A systematic review of axillary nodal irradiation for the management of the axilla in patients with early-stage breast cancer

BackgroundGiven numerous publications and clinical trials regarding axillary management in breast cancer, we sought to summarize this complex literature to help clarify this field for clinicians. This systematic review focuses on the role of irradiation of the axillary nodes (locoregional nodal irradiation [LRNI]) in the management of the axilla in patients with early-stage breast cancer in various clinical settings.MethodsWe searched MEDLINE and EMBASE databases, the Cochrane library, the proceedings of the ASCO, the ASTRO, the ESMO, the ESTRO, and the San Antonio Breast Cancer Symposium (2016–2019) meetings. The quality of the studies was assessed with design-specific tools. The study was registered in PROSPERO.ResultsWe included one systematic review, one individual patient data (IPD) meta-analysis, and five randomized controlled trials (RCTs). After axillary lymph node dissection (ALND), LRNI resulted in small benefits in breast cancer specific mortality, locoregional recurrence, and distant metastases-free survival but not overall survival. After a positive sentinel node biopsy (SLNB), LRNI may provide equivalent locoregional control and disease-free survival (DFS) compared to ALND with a lower risk of lymphedema. No randomized data is available for the neoadjuvant setting.ConclusionsThe summary of the role of radiation, is relevant to radiation oncologists for choosing the correct cohort of patient requiring LRNI and to surgeons making clinical decisions regarding the timing and type of breast reconstruction offered to patients.     

Resistencia a los anestésicos locales: ¿verdad o mito?

The report of anesthetic technique failure is crucial and the etiology of the problem should be determined. We describe a case of locoregional anesthesia failure, in which, after excluding its most common causes, the resistance to local anesthetics was considered as the most probable clinical hypothesis. For this reason, a genetic test was performed, as well as the efficacy of other local anesthetics was evaluated, constituting a different approach in the cases of locoregional anesthesia failure. True resistance to local anesthetics is difficult to diagnose so information about this is scarce in the literature. One of the proposed causes is a mutation of sodium channels where local anesthetics bind. If not recognized, the application of locorregional anesthesia in this patient's condition can lead to unpleasant experiences and unnecessary risks, related to toxic levels of local anesthetics. For this reason, the resistance to local anesthetics should be always precluded in cases of strong clinical suspicion. This approach could be applied in similar cases.     

Primary and recurrent regional metastases for lateralized oral cavity squamous cell carcinoma

ObjectivesMap regional lymph node metastases for lateralized oral cavity squamous cell carcinoma (OCSCC) and evaluate factors associated with regional metastases and recurrence.Materials and methodsRetrospective cohort study of 715 patients with lateralized OCSCC surgically treated in 1997–2011. Analysis was performed using log-rank, Kaplan-Meier, and multivariable logistic and Cox regression.ResultsRegional metastases were identified in ipsilateral levels IIA (24%), IB (18%), III (13%), V (9%), IV (7%), IA (2%) and IIB (1%) and the contralateral neck (3%). Lymphovascular invasion (LVI) (Hazard Ratio [HR] 2.2, 95% Confidence Interval [CI] 1.2–3.9) and T category (T3 vs. T1: HR 4.1, 95% CI 1.9–9.3; T4 vs. T1: HR 2.3, 95% CI 1.2–4.3) were associated with regional metastases. Most (71%) isolated regional metastatic recurrences were in undissected levels of the neck, including 58% in levels IV and V. Tumors of the hard palate (HR 4.3, 95% CI 1.2–16.1), upper alveolus (HR 3.2, 95% CI 1.0–4.7) or with LVI (HR 2.0, 95% CI 1.0–3.9) were associated with isolated regional recurrence. For upper alveolar/hard palate tumors, depth of invasion (DOI) ≥4 mm (P = .003) and LVI (P = .04) were associated with regional metastases.ConclusionsFor lateralized OCSCC, elective neck dissection of level IIB or the contralateral neck may rarely be needed, but additional surgical or radiation treatment of levels IV and V may be considered based on patient risk factors, including T category 3–4 or LVI. For upper alveolar/hard palate tumors, DOI ≥4 mm is an appropriate threshold for elective neck dissection.     

期刊视角的近代上海名医文化效应研究

以中国近代中医药期刊为主视角,以近代中医名家为研究主体,探讨近代上海名医文化区域特征。近代上海名医多家学渊源,国学功底深厚,以文会友,在期刊阵营中思想活跃;上海为近代中医药期刊创刊的主阵地,名医办刊办学,刊学相辅,使中医教育呈现出师承、家学、院校、函授等多种模式相结合的发展趋势。生逢乱世的近代上海名医,将中医的命运与民族命运紧密相连,注重扶持民族企业,研发自主品牌,这标志着近代中医民族品牌意识开始觉醒。近代上海名医具有传统中医的特色,深受江南地域文化影响,又注重吸收和借鉴西方医学,形成了异彩纷呈的海派特色。     

老年轻度认知障碍患者血清瘦素、甲状腺激素水平与局部脑血流量关系的研究

目的 通过检测老年轻度认知障碍（MCI）患者血清瘦素（LEP）、甲状腺激素水平，分析其与局部脑血流量（rCBF）的关系。方法 选择本院收治的128 例老年MCI 患者，另选健康者128 例作为对照组。检测血清LEP、甲状腺激素、大脑各区域rCBF 水平并分析其相关性。结果 老年MCI 组患者左右侧额叶、右侧颞叶、左侧顶叶、左右侧基底节区域脑血流量[（43.81±8.62）mL/（100 g·min）、（43.24±7.93）mL/（100 g·min）、（45.14±6.98）mL/（100 g·min）、（45.86±6.77）mL/（100 g·min）、（67.95±8.52）mL/（100 g·min）、（68.36±8.34）mL/（100 g·min）]低于对照组[（46.39±8.31）mL/（100 g·min）、（46.52±8.56）mL/（100 g·min）、（47.37±7.04）mL/（100 g·min）、（48.25±6.98）mL/（100 g·min）、（70.34±8.96）mL/（100 g·min）、（70.58±8.57）mL/（100 g·min）]（P＜0.05）。老年MCI 组患者血清LEP、T3、FT3 水平[（4.87±1.56）μg/L、（1.21±0.16）nmol/L、（3.04±0.36）pmol/L]低于对照组[（11.45±3.92）μg/L、（1.68±0.21）nmol/L、（4.82±1.21）pmol/L]（P＜0.05），TSH 水平为（2.78±0.75）IU/mL，高于对照组的（1.13±0.38）IU/mL（P＜0.05）。老年MCI 患者血清LEP 水平与左侧额叶、右侧颞叶、左侧顶叶rCBF 呈正相关（r=0.452、0.537、0.544，P 均＜0.05），T3 水平与左侧额叶、右侧颞叶rCBF 呈正相关（r=0.427、0.521，P 均＜0.05），FT3 水平与右侧颞叶rCBF 呈正相关（r=0.492，P＜0.05），TSH 水平与左侧额叶、右侧颞叶rCBF 呈负相关（r=-0.463、-0.489，P 均＜0.05）。结论 老年MCI 患者血清中LEP、T3、FT3 水平降低，TSH 水平升高，且与不同区域rCBF 有相关性，可通过调控脑血管功能影响rCBF 变化水平。     

Liver Transplantation Following Life-threatening Abdominal Trauma: A Case Series of 5 Patients at a Single Institution

Managing traumatic liver injury (TLI) is always challenging and demands precise clinical judgment. Currently, treatment of TLI in most circumstances is non-operative; however, surgical therapy might be required for severe TLI, particularly those that result in extensive blood loss. In the current institutional study carried out from June 1995 to April 2017, we describe our experience with 5 patients who received an orthotopic liver transplant for severe TLI. One patient passed away postoperatively from cerebral edema; 1 patient died of renal failure 4 years after the liver transplantation, and 3 patients are still alive. Based on our experience, we conclude that in patients with TLI, especially those with uncontrollable bleeding or those who develop liver failure, liver transplantation should be taken into consideration.     

Bloqueio do plano do eretor da espinha com técnica de múltiplos cateteres para esofagectomia aberta: relato de caso

Background and objective

Erector spinae plane block is a valid technique to provide simultaneously analgesia for combined thoracic and abdominal surgery.

Lingual lymph nodes: Anatomy,clinical considerations,and oncological significance

Lingual lymph nodes are an inconstant group of in-transit nodes, which are located on the route of lymph drainage from the tongue mucosa to the regional nodes in neck levels I and II. There is growing academic data on the metastatic spread of oral cancer, particularly regarding the spreading of oral tongue squamous cell carcinoma to lingual nodes. These nodes are not currently included in diagnostic and treatment protocols for oral tongue cancer. Combined information on surgical anatomy, clinical observations, means of detection, and prognostic value is presented. Anatomically obtained incidence of lingual nodes ranges from 8.6% to 30.2%. Incidence of lingual lymph node metastasis ranges from 1.3% to 17.1%. It is clear that lymph nodes that bear intervening tissues from the floor of the mouth should be removed to improve loco-regional control. Extended resection volume, which is required for the surgical treatment of lingual node metastasis, cannot be implied to every tongue cancer patient. As these lesions significantly influence prognosis, special efforts of their detection must be made. Reasonably, every tongue cancer patient must be investigated for the existence of lingual lymph node metastasis. Lymphographic tracing methods, which are currently implied for sentinel lymph node biopsies, may improve the detection of lingual lymph nodes.     

Pro-equity immunization and health systems strengthening strategies in select Gavi-supported countries

BackgroundAchieving universal immunization coverage and reaching every child with life-saving vaccines will require the implementation of pro-equity immunization strategies, especially in poorer countries. Gavi-supported countries continue to implement and report strategies that aim to address implementation challenges and improve equity. This paper summarizes the first mapping of these strategies from country reports.MethodsThirteen Gavi-supported countries were purposively selected with emphasis on Gavi’s priority countries. Following a scoping of different documents submitted to Gavi by countries, 47 Gavi Joint Appraisals (JAs) for the period 2016–2019 from the 13 selected countries were included in the mapping. We used a consolidated framework synthesized from 16 different equity and health systems frameworks, which incorporated UNICEF’s coverage and equity assessment approach – an adaptation of the Tanahashi model. Using search terms, the mapping was conducted using a combination of manual search and the MAXQDA qualitative analysis tool. Pro-equity strategies meeting the inclusion criteria were identified and compiled in an Excel database, and then populated on a tableau visualization dashboard.ResultsIn total, 258 pro-equity strategies were implemented by the 13 sampled Gavi-supported countries between 2016 and 2019. The framework determinants of social norms, utilization, and management and coordination accounted for more than three-quarters of all pro-equity strategies implemented in these countries. The median number of strategies reported per country was 17. Afghanistan, Nigeria, and Uganda reported the highest number of strategies that we considered as pro-equity.ConclusionFindings from this mapping can be useful in addressing equity gaps, reaching partially immunized, and ‘zero-dose’ vaccinated children, and valuable resource for countries planning to implement pro-equity strategies, especially as immunization stakeholders reimagine immunization delivery in light of COVID-19, and as Gavi finalizes its fifth organizational strategy. Future efforts should seek to identify pro-equity strategies being implemented across additional countries, and to assess the extent to which these strategies have improved immunization coverage and equity.