Insomnia in male veterans with and without military sexual trauma receiving care within a VA medical center.

STUDY OBJECTIVES: This study evaluated the prevalence and correlates of insomnia in male Veterans with MST who currently receive care within a VAMC. METHODS: We evaluated cross-sectional data from a VAMC (N=138) using the following instruments: ISI, PCL-5, QIDS-SR, AUDIT-C, and a nightmare question for insomnia, PTSD, depression, and drinking, respectively. Bivariate and multivariable analyses assessed the relationship between ISI and other clinical variables. RESULTS: About 31.9% screened positive for MST. When compared to those without MST (MST-), those with MST (MST+) had a higher prevalence of insomnia (95.5% vs 81.9%), higher ISI (20±5.1 vs. 16.7±7.2, p=0.003) and PCL-5 (48.5±14.4 vs. 38.2±19.8, p=0.0008) total scores. In the multivariable models, the ISI total score was associated with the PCL-5 total score (p=0.015) in MST+ individuals and with QIDS-SR (p<0.001) in MST- individuals. CONCLUSIONS: Most Veterans with MST within the VHA had insomnia, which was associated with their underlying psychiatric comorbidity.

Neurotropic melanoma arising from a neurocristic hamartoma.

Neurotropic melanoma is a rare type of malignant melanoma with nerve invasion or neural differentiation. Neurocristic cutaneous hamartoma is a rare, benign tumor of the skin and superficial soft tissue that arises from aberrant migration of neural crest cells. We report a rare case of a 74-year-old man with a clinically diagnosed giant congenital nevus of the right mid-back, histopathologically confirmed to be a neurocristic cutaneous hamartoma, who developed neurotropic spindle cell melanoma within the lesion. The patient was treated with serial re-excisions until clear margins were achieved.

Military sexual trauma: Exploring the moderating role of restrictive emotionality among male veterans.

Objective: Military Sexual Trauma (MST) has been found to be positively associated with mental health outcomes, such as posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, symptoms of anxiety, and insomnia severity (Jenkins et al., 2015; O'Brien & Sher, 2013). Male survivors of MST face unique challenges, including concerns associated with hypermasculinity (e.g., restrictive emotionality [RE]). Men with high RE (difficulty expressing emotions) report more negative mental health outcomes compared to men with low RE (Good et al., 1995). The present study investigated whether RE moderated the relationship between MST and negative mental health outcomes, while controlling for combat exposure (CE) and age to further assess confounding variables. Method: One hundred thirty-four adult male veterans in behavioral health treatment at a large VA medical center in the mid-Atlantic region of the United States were recruited. Participants provided self-reported data on MST and symptoms of PTSD, depression, anxiety, and insomnia, as well as their endorsement of restrictive emotionality. PROCESS v3.3 (Hayes, 2017) regression analytic method was used to test main and interaction effects. Results: MST was a significant predictor of PTSD symptoms and insomnia severity-but not depressive symptoms or symptoms of anxiety. RE also moderated the relationship between MST and PTSD symptoms, depressive symptoms, and insomnia, after controlling for CE and age. Conclusion: These findings suggest that restricting emotions has a negative influence on men's mental health functioning. Therefore, assessing male veterans' experiences of expressing their emotions within the context of masculinity and their military training will likely have implications on trauma processing and treatment outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A multimodal approach improves American Board of Surgery In-Training Examination scores.

BACKGROUND: There are several factors that influence ABSITE scores, but the optimal approach for remediation of poor scores is unclear. METHODS: A structured academic curriculum and focused remediation program (FRP) were implemented to improve academic performances. Within a 15-year period, ABSITE and American Board of Surgery qualifying exam (ABS QE) results were compared before and after the establishment of the program using a paired T-test. Subgroup analysis was performed for residents who completed the FRP. RESULTS: After establishing the FRP, the mean scores increased from 49.3% to 60% (p = 0.001). The proportion of first-time pass rates for the ABS QE increased from 89.5% to 100% (p = 0.18). With the subgroup analysis of FRP residents, the average improvement on the next ABSITE exam score was 51 percentile points (p = 0.003), raw score increased by 80 (p = 0.01) and percent correct increased by 7 percentage points (p = 0.006). CONCLUSIONS: A structured academic curriculum and FRP improves ABSITE scores. Additional strategies utilizing the self-regulated learning method can further assist trainees who remain struggling learners. Further study is required to determine direct correlation to the ABS QE.

The benefit of intraperitoneal chemotherapy for the treatment of colorectal carcinomatosis.

The clinical practice of hyperthermic intraperitoneal chemoperfusion (HIPEC) for carcinomatosis has lacked preclinical justification. A standardized mouse model was created to evaluate the independent effects of intraperitoneal chemotherapy. Diffuse colorectal carcinomatosis was generated in mice prior to intraperitoneal lavage with mitomycin C (MMC) at clinically comparable dosing for variable lengths of time. Tumor volumes, MMC tissue concentrations and survival were measured in comparison to saline lavage and intravenous MMC. Magnetic resonance imaging revealed a direct correlation between tumor volume, MMC dose and exposure time and survival. Intravenous MMC demonstrated a rapid clearance from the blood, lower peritoneal tissue concentrations, less tumor growth inhibition and decreased survival compared to intraperitoneal administration. Intraperitoneal chemotherapy inhibited tumor growth independent of cytoreduction or hyperthermia, demonstrated improved peritoneal tissue concentration and was associated with increased survival. These data support the clinical utility of the intraperitoneal chemotherapy component of HIPEC.

Increased expression levels of WAVE3 are associated with the progression and metastasis of triple negative breast cancer.

BACKGROUND: Breast Cancer (BC) is a heterogeneous disease comprised of at least five genetically distinct subtypes, which together form the second leading cause of cancer death in women in the United States. Within BC subtypes, those classified as Triple Negative BCs (TNBCs) exhibit dismal survival rates due to their propensity to develop distant metastases. We have identified the WAVE3 protein, which is a critical regulator of actin cytoskeleton dynamics that are required for the motility and invasion of cancer cells through its activation of the Arp2/3 complex, as a key regulator of the different steps of the invasion-metastasis cascade in BC, especially in the more aggressive TNBCs. Our published studies have also shown that elevated expression levels of WAVE3 in the TNBC cell lines directly contribute to their increased invasion and metastasis potentials both in vitro and in vivo in murine models of BC metastasis. METHODOLOGY/PRINCIPAL FINDINGS: Herein, we utilized both immunohistochemistry (IHC) of primary human BC tumors as well as quantitative real-time RT-PCR of WAVE3 in the peripheral blood of BC patients to clearly establish that WAVE3 is a predictive marker of overall BC patients' survival. High levels of WAVE3 were predictive for reduced distant recurrence-free survival as well as for decreased disease-specific mortality. Our analysis of WAVE3 expression levels in the peripheral blood of BC patients showed that WAVE3 is highly expressed in the blood of patients who developed metastatic breast cancer compared to those who did not. WAVE3 expression was also highly upregulated in the blood of BC patients with the more aggressive TNBC subtype. CONCLUSIONS: Together, these findings establish WAVE3 as a novel marker for increased risk of breast-cancer-specific mortality and for the metastatic potential of the TNBCs, and also identify WAVE3 as an attractive therapeutic target for the treatment of metastatic BC.

Foregut duplication cysts: a report of two cases with emphasis on embryogenesis.

Duplication cyst of the stomach with a pseudostratified columnar ciliated epithelium is extremely rare. We describe two cases of these cysts, with emphasis on their immunophenotype and embryogenesis. The first patient was a 29-year-old man who presented with cramping abdominal pain in his left lower quadrant. The second patient was a 26-year-old woman who had a history, over several years, of chronic epigastric abdominal pain radiating to her back. Both lesions were surgically removed. They showed the same histomorphology. The cysts were lined by a pseudostratified respiratory epithelium with ciliated cells. The first cyst was connected to the stomach, while the second cyst was not connected. Both cysts expressed thyroid transcription factor-1 (TTF-1) and surfactant. In this report, we explore the possible embryogenesis of these lesions in the light of TTF-1 and surfactant expression.

Small catheter tube thoracostomy: effective in managing chest trauma in stable patients.

BACKGROUND: Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. METHODS: Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. RESULTS: There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. CONCLUSION: SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation.

BACKGROUND: Despite our regular use of CT for suspected appendicitis, a recent study at our institution demonstrated a negative appendectomy (NA) rate similar to our rate 15 years earlier. Based on analysis of this data, a diagnostic pathway was implemented prospectively for adult patients with possible appendicitis. STUDY DESIGN: Rates of CT, NA, and perforation for nonpregnant patients over 14 years of age undergoing appendectomy between August 2001 and August 2002 (PRE) were compared with prospectively collected pathway data (PATH, August 2004 to August 2005). All PATH patients were evaluated by a surgeon before CT. All females underwent CT. CT was obtained in male patients with low suspicion or pain for longer than 48 hours. After negative CT, patients were discharged from the emergency department or admitted for observation. RESULTS: There was a substantial decrease in NA rate after implementation of the pathway (4% PATH [8 of 183] versus 16% PRE [31 of 196], p < 0.001), without a change in the rate of perforation (11% PATH [20 of 175] versus 8% PRE [13 of 165], p = 0.28) or frequency of preoperative CT (59% PATH [108 of 183] versus 60% PRE [118 of 196], p = 0.84). CONCLUSIONS: Frequent appendiceal CT alone does not ensure surgical diagnostic accuracy. CT need not be used in all patients to achieve very low NA rates. An evidence-based diagnostic algorithm incorporating early surgical evaluation, objective criteria for preoperative CT, deterrence of early operation after negative CT, and use of CT to facilitate safe discharge led to substantial improvements in the care of our adult population presenting with possible appendicitis.

Hepatic intra-arterial infusion of yttrium-90 microspheres in the treatment of recurrent hepatocellular carcinoma after liver transplantation: a case report.

Hepatocellular carcinoma (HCC) recurs with a reported frequency of 12%-18% after liver transplantation. Recurrence is associated with a mortality rate exceeding 75%. Approximately one-third of recurrences develop in the transplanted liver and are therefore amenable to local therapy. A variety of treatment modalities have been reported including resection, transarterial chemo-embolization (TACE), radiofrequency ablation (RFA), ethanol ablation, cryoablation, and external beam irradiation. Goals of treatment are tumor control and the minimization of toxic effect to functional parenchyma. Efficacy of treatment is mitigated by the need for ongoing immunosuppression. Yttrium-90 microspheres have been used as a treatment modality both for primary HCC and for pre-transplant management of HCC with promising results. Twenty-two months after liver transplantation for hepatitis C cirrhosis complicated by HCC, a 42-year old man developed recurrence of HCC in his transplant allograft. Treatment of multiple right lobe lesions with anatomic resection and adjuvant chemotherapy was unsuccessful. Multifocal recurrence in the remaining liver allograft was treated with hepatic intra-arterial infusion of yttrium-90 microspheres (SIR-Spheres, Sirtex Medical Inc., Lake Forest, IL, USA). Efficacy was demonstrated by tumor necrosis on imaging and a decrease in alpha-fetoprotein (AFP) level. There were no adverse consequences of initial treatment.

Abdominal computed tomography for postoperative abscess: is it useful during the first week?

While classic teaching dictates computed tomography (CT) for postoperative abdominal or pelvic abscess in the first week is of low yield, little evidence supports intentional delays in imaging for suspected abscess. This retrospective review examined all CT scans obtained for clinical suspicion of abscess between 3 and 30 days after abdominal or pelvic operation over a 3-year period. Scans were grouped into those obtained between 3 and 7 days after surgery (EARLY) and those obtained after day 7 (LATE). Diagnostic yield was compared between EARLY and LATE groups. Of 262 CT examinations (EARLY, n = 106; LATE, n = 156), 71 studies (27%) demonstrated abscess. There was no significant difference in the diagnostic yield of CT for abscess between EARLY and LATE groups (23% [24 of 106] versus 30% [47 of 156], P = 0.18). Of patients with an abscess, 63% (45 of 71) underwent percutaneous or operative drainage (EARLY 75% [18 of 24], LATE 57% [27 of 47], P = 0.15). Abdominal CT for postoperative abscess can be expected to be diagnostic in a substantial proportion of cases in the first week, the majority of which lead to percutaneous or operative drainage. Postoperative CT for intra-abdominal abscess should be obtained as clinically indicated, regardless of interval from surgery.

Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale.

BACKGROUND: Retrievable vena cava filters (RFs) offer the appeal of short-term prophylaxis for trauma patients temporarily at risk for pulmonary embolism (PE) without the long-term risks of permanent vena cava filters (PFs). However, the evidence that RFs and PFs reduce the risks of PE and death in trauma patients is not conclusive. RFs were introduced at our trauma center in August 2002. The purpose of this study was to evaluate the effects of RFs on our strategy to prevent PE in trauma patients. METHODS: We reviewed our trauma registry to compare rates of filter placement, filter-related complications (FRCs), and PE before (Group I: January 2000 to August 15, 2002) and after (Group II: August 16, 2002 through December 2004) RF introduction. Indication for filter placement, filter retrieval, FRCs, and incidence of PE were compared. RESULTS: There were 5,042 patients in Group I and 5,038 patients in Group II. There was a threefold increase in filter placement in Group II compared with Group I (55 [1.1%] versus 161 [3.2%]; p < 0.001). There were no significant differences between the rates of PE (0.2% versus 0.2%, p = 0.636) or major FRCs (1.8% versus 2.5%, p = 0.777). Major FRCs included two filter infections with sepsis, one vena cava thrombotic occlusion, one filter lodged in the jugular vein during retrieval, and one PE after filter placement. RF removal was attempted in 43 (27%) patients and successful in 33 (21%). CONCLUSION: The advent of RFs was associated with a threefold increase in vena cava filter placement in our trauma center. Major FRCs were encountered and a very low incidence of PE was not altered by their use. Successful removal could be verified in only 21% of RFs. The results of this study lead us to question the rationale for a more liberal use of vena cava filters in trauma patients.

The influence of age and gender on the utility of computed tomography to diagnose acute appendicitis.

Few studies have examined the effects of age and gender on the utility of diagnostic computed tomography (CT) for appendicitis. We retrospectively studied all adult patients undergoing appendectomy from January 2000 through December 2002 (633 patients). Patients 15-30 years old ("younger") were compared to patients >30 ("older") and further subdivided by gender. CT accuracy and the influence of CT on negative appendectomy (NA) rates for each group were evaluated. CT was associated with a lower NA rate in older patients (23% vs 8%, P = 0.004) but had no effect on NA rate in younger patients (26% vs 20%, P = 0.2). Appendiceal CT had greater sensitivity, negative predictive value, and accuracy in older than in younger patients. When subdivided by gender, CT was associated with lower NA rates for all female patients but had no effect in either age group of men. Although CT may be more accurate in patients older than 30 years, it has the greatest benefit in female patients, where it is associated with lower NA rates in all adult patients. CT should be strongly considered for all female patients before operation for suspected appendicitis. Further study is needed to determine which, if any, male patients benefit from preoperative CT.