Objective To analyze the prevention and treatment of postoperative hemorrhage after pancreaticoduodenectomy. Methods The clinical data of 142 patients undergoing pancreaticoduedenectomy from Jan 1995 to Dec 2008 were retrospectively analyzed. Results The incidence of postoperative hemorrhage was 14.1% (20/142), the mortality caused by this complication was 35% (7/20). Among these patients, intra-abdominal hemorrhage occurred in seven cases, and gastrointestinal hemorrhage occurred in 14 cases, with one case suffering both. There were three and four cases of early and delayed intra-abdominal hemorrhage respectively. Early and delayed gastrointestinal hemorrhage occurred in three and eleven cases respectively. Univariate analysis showed that operative blood loss, blood transfusion, infection and pancreatic fistula were significantly associated with postoperative hemorrhage. Multivariate analysis using Logistic regression identified two variables as independent factors associated with postoperative hemorrhage, namely, infection(OR=6.918) and pancreatic fistula(OR=3.948). Conclusions The incidence and mortality of hemorrhage after pancreaticoduodenectomy is still high. Skillful operation and prevention of pancreatic fistula, infection and stress ulcer are the key paints for reducing postoperative hemorrhage. Proper treatments should be used according to the site, onset and severity of hemorrhage.
Key words:
Pancreaticoduodenectomy; Postoperative hemorrhage; Treatment
Background: The primary objective of this study was to assess patient preferences for collagenase Clostridium histolyticum (CCH) treatment versus limited surgical fasciectomy in a cohort that has undergone both treatments for Dupuytren contracture. Methods: We retrospectively identified 68 patients who have undergone both limited surgical fasciectomy and CCH treatment for digital flexion contractures from Dupuytren disease. Patients were contacted by telephone and asked whether they preferred surgery or CCH treatment for their Dupuytren contracture. Multivariable logistic regression was used to determine factors associated with preference for surgery versus CCH treatment. Results: Of the 68 patients who were treated with both CCH and surgery, 37 patients (54.4%) preferred CCH treatment over surgery, 26 (38.2%) preferred surgery over CCH treatment, and 5 (7.4%) were unable to decide. Patients expressed common themes of the perceived ease of recovery following CCH treatment versus the perceived durability of contracture correction with surgery. Preference for surgical fasciectomy over CCH treatment was associated with lower American Society of Anesthesiologists Physical Status Classification (ASA) [odds ratio (OR): 0.32, 95% confidence interval (CI): 0.14-0.75]. The order of treatment was also associated with the treatment preference; treatment with surgery after CCH compared to treatment with CCH after surgery was associated with a preference for surgery (OR: 6.51, 95% CI: 2.15-19.7). Conclusions: In a cohort of patients who have undergone both treatments, patients were divided in their preferences, with a slight majority preferring CCH treatment over surgery. Treatment recommendations should be individualised to each patient's long-term goals and expectations. Level of Evidence: Level III (Therapeutic).
Background/Aim: Patella baja (PB) and pseudo-patella baja (PPB) have been shown to negatively influence outcomes after total knee arthroplasty. We hypothesized that there is a high incidence of PB and PPB after megaprosthetic total knee arthroplasty (M-TKA), and that this is associated with reduced range of motion. Patients and Methods: We retrospectively analysed all patients in our Orthopaedic Trauma Department after distal femur or proximal tibia replacement. Preoperative and one-year postoperative follow-up included measurement of range of motion and detection of PB and PPB using radiological indices. Results: We included 44 patients (age: 73±19 years). Preoperative PB detected by ISI could be reduced from 13 (36%) to 11 (25%) (p<0.01). Preoperative vs. postoperative ISI was 0.88±0.23 vs. 1.06±0.45 (p=0.03). PPB was observed preoperatively in 23 (63%) patients vs. 24 (54%) postoperatively. Preoperative vs. postoperative CDI was 0.70±0.24 vs. 0.95±0.43 (p=0.002). Preoperative flexion was 91°±30° vs. 85°±24° postoperatively (p>0.05). Conclusion: Both PB and PPB are frequently observed after M-TKA. A reduction in PB and PPB alone does not improve postoperative range of motion.
Background: The family of coiled-coil domain-containing (CCDC) proteins participates in a wide range of physiological functions and plays a pivotal role in governing the invasion and metastasis of malignant tumor cells. Nonetheless, the precise mechanism governing the interaction among the immune microenvironment, hypoxia pathway, and proliferation in hepatocellular carcinoma (HCC) remains elusive. In this study, our objective was to identify the prognostic significance of CCDC family genes in HCC. Methods: We conducted an analysis of RNA-seq data from HCC patients sourced from The Cancer Genome Atlas (TCGA) database. Our analysis involved comparing the expression profiles of 168 CCDC family genes between tumor and normal tissues to identify differentially expressed genes (DEGs). The prognostic value of these genes was verified using overall survival (OS) data from TCGA-LIHC patients, employing Univariate and multivariate Cox proportional hazards regression models and Kaplan-Meier plots. Subsequently, we constructed a prognostic signature known as the CCDC score and validated it using additional datasets (ICGC-LIRI-JP and GSE14520). Additionally, we performed functional enrichment analysis and conducted an assessment of the tumor immune microenvironment (TIME). Results: We identified 34 DEGs of the CCDC family. Among them, six DEGs (CCDC6/22/51/59/132/134) were upregulated and associated with poor prognosis. Higher CCDC score was an independent predictor of poor OS in TCGA-HCC patients (P<0.001, HR =2.37), which was validated in the ICGC-LIRI-JP (P=0.021, HR =2.15) and GSE14520 (P=0.002, HR =2.23) datasets. Functional enrichment analysis showed that hypoxia pathway genes were enriched in the high CCDC score group. Furthermore, immune microenvironment analysis demonstrated that high CCDC score was associated with a suppressed TIME caused by the extrinsic immune escape. Conclusions: The CCDC score, derived from six CCDC genes, exhibits remarkable expression levels in liver cancer and holds promise as an independent prognostic indicator. Our bioinformatics analysis revealed a high CCDC score is strongly associated with activation of the hypoxia pathway and an immunosuppressive tumor microenvironment in HCC. This profound finding may serve as a cornerstone for innovative targeted drug therapies and pave the way for further investigations into the underlying mechanisms of CCDC-related carcinogenesis in liver cancer.
Rural populations are at risk for poorer access to health services and lower quality care, and recent policy efforts have focused on the reduction of rural-urban health inequities. The objective of this study was to identify differences in (1) patient demographic factors, (2) the utilization of confirmatory electrodiagnostic (EDS) testing, and (3) preoperative EDS severity between rural and urban populations undergoing carpal tunnel release (CTR).
Abstract Combined major injury to both upper extremities, in which one hand is amputated and structurally intact but not replantable, and the other hand is unsalvageable, is a rare setting in which cross-hand replantation may be considered. We report a case of an emergency cross-hand replantation performed at the wrist level. In our case, insertions of the wrist flexor and extensor tendons at the second and third metacarpal bases were retained at the recipient, allowing for early active wrist motion and finger motion by tenodesis. Fascicle-specific nerve coaptations were performed. The patient achieved satisfactory functional results, allowing him independence with daily living activities and return to gainful employment. At the time of telemedicine follow-up at 5 years, he was employed full-time, reported no difficulty or mild difficulty with most daily activities, and preferred the use of his replanted hand over a contralateral prosthesis.
As an Asian American, I am expected to play the role of a “model minority.” Asian Americans are “supposed to” get good grades in school, go to prestigious universities, and get a job in a respectable profession. We are expected to achieve a degree of socioeconomic success through hard work and grit. When injustices occur, Asian Americans are not supposed to cry foul, but rather, turn the other cheek. After all, the occasional slights and racist slurs—are they not the taxes we pay for having “yellow skin” in America? Everyone has their crosses to bear, so are these not ours? Assumptions and expectations have been amplified since the outbreak of COVID-19. Allow me to share examples from my own recent experience: In summer 2020, state-mandated shutdowns of nonurgent, ambulatory orthopaedic surgery visits were just being lifted. I saw a patient for a postoperative visit after an arthroscopic rotator cuff repair. He had a successful outcome, but because of COVID-19 shutdowns, he had done most of his postoperative rehabilitation remotely. We talked about the strange and unexpected turn his postoperative course took. As we were talking about the pandemic, “Dr. Zhang,” he asked me, “You weren’t in Wuhan, China, were you?” I was taken aback by my perceived absurdity of his question. I laughed it off and reassured him that I had gone nowhere besides my house, the grocery store, and the hospital. We continued with our visit. More recently, as I was walking out of the hospital, a man approached me and asked, “Do you speak English?” I thought to myself, I am wearing scrubs, with an ID badge that says “M.D.”—why is he wondering if I speak English? The man was not wearing a mask, so I decided to just keep walking. Anti-Asian Aggression During the Pandemic There has been a surge in anti-Asian racism, harassment, and violence. The numbers of reported anti-Asian racist incidents and hate crimes in the last year are substantially higher than in years prior, and this is largely believed to be motivated by misplaced blame and anger about COVID-191,2. Incidents of verbal harassment and shunning are likely underreported, but the rise in cases of frank physical violence and assault are disconcerting1. In New York City alone, the number of hate crimes against individuals of Asian descent reported to the police rose from 3 in 2019 to 28 in 20202. In January 2021, in Portland, Oregon, a man physically assaulted an Asian American woman on the city bus, saying that the Chinese were to blame for the virus2. This incident hit me particularly close to home, because my mother is Asian American, lives in Portland, and takes the bus every day. In March 2021, a gunman was charged for a shooting rampage at 3 spas in the Atlanta area that killed 8 people, 6 of whom were women of Asian descent3. This tragedy highlighted the rising anti-Asian sentiment brewing across America during the pandemic, brought to national attention the increase in hatred directed at Asian Americans, and sparked vigils and mass protests against anti-Asian American violence. Being Anti-Racist in 2021 The events of the past year have made it painfully clear that it is not enough to be simply not racist (“I am a good person,” “I have nothing against Asians,” and “I would never use a racial slur”), but instead, we must be actively anti-racist (“What are my own implicit biases?” “How can I be an ally to marginalized groups?” and “How can I support positive change in my community?”). Microaggressions and microinvalidations can be unintentional. I do not think my patient who asked if I had traveled to Wuhan or the man on the street who asked if I spoke English intended to offend me. Yet, that is precisely what makes implicit bias or unconscious bias so difficult to recognize and eradicate. If we do not look for our blind spots, we will never find them. Reflecting on my own experiences, in the context of the national events in the past year, I realize that I missed opportunities for education and discourse regarding microaggressions4. When I see overt racism or racial microaggressions in the future, I will try to communicate in a nonjudgmental way, divorcing intention from consequence. Because microaggressions often occur unconsciously, stemming from the implicit bias of the perpetrator, it can be helpful to explain the hurtful impact of words and actions without assigning blame. In doing so, we can foster open discourse and help build an anti-racist community. Being a “model minority” in 2021 means taking an active role in affecting anti-racist change. As physicians and leaders, we all have the privilege of being in positions of influence, among our patients, our staff, our peers, and our community. By our words and actions, we have the opportunity to shape an inclusive future.
The adipose Nod-like receptor protein 3 (NLRP3) inflammasome senses danger-associated molecular patterns (DAMPs) and initiates insulin resistance, but the mechanisms of adipose inflammasome activation remains elusive. In this study, Homocysteine (Hcy) is revealed to be a DAMP that activates adipocyte NLRP3 inflammasomes, participating in insulin resistance. Hcy-induced activation of NLRP3 inflammasomes were observed in both adipocytes and adipose tissue macrophages (ATMs) and mediated insulin resistance. Lysophosphatidylcholine (lyso-PC) acted as a second signal activator, mediating Hcy-induced adipocyte NLRP3 inflammasome activation. Hcy elevated adipocyte lyso-PC generation in a hypoxia-inducible factor 1 (HIF1)-phospholipase A2 group 16 (PLA2G16) axis-dependent manner. Lyso-PC derived from the Hcy-induced adipocyte also activated ATM NLRP3 inflammasomes in a paracrine manner. This study demonstrated that Hcy activates adipose NLRP3 inflammasomes in an adipocyte lyso-PC-dependent manner and highlights the importance of the adipocyte NLRP3 inflammasome in insulin resistance.
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