Association between neutrophil-lymphocyte ratio and lymph node metastasis in gastric cancer : a meta-analysis

Introduction and Aim: The prognostic role of neutrophil to lymphocyte ratio (NLR) has been explored extensively in the literature. The aim of this meta-analysis was to evaluate the link between NLR and lymph node metastasis in gastric cancer. A method for increasing specificity and sensitivity of pre-treatment staging has implications on treatment algorithms and survival. Search Strategy: The relevant databases were searched as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart. After selection, 12 full text articles that met the inclusion criteria were included for quantitative analysis. 2 x 2 squares were generated using lymph node positive/negative, and NLR high/low data. The effect size for each study was calculated using the DerSimonian-Laird random effects model. P values were calculated using the chi-square method. Finally publication bias was evaluated. All statistics were calculated using R Studio. Results: Meta-analysis showed a 1.90 times (odds ratio, with 95% CI 1.52-2.38) increase in risk of positive lymph node status with high neutrophil to lymphocyte ratio. This has significant implications for cancer screening and staging, as NLR is a highly reproducible, cost-effective, and widely available prognostic factor for gastric cancer patients. Additionally, high or low NLR values may have implications for management pathways. Patients with lymph node metastasis can be offered neo adjuvant chemotherapy, avoiding salvage therapy in the form of adjuvant chemoradiotherapy, which is poorly tolerated. Conclusion: This meta-analysis shows an association between NLR and positive lymph node status in gastric cancer patients with implications for staging, as well as preoperative personalisation of therapy

Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation

BACKGROUND: Right hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 - 61% of cases when routine angiography is employed following a BDI. We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI. CASE PRESENTATION: A 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed. Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils. Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully. CONCLUSION: Obstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.Soondoos Raashed, Manju D Chandrasegaram, Khaled Alsaleh, Glen Schlaphoff, and Neil D Merret

Pancreatectomy for metastatic real cell carcinoma : twenty years of experience at a tertiary centre

Renal Cell Carcinoma (RCC) accounts for approximately 90% of primary renal malignancies, of which the clear cell subtype is most common. While metastatic disease is common at the time of diagnosis and generally confers a poor prognosis, metastatic RCC may demonstrate relatively indolent behaviour and present many years after resection of the primary tumour, including to the pancreas. The available literature suggested that surgical resection was appropriate for select patients, including those with a solitary pancreatic metastasis, minimal comorbidities and uncomplicated progress from initial treatment of their primary renal malignancy. A retrospective case series of patients presenting with RCC metastases to the pancreas, managed via surgical resection at a tertiary teaching hospital was reviewed. Analysis of patient demographics, investigations, management and outcomes were performed, with a focus on post-operative morbidity and overall survival. Between 2000 and 2020, 7 patients underwent pancreatic resection of RCC metastases at our tertiary teaching hospital with curative intent. Median age at time of resection was 66 years. No post-operative mortality or major morbidity was experienced by the 7 patients, although 4 patients developed some degree of pancreatic insufficiency. Four patients experienced recurrent metastatic RCC, with median time to recurrence of 3.5 years. This was the largest local study to describe an Australian experience of the surgical management of RCC pancreatic metastases. These patients are frequently afforded prolonged survival following pancreatic resection, but often develop other distant sites of disease and second renal tumours

Value-based care in surgery : implications in crisis and beyond

Over the past 2 years, surgeons and surgical systems have demonstrated an ability to rapidly adopt value-driven care, triage patients and make evidence-based decisions in response to crisis. Building on these successes, this paper explores a framework to expand these advances in creating a value-based approach to patient care through clinician leadership and state-wide clinical networks

Reflections on a health systems response to delivery of surgery during the COVID-19 pandemic : NSW experience

This paper presents a systems level reflection on emerging trends over the course of the pandemic to enable surgical systems to anticipate, monitor, respond and learn to support health system resilience, maintain surgical standards and mitigate workforce burnout

Management of acute appendicitis during the COVID-19 pandemic : a retrospective cohort study

Background: The Coronavirus Disease 2019 (COVID-19) pandemic profoundly impacted delivery of health care. South Western Sydney Local Health District (SWSLHD) experienced some of the highest cases, admissions and deaths during the Delta and Omicron waves in New South Wales. This study aims to determine the impact of the pandemic on emergency surgery services for adults presenting with acute appendicitis. Methods: A retrospective review of patient records was performed of adults presenting with acute appendicitis between 1st March 2021 and 31st March 2022, which was compared to a pre-COVID control period of the same dates in 2019–2020. Patients managed operatively or conservatively were included. Results: 1556 patients were included in the operative arm; 723 and 833 respectively in the study and control groups, which were comparable at baseline. 1.66% were COVID positive. During the pandemic, patients were significantly more likely to be investigated with computered tomography (CT) scan (p ≤ 0.001), present with complicated appendicitis (p = 0.03), and require caecectomy (p = 0.005). They had higher American Society of Anaesthesiology (ASA) scores (p = 0.001) and significantly lower negative appendectomy rates (p = 0.001). Fifty-two patients were included in the conservative arm; 29 and 23 respectively in the pandemic and control groups. Patients were comparable at baseline. There were two COVID positive patients. During the pandemic, there was a significant reduction in complications (p = 0.033), readmissions (0.044) and interval appendicectomy (p = 0.0044). Conclusion: We identified higher rates of complicated appendicitis, caecectomies and greater reliance on CT imaging preoperatively during the pandemic in SWSLHD

Il monastero benedettino di S. Giorgio in Braida a Verona: nuove prospettive di ricerca sulla rifabbrica romanica (sec. XII)

L’attuale aspetto rinascimentale della chiesa di San Giorgio in Braida è frutto di una serie di interventi promossi dai canonici veneziani di San Giorgio in Alga a partire dalla fine del XV secolo. Il monastero benedettino, tuttavia, fu fondato nella metà dell’XI secolo e completamente ricostruito fra il terzo e il quarto decennio del secolo successivo per volere del vescovo Bernardo. L’articolo ripercorre le vicende storiche dell’istituzione in età medievale e rende nota l’esistenza di alcune parti della compagine romanica tuttora inedite, che permettono d’inserire il cantiere di San Giorgio in Braida nel contesto delle coeve manifestazioni architettoniche veronesi

Association of biomarkers for human papillomavirus with survival among adults with Barrett high-grade dysplasia and esophageal adenocarcinoma

Importance: The presence of high-risk human papillomavirus (HPV) has been associated with a favorable outcome in Barrett high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). Nevertheless, the prognostic significance of other HPV-related biomarkers (ie, retinoblastoma protein [pRb], cyclin D1 [CD1], minichromosome maintenance protein [MCM2] and Ki-67) is unknown. Objective: To examine the association between HPV-related biomarkers and survival in adult patients with Barrett HGD and EAC. Design, Setting, and Participants: This retrospective case-control study examined the hypothesis that the HPV-related cell cycle markers (pRb, CD1, and Ki-67) and the viral surrogate marker (MCM2) may be associated with a favorable prognosis in Barrett HGD and EAC. Pretreatment biopsies were used for HPV DNA determination via polymerase chain reaction and immunohistochemistry for the HPV-related biomarkers. Recruitment of patients occurred in secondary and tertiary referral centers, with 151 patients assessed for eligibility. The study period was from December 1, 2002, to November 28, 2017, and the dates of analysis were from September 9, 2011, to November 28, 2017. Main Outcomes and Measures: Disease-free survival and overall survival. Results: Of 151 patients assessed for eligibility, 9 were excluded. Among the 142 patients with Barrett HGD or EAC (126 [88.7%] men; mean [SD] age, 66.0 [12.1] years; 142 [100%] white), 37 were HPV positive and 105 were HPV negative. No association with disease-free survival was noted for pRb, CD1, Ki-67, and MCM2. In regard to overall survival, only low expression of CD1 had a favorable prognosis (hazard ratio [HR], 0.53; 95% CI, 0.30-0.95; adjusted P = .03). All the biomarkers stratified by HPV status showed significant associations with survival. Patients with HPV-positive, low-expression pRb esophageal tumors were associated with a significantly improved disease-free survival compared with the HPV-negative, high-expression Rb tumors (HR, 0.33; 95% CI, 0.12-0.93; adjusted P = .04). Similarly, HPV-positive, low-expression CD1 was associated with a significantly favorable disease-free survival (HR, 0.26; 95% CI, 0.09-0.76; adjusted P = .01), as was HPV-positive, high-expression MCM2 (HR, 0.27; 95% CI, 0.09-0.78; adjusted P = .02). In regard to overall survival, HPV was significantly associated only with low CD1 (HR, 0.38; 95% CI, 0.15-0.94; adjusted P = .04). Conclusions and Relevance: This study's findings suggest that low expression of CD1 appears to be an independent prognostic marker in Barrett HGD and EAC. Human papillomavirus positivity in combination with pRb, CD1, MCM2, and Ki-67 was associated with a survival benefit in esophageal tumors. These findings suggest the possibility of personalization of therapy for Barrett HGD and EAC based on viral status

Targeting the undruggable in pancreatic cancer using nano-based gene silencing drugs

Pancreatic cancer is predicted to be the second leading cause of cancer-related death by 2025. The best chemotherapy only extends survival by an average of 18 weeks. The extensive fibrotic stroma surrounding the tumor curbs therapeutic options as chemotherapy drugs cannot freely penetrate the tumor. RNA interference (RNAi) has emerged as a promising approach to revolutionize cancer treatment. Small interfering RNA (siRNA) can be designed to inhibit the expression of any gene which is important given the high degree of genetic heterogeneity present in pancreatic tumors. Despite the potential of siRNA therapies, there are hurdles limiting their clinical application such as poor transport across biological barriers, limited cellular uptake, degradation, and rapid clearance. Nanotechnology can address these challenges. In fact, the past few decades have seen the conceptualization, design, pre-clinical testing and recent clinical approval of a RNAi nanodrug to treat disease. In this review, we comment on the current state of play of clinical trials evaluating siRNA nanodrugs and review pre-clinical studies investigating the efficacy of siRNA therapeutics in pancreatic cancer. We assess the physiological barriers unique to pancreatic cancer that need to be considered when designing and testing new nanomedicines for this disease

Augmenting forearm crutches with wireless sensors for lower limb rehabilitation

Forearm crutches are frequently used in the rehabilitation of an injury to the lower limb. The recovery rate is improved if the patient correctly applies a certain fraction of their body weight (specified by a clinician) through the axis of the crutch, referred to as partial weight bearing (PWB). Incorrect weight bearing has been shown to result in an extended recovery period or even cause further damage to the limb. There is currently no minimally invasive tool for long-term monitoring of a patient's PWB in a home environment. This paper describes the research and development of an instrumented forearm crutch that has been developed to wirelessly and autonomously monitor a patient's weight bearing over the full period of their recovery, including its potential use in a home environment. A pair of standard forearm crutches are augmented with low-cost off-the-shelf wireless sensor nodes and electronic components to provide indicative measurements of the applied weight, crutch tilt and hand position on the grip. Data are wirelessly transmitted between crutches and to a remote computer (where they are processed and visualized in LabVIEW), and the patient receives biofeedback by means of an audible signal when they put too much or too little weight through the crutch. The initial results obtained highlight the capability of the instrumented crutch to support physiotherapists and patients in monitoring usage