Supported transitional care applied to stroke survivors: A meta-analysis.

BACKGROUND: This meta-analysis aims to assess the outcomes of supported intervention transitional care compared to traditional care for stroke survivors. MATERIAL AND METHODS: A systematic literature review was accomplished and 4,437 stroke patients were recruited for the current study; 2,211 of them were treated with transitional care and 2,226 with traditional care. The inclusion criteria of the current study recruited only randomized clinical trials up until November 2023. A random analysis model was used to analyze the continuous and dichotomous models. RESULTS: Supported intervention transitional care (early supported discharge) for stroke survivors showed a significant (p = 0.002) impact regarding the functional status of patients as expressed by the Barthel index (mean difference (MD) = 0.57, 95% confidence interval (95% CI): 0.20-0.94, I² = 93.72%). On the other hand, there were no considerable (p > 0.05) differences regarding other outcomes such as activities of daily living, the Caregiver Strain Index (CSI), the modified Rankin scale (mRS), and mortality (MD = 0.29, 95% CI: -0.12-0.69, I² = 94.5%; MD = -0.13, 95% CI: -0.40-0.14, I² = 68.65%; MD = -0.13, 95% CI: -0.49-0.23, I² = 83.33%; and MD = -0.19, 95% CI: -0.58-0.17, I² = 0%; respectively). CONCLUSION: Supported transitional care allowed stroke survivors to succeed in enhancing their functional status outcomes compared with controls, while there was no significant impact regarding mortality rate. Further investigations and multicenter studies are required to enhance the evidence.

Comparison of Pipeline embolization device versus Tubridge embolization device in unruptured intracranial aneurysms: a multicenter, propensity score matched study.

BACKGROUND: Flow diverter devices (FDs) are increasingly used for treating unruptured intracranial aneurysms (UIAs), but limited studies compared different FDs. OBJECTIVE: To conduct a propensity score matched analysis comparing the Pipeline embolization device (PED) and Tubridge embolization device (TED) for UIAs. METHODS: Patients with UIAs treated with either PED or TED between July 2016 and July 2022 were included. Propensity score matching was performed to adjust for age, sex, comorbidities, smoking, drinking, aneurysm size, morphology, neck, location, parent artery diameter, adjunctive coiling, and angiographic follow-up duration. Perioperative complications and clinical and angiographic outcomes were compared after matching. RESULTS: 735 patients treated by PED and 290 patients treated by TED were enrolled. Compared with the PED group, patients in the TED group had a greater number of women and patients with ischemia, a smaller proportion of vertebrobasilar and non-saccular aneurysms, a smaller size and neck, and fewer adjunctive coils and overlapping stents, but a larger parent artery diameter and lumen disparities. After adjusting for these differences, 275 pairs were matched. No differences were found in perioperative complications (4.4% vs 2.5%, P=0.350), in-stent stenosis (16.0% vs 15.6%, P>0.999), or favorable prognosis (98.9% vs 98.5%, P>0.999). However, PED showed a trend towards better complete occlusion over a median 8-month angiographic follow-up (81.8% vs 75.3%, P=0.077). CONCLUSION: Compared with PED, TED provides a comparable rate of perioperative and short-term outcomes. Nevertheless, a better occlusion status in the PED group needs to be further verified over a longer follow-up period.

Pedigree-based QTL analysis of flower size traits in two multi-parental diploid rose populations.

Rose (Rosa spp.) is one of the most economically important ornamental species worldwide. Flower diameter, flower weight, and the number of petals and petaloids are key flower-size parameters and attractive targets for DNA-informed breeding. Pedigree-based analysis (PBA) using FlexQTL software was conducted using two sets of multi-parental diploid rose populations. Phenotypic data for flower diameter (Diam), flower weight (fresh (FWT)/dry (DWT)), number of petals (NP), and number of petaloids (PD) were collected over six environments (seasons) at two locations in Texas. The objectives of this study were to 1) identify new and/or validate previously reported QTL(s); 2) identify SNP haplotypes associated with QTL alleles (Q-/q-) of a trait and their sources; and 3) determine QTL genotypes for important rose breeding parents. Several new and previously reported QTLs for NP and Diam traits were identified. In addition, QTLs associated with flower weight and PD were identified for the first time. Two major QTLs with large effects were mapped for all traits. The first QTL was at the distal end of LG1 (60.44-60.95 Mbp) and was associated with Diam and DWT in the TX2WOB populations. The second QTL was consistently mapped in the middle region on LG3 (30.15-39.34 Mbp) and associated with NP, PD, and flower weight across two multi-parent populations (TX2WOB and TX2WSE). Haplotype results revealed a series of QTL alleles with differing effects at important loci for most traits. This work is distinct from previous studies by conducting co-factor analysis to account for the DOUBLE FLOWER locus while mapping QTL for NP. Sources of high-value (Q) alleles were identified, namely, 'Old Blush' and Rosa wichuraiana from J14-3 for Diam, while 'Violette' and PP-J14-3 were sources for other traits. In addition, the source of the low-value (q) alleles for Diam was 'Little Chief', and Rosa wichuraiana through J14-3 was the source for the remaining traits. Hence, our results can potentially inform parental/seedling selections as means to improve ornamental quality in roses and a step towards implementing DNA-informed techniques for use in rose breeding programs.

American Association for Thoracic Surgery Summer Intern Scholarship-Over a decade of experience.

OBJECTIVE: The study objective was to evaluate the experience of previous American Association for Thoracic Surgery Summer Intern Scholarship recipients. METHODS: A database of recipients of the American Association for Thoracic Surgery Summer Intern Scholarship in Cardiothoracic Surgery provided by the American Association for Thoracic Surgery was analyzed. A questionnaire was sent via email to recipients with 10 questions within the survey to assess the types of exposure during the internship, the impact of the internship on career choices, the current career setting, and any additional thoughts regarding the internship. RESULTS: Between 2007 and 2017, there were 356 awardees of the American Association for Thoracic Surgery Summer Intern Scholarship. These awardees were from 41 different medical schools and went to 39 different sponsoring institutions. Ultimately, 55 (15.5%) medical students chose a career in cardiothoracic surgery, with 153 (43.0%) awardees deciding to pursue a surgical subspecialty. Of those who received our survey, 75 awardees responded (29.2%). A majority of the American Association for Thoracic Surgery Summer Interns were exposed to the sponsoring surgeon (98.7%, n = 74) and operating room (88.0%, n = 66) on at least a weekly basis during the 8-week internship. All of the respondents participated in basic science or clinical research at their sponsoring institution. Some 92.0% (n = 69) of the awardees highly recommended this scholarship to medical students interested in cardiothoracic surgery. CONCLUSIONS: The awardees of the American Association for Thoracic Surgery Summer Intern Scholarship come from a variety of medical schools and visited a diverse group of sponsoring institutions. The 8-week program provides valuable early exposure for medical students to cardiothoracic surgeons, the operating room, and research opportunities. This experience was highly recommended by prior recipients to medical students interested in cardiothoracic surgery.

Omission of axillary staging in elderly patients with early stage breast cancer impacts regional control but not survival: A systematic review and meta-analysis.

INTRODUCTION: Management of early breast cancer in the elderly population is challenging due to different breast cancer biology and limited tolerance to aggressive treatments. The aim of this study is to evaluate whether the omission of axillary staging impacts breast cancer outcomes in elderly patients. PATIENTS AND METHODS: A systematic review and meta-analysis was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The electronic databases were searched in August 2014 using the following inclusion criteria: RESULTS: Two RCTs met the eligibility criteria and were included. A meta-analysis of the included RCTs of 692 patients found that axillary staging reduced the risk of axillary recurrence compared to no axillary staging (RR 0.24, 95% CI: 0.06 to 0.95, I2=0%, p=0.04). There were no differences observed in in-breast recurrence or distant recurrence (RR 1.20, 95% CI: 0.55 to 2.64, I2=62%, p=0.65, RR 1.17, 95% CI: 0.75 to 1.82, I2=0%, p=0.48, respectively). There were no differences observed in overall or breast-cancer specific mortality (RR 0.99, 95% CI: 0.79 to 1.24, I2=0%, p=0.92, RR 1.07, 95% CI: 0.72 to 1.57, I2=0%, p=0.75, respectively). DISCUSSION: Omission of axillary staging in elderly patients with clinically negative axillae results in increased regional recurrence but does not appear to impact survival.

Getting Started with Minimally Invasive Pancreaticoduodenectomy: Is It Worth It?

BACKGROUND: This study evaluates the safety and cost of introducing minimally invasive pancreaticoduodenectomy (MIPD) to a surgeon's practice. SUBJECTS AND METHODS: All MIPDs performed between December 2011 and July 2013 were compared with open pancreaticoduodenectomy (OPD) cases by the same surgeon. The primary outcomes were mortality, major morbidity, and re-operation. Secondary outcomes were perioperative and oncologic outcomes and cost. MIPD include total laparoscopic pancreaticoduodenectomy (TLPD) and laparoscopic-assisted pancreaticoduodenectomy (LAPD), where a small incision is used for reconstruction. Bivariate comparisons of outcomes were performed using nonparametric tests. RESULTS: In total, 44 pancreaticoduodenectomies were performed: 15 MIPDs (2 TLPDs and 13 LAPDs) and 29 OPDs. One death occurred in each group. Major complication rates were not significantly different (33% for MIPD versus 17% for OPD); however, there was a trend toward more re-operation after MIPD compared with OPD (20% versus 3%; P = .07). The incidence of pancreatic leak (20% for MIPD versus 14% for OPD), biliary leak (0% versus 7%, respectively), abscess formation (27% versus 14%, respectively), and intraabdominal hemorrhage (13% versus 3%, respectively) were not significantly different. MIPD achieved equivalent oncologic outcomes as OPD with 100% R0 margin and adequate lymph node retrieval. There was no statistical difference in median operative time (342 minutes for MIPD versus 358 minutes for OPD), length of stay (8 versus 9 days, respectively), operating room expenses (Canadian) ($7246.0 versus $6912.0, respectively), or total cost (Canadian) per case ($15,034.0 versus $18,926.0, respectively). CONCLUSIONS: MIPD and OPD had similar safety and cost in this introductory series. However, a trend toward a higher rate of re-operation for pancreatic leak suggests the need for caution in introducing this novel technique.

Starting a new laparoscopic liver surgery program: initial experience and improved efficiency.

BACKGROUND: Owing to the anatomic complexity of the liver and the risk of hemorrhage, most liver resections are still performed using an open procedure. We evaluated the outcomes of introducing a laparoscopic liver program to a community teaching hospital. METHODS: We retrospectively reviewed laparoscopic liver resections performed between August 2010 and July 2013 at St. Joseph's Health Centre in Toronto. The primary outcomes were mortality, major morbidity and negative margins. Secondary outcomes included other perioperative outcomes. We used nonparametric tests to compare the outcomes during the first (group A) and second (group B) halves of the study period. RESULTS: Group A included 19 patients and group B had 25 patients; 9 and 4 patients, respectively, had major resections. Group A had the only death due to liver failure. There was no difference in major complications (10.6% v. 16%) or length of stay (4.5 v. 4.6 d) between the groups. One patient in group B had a positive margin. There was a significant decrease in duration of surgery (from 237 to 170 min, p = 0.007), with a trend toward shorter duration for major resections (from 318 to 238 min, p = 0.07). Furthermore, more procedures were performed for malignancy in group B than group A (36.8% v. 84.0%, p = 0.001). CONCLUSION: Laparoscopic liver resection can be safely introduced into a Canadian community teaching hospital. Average duration of surgery decreased by 67 minutes despite a 2-fold increase in the number of cases performed for malignancy.

CONTEXTE: En raison de la complexité anatomique du foie et du risque d'hémorragie, la plupart des résections hépatiques s'effectuent encore par chirurgie ouverte. Nous avons évalué les résultats d'un programme hépatique laparoscopique instauré dans un hôpital d'enseignement communautaire. MÉTHODES: Nous avons passé en revue de manière rétrospective les résections hépatiques laparoscopiques effectuées entre août 2010 et juillet 2013 au St. Joseph's Health Centre de Toronto. Les paramètres principaux étaient la mortalité, la morbidité majeure et les marges négatives. Les paramètres secondaires incluaient d'autres variables périopératoires. Nous avons utilisé des tests non paramétriques pour comparer les variables durant la première moitié (groupe A) et la seconde moitié (groupe B) de la période de l'étude. RÉSULTANTS: Le groupe A incluait 19 patients et le groupe B, 25 patients; 9 et 4 patients, respectivement, ont subi des résections majeures. Le groupe A a enregistré le seul décès attribuable à une insuffisance hépatique. On n'a noté aucune différence quant aux complications majeures (10,6 % c. 16 %) ou quant à la durée de l'hospitalisation (4,5 c. 4,6 jours) entre les groupes. Un patient du groupe B a présenté une marge positive. On a noté en général une diminution significative de la durée de l'intervention (de 237 à 170 minutes, p = 0,007); dans le cas des résections majeures, on a noté une tendance à la diminution de la durée de l'intervention (de 318 à 238 minutes, p = 0,07). En outre, un plus grand nombre d'interventions ont été effectuées pour des cas de cancer dans le groupe B que dans le groupe A (36,8 % c. 84,0 %, p = 0,001). CONCLUSION: La résection hépatique laparoscopique peut être pratiquée de manière sécuritaire dans un hôpital d'enseignement communautaire canadien. La durée moyenne des interventions a diminué de 67 minutes, malgré une augmentation du double du nombre d'interventions effectuées pour des cas de cancer.

Lateral approach in laparoscopic distal pancreatectomy is safe and potentially beneficial compared to the traditional medial approach.

INTRODUCTION: Laparoscopic distal pancreatectomy has become widely accepted for the treatment of left-sided pancreatic lesions. Traditionally, a medial laparoscopic distal pancreatectomy (MDLP) has been employed, with division of the gland followed by medial to lateral mobilization. Recent technical reports of lateral laparoscopic distal pancreatectomy (LLDP) suggest that it offers easier access and more precise dissection. Data on this technique remain sparse and inconclusive, with no formal comparison with MLDP. We sought to compare outcomes of LLDP to MLDP. METHODS: We reviewed the charts of patients undergoing laparoscopic distal pancreatectomy at two academic institutions, from July 2009 to June 2013. Primary outcomes were operating time and estimated blood loss. Secondary outcomes included success of spleen-preserving procedures, length of sacrificed pancreas parenchyma, margins status, 30-day major morbidity (Clavien grade 3-5 complications), and length of stay. We reported data as proportions and medians. We performed comparative analysis using Chi square test or Fisher's exact test for categorical variables, and Mann-Whitney U test for continuous variables. RESULTS: We retrieved 43 cases (19 LLDP, 24 MLDP). Median operative time was shorter (166 vs 190 min; p = 0.03) and estimated blood loss lower (50 vs 250 mL; p < 0.01) with LLDP. No margin was positive with LLDP compared to 2 (8.3%) with MLDP. Major morbidity did not differ (LLDP 21.0% vs MLDP 25.0%; p = 0.76). Trends toward lower conversion rate (16.7 vs 5.3%; p = 0.36) and shorter length of stay (5 vs 4 days; p = 0.35) were not significant. CONCLUSION: LLDP is a feasible and safe approach for distal lesions of the pancreatic tail, associated with shorter operative time and decreased blood loss compared to traditional MLDP. Potential of decreased conversion rate and length of stay exists. These hypotheses need to be confirmed in larger prospective studies.

Laparoscopic pancreatectomy: indications and outcomes.

The application of minimally invasive approaches to pancreatic resection for benign and malignant diseases has been growing in the last two decades. Studies have demonstrated that laparoscopic distal pancreatectomy (LDP) is feasible and safe, and many of them show that compared to open distal pancreatectomy, LDP has decreased blood loss and length of hospital stay, and equivalent post-operative complication rates and short-term oncologic outcomes. LDP is becoming the procedure of choice for benign or small low-grade malignant lesions in the distal pancreas. Minimally invasive pancreaticoduodenectomy (MIPD) has not yet been widely adopted. There is no clear evidence in favor of MIPD over open pancreaticoduodenectomy in operative time, blood loss, length of stay or rate of complications. Robotic surgery has recently been applied to pancreatectomy, and many of the advantages of laparoscopy over open surgery have been observed in robotic surgery. Laparoscopic enucleation is considered safe for patients with small, benign or low-grade malignant lesions of the pancreas that is amenable to parenchyma-preserving procedure. As surgeons' experience with advanced laparoscopic and robotic skills has been growing around the world, new innovations and breakthrough in minimally invasive pancreatic procedures will evolve.

Quantifying the incidence and impact of postoperative prolonged alveolar air leak after pulmonary resection.

OBJECTIVE: Prolonged alveolar air leak (PAAL) is a frequent occurrence after lobectomy or lesser resections. The resulting complications and their impact are not well understood. Our aims are to prospectively determine the incidence and severity of PAAL after pulmonary resection using the Thoracic Morbidity & Mortality classification system and to identify risk factors. METHODS: A prospective collection of Thoracic Morbidity & Mortality data was performed for all consecutive pulmonary resections (n = 380; January 2008 to April 2010). Demographics, comorbidities, and preoperative cardiopulmonary assessment were retrospectively identified. The incidence and severity (grades I-V) of burden from PAAL were quantified using the Ottawa Thoracic Morbidity & Mortality system. Risk factors for PAAL and severe PAAL (defined as leading to major intervention, organ failure, or death) were sought with univariate and multivariate analyses. RESULTS: The incidences of PAAL and severe PAAL were 18% and 4.8%, respectively. PAAL prolonged the median hospital stay by 4 days. The majority of complications associated with PAAL were limited to pulmonary and pleural categories (90%). Significant predictors of PAAL from multivariate analysis include severe radiologic emphysema (odds ratio [OR], 2.8; confidence interval [CI], 1.2-6.2), histopathologic emphysema (OR, 1.9; CI, 1.1-3.6), percentage of predicted value for forced expiratory volume in 1 second less than 80% (OR, 1.9; CI, 1.1-3.3), and lobectomy (OR, 4.9; CI, 1.-14.1). Risk factors for severe PAAL include radiologic emphysema, percentage of predicted value for forced expiratory volume in 1 second less than 80%, forced expiratory volume in 1 second/forced vital capacity ratio less than 70%, and intraoperative difficulties (P < .05). CONCLUSIONS: PAAL leads to longer hospital stays, and approximately 4.8% of patients undergoing pulmonary resection experience PAAL that necessitates placement of additional chest drains, bronchoscopy, reoperation, or life support. Further study is required to assess the cost-effectiveness of measures to reduce PAAL.

The long-term gastrointestinal functional outcomes following curative anterior resection in adults with rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Significant variability and a lack of transparency exist in the reporting of anterior resection outcomes. OBJECTIVES: This study aimed to qualitatively analyze the long-term functional outcomes and assessment tools used in evaluating patients with rectal cancer following anterior resection, to quantify the incidence of these outcomes, and to identify risk factors for long-term incontinence. DATA SOURCES: MEDLINE, Embase, and CINAHL were searched using the terms rectal neoplasms, resection, and gastrointestinal function. STUDY SELECTION: The studies included were in English and evaluated adults with rectal cancer, curative anterior resection, and a minimum 1-year follow-up. Patients with recurrent/metastatic disease were excluded. Of the 805 records identified, 48 articles were included. INTERVENTION: The intervention performed was anterior resection. MAIN OUTCOME MEASURES: The main outcome measure was incontinence (gas, liquid stool, and solid stool). RESULTS: The histories of 3349 patients from 17 countries were summarized. Surgeries were conducted between 1978 to 2004 with a median follow-up of 24 months (interquartile range, 12, 57). Sixty-five percent of studies did not use a validated assessment tool. Reported outcomes and incidence rates were variable. The reported proportion of patients with incontinence ranged from 3.2% to 79.3%, with a pooled incidence of 35.2% (95% CI 27.9, 43.3). Risk factors for incontinence, identified by meta-regression, were preoperative radiation 0.009 and, in particular, short-course radiation (P = .006), and study quality (randomized controlled trial P = .004, observational P = .006). LIMITATIONS: The meta-analysis was limited by the significant heterogeneity of the primary data. CONCLUSIONS: Functional outcomes are inconsistently assessed and reported and require common definitions, and the more regular use of validated assessment tools, as well. Preoperative radiation and, in particular, short-course radiation may be a strong risk factor for incontinence; however, further studies are needed.

Ultrasonic vocalizations induced by sex and amphetamine in M2, M4, M5 muscarinic and D2 dopamine receptor knockout mice.

Adult mice communicate by emitting ultrasonic vocalizations (USVs) during the appetitive phases of sexual behavior. However, little is known about the genes important in controlling call production. Here, we study the induction and regulation of USVs in muscarinic and dopaminergic receptor knockout (KO) mice as well as wild-type controls during sexual behavior. Female mouse urine, but not female rat or human urine, induced USVs in male mice, whereas male urine did not induce USVs in females. Direct contact of males with females is required for eliciting high level of USVs in males. USVs (25 to120 kHz) were emitted only by males, suggesting positive state; however human-audible squeaks were produced only by females, implying negative state during male-female pairing. USVs were divided into flat and frequency-modulated calls. Male USVs often changed from continuous to broken frequency-modulated calls after initiation of mounting. In M2 KO mice, USVs were lost in about 70-80% of the mice, correlating with a loss of sexual interaction. In M5 KO mice, mean USVs were reduced by almost 80% even though sexual interaction was vigorous. In D2 KOs, the duration of USVs was extended by 20%. In M4 KOs, no significant differences were observed. Amphetamine dose-dependently induced USVs in wild-type males (most at 0.5 mg/kg i.p.), but did not elicit USVs in M5 KO or female mice. These studies suggest that M2 and M5 muscarinic receptors are needed for male USV production during male-female interactions, likely via their roles in dopamine activation. These findings are important for the understanding of the neural substrates for positive affect.