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OBJECTIVE: To evaluate the effectiveness and safety of salvage stereotactic ablative body radiotherapy (SABR) for recurrent renal cell carcinoma (RCC) after thermal ablation (TA). MATERIALS AND METHODS: This study was a multi-institutional retrospective analysis of patients with recurrent RCC following TA who received SABR between 2016 and 2020. The primary study outcome was freedom from local failure, evaluated radiographically based on Response Evaluation Criteria in Solid Tumours (RECIST) v1.1. Distant failure, cancer-specific survival (CSS), overall survival (OS), treatment-related toxicity and renal function changes following SABR were the secondary outcomes. The Kaplan-Meier method was used to estimate freedom from local and distant failure, CSS and OS. RESULTS: Seventeen patients with 18 biopsy-confirmed RCCs were included, with a median (interquartile range [IQR]) age at time of SABR of 75.2 (72.6-68.7) years, a median (IQR) tumour size of 3.5 (1.9-4.1) cm and follow-up (reverse Kaplan-Meier method) of 3.36 (95% confidence interval [CI] 1.6-4.1) years. Six of the 17 patients had a solitary kidney. Five patients had failed repeat TA prior to SABR. The median (IQR) time from TA procedure to SABR was 3.03 (1.5-5.1) years. No patient experienced local progression, with a local control rate of 100%. Four patients, two with baseline metastatic disease, experienced distant progression. The distant progression-free survival, CSS and OS at 3 years were 72.1% (95% CI 51.9%-100%), 92.3% (95% CI 78.9%-100%) and 82.1% (95% CI 62.1%-100%), respectively. The median (IQR) glomerular filtration rate before SABR was 58 (40-71) mL/min, and at last follow-up, it was 48 (33-57) mL/min. No patient experienced grade 3+ toxicity or went on to develop end-stage renal disease. CONCLUSION: The results showed that SABR appears to be an effective and safe salvage strategy in patients with recurrent RCC following TA.
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Background and Objectives: For preventing postoperative delirium (POD), identifying the risk factors is important. However, the relationship between blood transfusion and POD is still controversial. The aim of this study was to identify the risk factors of POD, to evaluate the impact of blood transfusion in developing POD among people undergoing spinal fusion surgery, and to show the effectiveness of big data analytics using a clinical data warehouse (CDW). Materials and Methods: The medical data of patients who underwent spinal fusion surgery were obtained from the CDW of the five hospitals of Hallym University Medical Center. Clinical features, laboratory findings, perioperative variables, and medication history were compared between patients without POD and with POD. Results: 234 of 3967 patients (5.9%) developed POD. In multivariate logistic regression analysis, the risk factors of POD were as follows: Parkinson's disease (OR 5.54, 95% CI 2.15-14.27; p < 0.001), intensive care unit (OR 3.45 95% CI 2.42-4.91; p < 0.001), anti-psychotics drug (OR 3.35 95% CI 1.91-5.89; p < 0.001), old age (≥70 years) (OR 3.08, 95% CI 2.14-4.43; p < 0.001), depression (OR 2.8 95% CI 1.27-6.2; p < 0.001). The intraoperative transfusion (OR 1.1, 95% CI 0.91-1.34; p = 0.582), and the postoperative transfusion (OR 0.91, 95% CI 0.74-1.12; p = 0.379) had no statistically significant effect on the incidence of POD. Conclusions: There was no relationship between perioperative blood transfusion and the incidence of POD in spinal fusion surgery. Big data analytics using a CDW could be helpful for the comprehensive understanding of the risk factors of POD, and for preventing POD in spinal fusion surgery.
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Delirio , Fusión Vertebral , Anciano , Transfusión Sanguínea , Data Warehousing , Delirio/epidemiología , Delirio/etiología , Humanos , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Fusión Vertebral/efectos adversosRESUMEN
Background and Objectives: As the use of sugammadex for reversing neuromuscular blockade during general anesthesia increases, additional effects of sugammadex have been reported compared to cholinesterase inhibitors. Here, we compare the incidence of postoperative catheter-related bladder discomfort (CRBD) between sugammadex and pyridostigmine/glycopyrrolate treatments for reversing neuromuscular blockade. Materials and Methods: We retrospectively analyzed patients aged ≥ 18 years who underwent surgery under general anesthesia, received sugammadex or pyridostigmine with glycopyrrolate to reverse neuromuscular blockade, and had a urinary catheter in the post-anesthesia care unit between March 2019 and February 2021. After applying the exclusion criteria, 1179 patients were included in the final analysis. The incidence and severity of CRBD were collected from post-anesthesia recovery records. Results: The incidence was 13.7% in the sugammadex group (n = 211) and 24.7% in the pyridostigmine group (n = 968). Following propensity score matching, 211 patients each were included in the pyridostigmine and sugammadex matched group (absolute standardized difference (ASD), 0.01-0.05). Compared to the pyridostigmine group, the odds ratio for CRBD occurring in the sugammadex group was 0.568 (95% confidential interval, 0.316-1.021, p = 0.059). Conclusions: Sugammadex has a similar effect on the occurrence of postoperative CRBD compared with pyridostigmine.
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Bromuro de Piridostigmina , Catéteres Urinarios , Glicopirrolato , Humanos , Bromuro de Piridostigmina/uso terapéutico , Estudios Retrospectivos , Sugammadex/uso terapéutico , Vejiga UrinariaRESUMEN
BACKGROUND: Predicting difficult airway is challengeable in patients with limited airway evaluation. The aim of this study is to develop and validate a model that predicts difficult laryngoscopy by machine learning of neck circumference and thyromental height as predictors that can be used even for patients with limited airway evaluation. METHODS: Variables for prediction of difficulty laryngoscopy included age, sex, height, weight, body mass index, neck circumference, and thyromental distance. Difficult laryngoscopy was defined as Grade 3 and 4 by the Cormack-Lehane classification. The preanesthesia and anesthesia data of 1677 patients who had undergone general anesthesia at a single center were collected. The data set was randomly stratified into a training set (80%) and a test set (20%), with equal distribution of difficulty laryngoscopy. The training data sets were trained with five algorithms (logistic regression, multilayer perceptron, random forest, extreme gradient boosting, and light gradient boosting machine). The prediction models were validated through a test set. RESULTS: The model's performance using random forest was best (area under receiver operating characteristic curve = 0.79 [95% confidence interval: 0.72-0.86], area under precision-recall curve = 0.32 [95% confidence interval: 0.27-0.37]). CONCLUSIONS: Machine learning can predict difficult laryngoscopy through a combination of several predictors including neck circumference and thyromental height. The performance of the model can be improved with more data, a new variable and combination of models.
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Laringoscopía , Aprendizaje Automático , Cuello/anatomía & histología , Cartílago Tiroides/anatomía & histología , Conjuntos de Datos como Asunto , Humanos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Although the standard treatment for the patients with recurrent and metastatic prostate cancer (CaP) is androgen deprivation therapy, castration-resistant prostate cancer (CRPC) eventually emerges. Our previous report indicated that bone morphogenetic protein 6 (BMP6) induced CRPC via tumour-infiltrating macrophages. In a separate line of study, we have observed that the WNT5A/BMP6 loop in CaP bone metastasis mediates resistance to androgen deprivation in tissue culture. Simultaneously, we have reported that BMP6 induced castration resistance in CaP cells via tumour-infiltrating macrophages. Therefore, our present study aims to investigate the mechanism of WNT5A and its interaction with macrophages on CRPC. METHODS: Doxycycline inducible WNT5A overexpression prostate cancer cell line was used for detailed mechanical study. RESULTS: WNT5A was associated with increased expression of chemokine ligand 2 (CCL2) in the human CaP cell line, LNCaP. Mechanistically, this induction of CCL2 by WNT5A is likely to be mediated via the mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK) signalling pathway. Our in vivo experiments demonstrated that the overexpression of WNT5A in LNCaP cells promoted castration resistance. Conversely, this resistance was inhibited with the removal of macrophages via clodronate liposomes. When patient-derived CaP LuCaP xenografts were analysed, high levels of WNT5A were correlated with increased levels of CCL2 and BMP6. In addition, higher levels of CCL2 and BMP6 were more commonly observed in intra-femoral transplanted tumours as compared to subcutaneous-transplanted tumours in the patient-derived PCSD1 bone-niche model. CONCLUSIONS: These findings collectively suggest that WNT5A may be a key gene that induces CRPC in the bone niche by recruiting and regulating macrophages through CCL2 and BMP6, respectively.
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Proteína Morfogenética Ósea 6/metabolismo , Quimiocina CCL2/metabolismo , Macrófagos/patología , Neoplasias de la Próstata Resistentes a la Castración/metabolismo , Regulación hacia Arriba , Proteína Wnt-5a/metabolismo , Anciano , Animales , Línea Celular Tumoral , Ácido Clodrónico/farmacología , Regulación Neoplásica de la Expresión Génica , Humanos , Sistema de Señalización de MAP Quinasas , Macrófagos/metabolismo , Masculino , Ratones , Persona de Mediana Edad , Trasplante de Neoplasias , Neoplasias de la Próstata Resistentes a la Castración/patología , Análisis de Matrices TisularesRESUMEN
BACKGROUND: Penile length (PL) shortening is an underreported phenomenon following radical prostatectomy (RP) and risk factors are not fully explored. We aimed to describe longitudinal patterns of PL recovery and evaluate factors predicting complete return to baseline PL. METHODS: PL measurement was performed during a preoperative and postoperative follow-up visits at 7 days and 3, 6, 9, and 12 months. Patients who completely recovered (CR: N = 397) their preoperative stretched PL measured during at least one of their follow-up visits were compared to those with incomplete recovery (IR: N = 131). Recovery patterns were analyzed for both groups and were also compared in regards to demographics, nerve-sparing techniques, prostate size, cardiovascular risk profiles, and phosphodiesterase-5 inhibitor (PDE5i) uses. Logistic regression analyses were performed using age and other relevant clinicopathologic variables to predict PL recovery. RESULTS: 60.2% of the total study population regained their preoperative PL at 12 months. Average percent (length) differences from baseline were - 1.70% (- 0.25 cm) and - 16.42% (- 2.35 cm) in the CR and the IR groups, respectively (p < 0.001). Multivariate logistic regression demonstrated that younger age (OR 0.962; 95%CI 0.931-0.994; p = 0.019), high preoperative erectile function (EF) (OR 1.028; 95%CI 1.001-1.056; p = 0.046), and consistent PDE5i use (OR 1.998; 95%CI 1.166-3.425; p = 0.012) were independent predictors of CR. At 12-month follow up, PL difference for consistent PDE5iusers was statistically different from those who did not use PDE5i consistently (- 3.25%vs. -6.64%; P = 0.001). CONCLUSION: Age, preoperative EF, and consistent use of PDE5i were associated with complete recovery of baseline PL after RP. The therapeutic effect of PDE5i was most pronounced at 12-month visit, suggesting an added benefit with long-term use.
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Erección Peniana/efectos de los fármacos , Pene/efectos de los fármacos , Inhibidores de Fosfodiesterasa 5/farmacología , Prostatectomía/tendencias , Recuperación de la Función/efectos de los fármacos , Esquema de Medicación , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Erección Peniana/fisiología , Pene/fisiología , Recuperación de la Función/fisiología , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Renal cell carcinoma (RCC) is one of the most lethal genitourinary cancers. The presence of androgen receptor (AR) in RCC has recently been shown to be associated with higher tumour stage irrespective of gender. Because the clinical context of androgens in female RCC patients is similar to that of prostate cancer patients undergoing androgen-deprivation therapy, mechanisms underlying the emergence of castration-resistant prostate cancer (CRPC) may be at play in AR-positive RCC cells. Therefore, we hypothesized that AR-positive RCC has intratumoral steroidogenesis and that anti-androgen therapy may result in tumour suppression. METHODS: Mice were injected with an AR-positive RCC cell line. When tumours became palpable, surgical castration was performed and tumour volume was measured. Using ELISA, the levels of intracellular testosterone and dihydrotesterone were measured in AR-positive human RCC cell lines. Lastly, male mice containing xenografts were treated with enzalutamide or abiraterone acetate (AA) for 3 weeks to measure tumour volume. RESULTS: We first observed in vivo that castration retards the growth of AR-positive RCC tumour xenograft in mice. Next, AR-positive human RCC cell lines and tissues were found to have elevated levels of testosterone and dihydrotestosterone and express key enzymes required for intracellular androgen biosynthesis. A mouse xenograft study with AR-positive RCC cell line using the commonly used anti-androgen therapies showed significant tumour suppression (P<0.01). CONCLUSIONS: Intracrine androgen biosynthesis is a potential source of androgen in AR-positive RCC and that the androgen signaling axis is a potential target of intervention in RCC.
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Andrógenos/biosíntesis , Carcinoma de Células Renales/metabolismo , Neoplasias Renales/metabolismo , Neoplasias de la Próstata Resistentes a la Castración/metabolismo , Neoplasias de la Próstata/metabolismo , Acetato de Abiraterona/farmacología , Animales , Antineoplásicos/farmacología , Apoptosis/efectos de los fármacos , Benzamidas , Western Blotting , Carcinoma de Células Renales/tratamiento farmacológico , Carcinoma de Células Renales/patología , Proliferación Celular/efectos de los fármacos , Dihidrotestosterona/metabolismo , Femenino , Humanos , Técnicas para Inmunoenzimas , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/patología , Masculino , Ratones , Ratones Desnudos , Nitrilos , Orquiectomía , Feniltiohidantoína/análogos & derivados , Feniltiohidantoína/farmacología , Pronóstico , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/patología , Neoplasias de la Próstata Resistentes a la Castración/tratamiento farmacológico , Neoplasias de la Próstata Resistentes a la Castración/patología , ARN Mensajero/genética , Reacción en Cadena en Tiempo Real de la Polimerasa , Receptores Androgénicos/química , Receptores Androgénicos/genética , Receptores Androgénicos/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Testosterona/metabolismo , Células Tumorales Cultivadas , Ensayos Antitumor por Modelo de XenoinjertoRESUMEN
PURPOSE: Active surveillance is now the treatment of choice in men with low risk prostate cancer. Although there is no consensus on which patients are eligible for active surveillance, prostate specific antigen above 10 ng/ml is generally excluded. In an attempt to determine the validity of using a prostate specific antigen cutoff of 10 ng/ml to counsel men considering active surveillance we analyzed a multi-institution database to determine the pathological outcome in men with prostate specific antigen greater than 10 ng/ml but histologically favorable risk prostate cancer. MATERIALS AND METHODS: We queried a prospectively maintained database of men with histologically favorable risk prostate cancer who underwent radical prostatectomy between 2003 and 2015. The cohort was categorized into 3 groups based on prostate specific antigen level, including low-less than 10 ng/ml, intermediate-10 or greater to less than 20 and high-20 or greater. Associations of prostate specific antigen group with adverse pathological and oncologic outcomes were analyzed. RESULTS: Of 2,125 patients 1,327 were categorized with histologically favorable risk disease. However on multivariate analyses the rates of up staging and upgrading were similar between the intermediate and low prostate specific antigen groups. In contrast compared to the intermediate prostate specific antigen group the high group had higher incidences of up staging (p = 0.02) and upgrading to 4 + 3 or greater disease (p = 0.046). Biochemical recurrence-free survival rates revealed no pairwise intergroup differences except between the low and high groups. CONCLUSIONS: Patients with preoperatively elevated prostate specific antigen between 10 and less than 20 ng/ml who otherwise had histologically favorable risk prostate cancer were not at higher risk for adverse pathological outcomes than men with prostate specific antigen less than 10 ng/ml.
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Estadificación de Neoplasias , Antígeno Prostático Específico/sangre , Próstata/patología , Prostatectomía/métodos , Neoplasias de la Próstata/diagnóstico , Anciano , Biomarcadores de Tumor/sangre , Biopsia , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , New Jersey/epidemiología , Pronóstico , Próstata/cirugía , Neoplasias de la Próstata/sangre , Neoplasias de la Próstata/cirugía , República de Corea/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendenciasRESUMEN
INTRODUCTION: There is no consensus on the best oral phosphodiesterase type 5 inhibitor (PDE5I) for patients undergoing penile rehabilitation after surgical nerve injury. AIM: To determine the mechanism of PDE5I on cultured neuronal cells and the effectiveness of local drug delivery using nanospheres (NSPs) to sites of nerve injury in a rat model of bilateral cavernous nerve injury (BCNI). METHODS: The effects of sildenafil, tadalafil, and vardenafil on cyclic adenosine monophosphate, cyclic guanosine monophosphate, and cell survival after exposure to hypoxia and H2O2 were measured in PC12, SH-SY5Y, and NTERA-2 (NT2) cell cultures. The effects of phosphodiesterase type 4 inhibitor (PDE4I) and PDE5I on neuronal cell survival were evaluated. Male rats underwent BCNI and were untreated (BCNI), immediately treated with application of empty NSPs (BCNI + NSP), NSPs containing sildenafil (Sild + NSP), or NSPs containing rolipram (Rol + NSP). MAIN OUTCOME MEASURES: Viability of neuronal cells was measured. Intracavernous pressure changes after cavernous nerve electrostimulation and expression of neurofilament, nitric oxide synthase, and actin in mid-shaft of penis were analyzed 14 days after injury. RESULTS: Sildenafil and rolipram significantly decreased cell death after exposure to H2O2 and hypoxia in PC12, SH-SY5Y, and NT2 cells. PC12 cells did not express PDE5 and knockdown of PDE4 significantly increased cell viability in PC12, SH-SY5Y, and NT2 cells exposed to hypoxia. The ratio of intracavernous pressure to mean arterial pressure and expression of penile neurofilament, nitric oxide synthase, and actin were significantly higher in the Sild + NSP and Rol + NSP groups than in the BCNI and BCNI + NSP groups. Limitations included analysis in only two PDE families using only a single dose. CONCLUSION: Sildenafil showed the most profound neuroprotective effect compared with tadalafil and vardenafil. Sildenafil- or rolipram-loaded NSP delivery to the site of nerve injury prevented erectile dysfunction and led to increased neurofilament, nitric oxide synthase, smooth muscle content in rat penile tissue after BCNI.
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Disfunción Eréctil/tratamiento farmacológico , Inhibidores de Fosfodiesterasa 5/administración & dosificación , Citrato de Sildenafil/administración & dosificación , Animales , GMP Cíclico/metabolismo , Humanos , Peróxido de Hidrógeno , Masculino , Músculo Liso/metabolismo , Óxido Nítrico Sintasa/metabolismo , Erección Peniana/efectos de los fármacos , Pene/cirugía , Inhibidores de Fosfodiesterasa 5/uso terapéutico , Prostatectomía , Ratas , Ratas Sprague-Dawley , Traumatismos del Sistema NerviosoRESUMEN
PURPOSE: The role of androgen receptor in renal cell carcinoma is not well understood. In this study the correlation between androgen receptor mRNA expression and clinicopathological features in patients with localized renal cell carcinoma was investigated. Additionally, human renal cell carcinoma cell lines were examined for the presence and effect of androgen receptor. MATERIALS AND METHODS: Androgen receptor mRNA expression was evaluated by quantitative real-time polymerase chain reaction in 115 tumor samples from patients with primary pathological stage T1 or T2 (pT1/pT2) renal cell carcinoma and 57 specimens of corresponding normal kidney tissue. Reverse transcriptase-polymerase chain reaction and Western blot were done to examine the expression of androgen receptor in human renal cell carcinoma cell lines. Effects on cellular proliferation were investigated after activating and blocking androgen signaling in tissue culture. RESULTS: Androgen receptor mRNA expression levels were significantly higher in patients with pT2 tumors than in those with pT1 tumors (p = 0.011). Kaplan-Meier estimates revealed significant differences in time to progression and cancer specific survival between low and high androgen receptor mRNA expression groups regardless of gender. Multivariate Cox regression analysis demonstrated that the level of androgen receptor expression was an independent predictor of cancer specific survival (HR 15.546, 95% CI 1.320-183.131, p = 0.029). In tissue culture treatment with dihydrotestosterone caused proliferation in androgen receptor positive cell lines while enzalutamide resulted in reduced cell viability in a dose dependent manner. CONCLUSIONS: In patients with localized renal cell carcinoma the androgen receptor mRNA expression level is associated with prognosis. In addition, cell culture data suggest that enzalutamide may have an effect in limiting the growth of androgen receptor positive renal cell carcinoma.
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Carcinoma de Células Renales/genética , Regulación Neoplásica de la Expresión Génica , Neoplasias Renales/genética , ARN Neoplásico/genética , Receptores Androgénicos/genética , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor/biosíntesis , Biomarcadores de Tumor/genética , Western Blotting , Carcinoma de Células Renales/metabolismo , Carcinoma de Células Renales/patología , Línea Celular Tumoral , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Renales/metabolismo , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Reacción en Cadena en Tiempo Real de la Polimerasa , Receptores Androgénicos/biosíntesis , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND: The presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population. METHODS: Data were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR). RESULTS: Of the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP. CONCLUSIONS: There was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.
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Tejido Adiposo/patología , Ganglios Linfáticos/patología , Pelvis/patología , Próstata/patología , Neoplasias de la Próstata/mortalidad , Neoplasias de la Próstata/patología , Supervivencia sin Enfermedad , Humanos , Incidencia , Internacionalidad , Metástasis Linfática , Masculino , Pronóstico , Neoplasias de la Próstata/cirugía , República de Corea/epidemiología , Factores de Riesgo , Análisis de Supervivencia , Taiwán/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Stereotactic ablative radiotherapy (SAbR) is an emerging non-invasive definitive treatment option for primary renal cell carcinoma (RCC), particularly when surgery is not ideal. Employing ablative doses, SAbR delivered in one to five fractions to the primary tumor has been shown to achieve high local control rates with favorable toxicity profile in multiple retrospective and prospective series, and has dispelled previous notions of RCC radio-resistance. Moreover, emerging evidence suggests possible immunomodulatory effects, leading to clinical investigations of SAbR in combination with systemic and surgical management in patients with metastatic disease. In this review, we summarize key evidence supporting SAbR delivered to the primary tumor including preclinical rationale, dose escalation studies, recent prospective trials, and outcomes from ongoing multi-institutional registries. We also discuss areas of active clinical investigation including the use of primary SAbR in combination with systemic therapies in patients with metastatic disease. The accumulated body of evidence supports SAbR as promising indication being increasingly incorporated into the multi-disciplinary management of primary RCC.
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Accurate prediction of difficult direct laryngoscopy (DDL) is essential to ensure optimal airway management and patient safety. The present study proposed an AI model that would accurately predict DDL using a small number of bedside pictures of the patient's face and neck taken simply with a smartphone. In this prospective single-center study, adult patients scheduled for endotracheal intubation under general anesthesia were included. Patient pictures were obtained in frontal, lateral, frontal-neck extension, and open mouth views. DDL prediction was performed using a deep learning model based on the EfficientNet-B5 architecture, incorporating picture view information through multitask learning. We collected 18,163 pictures from 3053 patients. After under-sampling to achieve a 1:1 image ratio of DDL to non-DDL, the model was trained and validated with a dataset of 6616 pictures from 1283 patients. The deep learning model achieved a receiver operating characteristic area under the curve of 0.81-0.88 and an F1-score of 0.72-0.81 for DDL prediction. Including picture view information improved the model's performance. Gradient-weighted class activation mapping revealed that neck and chin characteristics in frontal and lateral views are important factors in DDL prediction. The deep learning model we developed effectively predicts DDL and requires only a small set of patient pictures taken with a smartphone. The method is practical and easy to implement.
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Aprendizaje Profundo , Intubación Intratraqueal , Laringoscopía , Humanos , Laringoscopía/métodos , Estudios Prospectivos , Femenino , Masculino , Persona de Mediana Edad , Adulto , Intubación Intratraqueal/métodos , Anciano , Procesamiento de Imagen Asistido por Computador/métodos , Teléfono Inteligente , Curva ROCRESUMEN
Post-craniotomy headache (PCH) is a common postoperative complication, and some of these patients progress to chronic PCH (CPCH). We aimed to identify clinical variables associated with PCH and its progression to CPCH, especially possible associations between age and sex differences. Therefore, we examined clinical information on PCH using the Clinical Data Warehouse over 10 years. Of the 1326 patients included, 927 patients (69.9%) experienced PCH. In multivariate analysis for PCH, age was inversely related to risk (p = 0.003), and being female showed a significant association with an increased risk of PCH (p = 0.002). There was also a significant inverse relationship between age and severity of the worst headache, with younger female patients reporting greater severity of the worst headache (p < 0.001). Of the 927 patients who experienced PCH, 319 (34.4%) progressed to CPCH. Sex was a significant factor, with females having a higher risk of developing CPCH compared to males (p < 0.001). In addition, the presence of preoperative headaches significantly increased the risk of CPCH (p = 0.001). The occurrence of PCH is associated with younger age and female sex. In particular, female sex and preoperative headaches increased the risk of developing CPCH. These clinical factors should be considered in patients undergoing neurosurgery.
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This retrospective study investigated the association of sugammadex with postoperative pulmonary complication risk between 2013 and 2021 in patients with severe burn of five hospitals. Postoperative pulmonary complications included atelectasis, pulmonary edema, pulmonary effusion, pneumothorax, pneumonia, pulmonary thromboembolism, respiratory failure and acute respiratory distress. To identify whether sugammadex reduced the risk of postoperative pulmonary complication in patients with severe burn who underwent surgery, Kaplan-Meier curve were used to check the difference of incidence according to surgical cases and time-varying Cox hazard regression were used to calculate the hazard ratio. The study included 1213 patients with severe burn who underwent 2259 surgeries. Postoperative pulmonary complications were occurred in 313 (25.8%) patients. Among 2259 surgeries, sugammadex was used in 649 (28.7%) surgeries. Cumulative postoperative pulmonary complication were 268 (16.6%) cases in surgeries without sugammadex, and 45 (6.9%) cases in surgeries with sugammadex, respectively (P < 0.005). The postoperative pulmonary complications risk was reduced significantly in patients who use sugammadex than those who did not use sugammadex. (Adjusted hazard ratio, 0.61; 95% confidence interval, 0.42-0.89; P = 0.011). In conclusion, sugammadex reduced risk of postoperative pulmonary complications compared with nonuse of sugammadex in patients with severe burn who underwent surgery.
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Quemaduras , Atelectasia Pulmonar , Humanos , Sugammadex , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Quemaduras/complicaciones , Quemaduras/cirugíaRESUMEN
BACKGROUND: The Controlling Nutritional Status (CONUT) score and the prognostic nutritional index (PNI) have emerged as important nutritional indices because they provide an objective assessment based on data. We aimed to investigate how these nutritional indices relate to outcomes in patients with sepsis. METHODS: Data were collected retrospectively at five hospitals for patients aged ≥18 years receiving treatment for sepsis between January 1, 2017, and December 31, 2021. Serum albumin and total cholesterol concentrations, and peripheral lymphocytes were used to calculate the CONUT score and PNI. To identify predictors correlated with 30-day mortality, analyses were conducted using univariate and multivariate Cox proportional hazards models. RESULTS: The 30-day mortality rate among 9,763 patients was 15.8% (n=1,546). The median CONUT score was 5 (interquartile range [IQR], 3-7) and the median PNI score was 39.6 (IQR, 33.846.4). Higher 30-day mortality rates were associated with individuals with moderate (CONUT score: 5-8; PNI: 35-38) or severe (CONUT: 9-12; PNI: <35) malnutrition compared with those with no malnutrition (CONUT: 0-1; PNI: >38). With CONUT scores, the hazard ratio (HR) associated with moderate malnutrition was 1.52 (95% confidence interval [CI], 1.24-1.87; P<0.001); for severe, HR=2.42 (95% CI, 1.95-3.02; P<0.001). With PNI scores, the HR for moderate malnutrition was 1.29 (95% CI, 1.09-1.53; P=0.003); for severe, HR=1.88 (95% CI, 1.67-2.12; P<0.001). CONCLUSIONS: The nutritional indices CONUT score and PNI showed significant associations with mortality of sepsis patients within 30 days.
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This study aimed to compare the video laryngoscope views facilitated by curved blades 3 and 4 with an exploration of the relationship between these views and patient height. Conducted as a randomized controlled trial, this study enrolled adults scheduled for surgery under general anesthesia. Intubation procedures were recorded, and the percentage of glottic opening was measured before tube insertion. Multivariate analysis validated the impact of various factors, including blade size and patient height, on the percentage of glottic opening scores. A total of 192 patients were included. The median percentage of glottic opening scores for curved blades 3 and 4 were 100 and 83, respectively (p < 0.001). The unstandardized coefficient indicated a significant negative impact of blade 4 on the percentage of glottic opening scores (-13, p < 0.001). In the locally estimated scatterplot smoothing analysis, blade 3 exhibited a steady rise in glottic opening scores with increasing height, whereas blade 4 showed a peak followed by a decline around 185 cm. The unstandardized coefficient of height showed no significant association (0, p = 0.819). The study observed superior laryngoscopic views with blade 3 compared to blade 4. However, no significant association was found between laryngoscopic views and patient height.
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The spread of carbapenem-resistant Enterobacterales (CRE) poses a public health threat worldwide. We aimed to compare the mortality rates between the carbapenemase-producing (CP) and non-CP CRE bacteremia. We conducted a retrospective cohort study in patients with CRE bacteremia after propensity score (PS) matching. We performed a Kaplan-Meier curve analysis to identify the cumulative hazard for 30-day mortality. There were 318 patients with CRE between January 1, 2018, and December 31, 2022. There were 252 patients with CP-CRE and 66 with non-CP-RE, respectively. Before PS matching, the 30-day mortality rates were 40.9% in the non-CP-CRE group and 53.2% in the CP-CRE group (p = 0.097). In patients in the intensive care unit (ICU), the mortality rates were 49.0% in the non-CP-CRE group and 57.1% in the CP-CRE group (p = 0.340). After PS matching, the hazard ratio (HR) for mortality in the CP-CRE group was 1.49 (95% confidence interval [CI] 0.74-3.03), p = 0.266). In ICU patients, the HR of CP-CRE was 1.11 (95% CI 0.36-3.39, p = 0.860). The Kaplan-Meier curve for 30-day mortality showed no difference in cumulative hazard. After PS matching, there was no difference in 30-day mortality between patients with CP-CRE and non-CP-CRE bacteremia.
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Bacteriemia , Humanos , Puntaje de Propensión , Estudios Retrospectivos , Bacteriemia/tratamiento farmacológico , Carbapenémicos/farmacología , Carbapenémicos/uso terapéuticoRESUMEN
Age-related differences in pain perception have been reported in various contexts; however, their impact on postoperative pain intensity remains poorly understood, especially across different surgical procedures. Data from five hospitals were retrospectively analyzed, encompassing patients who underwent 10 distinct surgical procedures. Numeric rating scale scores were used to assess the worst postoperative pain intensity during the 24 h after surgery. The multivariate linear regression model analyzed the relationship between age and pain intensity. Subgroup analyses were performed according to sex and patient-controlled analgesia (PCA). This study included 41,187 patients. Among the surgeries studied, lumbar spine fusion (ß = -0.155, p < 0.001) consistently and significantly exhibited a decrease in worst postoperative pain with increasing age. Similar trends were observed in cholecystectomy (ß = -0.029, p < 0.001) and several other surgeries; however, the results were inconsistent across all analyses. Surgeries with higher percentages of PCA administration had lower median worst-pain scores. In conclusion, age may affect postoperative pain intensity after specific surgeries; however, a comprehensive understanding of the complex interplay between age, surgical intervention, and pain intensity is required. Pain management strategies should consider various factors, including age-related variations.
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Headaches, particularly migraine, are associated with gastrointestinal (GI) disorders. In addition to the gut-brain axis, the lung-brain axis is suspected to be involved in the relationship between pulmonary microbes and brain disorders. Therefore, we investigated possible associations of migraine and non-migraine headaches (nMH) with respiratory and GI disorders using the clinical data warehouse over 11 years. We compared data regarding GI and respiratory disorders, including asthma, bronchitis, and COPD, among patients with migraine, patients with nMH, and controls. In total, 22,444 patients with migraine, 117,956 patients with nMH, and 289,785 controls were identified. After adjustment for covariates and propensity score matching, the odds ratios (ORs) for asthma (1.35), gastroesophageal reflux disorder (1.55), gastritis (1.90), functional GI disorder (1.35), and irritable bowel syndrome (1.76) were significantly higher in patients with migraine than in controls (p = 0.000). The ORs for asthma (1.16) and bronchitis (1.33) were also significantly higher in patients with nMH than in controls (p = 0.0002). When the migraine group was compared with the nMH group, only the OR for GI disorders was statistically significant. Our findings suggest that migraine and nMH are associated with increased risks of GI and respiratory disorders.