Clinical, oncological, and prognostic differences of patients with subsequent skeletal-related events in bone metastases.

Aims: Advances in treatment have extended the life expectancy of patients with metastatic bone disease (MBD). Patients could experience more skeletal-related events (SREs) as a result of this progress. Those who have already experienced a SRE could encounter another local management for a subsequent SRE, which is not part of the treatment for the initial SRE. However, there is a noted gap in research on the rate and characteristics of subsequent SREs requiring further localized treatment, obligating clinicians to extrapolate from experiences with initial SREs when confronting subsequent ones. This study aimed to investigate the proportion of MBD patients developing subsequent SREs requiring local treatment, examine if there are prognostic differences at the initial treatment between those with single versus subsequent SREs, and determine if clinical, oncological, and prognostic features differ between initial and subsequent SRE treatments. Methods: This retrospective study included 3,814 adult patients who received local treatment - surgery and/or radiotherapy - for bone metastasis between 1 January 2010 and 31 December 2019. All included patients had at least one SRE requiring local treatment. A subsequent SRE was defined as a second SRE requiring local treatment. Clinical, oncological, and prognostic features were compared between single SREs and subsequent SREs using Mann-Whitney U test, Fisher's exact test, and Kaplan-Meier curve. Results: Of the 3,814 patients with SREs, 3,159 (83%) patients had a single SRE and 655 (17%) patients developed a subsequent SRE. Patients who developed subsequent SREs generally had characteristics that favoured longer survival, such as higher BMI, higher albumin levels, fewer comorbidities, or lower neutrophil count. Once the patient got to the point of subsequent SRE, their clinical and oncological characteristics and one-year survival (28%) were not as good as those with only a single SRE (35%; p < 0.001), indicating that clinicians' experiences when treating the initial SRE are not similar when treating a subsequent SRE. Conclusion: This study found that 17% of patients required treatments for a second, subsequent SRE, and the current clinical guideline did not provide a specific approach to this clinical condition. We observed that referencing the initial treatment, patients in the subsequent SRE group had longer six-week, 90-day, and one-year median survival than patients in the single SRE group. Once patients develop a subsequent SRE, they have a worse one-year survival rate than those who receive treatment for a single SRE. Future research should identify prognostic factors and assess the applicability of existing survival prediction models for better management of subsequent SREs.

ChatGPT v4 outperforming v3.5 on cancer treatment recommendations in quality, clinical guideline, and expert opinion concordance.

Objectives: To assess the quality and alignment of ChatGPT's cancer treatment recommendations (RECs) with National Comprehensive Cancer Network (NCCN) guidelines and expert opinions. Methods: Three urologists performed quantitative and qualitative assessments in October 2023 analyzing responses from ChatGPT-4 and ChatGPT-3.5 to 108 prostate, kidney, and bladder cancer prompts using two zero-shot prompt templates. Performance evaluation involved calculating five ratios: expert-approved/expert-disagreed and NCCN-aligned RECs against total ChatGPT RECs plus coverage and adherence rates to NCCN. Experts rated the response's quality on a 1-5 scale considering correctness, comprehensiveness, specificity, and appropriateness. Results: ChatGPT-4 outperformed ChatGPT-3.5 in prostate cancer inquiries, with an average word count of 317.3 versus 124.4 (p < 0.001) and 6.1 versus 3.9 RECs (p < 0.001). Its rater-approved REC ratio (96.1% vs. 89.4%) and alignment with NCCN guidelines (76.8% vs. 49.1%, p = 0.001) were superior and scored significantly better on all quality dimensions. Across 108 prompts covering three cancers, ChatGPT-4 produced an average of 6.0 RECs per case, with an 88.5% approval rate from raters, 86.7% NCCN concordance, and only a 9.5% disagreement rate. It achieved high marks in correctness (4.5), comprehensiveness (4.4), specificity (4.0), and appropriateness (4.4). Subgroup analyses across cancer types, disease statuses, and different prompt templates were reported. Conclusions: ChatGPT-4 demonstrated significant improvement in providing accurate and detailed treatment recommendations for urological cancers in line with clinical guidelines and expert opinion. However, it is vital to recognize that AI tools are not without flaws and should be utilized with caution. ChatGPT could supplement, but not replace, personalized advice from healthcare professionals.

The FIB-4 scores in the emergency department to predict the outcomes of COVID-19 patients in taiwan.

Objective: We aimed to determine the reliability of using the Fibrosis-4 (FIB-4) index in COVID-19 patients without underlying liver illness. Method: We employed multivariate logistic regression to identify variables that exhibited statistically significant influence on the ultimate outcome. Multilayer perceptron analysis was employed to develop a prediction model for the FIB-4 index concerning ICU admission and intubation rates. However, the scarcity of cases rendered the assessment of the mortality rate unfeasible. We plotted ROC curves to analyze the predictive strength of the FIB-4 index across various age groups. Result: In univariate logistic regression, only the FIB-4 index and respiratory rate demonstrated statistical significance on all poor outcomes. The FIB-4 index for mortality prediction had an ROC and AUC of 0.863 (95% CI: 0.781-0.9444). It demonstrates predictive power across age groups, particularly for age ≥65 (AUC: 0.812, 95% CI: 0.6571-0.9673) and age <65 (AUC: 0.878, 95% CI: 0.8012-0.9558). Its sensitivity for intubation and ICU admission prediction is suboptimal. Conclusion: FIB-4 index had promising power in prediction of mortality rate in all age groups.

The effect of bone remodeling with photobiomodulation in dentistry: a review study.

Photobiomodulation (PBM) has been emerging as a promising alternative therapy in dentistry. However, various parameters of PBM are used in different studies, and there is limited cumulative data on PBM for improving bone formation in clinical trials. The aim of this review was to evaluate the effectiveness of PBM in the process of bone remodeling in dentistry using randomized controlled trials. Initially, a total of 1,011 articles published from January 2008 to December 2021 were retrieved from five electronic databases (PubMed, Scopus, Cochrane Library, EMBASE, and CINAHL). After a two-step review, nine articles met the inclusion criteria. The parameter of PBM, group, treatment sessions, assessment times and outcomes of the included studies were reviewed. Eighty-nine percent of the studies revealed positive effects on bone formation between the laser group and the control group. Only one article reported that light-emitting diode did not significantly enhance osteogenesis. Additionally, the present study shows that Gallium aluminum arsenide of near infrared (NIR) laser with continuous mode is the most commonly used form of PBM. The biostimulatory effects are dependent on several parameters, with wavelength and dose being more important than others. Based on this review, it is suggested that the NIR range and an appropriate dose of PBM could be used to increase the efficiency of stimulating bone healing and remodeling. However, standardization of treatment protocols is needed to clarify therapeutic strategies in dentistry.

Determining patients with spinal metastases suitable for surgical intervention: A cost-effective analysis.

BACKGROUND: Both nonoperative and operative treatments for spinal metastasis are expensive interventions. Patients' expected 3-month survival is believed to be a key factor to determine the most suitable treatment. However, to the best of our knowledge, no previous study lends support to the hypothesis. We sought to determine the cost-effectiveness of operative and nonoperative interventions, stratified by patients' predicted probability of 3-month survival. METHODS: A Markov model with four defined health states was used to estimate the quality-adjusted life years (QALYs) and costs for operative intervention with postoperative radiotherapy and radiotherapy alone (palliative low-dose external beam radiotherapy) of spine metastases. Transition probabilities for the model, including the risks of mortality and functional deterioration, were obtained from secondary and our institutional data. Willingness to pay thresholds were prespecified at $100,000 and $150,000. The analyses were censored after 5-year simulation from a health system perspective and discounted outcomes at 3% per year. Sensitivity analyses were conducted to test the robustness of the study design. RESULTS: The incremental cost-effectiveness ratios were $140,907 per QALY for patients with a 3-month survival probability >50%, $3,178,510 per QALY for patients with a 3-month survival probability <50%, and $168,385 per QALY for patients with independent ambulatory and 3-month survival probability >50%. CONCLUSIONS: This study emphasizes the need to choose patients carefully and estimate preoperative survival for those with spinal metastases. In addition to reaffirming previous research regarding the influence of ambulatory status on cost-effectiveness, our study goes a step further by highlighting that operative intervention with postoperative radiotherapy could be more cost-effective than radiotherapy alone for patients with a better survival outlook. Accurate survival prediction tools and larger future studies could offer more detailed insights for clinical decisions.

Lung abscess with chronic cough secondary to xanthogranulomatous pyelonephritis: A rare case report.

RATIONALE: Xanthogranulomatous pyelonephritis (XGPN) is a form of chronic pyelonephritis caused by chronic calculus obstruction and bacterial infection, leading to the destruction of the renal parenchyma and calyces. Conservative treatment is usually not sufficient, and surgical intervention is still the main curative approach. XGPN with transdiaphragmatic extension and lung abscess formation is a rare condition. PATIENT CONCERNS: We report a 64-year-old woman who presented with persistent productive cough. DIAGNOSES: Lung abscess secondary to XPGN. Both nephrostomy urine and sputum cultures showed Proteus mirabilis infection with the same antibiotic sensitivity spectrum, but blood culture was negative. INTERVENTIONS: Laparoscopic radical nephrectomy and prolonged antibiotic treatment. OUTCOMES: The lung abscess and cough gradually resolved in 1 month after nephrectomy. CONCLUSION: Lung abscess secondary to transdiaphragmatic extension of XGPN is rare but should be considered in patients with lower lung infections that are unresponsive to treatment, especially infections due to unusual respiratory pathogens such as P mirabilis.

Ultrasound-Guided Perineural Vitamin B12 Injection for Brachial Plexus Injury: A Preliminary Study.

Individuals with brachial plexus injury (BPI) require upper limb function restoration, but the treatment remains controversial. Vitamin B12 may aid in pain control and nerve regeneration. We present the technical aspects of ultrasound-guided perineural vitamin B12 injection for BPI. The demonstrative case is a 50-year-old man with BPI resulting from a traffic accident. Under ultrasound guidance, vitamin B12 was injected precisely into the brachial plexus compartment around the swollen neuroma of the C6 root. Motor and sensory functions of the left upper extremity improved over 6 months. Ultrasound-guided perineural vitamin B12 injection may be an efficient and personalized intervention in cases of post-ganglionic BPI that failed to improve in the first 3 months.

NKG2A and circulating extracellular vesicles are key regulators of natural killer cell activity in prostate cancer after prostatectomy.

Extracellular vesicles (EVs) are an important regulatory factor for natural killer cell activity (NKA) in the tumor microenvironment. The relationship between circulating EVs in the peripheral blood and natural killer (NK) cells in prostate cancer (PCa) is unclear. This study aimed at investigating the key regulators in the interaction between circulating EVs and NK cells in PCa patients before and after tumor removal. NK-cell characteristics were prospectively assessed in 79 patients treated with robot-assisted laparoscopic radical prostatectomy preoperatively and postoperatively. Compared with healthy donors, the existence of prostate tumors increased the number of circulating EVs and altered ligand expression of EVs. Circulating EVs extracted from cancer patients significantly decreased NKA of NK cells compared with those extracted from healthy donors. Upon treatment with an inhibiting antibody or small interfering RNA, natural killer cell protein group 2A (NKG2A) was identified as the main NKA regulator in cancer patients for accepting the signal from circulating EVs. After surgery, NKA was increased and NKG2A expression on NK cells was significantly reduced. The expression of ligands for natural killer cell protein group 2D (NKG2D) on EVs and the level of circulation EVs both significantly increased. With the decrease in NKG2A levels on NK cells and the increase in total NKG2D ligands on circulating EVs, which was increased postoperatively, both NKG2A on NK cells and NKG2D ligands on circulating exosomes are main regulators of NKA restoration after prostatectomy.

Dynamic ultrasound for evaluating the adequacy of median nerve decompression following minimally invasive carpal tunnel release: technical innovation and case study.

Background: Minimally invasive carpal tunnel release has recently emerged as the primary surgical approach for recalcitrant carpal tunnel syndrome. A major concern related to surgical failure with this technique is the incomplete release of the flexor retinaculum. Case presentation: We developed a technique using dynamic ultrasound for evaluating the adequacy of median nerve decompression following minimally invasive carpal tunnel release. This novel imaging method was applied to two patients who showed significant symptom relief after the intervention. This case study also provides details of the dynamic ultrasound protocol and highlights the advantages of this technique. Conclusion: Dynamic ultrasound imaging can be used to confirm the completeness of carpal tunnel decompression. A large-scale prospective trial should be conducted to validate whether additional dynamic ultrasound examination can improve the outcome of minimally invasive carpal tunnel release.

Management of cervical fractures in ankylosing spondylitis patients: immediate fixation effort via vertebroplasty with one-staged combined anterior and posterior fixation.

The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.

The hypoxia-age-shock index at triage to predict the outcomes of Covid-19 patients.

STUDY OBJECTIVE: The coronavirus disease 2019 (COVID-19) outbreak has caused a severe burden on medical professionals, as the rapid disposition of patients is important. Therefore, we aimed to develop a new clinical assessment tool based on the shock index (SI) and age-shock index (ASI). We proposed the hypoxia-age-shock index (HASI) and determined the usability of triage for COVID-19 infected patients in the first scene. METHODS: The predictive power for three indexes on mortality, intensive care unit (ICU) admission, and endotracheal intubation rate was evaluated using the receiver operating curve (ROC). We used DeLong's method for comparing the ROCs. RESULTS: The area under the curve (AUC) for ROC on mortality for SI, ASI, and HASI were 0.546, 0.771, and 0.773, respectively. The AUC on ICU admission mortality for SI, ASI, and HASI were 0.581, 0.700, and 0.743, respectively. The AUC for intubation for SI, ASI, and HASI were 0.592, 0.708, and 0.757, respectively. The AUC differences between HASI and SI showed statistically significant (P = 0.001) results on mortality, ICU admission, and intubation. Additionally, statistically significant results were found for the AUC difference between the HASI and ASI on ICU admission and intubation (P = 0.001 and P = 0.004, respectively). CONCLUSION: HASI can provide a better prediction compared to ASI on ICU admission and endotracheal intubation. HASI was more sensitive in mortality, ICU admission, and intubation prediction than the ASI.

Analysis of the clinical and radiological outcomes of percutaneous cervical nucleoplasty: A case-control study.

BACKGROUND: Percutaneous cervical nucleoplasty (PCN) is a simple, safe, and effective treatment for contained cervical herniated intervertebral disc (CHIVD). However, few studies have compared the actual benefits of PCN against conservative treatment (CT), either clinically or radiographically. PURPOSE: The present study sought to analyze and to compare the outcomes of symptomatic contained CHIVD treated with PCN or CT. METHODS: The present study was designed as a case-control comparative study. Patients who indicated for PCN after a failed CT for more than 6 months were recruited. After the exclusion of some patients who did not meet the selection criteria of the study, we finally enrolled 71 patients treated with PCN. In addition, another 21 patients who indicated for PCN but finally chose to receive CT continuously were also enrolled and categorized as the control group. All patients completed the 6-month follow-up. Pain levels and functional outcomes were evaluated pre- and post-operatively by assessing the visual analog scale (VAS), Oswestry Disability Index (ODI), and Neck Disability Index (NDI). Radiographic images of 72 of 104 intervened segments were collected to measure disc height and other cervical spinal alignments, such as range of motion, C2-7 Cobb's angle, and C2-7 sagittal vertical axis. RESULTS: Compared with the CT group, the PCN group showed significantly better outcomes on VAS, ODI, and NDI at the 1-month post-operative follow-up, which continued through at least the 6-month follow-up (P < 0.01 for VAS and P < 0.05 for ODI and NDI). The mean disc height significantly decreased, from 6.04 ± 0.85 mm to 5.76 ± 1.02 mm, 3 months after PCN treatment (P = 0.003). However, the degree of disc height decrease did not correlate with the changes of the substantial VAS improvement. CONCLUSIONS: To provide therapeutic benefits for symptomatic contained CHIVD patients after an invalid CT for 6 months, PCN seems to be a better option than CT. The reduced disc heights did not alter the clinical outcomes of PCN.

Repeated vertebral compression fractures in young adult may imply functional adrenal tumor.

BACKGROUND: Patients with adrenal Cushing's syndrome (ACS) typically present with central obesity, hirsutism, hypertension, or glucose intolerance, which can be easily identified by a clinical physician. However, recognizing those with subclinical CS or those with less common symptoms and signs is challenging to the subspecialist, which can lead to delayed diagnosis and treatment. We report a case who presented with repeated vertebral fractures in 6 months. Typical physical appearance of CS was not shown so that suspicions were not raised until severe osteoporosis was demonstrated from bone marrow density study. From our case report, endocrine tests and image survey should always be considered in young patients with repeat vertebral fractures. CASE PRESENTATION: A 48-year-old man presented with severe back pain for 3 months. Second and fifth lumbar spine (L2 and L5) vertebral compression fractures were noted from X-ray and magnetic resonance imaging (MRI), and vertebroplasty was performed by orthopedic surgeons. After 1 month, a newly developed compression fracture of the ninth to twelfth thoracic spine and L4-L5 were noted. Severe osteoporosis was noted from the hip bone mineral density test, and he was referred to an endocrinologist for analysis. Serial endocrine tests confirmed hypercortisolism, and subsequent abdomen MRI showed a left adrenal tumor. ACS was diagnosed. Left laparoscopic adrenalectomy was performed, and the patient received cortisol supplement for 12 months. Thereafter, no new fractures were identified. CONCLUSIONS: ACS should be considered and carefully verified in middle-aged adults who present with severe osteoporosis and repeated vertebral compression fracture.

Quantitative evaluation of correlation between lumbosacral lordosis and pelvic incidence in standing position among asymptomatic Asian adults: a prospective study.

The determination of lumbopelvic alignment is essential for planning adult spinal deformity surgery and for ensuring favorable surgical outcomes. This prospective study investigated the correlation between the lumbar section of lumbar spine lordosis and increasing pelvic incidence in 324 Asian adults with a mean age of 55 ± 13 years (range: 20-80 years), comprising 115 male and 209 female volunteers. Participants were divided into three groups based on pelvic incidence (G1, G2, and G3 had pelvic incidence of < 45°, 45-55°, and ≥ 55°, respectively). We determined that distal and proximal lumbar lordosis contributed differentially to the increase in pelvic incidence, whereas the lordosis ratio of the L3-L4 and L4-L5 segments mostly remained constant. The mean contribution ratio of the segmental lordosis from L1 to S1 was as follows: L1-L2, 2.3%; L2-L3, 11.7%; L3-L4, 18.1%; L4-L5, 25.2%; and L5-S1, 42.7%. Pelvic incidence had a stronger correlation with proximal lumbar lordosis than did distal lumbar lordosis. The ratios of proximal lumbar lordosis to distal lumbar lordosis were 37.8% in G1, 45.8% in G2, and 55.9% in G3. These findings serve as a reference for future lumbar spine correction or fusion surgery for Asian adults.