured human thyroid cancer cells were investigated. After slicing miR-128 in human thyroid cancer cells, the proliferation was measured by methyl thiazolyl tetrazolium (MTT) method, the expression of miR-128, CCAAT/enhancer binding protein-α (C/EBPα), peroxisome proliferator-activated receptor-γ (PPARγ), Caspase-3 and Caspase-9 was determined by RT-PCR, and protein expression of chemokine receptor 4 (CXCR4) and Ras homolog gene family, member A (RhoA) was analyzed by Western blot. It was found that knockdown of miR-128 promoted the optical density (OD) value of cells, enhanced mRNA expression of PPARγ and C/EBPα, while inhibited cell apoptotic rate, and Caspase-3, Caspase-9 expression. Furthermore, higher protein expression of CXCR4 and RhoA was found in the absence of miR-128. Notably, miRNA-128 over-expression-inhibited proliferation and induced-apoptosis of human thyroid cancer cells were partially changed following the block of CXCR4/RhoA signaling pathway by the CXCR4 inhibitor (AMD3100). It was indicated that miR-128 down-regulated proliferation while promoted apoptosis of human thyroid cancer cells through suppression of CXCR4/RhoA signaling pathway.

A novel grade-lymph node ratio model predicts the prognosis of the advanced gastric cancer patients after neoadjuvant radiotherapy.

Although local advanced gastric cancer (AGC) could benefit from neoadjuvant radiotherapy (NRT), there are few studies evaluating patients' survival after NRT. In current study, we aimed to investigate the value of prognostic factors in AGC patients after NRT and to evaluate whether post-therapy pathological characteristics were predictive factors in these patients. We retrospectively analyzed AGC patients who underwent NRT from Surveillance, Epidemiology, and End Results (SEER) Database. The patients' clinical and post-therapy pathological characteristics were analyzed. The best cutoff points for continuous variables were identified by X-tile. The discrimination of risk factors were compared by receiver operating characteristic (ROC) curve. As a result, 1,429 AGC patients were included into this study. In the multivariate analysis, the lymph nodes status and histology grade were significant risk factors for DSS (disease special survival). Then, we propose a novel Grade-lymph node Ratio (G-R) staging system for the AGC patients' survival prognosis. Clearly, the new G-R staging system has a more-accurate 3-year and 5-year DSS prediction than the AJCC staging system (p = 0.001, 0.007, respectively). In conclusions, the current large, general population-based study demonstrated that the G-R staging system resulting in more-accurate DSS prediction. It could be regarded as a reliable classification for AGC patients after NRT in future.

18FDG PET-CT for diagnosis of distant metastases in breast cancer patients. A meta-analysis.

BACKGROUND: We performed a meta-analysis to evaluate the value of (18)FDG PET-CT for diagnosis of distant metastases in breast cancer patients. METHODS: Studies about PET-CT were systematically searched in the MEDLINE and EMBASE databases. We calculated sensitivities, specificities, likelihood ratios, and constructed summary receiver operating characteristic curves for PET-CT. We also compared the performance of PET-CT with that of conventional imaging by analyzing studies that had also used conventional imaging on the same patients. RESULTS: Across 8 PET-CT studies (748 patients), sensitivity and specificity of PET-CT were 0.96 (95% confidence interval [CI] = 0.90-0.98) and 0.95 (95% CI = 0.92-0.97). Across 6 comparative studies (664 patients), sensitivity and specificity of PET-CT were 0.97 (95% CI = 0.84-0.99) and 0.95 (95% CI = 0.93-0.97), and of conventional imaging were 0.56 (95% CI = 0.38-0.74) and 0.91 (95% CI = 0.78-0.97), respectively. CONCLUSIONS: Compared with conventional imaging, (18)FDG PET-CT has higher sensitivity for diagnosis of distant metastases in breast cancer patients.

Totally extraperitoneal laparoscopic hernioplasty: the optimal surgical approach.

INTRODUCTION: The total extraperitoneal (TEP) laparoscopic repair of a groin hernia is increasingly being used because of less pain, rapid recovery, and low recurrence rate, but different variants of surgical approaches for TEP are reported by a number of centers and the merits and demerits associated with each approach are not well described. The aim of this study was to compare the clinical outcome of laparoscopic totally extraperitoneal inguinal hernioplasty (TEP) with 4 different variants of surgical approach. METHODS: Between August 2004 and March 2008, 99 patients with unilateral inguinal hernia who underwent TEP without mesh fixation through 4 different variants of surgical approach depended on the anatomical positions of abdominal wall were enrolled in this prospective randomized study. The primary endpoints were operative time, incidence of peritoneal tear, and incidence of the arcuate line impeding the position of the mesh. Secondary endpoints were postoperative analgesic requirements and incidence of seroma. RESULTS: Ninety-nine patients underwent 4 surgical approaches, including the midline approach between the rectus muscle and the posterior rectus sheath (anterior to the posterior rectus sheath, MR) in 25 patients, the midline approach between the peritoneum and the posterior rectus sheath (posterior to the posterior rectus sheath, MP) in 25 patients, the lateral approach between the rectus muscle and the posterior rectus sheath (LR) in 25 patients, and the lateral approach between the peritoneum and the posterior rectus sheath (LP) in 24 patients. The groups were similar in age, weight, body height, and diagnostic categories of hernia. All cases were operated successfully without conversion to open surgery or transabdominal preperitoneal, and followed up for 6 to 43 months with no recurrence. The mean operating time was 55.5 minutes (25 to 130 min) and there was not significant difference between the groups in the operative time. The only type of complication was seroma formation that occurred in 20 patients retrieved without requiring drainage, and there was no significant difference in the incidence of seroma among 4 groups. Only in the MR group and the LR group, the arcuate line in 20 patients impedes the 15 x 10 cm polypropylene mesh positioning. Peritoneal tears were observed without routine closure in 36.7% of patients in the 2 groups of the lateral approach, whereas in only 12% in the 2 groups of the midline approach (P<0.01). Eleven patients required postoperative analgesics, and there was significant difference between the lateral approach groups and the midline approach groups (P<0.05). CONCLUSIONS: TEP is a mature technique and may be safely carried out with fewer complications and lower recurrence rate. Considering the body habitus of each patient and the large dissection surface area resulting in postoperative adhesions and bleeding, according to the principles of "Minimally Invasive Surgery" and the requirement of a maximal cosmetic result, the surgeon should select the midline approach between the peritoneum and the posterior rectus sheath as much as possible.