Background Data on long-term blood pressure (BP) control after adrenalectomy for primary hyperaldosteronism are limited. We analyzed long-term outcomes to identify factors predictive of cure. Methods ...We performed a retrospective cohort study of patients undergoing adrenalectomy for primary hyperaldosteronism (1997–2013). BP and antihypertensive medications were assessed at long-term follow-up (≥12 months). Primary outcome was cure, defined as normotension off antihypertensives. Results Of 85 patients, 15.3% ( n = 13) were cured, 54.1% ( n = 46) were normotensive while remaining on anti-hypertensives, and 30.6% ( n = 26) were hypertensive. Younger age ( P = .011), female sex ( P < .001), lesser body mass index ( P = .018), shorter duration of hypertension ( P = .002), lower creatinine ( P = .001), and fewer preoperative antihypertensive medications ( P < .001) were associated with cure. Female sex, body mass index ≤25 kg/m2 , hypertension <5 years, creatinine ≤0.8 mg/dL, and <2 antihypertensives were incorporated into a scoring system. For a score of 0–1 ( n = 61) the cure rate was 3%; 100% of patients with a score of 4–5 ( n = 3) were cured. This scoring system performed comparably to the Aldosterone Resolution Score, which has been used to evaluate short-term postoperative outcomes. Conclusion This is the largest study to identify factors associated with long-term BP control after adrenalectomy and incorporate these into a scoring system. These data provide a potential tool to guide preoperative patient counseling.
Poorly differentiated thyroid carcinoma (PDTC) is an aggressive form of thyroid cancer that currently has limited effective treatment options. Immune checkpoint inhibitors (ICIs) have shown to be an ...effective treatment for a variety of carcinomas. In this study, we explore whether immune checkpoint pathways, such as programmed cell death ligand 1 (PD-L1) and indoleamine 2,3-dioxygenase 1 (IDO1), are activated in a cohort of patients with PDTC to determine whether ICIs may be an effective therapy for these patients. PDTC from 28 patients were stained for IDO1, PD-L1, and CD8 using immunohistochemistry. Staining was scored using an H-score, and PD-L1 and IDO1 expression was correlated with clinicopathologic characteristics. Positivity for PD-L1 and IDO1 was set at an H-score cutoff of five. Twenty-five percent (
n
= 7/28) of the PDTC were positive for PD-L1 expression. Twenty-nine percent (
n
= 2/7) of the PD-L1 positive PDTCs also co-expressed IDO1. The expression of PD-L1 in PDTC was significantly associated with tumor size and multifocality, with a non-significant trend towards associations with older age, extrathyroidal extension, presence of metastasis, higher stage, increased number of CD8+ T cells, and decreased disease-free and overall survival. PD-L1 expression occurs in a subset of PDTC, and is associated with a subset of clinical features of aggressive thyroid disease. Given the limited effective treatments for this patient population, consideration for ICIs as monotherapy or in combination with an IDO1 inhibitor should be explored as a novel treatment modality for patients with PDTC.
Abstract Background Primary leiomyosarcomas of the inferior vena cava (IVC) pose unique surgical challenges. Due to the rarity of the disease, little definitive data exists on prognosis and treatment ...options. Methods A pooled data analysis was performed on all cases of initial IVC leiomyosarcoma resection identified by literature search ( n = 371) and our institutional database ( n = 6). Kaplan–Meier and Cox regression analyses were performed to identify factors associated with disease-free survival (DFS) and overall survival (OS). Results Patients were predominantly female (76%, n = 286); the median age of presentation was 55 years. Five-year DFS and OS were 6% and 55%, respectively. Preoperative factors independently associated with decreased OS included older age (HR:1.05, 95% CI:1.00–1.09), larger tumor size (HR:1.14, 95% CI:1.04–1.24), resection of adjacent organ(s) (HR:3.62, 95% CI:1.34–9.77), and R2 resection (HR:7.80, 95% CI:1.94–32.05). Isolated involvement of the suprarenal infrahepatic IVC was associated with longer OS (HR:0.22, 95% CI:0.06–0.78). A scoring system incorporating independent predictors of OS stratified outcomes: score 4–5 ( n = 10, median OS 6 months), score 2–3 ( n = 88, median OS 23 months) compared to a score of 0–1 ( n = 44, median OS 29 months). Conclusions Following resection of IVC leiomyosarcomas, recurrence is a near certainty; long-term survival, however is possible. The dominant predictors of survival include margin status, tumor size and radical resection. These can be combined into a risk score that has prognostic value.
Parathyroidectomy in dialysis patients Kuo, Lindsay E., MD; Wachtel, Heather, MD; Karakousis, Giorgos, MD ...
The Journal of surgical research,
08/2014, Letnik:
190, Številka:
2
Journal Article
Recenzirano
Abstract Background The optimal surgical treatment for secondary hyperparathyroidism is not well defined. Subtotal parathyroidectomy and total parathyroidectomy (tPTX) with autotransplant are ...accepted options; treatment method is left to surgeon preference. We sought to describe different characteristics of patients with secondary hyperparathyroidism receiving surgical treatment and to compare outcomes between the two treatment strategies. Methods We conducted a retrospective cohort study of patients aged >18 y and on dialysis who received a parathyroidectomy (Current Procedural Terminology code = 60500) using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2008–2011). Procedures were classified as subtotal if no autotransplant was performed and total if autotransplant was performed. Descriptive statistics were performed. The primary outcome variable of interest was 30-day morbidity. Secondary outcome variables studied were operative time, postoperative length of stay (LOS), 30-day mortality, and 30-day readmission. Univariate analyses were performed. Results A total of 898 patients studied; of which, 236 patients (26.4%) received a tPTX and 662 (73.7%) received a subtotal parathyroidectomy. The median age was 49 y (interquartile range IQR: 38, 59), and majority of patients were American Society of Anesthesiologists class III (629, 70%). Nearly half of the patients were black (447, 49.8%); blacks were more likely to receive a tPTX than whites (30.2% versus 19.9%, P = 0.01). Median operative time (133 min, IQR: 92, 160 versus 120 min, IQR: 103, 181; P < 0.01) and median LOS (4 d, IQR: 3, 7 versus 4 d, IQR: 2, 6; P < 0.01) were longer after a tPTX. There was no difference in the 30-day morbidity, mortality, or readmission rates between the two treatments. Conclusions We used a national multi-institutional data set to show that despite the high-risk patient cohort and difference in operative duration, there is no difference in the more general postoperative complication rates.
Abstract Background Persistent and recurrent hyperparathyroidism necessitate reoperation, which is associated with increased procedure-specific complication rates. The effect of reoperative ...parathyroidectomy on more generalized outcomes is poorly understood. We sought to determine patient, provider, and perioperative characteristics associated with reoperation, as well as to determine the associated risks. Methods All patients receiving a parathyroidectomy in the American College of Surgeons National Surgical Quality Improvement Program database (2008–2011) were identified. Patients receiving initial parathyroidectomy were compared with those receiving reoperative parathyroidectomy. Descriptive statistics and univariate analyses were performed. Multivariate logistic regression models were developed for significant outcome measures. Results Of 9114 parathyroidectomies performed, 8738 (95.9%) were initial and 376 (4.1%) were reoperative. The annual rate of reoperation was 3.6%–4.8%. Patients undergoing reoperative parathyroidectomy were more likely to be obese (48.5 versus 40.0%, P = 0.009) and American Society of Anesthesiologist class 3 (40.7 versus 30.3%, P = 0.001) than patients undergoing initial parathyroidectomy. There was no difference in gender, age, or race. Reoperations had a longer median operative time (101 minimum, interquartile range IQR 74–146 versus 76 55–105, P <0.001) and a longer postoperative length of stay (median days until discharge 1, IQR 1–1 versus 1, IQR 0–1, P <0.001). No difference was found in the rates of mortality and common postoperative morbidity as measured in NSQIP. Patients undergoing reoperation were more likely to be readmitted within 30 d (12.7 versus 2.6%, P <0.001). After adjusting for confounders, reoperation continued to be significantly associated with readmission (odds ratio 3.82, confidence interval: 1.63–8.97; P = 0.002). Conclusions Obesity and an American Society of Anesthesiologist 3 classification are independently associated with reoperation. Readmission within 30 d is associated with reoperation and is a target for patient education and quality improvement after this procedure.
Although T cell dysfunction and lymphopenia are key features of immunodeficient patients with the Wiskott-Aldrich syndrome and Wiskott-Aldrich syndrome protein (WASP)-deficient mice, T cell ...development appears relatively normal. We hypothesized that N-WASP, a ubiquitously expressed homologue of WASP, may serve a redundant function with WASP. To examine the unique and redundant activities of WASP and N-WASP, we generated ES cells devoid of WASP and N-WASP double knockout (DKO) and used the RAG-2-deficient blastocyst complementation system to generate DKO lymphocytes. Moreover, we mated WASP KO mice with mice containing a conditionally targeted N-WASP allele and used the Cre-loxP system to generate mice lacking WASP and N-WASP in T cells conditional DKO (cDKO). In both systems, N-WASP-deficient cells were indistinguishable from WT cells. In contrast, T cell development in DKO and cDKO mice was markedly altered, as shown by thymic hypocellularity and reduced numbers of peripheral T cells. We found that the combined activity of WASP and N-WASP was important for CD4⁻CD8⁻ double-negative (DN)-to-CD4⁺CD8⁺ double-positive (DP) cell transition, and this may be partly explained by reduced cycling DN3 cells. In addition, decreased migratory responses of CD4⁺CD8⁻ and CD4⁻CD8⁺ single-positive (SP) cells and increased percentage of CD69lowCD24low and CD62Llow SP cells in cDKO cells imply retention of SP cells in the thymus. In summary, this study suggests that, although WASP serves a unique role for peripheral T cell function, T cell development depends on the combined activity of WASP and N-WASP.
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