Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis.

BACKGROUND: In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES: A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS: A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS: Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Vomiting-induced costal cartilage fracture: a case report.

The use of ultrasonography as a first line imaging test in cases of possible costal cartilage fracture can be pivotal. In this case report, we present the case of a patient with a suspected atraumatic vomiting-induced costal cartilage fracture. The costal cartilage fracture was non-displaced and incomplete, thus not visible in a Computed Tomography scan. When Ultrasound imaging was employed at the area of tenderness, soft tissue edema and hematoma around the cartilage were visualized. High level of suspicion for a cartilage fracture in this case revealed a subtle osseous injury.

A case of incidental infantile gallbladder adenomyomatosis: an unusual US finding of uncertain clinical significance.

Adenomyomatosis of the gallbladder is defined as hypertrophy of the gallbladder mucosal epithelium that invaginates into a thickened muscularis propria, leading to the formation of intramural diverticula. It is typically considered a benign condition most commonly affecting adults and, rarely, children. In this case report, we present a case of gallbladder adenomyomatosis in a 3-month-old infant. The diagnosis was made incidentally on ultrasound examination of the abdomen, in an otherwise asymptomatic child with no laboratory test abnormalities and no underlying disease. The purpose of this case report is to make infantile adenomyomatosis and its implications known to clinicians, as the literature on this topic is limited. To the best of our knowledge, this is the youngest reported case of adenomyomatosis in the pediatric population.

COVID-19 in Ophthalmology. Current Disease Status and Challenges during Clinical Practice.

Purpose: The novel coronavirus disease 2019 (COVID-19) has raised a global public health concern. The purpose of this review is to summarize the evidence currently available on COVID-19 for its ocular implications and manifestations from both pathogenetic and clinical standpoints. Methods: For this narrative review, more than 100 relevant scientific articles were considered from various databases (PubMed, Google Scholar, and Science Direct) using keywords such as coronavirus outbreak, COVID-19, ophthalmology, ocular symptoms. Results:Daily healthcare both from patient and physician perspective, as well as on some guidelines regarding prevention and management have dramatically changed over the last few months. Although COVID-19 infection mainly affects the respiratory system as well as the gastrointestinal, cardiovascular, and urinary systems, it may cause a wide spectrum of ocular manifestations. Various challenges have to be faced to minimize exposure for both patients and physicians. Conclusion:The risk of COVID-19 infection should be considered and medical care should be prioritized for urgent cases. Appropriate management for patients with chronic cases that may result in adverse outcomes should not be neglected, while patients that can be monitored remotely should be identified.

Maximizing patient benefit through a reversed pathway from specialist to generalist: the case of chronic pain.

Polymyalgia Rheumatica (PMR) is a syndrome characterized by chronic pain and/or stiffness in the neck, shoulders or upper arms and hips. It affects adult patients usually over 50 years old and is treated with low-dose oral corticosteroids. In this case, a 68-year-old female with a history of PMR, diagnosed by a specialist sporadically seen in the past, presented to a primary care physician due to herpes zoster (HZ) infection. Thorough history taking, along with a careful review of previous laboratory results, raised serious doubts concerning her diagnosis (PMR). Because the patient described diffuse pain throughout her body, sleep disturbances and a depressed emotional state, fibromyalgia was suspected instead and appropriate treatment was given. The patient remained free of symptoms and corticosteroids for almost a year. Information from this case may help to point out that PMR is a disorder that can be easily confused with other chronic pain conditions with similar manifestations, especially when the initial diagnosis is sped up in terms of consultation depth and care continuity. Under certain circumstances, primary care can lead to improved clinical outcomes.

Satisfaction and Perceived Barriers of General Practice Residents in Relation to Their Educational Needs Coverage During Residency in Greece.

Objectives: This study aimed to assess satisfaction and report on perceptions of General Practice (GP) residents during residency in Greece, through an online questionnaire at a national level. Material and methods:A mixed type method study was shaped. Both quantitative analysis and a quasiqualitative approach were used, while information from an open-ended question was processed. The study included answers of GP residents recruited with a national sample pool technique. Results:There were 177 responders from 430 registered residents. Using a grading system from 1 to 10, the median value showing how much satisfied the participants were during their training was 4.48 (95% CI 4.16-4.79), while GP logbook was regarded as useful (median value 6.29, 95% CI 5.84-6.73). The training program was reported as insufficient to prepare residents for their future work as primary health care physicians, with a median rating of 4.09 (95% CI 3.78-4.41). The overall educational gain was regarded as poor compared to residents' expectations, with a median rating of 4.71 (95% CI 4.38-5.07). From free text responses of 83 participants, an organized educational program based on logbook skill acquirement with interaction between coordinator and resident emerged as a priority. Conclusion: Understanding general practitioners' perceptions, satisfaction level and expectations may help to design reform initiatives and cover their educational needs during residency in a holistic manner. Experience from local settings may be useful to offer more comprehensive messages. In a rapidly changing health environment, quickly collecting and analyzing emerging data appears to be a practical way for correcting decisions and avoiding previous errors.

Circulating miRNAs as a marker of metastatic disease and prognostic factor in metastatic breast cancer.

BACKGROUND: Circulating miRNAs (miRs) are increasingly recognized as potential biomarkers in cancer. We aimed to evaluate the differential expression of miR-23b and miR-190 which are involved in tumor dormancy, miR-21 involved in metastasis and miR-200b and miR-200c involved in epithelial-mesenchymal transition (EMT) and metastasis, in the plasma of patients with early and metastatic breast cancer (MBC). We also aimed to identify associations of the expression levels with patient and disease characteristics and outcomes in metastatic patients treated with first-line chemotherapy. RESULTS: miR-21 (p < 0.001), miR-23b (p = 0.033), miR-200b (p < 0.001) and miR-200c (p < 0.001) expression was higher in metastatic compared to early breast cancer. ROC curve analysis showed that miR-21 (AUC = 0.722; p < 0.001) and miR-200b (AUC = 0.720; p < 0.001) distinguished with high accuracy among the two disease states, whereas the combination of miR-21, miR-190, miR-200b and miR-200c, further improved accuracy (AUC = 0.797; p < 0.001). High miR-200b expression independently predicted for shorter OS (p = 0.026) in MBC. High expression of both miR23b and miR-190 emerged as a strong independent factor associated with shorter PFS (p = 0.001) in de novo metastatic patients and high miR-200b independently predicted for decreased OS in the HER2-negative subgroup (p = 0.007). MATERIALS AND METHODS: Blood samples were obtained from patients with early (n = 133) and MBC (n = 110) before adjuvant or first-line chemotherapy, respectively. Plasma miRNA expression levels were assessed by RT-qPCR and were classified as high or low according to the median values. CONCLUSIONS: Our results are in support of the concept that circulating miRNAs represent a tool with significant diagnostic and prognostic implications in breast cancer.