The Impact of Early Recurrence on Quality of Life after Cytoreduction with HIPEC.

Improved oncological outcomes after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in highly selected patients have been well documented. The extensive nature of the procedure adversely affects quality of life (QoL). The aim of this study is to longitudinally evaluate QoL following CRS/HIPEC. This is a retrospective review of a prospectively maintained database of patients with peritoneal malignancies undergoing CRS/HIPEC. Clinicopathological data, oncologic outcomes, and QoL were analyzed preoperatively and postoperatively at 2 weeks, and 1, 3, 6, and 12 months. The Functional Assessment of Cancer Therapy-Colorectal instrument was used to determine changes in QoL after CRS/HIPEC and the impact of early recurrence (<12 months) on QoL. Thirty-six patients underwent CRS/HIPEC over 36 months. The median peritoneal cancer index score was 18 and the completeness of cytoreduction-0/1 rate was 97.2 per cent. Postoperative major morbidity was 16.7 per cent with one perioperative death. Disease-free survival was 12.6 months in patients with high-grade tumors versus 31.0 months in those with low-grade tumors (P = 0.03). QoL decreased postoperatively and improved to baseline in six months. Patients with early recurrence had a decrease in global QoL compared with preoperative QoL at 6 (P < 0.03) and 12 months (P < 0.05). This correlation was not found in patients who had not recurred. Patients who undergo CRS/HIPEC have a decrease in QoL that plateaus in 3 to 6 months. Early recurrence adversely impacts QoL at 6 and 12 months. This study emphasizes the importance of patient selection for CRS/HIPEC. The expected QoL trajectory in patients at risk for early recurrence must be carefully weighed against the potential oncological benefit of CRS/HIPEC.

Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it.

BACKGROUND: Aggressive screening to diagnose blunt cerebrovascular injury (BCVI) results in early treatment, leading to improved outcomes and reduced stroke rates. While computed tomographic angiography (CTA) has been widely adopted for BCVI screening, evidence of its diagnostic sensitivity is marginal. Previous work from our institution using 32-channel multidetector CTA in 684 patients demonstrated an inadequate sensitivity of 51% (Ann Surg. 2011,253: 444-450). Digital subtraction angiography (DSA) continues to be the reference standard of diagnosis but has significant drawbacks of invasiveness and resource demands. There have been continued advances in CT technology, and this is the first report of an extensive experience with 64-channel multidetector CTA. METHODS: Patients screened for BCVI using CTA and DSA (reference) at a Level 1 trauma center during the 12-month period ending in May 2012 were identified. Results of CTA and DSA, complications, and strokes were retrospectively reviewed and compared. RESULTS: A total of 594 patients met criteria for BCVI screening and underwent both CTA and DSA. One hundred twenty-eight patients (22% of those screened) had 163 injured vessels: 99 (61%) carotid artery injuries and 64 (39%) vertebral artery injuries. Sixty-four-channel CTA demonstrated an overall sensitivity per vessel of 68% and specificity of 92%. The 52 false-negative findings on CTA were composed of 34 carotid artery injuries and 18 vertebral artery injuries; 32 (62%) were Grade I injuries. Overall, positive predictive value was 36.2%, and negative predictive value was 97.5%. Six procedure-related complications (1%) occurred with DSA, including two iatrogenic dissections and one stroke. CONCLUSION: Sixty-four-channel CTA demonstrated a significantly improved sensitivity of 68% versus the 51% previously reported for the 32-channel CTA (p = 0.0075). Sixty-two percent of the false-negative findings occurred with low-grade injuries. Considering complications, cost, and resource demand associated with DSA, this study suggests that 64-channel CTA may replace DSA as the primary screening tool for BCVI. LEVEL OF EVIDENCE: Diagnostic study, level III.

Patched regulation of axon guidance is by specifying neural identity in the Drosophila nerve cord.

Within an axon bundle, one or two are pioneering axons and the rest are follower axons. Pioneering axons are projected first and the follower axons are projected later but follow a pioneering axon(s) pathway. It is not clear whether the pioneering axons have a guidance role for follower axons. In this paper, we have investigated the role of Patched (Ptc) in regulating the guidance of medial tract, one of the longitudinal tracts in the nerve cord. In patched mutants the medial longitudinal tract fails to fasciculate on its own side along the nerve cord, instead it abnormally crosses the midline and fasciculates with the contralateral tract. Interestingly, the medial tracts cross the midline ignoring the axon-repellant Slit on the midline and Roundabout on growth cones. The medial tract is pioneered by neurons pCC and vMP2. Our results show that guidance defects of this tract are due to loss and mis-specification of vMP2, which results in the projection from pCC to either stall or project outward near the location of vMP2. Thus, both pioneering neurons are necessary for the proper guidance of pioneering and follower axons. We also show that the loss of Ptc activity in the neuroectoderm prior to the formation of S1 and S2 neuroblasts causes the majority of axon guidance defects. These results provide insight into how mis-specification and loss of neurons can non-autonomously contribute to defects in axon pathfinding.