Purpose
The newly introduced erector spinae plane block (ESPB) has given anesthesiologists an alternative regional anesthetic technique for thoracic analgesia. Although ESPB and retrolaminar block ...(RLB) have similar puncture sites, no clinical study comparing ESPB and RLB has been reported. The aim of this study was to compare ESPB and RLB in terms of analgesic efficacy in the context of multimodal analgesia following breast surgery.
Methods
Fifty female patients undergoing breast surgery under general anesthesia were randomly allocated to receive either ultrasound-guided ESPB or RLB with 20 mL of 0.375% levobupivacaine for postoperative analgesia. The primary outcome was analgesic efficacy in terms of time to first postoperative rescue analgesic after the block procedure. The secondary outcomes were consumption of remifentanil during anesthesia, pain intensity at rest for 24 h postoperatively, and occurrence of postoperative nausea and vomiting (PONV).
Results
After excluding five patients, 45 patients (22 and 23 patients in the ESPB and RLB group, respectively) were analyzed. Median time until the first postoperative rescue analgesic after the block procedure in the ESPB group was not significantly longer than that in the RLB group (8.6 range 2.7–24 vs. 4.8 3.0–24 h;
P
= 0.83). There was no significant difference in the consumption of remifentanil during anesthesia, pain intensity at rest for 24 h postoperatively, and occurrence of PONV between the two groups.
Conclusion
ESPB is equivalent, and not superior, to RLB for postoperative analgesia after breast surgery when 20 mL of 0.375% levobupivacaine is injected at the fourth thoracic vertebra.
Several surgical procedures for chronically ruptured Achilles tendons have been reported. Resection of the interposed scar tissue located between the tendon stumps and reconstruction using normal ...autologous tissue have been well described. We developed a direct repair procedure that uses scar tissue, which obviates the need to use normal autologous tissue.
Thirty consecutive patients with Achilles tendon ruptures with a delay in diagnosis of >4 weeks underwent removal of a section of scar and healing tissue with direct primary suture of the ends of the tendon without the use of allograft or autograft. Patients were followed for a mean time of 33 months. Preoperative and postoperative clinical outcomes were measured with the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, the patients underwent preoperative and postoperative functional measurements and magnetic resonance imaging. Lastly, we evaluated the histology of the interposed healing tissue.
The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. At the time of the latest follow-up, none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Preoperative T2-weighted magnetic resonance imaging showed that 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative T2-weighted magnetic resonance imaging findings included fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers.
Shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
It is unknown whether postoperative incomplete reduction of the sesamoids is a risk factor for the recurrence of hallux valgus. The purpose of the present study was to clarify the relationship ...between the postoperative relative sesamoid position and the recurrence of hallux valgus.
Dorsoplantar weight-bearing radiographs of sixty normal feet (the control group) and sixty-five feet with hallux valgus (the hallux valgus group) in a study of adult women were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs were assessed preoperatively, at the early follow-up interval (at a mean of 3.1 months), and at the most recent follow-up interval (at a mean of forty-five months). The position of the medial sesamoid was classified with a grading system ranging from I through VII as described by Hardy and Clapham. In the feet with hallux valgus, we defined a grade of IV or less as the normal position of the medial sesamoid (the normal-position group) and grade V or greater as lateral displacement of the sesamoid (the displacement group).
Fifty feet (83%) in the control group were classified as grade IV or less and ten, as grade V. All feet in the hallux valgus group were classified as grade V or greater preoperatively, forty-eight feet (74%) were classified as grade IV or less at the early follow-up evaluation, and forty-two feet (65%) were classified as grade IV or less at the most recent follow-up evaluation. The average hallux valgus angle in the hallux valgus group was 38.3 degrees (range, 25 degrees to 60 degrees ) preoperatively, 11.9 degrees (range, 4 degrees to 28 degrees ) at the time of the early follow-up, and 13.9 degrees (range, 0 degrees to 33 degrees ) at the time of the most recent follow-up. There was no significant difference in the average hallux valgus angle between the early and most recent follow-up evaluations in the feet that were considered to be in the normal-position group at the time of the early follow-up (p = 0.084). In the feet that were considered to be in the displacement group at the time of the early follow-up, the average hallux valgus angle at the time of the most recent follow-up was significantly greater than that at the time of the early follow-up (19.5 degrees +/- 8.4 degrees compared with 15.0 degrees +/- 5.8 degrees ) (p = 0.0082). The feet that were in the displacement group at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus at that time than did those in the normal-position group (odds ratio, 10.0; 95% confidence interval, 2.75 to 36.33).
Postoperative incomplete reduction of the sesamoids can be a risk factor for the recurrence of hallux valgus. The identification of incomplete reduction of the sesamoids intraoperatively may allow modification of surgical procedures and improvement of the surgical results.
Background:
Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) ...injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments.
Hypothesis:
Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries.
Study Design:
Case series; Level of evidence, 4.
Methods:
Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated.
Results:
Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation.
Conclusion:
MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.
The prognosis of advanced pancreatic adenocarcinoma is still extremely poor. This study sought to determine the efficacy of, and immunological response to, peptide vaccination therapy in patients ...with this disease. In this multicenter randomized phase II study, patients with advanced pancreatic adenocarcinoma after gemcitabine and/or tegafur/gimeracil/oteracil were randomly assigned to 3 groups that each received a 2‐step treatment course. In Step 1, the groups received treatments of: (i) survivin 2B peptide (SVN‐2B) plus interferon‐β (IFNβ); (ii) SVN‐2B only; or (iii) placebo until the patients show progression. In Step 2, all patients who consented to participate received 4 treatments with SVN‐2B plus IFNβ. The primary endpoint was progression‐free survival (PFS) after initiation of Step 1 treatment. Secondary endpoints included immunological effects assessed by analysis of PBMCs after Step 1. Eighty‐three patients were randomly assigned to receive SVN‐2B plus IFNβ (n = 30), SVN‐2B (n = 34), or placebo (n = 19). No significant improvement in PFS was observed. Survivin 2B‐specific CTLs were found to be increased in the SVN‐2B plus IFNβ group by tetramer assay. Among patients who participated in Step 2, those who had received SVN‐2B plus IFNβ in Step 1 showed better overall survival compared with those who had received placebo in Step 1. Patients vaccinated with SVN‐2B plus IFNβ did not have improved PFS, but showed significant immunological reaction after vaccination. Subgroup analysis suggested that a longer SVN‐2B plus IFNβ vaccination protocol might confer survival benefit. (Clinical trial registration number: UMIN 000012146).
Randomized phase II trial of survivin 2B peptide vaccination for patients with HLA‐A24‐positive pancreatic adenocarcinoma is reported. Although peptide vaccination did not improved progression‐free survival, subgroup analysis revealed that longer peptide vaccination might confer survival benefit.
Detailed information regarding differences in plantar pressure distribution between hallux valgus and healthy feet is unavailable. The purposes of the present study were to clarify the ...characteristics of the plantar pressure distribution in patients with hallux valgus compared with healthy matched controls and to determine whether hallux valgus leads to dysfunction of the great toe during walking.
The study consisted of 25 patients with symptomatic moderate-to-severe hallux valgus (HV group) and 13 healthy matched volunteers (C group) without hallux valgus. All patients and volunteers were women. The HV and C groups did not differ significantly in age, height, weight, and body mass index. Plantar pressure during walking was measured using F-scan. The plantar aspect of the foot was divided into eight regions. The peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force time integral (FTI) were measured in each region.
The Peak-P of the great toe did not differ significantly between the HV and C groups. However, all other parameters: Max-F, Con-T, Con-A, and FTI of the great toe in the HV group were significantly lower than in the C group. In the central forefoot, the Peak-P and Max-F in the HV group were significantly higher than in the C group.
The present study demonstrated that a moderate-to-severe hallux valgus deformity leads to dysfunction of the great toe during walking and may increase mechanical loading on the central forefoot.
In clinical practice, drains had been routinely used for reducing seroma formation after breast surgery. However, an optimal timing to remove drains does not identify yet.
This study aimed to compare ...the clinical outcome, such as seroma formation, surgical site infection (SSI), and a length of hospital stay between early removal and late removal. A systematic review was performed using PubMed, MEDLINE, and the Cochrane Library. Breast cancer patients who received surgery using drains were eligible. Those parameters were compared between early vs late removal.
Eleven studies included in this meta-analysis. Seroma formation in the early removal group was significantly higher than the one in the late removal group (RR = 1.58: 95%CI 1.25-2.01, P = 0.0001), meanwhile no significant difference was found among the groups for SSI (RR = 0.82: 95%CI 0.51-1.31, P= 0.40). A length of hospital stay in the early removal group was also significantly shorter than late removal (RR -3.31: 95%CI -5.13-1.49, P = 0.0004).
Seroma formation was significantly higher in patients who had early drain removal. Conversely, SSI incidence was low, and early removal did not increase SSI incidence. In conclusion, early drain removal has no proved clinical benefit in these settings besides reduction of hospital stays.
Human endoplasmic reticulum oxidoreductin 1‐α (hERO1‐α) is an oxidizing enzyme that exists in the endoplasmic reticulum and its expression is augmented under hypoxia. It regulates a redox state of ...various kinds of protein through reoxidation of “client” protein disulfide isomerase. Interestingly, although the expression of hERO1‐α in normal tissues was comparatively limited, various types of cancer cells expressed it in large amounts. Therefore, we examined the role of ERO1‐α in tumor growth using murine breast cancer line 4T1 and found that knockdown of murine ERO1‐α inhibited in vivo tumor growth and decreased lung metastasis compared with wild‐type 4T1. Moreover, we investigated the relationship between expression of hERO1‐α and prognosis in breast cancer patients. Seventy‐one patients with breast cancer who underwent surgery between 2005 and 2006 in Sapporo Medical University Hospital (Sapporo, Japan) were analyzed in this study. Significant differences were found between the hERO1‐α‐positive group (n = 33) and hERO1‐α‐negative group (n = 38) in nuclear grade (P < 0.001) and intrinsic subtype (P = 0.021) in univariate analysis. More importantly, in multivariate analysis of disease‐free survival by Cox regression, expression of hERO1‐α was the only independent prognosis factor (P = 0.035). Finally, in univariate survival analysis, patients positive for hERO1‐α had significantly shorter disease‐free survival and overall survival than those patients negative for hERO1‐α. These findings indicate that the expression of hERO1‐α in cancer cells is associated with poorer prognosis and thus can be a prognostic factor for patients with breast cancer.
CYP2D6 is the key enzyme responsible for the generation of the potent active metabolite of tamoxifen, "endoxifen." There are still controversial reports questioning the association between
genotype ...and tamoxifen efficacy. Hence, we performed a prospective multicenter study to evaluate the clinical effect of
genotype on tamoxifen therapy.
We enrolled 279 patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 to 28 days. Ki-67 response in breast cancer tissues after tamoxifen therapy was used as a surrogate marker for response to tamoxifen. We prospectively investigated the effects of allelic variants of
on Ki-67 response, pathological response, and hot flushes.
Ki-67 labeling index in breast cancer tissues significantly decreased after preoperative tamoxifen monotherapy (
= 0.0000000000000013). Moreover, proportion and Allred scores of estrogen receptor-positive cells in breast cancer tissues were significantly associated with Ki-67 response (
= 0.0076 and 0.0023, respectively). Although
variants were not associated with pathologic response nor hot flushes, they showed significant association with Ki-67 response after preoperative tamoxifen therapy (
= 0.018; between two groups, one with at least one wild-type allele and the other without a wild-type allele).
This is the first prospective study evaluating the relationship between
variants and Ki-67 response after tamoxifen therapy. Our results suggest that genetic variation in
is a key predictor for the response to tamoxifen in patients with breast cancer.
.
Survivin, a member of the inhibitor of apoptosis protein (IAP) family containing a single baculovirus IAP repeat domain, is highly expressed in cancerous tissues but not in normal counterparts. Our ...group identified an HLA‐A24‐restricted antigenic peptide, survivin‐2B80–88 (AYACNTSTL), that is recognized by CD8 + CTLs and functions as an immunogenic molecule in patients with cancers of various histological origins such as colon, breast, lung, oral, and urogenital malignancies. Subsequent clinical trials with this epitope peptide alone resulted in clinical and immunological responses. However, these were not strong enough for routine clinical use as a therapeutic cancer vaccine, and our previous study of colon cancer patients indicated that treatment with a vaccination protocol of survivin‐2B80–88 plus incomplete Freund's adjuvant (IFA) and α‐interferon (IFNα) conferred overt clinical improvement and enhanced the immunological responses of patients. In the current study, we further investigated whether this vaccination protocol could efficiently provide not only improved immune responses but also better clinical outcomes for advanced pancreatic cancers. Tetramer and enzyme‐linked immunosorbent spot analysis data indicated that more than 50% of the patients had positive clinical and immunological responses. In contrast, assessment of treatment with IFNα only to another group of cancer patients resulted in no obvious increase in the frequency of survivin‐2B80‐88 peptide‐specific CTLs. Taken together, our data clearly indicate that a vaccination protocol of survivin‐2B80‐88 plus IFA and IFNα is very effective and useful in immunotherapy for this type of poor‐prognosis neoplasm. This trial was registered with the UMIN Clinical Trials Registry, no. UMIN000000905. (Cancer Sci 2013; 104: 124–129)
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