Prognostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet-neutrophil (PN) index in locally advanced rectal cancer patients: a retrospective cohort study.

Introduction: In locally advanced rectal cancers (LARC), tumour node metastasis (TNM) staging is far from optimal. The authors aimed to investigate the value of previously described circulating biomarkers as predictors of prognosis. Methods: Retrospective analysis of 245 LARC patients diagnosed between January 2010 and December 2022, who underwent neoadjuvant chemoradiotherapy and surgery at two centres. A Cox regression and Kaplan-Meier analysis were performed. Results: Post-treatment platelet-to-lymphocyte ratio (PLR) predicted pathological complete response. The neutrophil-to-lymphocyte ratio (NLR) in two timepoints of the treatment significantly predicted overall survival, whereas the platelet-neutrophil (PN) index significantly predicted disease-free survival. In pathological stage II, the PN index predicted patients with a higher risk of disease-free survival. Conclusion: Blood parameters might allow the definition of subgroups of risk beyond TNM for the application of different therapeutic strategies.

Application of artificial intelligence in predicting malignancy risk in breast masses on ultrasound / Aplicação de inteligência artificial na predição de risco de malignidade em nódulos mamários na ultrassonografia

Abstract Objective: To evaluate the results obtained with an artificial intelligence-based software for predicting the risk of malignancy in breast masses from ultrasound images. Materials and Methods: This was a retrospective, single-center study evaluating 555 breast masses submitted to percutaneous biopsy at a cancer referral center. Ultrasonographic findings were classified in accordance with the BI-RADS lexicon. The images were analyzed by using Koios DS Breast software and classified as benign, probably benign, low to intermediate suspicion, high suspicion, or probably malignant. The histological classification was considered the reference standard. Results: The mean age of the patients was 51 years, and the mean mass size was 16 mm. The radiologist evaluation had a sensitivity and specificity of 99.1% and 34.0%, respectively, compared with 98.2% and 39.0%, respectively, for the software evaluation. The positive predictive value for malignancy for the BI-RADS categories was similar between the radiologist and software evaluations. Two false-negative results were identified in the radiologist evaluation, the masses in question being classified as suspicious by the software, whereas four false-negative results were identified in the software evaluation, the masses in question being classified as suspicious by the radiologist. Conclusion: In our sample, the performance of artificial intelligence-based software was comparable to that of a radiologist.

Resumo Objetivo: O objetivo deste trabalho foi avaliar os resultados de um software baseado em algoritmo de inteligência artificial para predição do risco de malignidade em nódulos mamários. Materiais e Métodos: Estudo retrospectivo e unicêntrico que avaliou 555 nódulos mamários submetidos a biópsia percutânea em um centro de referência oncológico. Os achados ultrassonográficos foram classificados de acordo com o léxico do BI-RADS. As imagens foram analisadas pelo software Koios DS Breast e divididas em benigna ou provavelmente benigna, suspeita baixa ou intermediária, suspeita alta ou provavelmente maligna. O resultado histopatológico foi considerado como padrão ouro. Resultados: A média de idade das pacientes foi de 51 anos e o tamanho médio dos nódulos foi de 16 mm. A sensibilidade e a especificidade foram de 99,1% e 34,0% para o radiologista e 98,2% e 39,0% para o software, respectivamente. O valor preditivo positivo para malignidade para as categorias BIRADS foi semelhante para o radiologista e para o software. Foram identificados dois resultados falso-negativos na avaliação pelo radiologista que foram classificados como suspeitos pelo software, e quatro resultados falso-negativos na avaliação pelo software que foram classificados como suspeitos pelo radiologista. Conclusão: Na nossa amostra, o software de inteligência artificial demonstrou resultados comparáveis à avaliação pelo radiologista.

Evaluation of ctDNA in the Prediction of Response to Neoadjuvant Therapy and Prognosis in Locally Advanced Rectal Cancer Patients: A Prospective Study.

"Watch and wait" is becoming a common treatment option for patients with locally advanced rectal cancer (LARC) submitted to neoadjuvant treatment. However, currently, no clinical modality has an acceptable accuracy for predicting pathological complete response (pCR). The aim of this study was to assess the clinical utility of circulating tumor DNA (ctDNA) in predicting the response and prognosis in these patients. We prospectively enrolled a cohort of three Iberian centers between January 2020 and December 2021 and performed an analysis on the association of ctDNA with the main response outcomes and disease-free survival (DFS). The rate of pCR in the total sample was 15.3%. A total of 24 plasma samples from 18 patients were analyzed by next-generation sequencing. At baseline, mutations were detected in 38.9%, with the most common being TP53 and KRAS. Combination of either positive magnetic resonance imaging (MRI) extramural venous invasion (mrEMVI) and ctDNA increased the risk of poor response (p = 0.021). Also, patients with two mutations vs. those with fewer than two mutations had a worse DFS (p = 0.005). Although these results should be read carefully due to sample size, this study suggests that baseline ctDNA combined with mrEMVI could potentially help to predict the response and baseline ctDNA number of mutations might allow the discrimination of groups with different DFS. Further studies are needed to clarify the role of ctDNA as an independent tool in the selection and management of LARC patients.

Application of artificial intelligence in predicting malignancy risk in breast masses on ultrasound.

Objective: To evaluate the results obtained with an artificial intelligence-based software for predicting the risk of malignancy in breast masses from ultrasound images. Materials and Methods: This was a retrospective, single-center study evaluating 555 breast masses submitted to percutaneous biopsy at a cancer referral center. Ultrasonographic findings were classified in accordance with the BI-RADS lexicon. The images were analyzed by using Koios DS Breast software and classified as benign, probably benign, low to intermediate suspicion, high suspicion, or probably malignant. The histological classification was considered the reference standard. Results: The mean age of the patients was 51 years, and the mean mass size was 16 mm. The radiologist evaluation had a sensitivity and specificity of 99.1% and 34.0%, respectively, compared with 98.2% and 39.0%, respectively, for the software evaluation. The positive predictive value for malignancy for the BI-RADS categories was similar between the radiologist and software evaluations. Two false-negative results were identified in the radiologist evaluation, the masses in question being classified as suspicious by the software, whereas four false-negative results were identified in the software evaluation, the masses in question being classified as suspicious by the radiologist. Conclusion: In our sample, the performance of artificial intelligence-based software was comparable to that of a radiologist.

Objetivo: O objetivo deste trabalho foi avaliar os resultados de um software baseado em algoritmo de inteligência artificial para predição do risco de malignidade em nódulos mamários. Materiais e Métodos: Estudo retrospectivo e unicêntrico que avaliou 555 nódulos mamários submetidos a biópsia percutânea em um centro de referência oncológico. Os achados ultrassonográficos foram classificados de acordo com o léxico do BI-RADS. As imagens foram analisadas pelo software Koios DS Breast e divididas em benigna ou provavelmente benigna, suspeita baixa ou intermediária, suspeita alta ou provavelmente maligna. O resultado histopatológico foi considerado como padrão ouro. Resultados: A média de idade das pacientes foi de 51 anos e o tamanho médio dos nódulos foi de 16 mm. A sensibilidade e a especificidade foram de 99,1% e 34,0% para o radiologista e 98,2% e 39,0% para o software, respectivamente. O valor preditivo positivo para malignidade para as categorias BIRADS foi semelhante para o radiologista e para o software. Foram identificados dois resultados falso-negativos na avaliação pelo radiologista que foram classificados como suspeitos pelo software, e quatro resultados falso-negativos na avaliação pelo software que foram classificados como suspeitos pelo radiologista. Conclusão: Na nossa amostra, o software de inteligência artificial demonstrou resultados comparáveis à avaliação pelo radiologista.

ctDNA on liquid biopsy for predicting response and prognosis in locally advanced rectal cancer: A systematic review.

BACKGROUND: The management of locally advanced rectal cancer (LARC) requires a multidisciplinary approach, with an increasing interest for non-operative strategies. Liquid biopsy for obtaining circulating tumor DNA (ctDNA) can provide information on neoadjuvant chemoradiotherapy (nCRT) pathological response and cancer-specific prognosis, and therefore might be a promising guide for these treatments. METHODS: A systematic review of the studies available in literature has been performed to assess the role of ctDNA as a predictive and prognostic biomarker in LARC patients. RESULTS: We retrieved 21 publications, of which 17 full-text articles and 4 abstracts. Results have been labelled into two groups: predictive and prognostic. Data about the usefulness of liquid biopsy in this setting is still inconclusive. However, baseline higher levels of longer fragments of cell-free DNA and integrity index, tumor-specific mutations and certain methylated genes could predict non-responders. Also, undetectable baseline ctDNA and decrease of common rectal cancer mutations throughout treatment (dynamic monitoring) were predictive factors of pathological complete response. The continuous detection of ctDNA in different timepoints of treatment (minimal residual disease) was consistently associated with worse prognosis. CONCLUSIONS: ctDNA is a promising biomarker that could assist predicting treatment response to nCRT and prognosis in patients with LARC. The ideal methods and timings for the liquid biopsy still have to be defined.

Pityriasis rosea-like rash after COVID-19 vaccination with Oxford-AstraZeneca: a possible trigger?

Scholars around the world have dedicated themselves to developing an effective vaccine against SARS-CoV-2. However, vaccines have produced adverse effects in some patients. We report the case of a 44-year-old man who developed a pruritic papulosquamous rash on the trunk with a characteristic pattern known as Christmas tree after receiving the first dose of the Oxford-AstraZeneca COVID-19 vaccine, similar to pityriasis rosea (PR). He had no previous symptoms of viral infection and tested negative for neutralizing antibodies (enzyme immunoassay) against COVID-19. There are few reports in the literature about the relationship between the onset of cutaneous adverse reactions and the Oxford-AstraZeneca vaccine, therefore, the dissemination of this case is of paramount importance.

Can pretreatment blood biomarkers predict pathological response to neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer?

Aims: To investigate the value of previously described pretreatment hematological and biochemical biomarkers as predictors of pathological response. Methods: The authors performed a retrospective analysis of 191 patients with locally advanced rectal cancer who underwent long-course neoadjuvant chemoradiotherapy at two Portuguese centers. The authors performed logistic regression analysis to search for predictive markers of pathological complete and good response. Results: High platelet-neutrophil index (p = 0.042) and clinical tumor stage >2 (p = 0.015) were predictive of poor response. None of the analyzed biomarkers predicted pathological complete response in this study. Conclusion: A high platelet-neutrophil index before neoadjuvant chemoradiotherapy could help predict poorer pathological response in patients with locally advanced rectal cancer. However, no other blood biomarker predicted incomplete or poor response in this study.

Translation and validation of the Simplified Psoriasis Index (SPI) into Brazilian Portuguese

Abstract: Background: The Simplified Psoriasis Index is a tool that assesses the current severity, psychosocial impact, past history and interventions in patients with psoriasis through separate components. Two versions are available, one in which the current severity of the disease is evaluated by the patient themselves and another by the physician. Objectives: Translate the Simplified Psoriasis Index into Brazilian Portuguese and verify its validity. Methods: The study was conducted in two stages; the first stage was the translation of the instrument; the second stage was the instrument's validation. Results: We evaluated 62 patients from Complexo Hospitalar Santa Casa de Porto Alegre and Hospital Universitário de Brasília. The Simplified Psoriasis Index translated into Portuguese showed high internal consistency (Cronbach test 0.68). Study limitations: Some individuals, because of poor education, might not understand some questions of the Simplified Psoriasis Index. Conclusions: The Brazilian Portuguese version of the Simplified Psoriasis Index was validated for our population and can be recommended as a reliable instrument to assess the patients with psoriasis.

Translation and validation of the Simplified Psoriasis Index (SPI) into Brazilian Portuguese.

BACKGROUND: The Simplified Psoriasis Index is a tool that assesses the current severity, psychosocial impact, past history and interventions in patients with psoriasis through separate components. Two versions are available, one in which the current severity of the disease is evaluated by the patient themselves and another by the physician. OBJECTIVES: Translate the Simplified Psoriasis Index into Brazilian Portuguese and verify its validity. METHODS: The study was conducted in two stages; the first stage was the translation of the instrument; the second stage was the instrument's validation. RESULTS: We evaluated 62 patients from Complexo Hospitalar Santa Casa de Porto Alegre and Hospital Universitário de Brasília. The Simplified Psoriasis Index translated into Portuguese showed high internal consistency (Cronbach test 0.68). STUDY LIMITATIONS: Some individuals, because of poor education, might not understand some questions of the Simplified Psoriasis Index. CONCLUSIONS: The Brazilian Portuguese version of the Simplified Psoriasis Index was validated for our population and can be recommended as a reliable instrument to assess the patients with psoriasis.

The open abdomen: analysis of risk factors for mortality and delayed fascial closure in 101 patients.

INTRODUCTION: The core concepts of damage control and open abdomen in trauma surgery have been expanding for emergent general surgery. Temporary closures allow ease of access to the abdominal cavity for source control.The aim of the current study was to assess the outcomes of patients who underwent open abdomen management for acute abdominal conditions and evaluate risk factors for worse outcomes and inability of fascial closure during the initial hospitalization. METHODS: We conducted a retrospective analysis of 101 patients submitted to laparostomy in a single institution from January 2009 to March 2017. The evaluated outcomes were mortality, local morbidity, and rate of primary fascial closure. RESULTS: The most common indications for open abdomen were bowel perforation, bowel ischemia, and necrotizing pancreatitis. Global in-hospital mortality rate was 62.4%. For the 37 patients discharged from the hospital, a definitive abdominal closure was attained in 28.Multivariable logistic regression analysis revealed that people older than 60 years of age and with Acute Physiology and Chronic Health Evaluation (APACHE II) scores over 18.5 had higher in-hospital mortality rates. Definitive fascial closure was statistically associated with a lower number of re-interventions and ICU stay. CONCLUSIONS: Open abdomen management may be appropriate in these critically ill patients; however, it continues to be associated with significantly high mortality, especially in elder patients and with higher APACHE II scores. Recognition of risk factors for fascia closure failure should promote the investigation for a tailored surgical approach in these patients.

Validation of a Difficulty Grading Score in Laparoscopic Splenectomy.

INTRODUCTION: Laparoscopic splenectomy (LS) is the gold standard for the treatment of many spleen-related disorders. However, in the presence of splenomegaly, the rate of conversion to open surgery can be as high as 33.9% and is associated with longer operative times and higher costs. In an attempt to improve risk stratification and patient selection for LS, a score that includes four preoperative parameters (age, gender, diagnosis, and spleen size) has been developed. The aim was the validation of a difficulty grading score, in predicting conversion and poorer outcomes. METHODS: Retrospective analysis of 153 consecutive patients subjected to LS from January 2006 through December 2016 was performed. Several parameters were reviewed and correlation with evaluated outcomes was analyzed. RESULTS: Conversion to open surgery occurred in 13 (8.50%) patients and was highly associated with serious intraoperative complications. Spearman correlation showed a significant association between the score and risk of conversion, operative time, and postoperative complications, but not with intraoperative bleeding. DISCUSSION: Patient and disease features, incorporated in a difficulty grading score, can reliably determine the difficulty of LS and predict risk of conversion, intraoperative, and postoperative complications. This simple and reproducible score improves risk stratification for LS and could be practical in daily clinical activities.

Mixed Adenoneuroendocrine Carcinoma Causing Colonic Intussusception.

Colonic intussusception is a rare cause of intestinal obstruction in adults and is caused by a malignant lesion in about 70% of cases. Early diagnosis and treatment are essential. We present a 64-year-old male patient with right colonic intussusception caused by a mixed adenoneuroendocrine carcinoma (MANEC), presenting as a giant pedunculated polyp (54 mm of largest diameter). The patient underwent right colectomy with primary anastomosis and adjuvant chemotherapy. The diagnosis of intussusception of the colon in adults is difficult because of its rarity and nonspecific clinical presentation. In this case, the cause was a rare histological type malignant tumor (MANEC).

Gallstones and Bariatric Surgery: To Treat or Not to Treat?

BACKGROUND: Obesity and rapid weight loss after bariatric surgery are risk factors for gallstone disease. OBJECTIVES: The present study sought to evaluate the feasibility of selective concomitant cholecystectomy only in patients with symptomatic disease and study risk factors for the development of symptomatic gallstones after bariatric surgery. METHODS: Between January 2010 and December 2012, 734 consecutive patients presenting to our institution underwent bariatric surgery. From these, 81 patients were excluded due to prior or concurrent cholecystectomy. The remaining 653 patients with in situ gallbladder were followed for 12 months and were clinically screened for symptomatic or complicated cholelithiasis. Clinical and demographic characteristics were compared at baseline and 12 months after surgery. RESULTS: Of the 653 patients with in situ gallbladder, only 24 (3.3 %) developed symptomatic gallstones and only nine presented complicated disease. None of the patients with asymptomatic disease at the time of surgery progressed to symptomatic or complicated disease. Patients who developed symptomatic disease were not significantly different, although there was a trend toward longer obesity evolution, lower insulin levels, and lower hepatic enzymes level. A multivariate regression analysis revealed that patients with gastric sleeve were more likely to develop symptomatic gallstones. CONCLUSIONS: Although further studies are required, the management of gallstones in morbidly obese patients should not be different from normal-weight patients. Therefore, performing a laparoscopic cholecystectomy only in symptomatic patients is an effective approach and asymptomatic gallstones should not be treated at the time of bariatric surgery.

Efficacy of Triamcinolone Hexacetonide versus Methylprednisolone Acetate Intraarticular Injections in Knee Osteoarthritis: A Randomized, Double-blinded, 24-week Study.

OBJECTIVE: Intraarticular (IA) corticosteroid injections are broadly used in knee osteoarthritis (OA); however, the best corticosteroid agent is not well defined. The aim of the present study was to compare the efficacy of triamcinolone hexacetonide (TH) and methylprednisolone acetate (MA) injections in knee OA. METHODS: Patients with symptomatic knee OA and Kellgren-Lawrence grade II or III were randomized to receive 40 mg of IA TH or MA. Evaluations were performed at 4, 12, and 24 weeks. The primary outcome was a change in the patient's assessment of pain by visual analog scale from baseline to Week 4. Secondary outcomes included a global assessment of the disease by patients and physicians, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne index (LI), and Outcome Measures in Rheumatology Clinical Trials and Osteoarthritis Research Society International (OMERACT-OARSI) criteria of response. Generalized estimating equations were used in statistical analysis. RESULTS: The intention-to-treat population included 100 patients; 50 in each study arm. A significant improvement in pain was observed at Week 4 for both groups (p < 0.0001), with no difference between them (p = 0.352). This improvement was sustained up to Week 24. A significant improvement from the baseline was observed for both the patient's and the physician's global assessments, WOMAC questionnaire, and LI, with no differences between the groups. Improvements in the secondary outcomes were sustained during the study. The OMERACT-OARSI criteria of response was achieved by 74% and 72% of patients in the TH and the MA groups, respectively. CONCLUSION: Both IA therapies are equally effective, and improvement in pain and function can be sustained for up to 24 weeks. Controlled-trials.com identifier: ISRCTN15077843.

Nonrecurrent Laryngeal Nerve and Associated Anatomical Variations: The Art of Prediction.

INTRODUCTION: A nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variation in which the nerve enters the larynx directly off the cervical vagus nerve. CASE REPORT: We present 2 patients who underwent thyroid surgery for benign disease. Intraoperatively, type 2a and 1 NRLN were identified. Due to the frequent association with a vascular abnormality, an ultrasound and a computed tomography were performed which showed a right aberrant subclavian artery with a retroesophageal course and a common trunk of the common carotids in both patients. DISCUSSION AND CONCLUSION: The presence of an NRLN is a major risk during surgical procedures and the surgeon should be aware of the possibility of its existence. NRLN may be associated with rare vascular anomalies, such as arteria lusoria and a bicarotid trunk. This paper reveals this association in 2 patients for the first time.

Management of complications of injectable silicone.

Soft tissue augmentation is a common procedure, and a wide variety of injectable fillers are used. Liquid injectable silicone (LIS) was the first highly popularized injectable filler. LIS is a permanent filler and can be used in the correction of facial furrows and wrinkles. Some complications are inherent to the procedure and can resolve spontaneously, such as redness, swelling, and immediate hypersensitivity reactions. Unintended reactions, such as granulomas, infections, vascular occlusion, can also follow the treatment with LIS and may appear several years after the injections. These can be difficult to manage, show little or no tendency to spontaneous resolutions, and rarely resolve completely. Injecting physicians must be aware of these potential complications caused by LIS because early medical care and treatment, including psychological support for these patients, can minimize the consequences for patients and physicians, and may also help obtaining better outcomes when treating complications.

Phaeohyphomycosis of the ungual apparatus - case report.

Phaeohyphomycosis is a disease caused by dematiaceous fungi with a worldwide geographic distribution and broad spectrum. It is most commonly found in adult individuals of both genders and all races. We report the case of a 57-year-old woman with phaeohyphomycosis in the ungual apparatus.

Phaeohyphomycosis of the ungual apparatus - Case report

Phaeohyphomycosis is a disease caused by dematiaceous fungi with a worldwide geographic distribution and broad spectrum. It is most commonly found in adult individuals of both genders and all races. We report the case of a 57-year-old woman with phaeohyphomycosis in the ungual apparatus.

Late reaction to ustekinumab infusion.

Psoriasis is a chronic inflammatory disease that directly affects the quality of life. Biologics are prescribed for patients unresponsive to conventional treatments and with severe forms of the disease. Ustekinumab is a fully human monoclonal antibody against the p40 subunit of interleukins 12/23 that is being used with satisfactory responses, achieving an improvement in the baseline Psoriasis Area and Severity Index of approximately 75% after 12 weeks of treatment. It has few side effects, including grater susceptibility to infections and development of reactions to the drug. Our report discusses a case of a cutaneous reaction to the use of ustekinumab in a 27 year-old male patient after the third dose of the medication. No similar case has been reported in the literature.

Aortic isthmus blood flow in fetuses of diabetic mothers.

OBJECTIVE: To test the hypothesis that the aortic isthmus flow index (IFI) is lower in fetuses of diabetic mothers than in fetuses of nondiabetic mothers. STUDY DESIGN: We performed a cross-sectional observational study to assess the IFI in fetuses, with (n = 13) and without (n = 37) myocardial hypertrophy, of mothers with diabetes mellitus and in fetuses of nondiabetic mothers (n = 23). Analysis of variance and Tukey test were used to assess differences among the groups. RESULTS: There were no differences in maternal or gestational age among the groups. In fetuses of diabetic mothers, the mean IFI in fetuses with myocardial hypertrophy was 1.19 ± 0.06, and in fetuses without it was 1.18 ± 0.09. The mean IFI in fetuses of nondiabetic mothers was 1.32 ± 0.07 (P < 0.001). CONCLUSIONS: The IFI in fetuses of diabetic mothers is lower than in fetuses of nondiabetic mothers, possibly as a result of a decreased left ventricular compliance.