Recent Evolution in the Management of Lymph Node Metastases in Melanoma

Introduction. Based upon two large randomized international clinical trials (German Dermatologic Cooperative Oncology Group (DeCOG-SLT) and Multicenter Selective Lymphadenectomy Trial II (MSLT-II)) which were published in 2016 and 2017, respectively, active surveillance has been demonstrated to have equivalent survival outcomes to completion lymphadenectomy (CLND) for a subset of patients who have microscopic lymph node disease. In this study, we examined the changes in national practice patterns regarding the utilization of CLND after positive sentinel lymph node biopsy (SLNB). Methods. Using the National Cancer Database, we examined CLND utilization in SLN-positive patients diagnosed with melanoma between 2012 and 2016. A hierarchal logistical regression model with hospital-level random intercepts was constructed to examine the factors associated with SLNB followed by observation vs. SLNB with CLND. Results. Of the 148,982 patients identified, 43% (n = 63,358) underwent SLNB, and 10.3% (n = 6,551) had a SLNB with microscopic disease. CLND was performed for 57% (n = 2,817) of these patients. Patients were more likely to undergo CLND if they were < 55 years of age (OR, 0.687;  p = <0.0001), ages 56 - 65 (OR, 0.886; p = 0.0237), Charlson Deyo Score = 0 (OR, 0.859; p = 0.0437), or were diagnosed with melanoma in 2012 (OR, 0.794, p = <0.0001). Conclusions. We found the utilization of CLND among patients with microscopic nodal melanoma to be significantly lower in 2016 compared to 2012. Younger age, lack of comorbidities, and primary tumor location on the trunk or head/neck were associated with higher utilization of CLND

Attitudes toward Rubella and Varicella Vaccination during Preconception Care

Introduction. MMR and Varicella vaccines contain live attenuated virus, a contraindication during pregnancy. For this reason, it is important to clinically assess barriers to vaccination during the preconception time period to avoid the known fetal morbidity associated with congenital Rubella or Varicella infection. Methods. To determine the prevalence of patients with nonimmune status for Rubella and Varicella in the setting of advanced reproductive care. Secondary outcomes of interest included further understanding nonimmune reproductive-aged women's attitudes toward MMR and Varicella vaccination during the preconception time frame. Patient records were with lab orders for Rubella or Varicella immunoglobulin titers, placed at the KU Advanced Reproductive Care clinic between January 2017 and June 2020. A cross-sectional survey was administered to patients with a laboratory reported negative titer result. Results. Prevalence of nonimmunity within the study population to either Rubella and/or Varicella was 10.7% (n=1,979), to Rubella, 6.0% (n=134) and to Varicella, 3.8% (n=85) out of a total 2,217 patient records reviewed. The women who did not receive recommended vaccines following a nonimmune titer result (n=19) most commonly cited their rationale was to not further delay fertility treatment (n=8). Conclusions. The prevalence of nonimmune persons in the study population fell within the range recognized to be sufficient for herd immunity. The risk/benefit analysis of postponing fertility treatment to achieve adequate levels of immunity should be a focused discussion when establishing fertility treatment goals with patients in the setting of advanced reproductive care

Optimization of Nutrition after Brain Injury: Mechanistic and Therapeutic Considerations

Emerging science continues to establish the detrimental effects of malnutrition in acute neurological diseases such as traumatic brain injury, stroke, status epilepticus and anoxic brain injury. The primary pathological pathways responsible for secondary brain injury include neuroinflammation, catabolism, immune suppression and metabolic failure, and these are exacerbated by malnutrition. Given this, there is growing interest in novel nutritional interventions to promote neurological recovery after acute brain injury. In this review, we will describe how malnutrition impacts the biomolecular mechanisms of secondary brain injury in acute neurological disorders, and how nutritional status can be optimized in both pediatric and adult populations. We will further highlight emerging therapeutic approaches, including specialized diets that aim to resolve neuroinflammation, immunodeficiency and metabolic crisis, by providing pre-clinical and clinical evidence that their use promotes neurologic recovery. Using nutrition as a targeted treatment is appealing for several reasons that will be discussed. Given the high mortality and both short- and long-term morbidity associated with acute brain injuries, novel translational and clinical approaches are needed

Effect of Morning and Evening Exercise on Energy Balance: A Pilot Study

The purpose of this study was to evaluate the feasibility and acceptability of randomizing adults with overweight and obesity (BMI 25–40 kg/m2) to morning (06:00–10:00) or evening (15:00–19:00) aerobic exercise. Participants completed four exercise sessions per week in the morning (AM, n = 18) or evening (PM, n = 15). The exercise program was 15 weeks and progressed from 70 to 80% heart rate maximum and 750–2000 kcal/week. Bodyweight, body composition, total daily energy expenditure (TDEE), energy intake (EI), sleep, sedentary behavior (SB), non-exercise physical activity (NEPA), and maximal aerobic capacity were assessed at baseline and week 15. Study retention was 94% and adherence to the supervised exercise program was ≥90% in both groups. Weight change was −0.9 ± 2.8 kg and −1.4 ± 2.3 kg in AM and PM, respectively. AM and PM increased TDEE (AM: 222 ± 399 kcal/day, PM: 90 ± 150 kcal/day). EI increased in AM (99 ± 198 kcal/day) and decreased in PM (−21 ± 156 kcal/day) across the intervention. It is feasible to randomize adults with overweight and obesity to morning or evening aerobic exercise with high levels of adherence. Future trials are needed to understand how the timing of exercise affects energy balance and body weight regulation