Applicative Limitations of Indocyanine Green Fluorescence Assistance to Laparoscopic Lymph Node Dissection in Total Gastrectomy for Cancer.

BACKGROUND: Indocyanine green (ICG) fluorescence has been recently introduced as a novel imaging technique improving the accuracy of lymph node (LN) dissection in gastric cancer (GC) surgery, although procedure standardization and achievements have not been clearly defined. This study analyzed the feasibility and effectiveness of ICG-guidance for laparoscopic D2-lymphadenectomy during total gastrectomy for cancer. METHODS: This study retrospectively analyzed a single-center series of patients who underwent laparoscopic total gastrectomy for cancer between April 2015 and August 2021. All patients underwent surgery with standard D2 LN dissection. Intraoperative ICG-fluorescence was institutionally implemented in April 2018 and was performed routinely afterward. Primary outcomes were LN harvest and ratio. Secondary endpoints included operative time and subgroup analysis to assess variables potentially affecting LN retrieval. RESULTS: The study population included 102 patients, and ICG-fluorescence was applied in 38 (37.3%). ICG and no-ICG groups presented similar median age, gender proportions, ASA score and comorbidities (age-adjusted Charlson Comorbidity Index), body mass index, and advanced pathological stage. The median of LNs retrieved was significantly higher after the intraoperative ICG-guidance (44 vs. 32; p = 0.004), although this association was not significant after neoadjuvant therapy or among patients with positive LNs. Lymph node ratio and operative time were not significantly impacted by ICG fluorescence. Multivariate analysis identified the ICG-assistance as the only independent determinant for LN harvest (p = 0.029). CONCLUSIONS: ICG-guidance contributes to a significantly wider LN retrieval after laparoscopic D2-lymphadenectomy during total gastrectomy for cancer. However, neoadjuvant therapy and positive LN stage appeared to limit the procedural effectiveness to ICG-assisted LN identification.

How a modified Nissen procedure works: a mechanistic study using intraoperative esophageal high-resolution manometry.

OBJECTIVE: We aimed at demonstrating how a modified Nissen procedure works by analyzing intraoperatively the variations of the low esophageal sphincter pressure values using high resolution manometry. METHODS: This study included 15 patients with documented gastroesophageal reflux disease who underwent a laparoscopic modified Nissen procedure. Data regarding the changes in the pressure values were recorded at each step of the procedures using high resolution manometry and after the progressive insufflation of air in the stomach. Categorical data were compared between the preoperative and postoperative periods using Fisher's test, and continuous data were compared using Mann-Whitney U non-parametric test. Preoperative versus postoperative variations in continuous data were assessed using Wilcoxon's non-parametric test for paired data. RESULTS: Intraoperative manometric data showed a rise of basal LES pressure until the creation of the wrap. An evident increase of pressure values was recorded after gastric air insufflation, as consequence of the increase of intragastric pressure. No intraoperative and postoperative complications were observed. All patients experienced a significant reduction in terms of intensity and frequency of gastroesophageal reflux symptoms and no patients complained of dysphagia. CONCLUSIONS: Intraoperative high resolution manometry was feasible in all patients and demonstrated that the modified Nissen procedure works by increasing the LES pressure in response to gastric distension, without impeding the progression of the bolus into the stomach.

Surgical Technique and Implementation of Total Minimally Invasive (Laparo-Thoracoscopic) Ivor Lewis Esophagectomy for Cancer.

BACKGROUND/OBJECTIVES: Esophagectomy represents a major oncological operation due to the surgical involvement of both the abdominal and thoracic cavities. The minimally invasive technique has been developed to minimize the operative impact on patients undergoing esophageal resections, often presenting with nutritional deterioration and poor functional reserves. METHODS: The present article provides an illustrative description of the total minimally invasive (laparo-thoracoscopic) Ivor Lewis esophagectomy for cancer integrated with complementary components of perioperative clinical management. This standardized surgical technique of two-field esophagectomy (i.e., laparoscopy and thoracoscopy) was depicted based on the experience of a tertiary center for esophageal cancer care with more than 1500 cases operated on, and in accordance with the SUPER reporting guidelines. RESULTS AND CONCLUSIONS: The accomplishment of the following descriptive and illustrative content allowed the development of remarks on the strengths and possible flaws of this specific procedure, providing a measurable opportunity to absorb technical details of the most widespread surgical resection for esophageal cancer worldwide.

Endoscopic Management of Post-Esophagectomy Delayed Gastric Conduit Emptying (DGCE): Results from a Cohort Study in a Tertiary Referral Center with Comparison between Procedures.

Background/Objectives: Delayed gastric conduit emptying (DGCE) occurs in 15-39% of patients who undergo esophagectomy. Intra-Pyloric Injection of Botulinum Toxin (IPBT), Pneumatic Balloon Dilation (PBD), and the same session combination (BTPD) represent the main endoscopic procedures, but comparative data are currently unavailable. Methods: We retrospectively analyzed prospectively collected data on all consecutive patients with DGCE treated endoscopically with IPBT, PBD, or BTPD. ISDE Diagnostic Criteria were used for DGCE diagnosis and classification. A Gastric Outlet Obstruction Score was used for clinical staging. All patients undergoing IPBT received 100 UI of toxin, while those undergoing PBD were dilated up to 20 mm. Clinical success (CS) was defined as the resolution of symptoms/resumption of feeding at discharge or expanding dietary intake at any rate. Recurrence was defined as symptom relapse after more than 15 days of well-being requiring endoscopic/surgical intervention. Results: A total of 64 patients (81.2% male, 90.6% Ivor-Lewis esophagectomy, 77.4% adenocarcinoma) with a median age of 62 years (IQR 55-70) were enrolled: 18 (28.1%) in the IPBT group, 24 (37.5%) in the PBD group, and 22 (34.4%) in the BTPD group. No statistically significant differences were found in the baseline characteristics, surgical techniques, and median follow-up among the three groups. BTPD showed a higher CS rate (100%) compared to the PD and BTPD groups (p = 0.02), and a Kaplan-Meier analysis with a log-rank test revealed that the BTPD group was associated both with a significatively shorter mean time to refeed of 1.16 days (95% CI 0.8-1.5; p = 0.001) and a shorter median time to discharge of one day (95% CI 1-3; p = 0.0001). Conclusions: Endoscopic management of DGCE remains challenging. Waiting for further strong evidence, BTPD can offer patients a higher clinical efficacy rate and a shorter time to refeed and be discharged.

Corrigendum: The effects of an acceptance and commitment-informed interdisciplinary rehabilitation program for chronic airway diseases on health status and psychological symptoms.

[This corrects the article DOI: 10.3389/fpsyg.2021.818659.].

COVID-19 vaccine effectiveness against hospitalizations in Paraguay, May 2021-April 2022: A test-negative design.

BACKGROUND: Vaccine effectiveness (VE) estimates vary by population characteristics and circulating variants. North America and Europe have generated many COVID-19 VE estimates but relied heavily on mRNA vaccines. Fewer estimates are available for non-mRNA vaccines and from Latin America. We aimed to estimate the effectiveness of several COVID-19 vaccines in preventing SARS-CoV-2-associated severe acute respiratory infection (SARI) in Paraguay from May 2021 to April 2022. METHODS: Using sentinel surveillance data from four hospitals in Paraguay, we conducted a test-negative case-control study to estimate COVID-19 vaccine effectiveness against SARI by vaccine type/brand and period of SARS-CoV-2 variant predominance (Gamma, Delta, Omicron). We used multivariable logistic regression adjusting for month of symptom onset, age group, and presence of ≥1 comorbidity to estimate the odds of COVID-19 vaccination in SARS-CoV-2 test-positive SARI case-patients compared to SARS-CoV-2 test-negative SARI control-patients. RESULTS: Of 4,229 SARI patients, 2,381 (56%) were SARS-CoV-2-positive case-patients and 1,848 (44%) were SARS-CoV-2-negative control-patients. A greater proportion of case-patients (73%; 95% CI: 71-75) than of control-patients (40%; 95% CI: 38-42) were unvaccinated. During the Gamma variant-predominant period, VE estimates for partial vaccination with mRNA vaccines and Oxford/AstraZeneca Vaxzevria were 90.4% (95% CI: 66.4-97.6) and 52.2% (95% CI: 25.0-69.0), respectively. During the Delta variant-predominant period, VE estimates for complete vaccination with mRNA vaccines, Oxford/AstraZeneca Vaxzevria, or Gamaleya Sputnik V were 90.4% (95% CI: 74.3-97.3), 83.2% (95% CI: 67.8-91.9), and 82.9% (95% CI: 53.0-95.2), respectively. The effectiveness of all vaccines declined substantially during the Omicron variant-predominant period. CONCLUSIONS: This study contributes to our understanding of COVID-19 VE in Latin America and to global understanding of vaccines that have not been widely used in North America and Europe. VE estimates from Paraguay can parameterize models to estimate the impact of the national COVID-19 vaccination campaign in Paraguay and similar settings.

Sarcopenia and Patient's Body Composition: New Morphometric Tools to Predict Clinical Outcome After Ivor Lewis Esophagectomy: a Multicenter Study.

BACKGROUND: The impact of preoperative body composition as independent predictor of prognosis for esophageal cancer patients after esophagectomy is still unclear. The aim of the study was to explore such a relationship. METHODS: This is a multicenter retrospective study from a prospectively maintained database. We enrolled consecutive patients who underwent Ivor-Lewis esophagectomy in four Italian high-volume centers from May 2014. Body composition parameters including total abdominal muscle area (TAMA), visceral fat area (VFA), and subcutaneous fat area (SFA) were determined based on CT images. Perioperative variables were systematically collected. RESULTS: After exclusions, 223 patients were enrolled and 24.2% had anastomotic leak (AL). Sixty-eight percent of patients were sarcopenic and were found to be more vulnerable in terms of postoperative 90-day mortality (p = 0.028). VFA/TAMA and VFA/SFA ratios demonstrated a linear correlation with the Clavien-Dindo classification (R = 0.311 and 0.239, respectively); patients with anastomotic leak (AL) had significantly higher VFA/TAMA (3.56 ± 1.86 vs. 2.75 ± 1.83, p = 0.003) and VFA/SFA (1.18 ± 0.68 vs. 0.87 ± 0.54, p = 0.002) ratios. No significant correlation was found between preoperative BMI and subsequent AL development (p = 0.159). Charlson comorbidity index correlated significantly with AL (p = 0.008): these patients had a significantly higher index (≥ 5). CONCLUSION: Analytical morphometric assessment represents a useful non-invasive tool for preoperative risk stratification. The concurrent association of sarcopenia and visceral obesity seems to be the best predictor of AL, far better than simple BMI evaluation, and potentially modifiable if targeted with prehabilitation programs.

Psychiatric emergencies in migrant adolescents.

BACKGROUND: Stress factors associated with migration may expose minor immigrants to mental health problems. The aim of the study was to describe acute psychiatric problems, in terms of reasons for hospitalization and diagnosis at discharge, in a sample of Italian and Migrant adolescents (both first and second generation). METHODS: We collected data on socio-demographic and clinical-diagnostic characteristics of 423 Italian and Migrant adolescents (mean age: 15 years ± 1.44; range 12-17.91), hospitalized at the Child and Adolescent Neuropsychiatry Unit of the Spedali Civili of Brescia between 2014 and 2019, period prior to the coronavirus disease 19 (COVID-19) pandemic. RESULTS: A reduction in the percentage of hospitalized Italian subjects and an increase of Migrant ones was found among years (p<0.001). Suicidal attempts and psychomotor agitation were the main reasons for hospitalization in both Italian and Migrant groups; in addition, the former presented a higher number of accesses for eating disorders, while the latter for psychotic disorders. Comparing the two groups at discharge, a higher frequency of anxiety disorders (p<0.001), eating disorders (p<0.001), somatic and conversion disorders (p=0.013), and obsessive-compulsive disorder (p=0.022) was detected in the Italian sample; conversely, there was a higher frequency of suicidal attempt (p=0.025), personality disorders (p<0.001), disruptive behavior, impulse control and conduct disorders (p=0.014), and post-traumatic stress disorder (p=0.019) in the Migrant group. CONCLUSIONS: These observations, carried out during a pre-COVID-19 period, provide a starting point for understanding the psychopathology of Migrant adolescents and underline the importance of early diagnosis to guide appropriate interventions.

The Effects of an Acceptance and Commitment-Informed Interdisciplinary Rehabilitation Program for Chronic Airway Diseases on Health Status and Psychological Symptoms.

BACKGROUND: Chronic airway diseases are prevalent and costly conditions. Interdisciplinary rehabilitation programs that include Acceptance and Commitment-based (ACT) components could be important to tackle the vicious circle linking progression of the disease, inactivity, and psychopathological symptoms. METHODS: A retrospective evaluation of routinely collected data of an interdisciplinary rehabilitation program was performed. The program included group sessions including patient education, breathing exercise, occupational therapy and an ACT-based psychological treatment, and individual sessions of physical therapy. Demographic data, clinical characteristics of the patients and the values of outcome variables (health status, quality of life, anxiety, and depression) before treatment, at discharge, at 3 months, and at 6 months were extracted from medical records. Multiple imputation was employed to address missing data. Linear mixed models were employed to assess changes over time. Multivariable logistic regression was performed to assess predictors of a minimum clinically important change of health status from baseline to the 6-months follow-up. RESULTS: Data from 31 patients with chronic obstructive pulmonary disease (COPD) and 12 patients with bronchiectasis were extracted. Health status improved from baseline to discharge to the 3 months follow-up, but not to the 6 months follow-up. Anxiety and depression improved across all the time points. Quality of life did not improve over time. Having a worse health status at baseline and fewer depressive symptoms were significantly associated with achieving a minimum clinically important change of health status at 6 months. The effects of the interdisciplinary program were not different for patients with COPD or with bronchiectasis. DISCUSSION: Interdisciplinary programs including ACT-based components are promising treatments for the rehabilitation of patients with chronic airway diseases.

Two novel ALDH7A1 (antiquitin) splicing mutations associated with pyridoxine-dependent seizures.

Pyridoxine-dependent seizures (PDS) is a rare autosomal recessive disorder causing intractable seizures in neonates and infants. Patients are typically resistant to conventional anticonvulsants but respond well to the administration of pyridoxine. We report two unrelated patients affected with PDS as a result of alpha-aminoadipic semialdehyde (alpha-AASA) dehydrogenase deficiency caused by pathogenic ALDH7A1/antiquitin mutations. Two of the three reported mutations are novel and result in erroneous splicing, as showed by messenger RNA (mRNA) studies. So far, the vast majority of the patients clinically diagnosed as PDS show alpha-AASA dehydrogenase deficiency, caused by mutations in the ALDH7A1 gene. However, despite the availability of reliable biomarkers, early consideration of a pyridoxine trial is still the most important issue in a child with therapy-resistant seizures.

SLC19A3 related disorder: Treatment implication and clinical outcome of 2 new patients.

Encephalopathies with neostriatal involvement constitute a heterogeneous group of acquired and genetically inherited conditions that include Bilateral Striatal Necrosis (BSN) and other Striatal Lesions (SL) (Tonduti et al). We describe two new patients suffering from BSN due to biallelic SLC19A3 mutations. In the first patient vitamin supplementation was started early on, resulting in the remission of the clinical picture, and an almost complete normalization of the neuroradiological findings. In the second one treatment was started late, compliance was irregular and the resulting clinical outcome was poor. The clinical outcome of our two patients confirms and further stresses the importance of the early administration of vitamin supplementation in all patients presenting with neostriatal lesions, or clear bilateral striatal necrosis. Patient 2 didn't present any additional episode of acute decompensation after the age of 20 years despite having completely stopped treatment. This suggests the existence of an age dependency of thiamin requirement in humans.

COVID-19 y coberturas de vacunación del calendario regular del Paraguay, efecto de la pandemia

RESUMEN Introducción: La pandemia de COVID-19 produjo una crisis sanitaria afectando las coberturas de vacunación de los países. Objetivo : Describir la cobertura de vacunación de los biológicos trazadores durante el periodo prepandémico (2015- 2019) y pandémico (2020-2021) en Paraguay. Materiales y Métodos: Estudio descriptivo observacional de corte transverso, que comprendió a niños de 0 a 5 años de edad, de las 18 Regiones Sanitarias del País. Se analizaron las coberturas de vacunación del Programa Ampliado de Inmunización, periodo prepandémico (2015-2019) y pandémico (2020-201). Se incluyeron los biológicos trazadores: BCG, DPT1, DPT3, IPV1 y bOPV3, SPR1, SPR2 y vacuna antiamarílica (AA), el cálculo de cobertura de vacunación a nivel país se realizó por medio del análisis del reporte electrónico semanal de dosis de vacunas administradas por Región Sanitaria. Se estableció la comparación de las coberturas de vacunación por biológico trazador, por periodos y rango de edad. Resultados: Durante la pandemia se constató un descenso de cobertura de vacunación de los biológicos trazadores, para BCG: 4 % (2020), 15% (2021);DPT1: 5 % (2020), 13 % (2021); DPT3: 9 % (2020), 22 %(2021); IPV1: 5 % (2020),16 % (2021); bOPV3: 7% (2020),19 % (2021); SPR1: 9 %, SPR2: 13 % (2020),SPR1:17%, SPR2:16 % (2021) y AA: 7% (2020), 15% (2021). Conclusión: Durante la pandemia de Covid-19 disminuyeron las coberturas de vacunación de todos los biológicos trazadores, similar descenso se constató en otros países de América, existe el riesgo de aparición de brotes de enfermedades prevenibles por vacunación por el acúmulo de susceptibles.

ABSTRACT Introduction: The COVID-19 pandemic produced a health crisis affecting countries' vaccination coverage statistics. Objective: To describe the coverage of recommended vaccines during the pre-pandemic (2015-2019) and pandemic (2020-2021) periods in Paraguay. Materials and Methods: This was a descriptive, observational cross-sectional study, comprising children from 0 to 5 years of age, from the Country's 18 Health Regions. The vaccination coverage of the National Expanded Immunization Program, pre-pandemic (2015-2019) and pandemic (2020-201) periods were analyzed. The recommended vaccinations included were: BCG, DTP1, DTP3, IPV1 and bOPV3, MMR1, MMR2 and yellow fever vaccine (AA), the calculation of vaccination coverage at the country level was carried out through the analysis of the weekly electronic report of doses of vaccines administered by Health Region. The comparison of vaccination coverage by recommended vaccine was established, by periods and age range. Results: During the pandemic, a decrease in vaccination coverage of the recommended vaccines was observed, for BCG: 4% (2020), 15% (2021); DTP1: 5% (2020), 13% (2021); DTP3: 9% (2020), 22% (2021); IPV1: 5% (2020), 16% (2021); bOPV3: 7% (2020), 19% (2021); MMR1: 9%, MMR2: 13% (2020), MMR1: 17%, MMR2: 16% (2021) and AA: 7% (2020), 15% (2021). Conclusion: During the Covid-19 pandemic, vaccination coverage of all recommended vaccines decreased, a similar decrease was found in other countries in the Americas, there is a risk of outbreaks of vaccine-preventable diseases due to the accumulation of susceptible populations.

Absent or reverse end-diastolic flow in the umbilical artery: intellectual development at school age.

OBJECTIVE: This study was designed to establish whether, in growth-retarded fetuses, absent or reverse end-diastolic (ARED) flow velocity in the umbilical artery can be predictive of an increased incidence of long-term neurological and intellectual impairment. STUDY DESIGN: A total of 14 children with intra-uterine growth retardation (IUGR) and ARED flow in the umbilical artery and 11 children without this velocimetric pattern were examined by pediatric neuropsychiatrists at a median age of 8.7 years to evaluate and compare their neurological and intellectual development. RESULTS: The incidence of major neurological sequelae was higher in the children with ARED velocity in the umbilical artery (21%) than in those without this velocimetric pattern (9%), as was the incidence of mild neurological sequelae (35% versus 27%). No differences in mean intelligence quotient (IQ) as evaluated by mean of Intelligence Scale for Children-Revised (WISC-R) scale were found between the two groups of children at school age. CONCLUSIONS: Our data demonstrate that Doppler velocimetry in the umbilical artery is a reliable predictor for neurological sequelae when ARED flow is present but cannot be considered a good predictor of intellectual performance at school.

A clinical and genetic study of 33 new cases with early-onset absence epilepsy.

PURPOSE: To investigate the electroclinical features and the outcome of patients with typical absences starting before the 3 years of life. METHODS: We reviewed the clinical data of patients with absences started before 3 years observed over a 15-year period. Mutation analysis of SLC2A1 (GLUT-1) gene was performed when possible. Their clinical features were compared with those of subjects with a diagnosis of childhood absence epilepsy (CAE). RESULTS: Among 33 children with absence epilepsy starting before 3 years of life, there were 20 boys and 13 girls. Mean seizure onset was at 28.0 ± 8.3 (range: 8-36) months of life. Two children displayed borderline intellectual functioning at long-term follow-up. Twenty-eight (85%) patients showed excellent response to therapy. Three subjects evolved into a different form of idiopathic generalized epilepsy (IGE). No SLC2A1 mutation was identified in 20 (60.6%) patients tested. The main clinical features of patients with early-onset absences did not differ from those of CAE except for increased prevalence of males (p=0.002) and longer treatment duration (p=0.001) in the former. CONCLUSIONS: Strong similarities in the electroclinical features and outcome between children with early-onset absences and those with CAE support the view that these conditions are part of the wide spectrum of IGE.

Lupus eritematoso incompleto con inicio como púrpura trombocitopénica autoinmune, en una lactante de 5 meses de edad / Incomplete lupus erythematosus initially manifesting as autoimmune thrombocytopenic purpura in a five-month old infant

La Púrpura Trombocitopénica Idiopática representa la forma más frecuente de trombocitopenia en la infancia, en ausencia de un trastorno sistémico asociado identificable en la mayoría de los casos. El lupus eritematoso sistémico es una enfermedad de base genética, autoinmune, crónica, multisistémica. El Lupus Eritematoso Incompleto es aquel que se presenta en pacientes que no reúnen criterios de clasificación para lupus eritematoso sistémico de acuerdo al ACR (American College of Rheumatology), junto con Anticuerpos Antinucleares positivos. Se presenta el caso de una lactante menor de 5 meses de edad con diagnóstico de Lupus Eritematoso Incompleto (la menor reportada hasta el momento) que inició su enfermedad con Púrpura Trombocitopénica Autoinmune, además de anticuerpos antinucleares y anticardiolipinas positivos sin afectación en otros sistemas. Por lo que consideramos que la prueba de anticuerpos antinucleares debe solicitarse en casos de púrpura trombocitopénica autoinmune, con el seguimiento adecuado, ya que esta prueba positiva es considerada de riesgo para el desarrollo posterior de lupus eritematoso sistémico, a fin de prevenir daños importantes y mejorar el pronóstico de la enfermedad.

Idiopathic thrombocytopenic purpura is the most common form of thrombocytopenia during childhood, and usually appears without an associated systemic condition being identified. Systemic Lupus Erythematosus is a chronic and multisystemic genetically-based autoimmune disease. Incomplete lupus erythematosus is considered to be present when the patient does not mean the criteria for systemic lupus erythematosus devised by the American College of Rheumatology (ACR) together with positive anti-nuclear antibody titer levels. We present the case of a five-month old female infant diagnosed with incomplete lupus erythematosus (as of current data) whose condition first manifested as autoimmune thrombocytopenic purpura and whose antinuclear and anticardiolipin antibodies titers were positive, but without detected effects on other systems. Since this test is considered to determine the existence of risk of later development of systemic lupus erythematosus, we suggest that antinuclear antibody testing should be requested in cases of autoimmune thrombocytopenic purpura and that adequate follow up be carried out to help avoid negative outcomes and improve patient prognosis.