Paul Kang

Vitamin D status and breast cancer in Saudi Arabian women: case-control study.

BACKGROUND The role of vitamin D in breast cancer prevention is equivocal. Saudi Arabian women may be at greater risk of vitamin D deficiency because of a darker skin type and a greater likelihood of reduced ultraviolet B radiation exposure. Data regarding the vitamin D status of Saudi Arabian women and its relation to breast cancer risk are lacking. OBJECTIVE The purpose of this research was to evaluate the association between circulating concentrations of 25-hydroxyvitamin D [25(OH)D] and breast cancer risk in Saudi Arabian women. DESIGN A case-control study was conducted among 120 breast cancer cases and 120 controls. The study population was drawn from patients admitted to King Fahd Hospital in Jeddah, Saudi Arabia, from June to August 2009. Participants completed questionnaires on diet and medical history, and serum samples were collected from all women to measure circulating 25(OH)D concentrations. RESULTS The participants had a mean age of 47.8 y and a mean body mass index (BMI; in kg/m(2)) of 30.0. Breast cancer cases had significantly lower (mean ± SD) serum concentrations of 25(OH)D (9.4 ± 6.4 ng/mL) than did controls (15.4 ± 12.3 ng/mL; P = 0.001). In comparison with those in the highest category of vitamin D status for this population (≥20 ng/mL), the adjusted ORs (95% CIs) for invasive breast cancer were 6.1 (2.4, 15.1) for women with a serum 25(OH)D concentration <10 ng/mL and 4.0 (1.6, 10.4) for women with a serum concentration of ≥10 to <20 ng/mL (P-trend = 0.0001). CONCLUSION An inverse association exists between serum 25(OH)D concentrations and breast cancer risk in Saudi Arabian women. This trial was registered at clinicaltrials.gov as NCT01817231.

Extracorporeal membrane oxygenation as a bridge to lung transplantation: A single-center experience in the present era

Objective: Extracorporeal membrane oxygenation has been used as a bridge to lung transplantation in patients with rapid pulmonary function deterioration. The reported success of this modality and perioperative and functional outcomes are varied. Methods: We retrospectively reviewed all patients who underwent lung transplantation at our institution over 1 year (January 1, 2015, to December 31, 2015). Patients were divided into 2 groups depending on whether they required extracorporeal membrane oxygenation support as a bridge to transplant; preoperative characteristics, lung transplantation outcomes, and survival were compared between groups. Results: Of the 93 patients, 12 (13%) received bridge to transplant, and 81 (87%) did not. Patients receiving bridge to transplant were younger, had higher lung allocation scores, had lower functional status, and were more often on mechanical ventilation at listing. Most patients who received bridge to transplant (n = 10, 83.3%) had pulmonary fibrosis. Mean pretransplant extracorporeal membrane oxygenation support was 103.6 hours in duration (range, 16‐395 hours). All patients who received bridge to transplant were decannulated immediately after lung transplantation but were more likely to return to the operating room for secondary chest closure or rethoracotomy. Grade 3 primary graft dysfunction within 72 hours was similar between groups. Lung transplantation success and hospital discharge were 100% in the bridge to transplant group; however, these patients experienced longer hospital stays and higher rates of discharge to acute rehabilitation. The 1‐year survival was 100% in the bridge to transplant group and 91% in the non–bridge to transplant group (log‐rank, P = .24). The 1‐year functional status was excellent in both groups. Conclusions: Extracorporeal membrane oxygenation can be used to safely bridge high‐acuity patients with end‐stage lung disease to lung transplantation with good 30‐day, 90‐day, and 1‐year survival and excellent 1‐year functional status. Long‐term outcomes are being studied.

The effect of statins on rate of cognitive decline in mild cognitive impairment

This studys aims are to identify whether a relationship between statin use and rate of cognitive decline exists. The relationship between statins and mild cognitive impairment (MCI) has been investigated in the past with the evidence showing mixed results.

Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease

Objectives: Gastroesophageal reflux disease (GERD) is prevalent after lung transplantation. Fundoplication slows lung function decline in patients with GERD, but the optimal timing of fundoplication is unknown. Methods: We retrospectively reviewed patients who underwent fundoplication after lung transplantion at our center from April 2007 to July 2014. Patients were divided into 2 groups: early fundoplication (<6 months after lung transplantation) and late fundoplication (≥6 months after lung transplantation). Annual decline in percent predicted forced expiratory volume in 1 second (FEV1) was analyzed. Results: Of the 251 patients who underwent lung transplantation during the study period with available pH data, 86 (34.3%) underwent post‐transplantation fundoplication for GERD. Thirty of 86 (34.9%) had early fundoplication and 56 of 86 (65.1%) had late fundoplication. Median time from lung transplantation to fundoplication was 4.6 months (interquartile range, 2.0–5.2) and 13.8 months (interquartile range, 9.0–16.1) for the early and late groups, respectively. The median DeMeester score was comparable between groups. One‐, 3‐, and 5‐year actuarial survival rates in the early group were 90%, 70%, and 70%, respectively; in the late group, these rates were 91%, 66%, and 66% (log rank P = .60). Three‐ and 5‐year percent predicted FEV1 was lower in the late group by 8.9% (95% confidence interval, −30.2 to 12.38; P = .46) and 40.7% (95% confidence interval, −73.66 to −7.69; P = .019). A linear mixed model showed a 5.7% lower percent predicted FEV1 over time in the late fundoplication group (P < .001). Conclusions: In this study, patients with early fundoplication had a higher FEV1 5 years after lung transplantation. Early fundoplication might protect against GERD‐induced lung damage in lung transplant recipients with GERD.

Effect of geography on the analysis of coccidioidomycosis-associated deaths, United States

Because coccidioidomycosis death rates vary by region, we reanalyzed coccidioidomycosis-associated mortality in the United States by race/ethnicity, then limited analysis to Arizona and California. Coccidioidomycosis-associated deaths were shown to increase among African-Americans but decrease among Native Americans and Hispanics. Separately, in a Native American cohort, diabetes co-varied with coccidioidomycosis-associated death.

Identifying an Oxygenation Index Threshold for Increased Mortality in Acute Respiratory Failure

BACKGROUND: The objective of this work was to examine current oxygenation index (OI) data and outcomes using electronic medical record data to identify a specific OI value associated with mortality. METHODS: This study was a retrospective electronic medical record data review from the pediatric ICU of Phoenix Childrens Hospital, with data mining for variables to calculate OIs on subjects age 1 month to 20 y mechanically ventilated > 24 h, excluding those with known intracardiac shunts or cyanotic heart disease. Age, length of hospital stay, duration of mechanical ventilation, and outcomes were also assessed. The Wilcoxon signed-rank test was used to compare continuous variables, receiver operating characteristic analysis was used in determining discriminant ability, and logistic regression was conducted to determine the odds ratio (OR) for risk of death with increasing OI. RESULTS: OI was calculated on 65 subjects, of whom 6 died (9%). The median maximum OI was 10 for all subjects, 17 for non-survivors, and 8 for survivors (P = .14 via Wilcoxon rank-sum test). ORs indicated a 2.4-fold increase in the odds of death (P = .09, 95% CI 0.9–6.6) for each increasing point in maximum OI. Mean OI OR revealed a 1.9-fold increase in the odds of death (P = .25, 95% CI 0.6–5.9). Receiver operating characteristic analysis indicated a higher discriminate ability for maximum OI (area under the curve = 0.68) than mean OI (area under the curve = 0.58). OI cut-points for mortality were established. Mortality was unchanged until maximum OI > 17, for which mortality nearly tripled at a value of 18% versus 6–7% for range 0–17. CONCLUSIONS: Limitations exist in obtaining serial OI values from current electronic medical records. Serial assessment of OI values may allow creation of alert values for increased mortality risk. Consideration of escalation of therapies for respiratory failure, such as high-frequency ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation may be warranted at lower OIs than historically reported.

Myeloid Disease Mutations of Splicing Factor SRSF2 Cause G2‐M Arrest and Skewed Differentiation of Human Hematopoietic Stem and Progenitor Cells

Myeloid malignancies, including myelodysplastic syndromes, chronic myelomonocytic leukemia, and acute myeloid leukemia, are characterized by abnormal proliferation and differentiation of hematopoietic stem and progenitor cells (HSPCs). Reports on analysis of bone marrow samples from patients have revealed a high incidence of mutations in splicing factors in early stem and progenitor cell clones, but the mechanisms underlying transformation of HSPCs harboring these mutations remain unknown. Using ex vivo cultures of primary human CD34+ cells as a model, we find that mutations in splicing factors SRSF2 and U2AF1 exert distinct effects on proliferation and differentiation of HSPCs. SRSF2 mutations cause a dramatic inhibition of proliferation via a G2‐M phase arrest and induction of apoptosis. U2AF1 mutations, conversely, do not significantly affect proliferation. Mutations in both SRSF2 and U2AF1 cause abnormal differentiation by skewing granulo‐monocytic differentiation toward monocytes but elicit diverse effects on megakaryo‐erythroid differentiation. The SRSF2 mutations skew differentiation toward megakaryocytes whereas U2AF1 mutations cause an increase in the erythroid cell populations. These distinct functional consequences indicate that SRSF2 and U2AF1 mutations have cell context‐specific effects and that the generation of myeloid disease phenotype by mutations in the genes coding these two proteins likely involves different intracellular mechanisms. Stem Cells 2018;36:1663–1675

Safety and Accuracy of Core Needle Biopsy for Soft Tissue Masses in an Ambulatory Setting

Background Percutaneous needle biopsy has been found to be a safe and accurate method for the initial investigation of soft tissue masses. The notion exists that needle biopsies should be performed in specialized sarcoma centers, which can place a financial burden on patients without a sarcoma center near their place of residence. There is no consensus in the current literature regarding the diagnostic accuracy and clinical utility of clinic-based percutaneous core needle biopsy performed by community orthopedic surgeons with fellowship training in musculoskeletal oncology. Questions/Purposes Our primary goal was to determine if office-based core needle biopsy of soft tissue masses could safely yield accurate diagnoses when performed by a community orthopedic surgeon with fellowship training in musculoskeletal oncology. Patients and Methods We retrospectively reviewed the charts of 105 patients who underwent percutaneous core needle biopsy of soft tissue masses in a community clinic. All procedures were performed by one fellowship-trained musculoskeletal oncologist. Accuracy of the initial clinic-based needle biopsy was determined through comparison to the results of pathological analysis of the surgically excised masses. Final data analysis included 69 patients who underwent both clinic-based biopsy and subsequent surgical excision of their masses. Results We found clinic-based biopsies to be 87.0% accurate for exact diagnosis and 94.2% accurate in determining whether the mass was benign or malignant (p < 0.0001). Minor complications related to the clinic-based biopsy occurred in 5.80% of cases, with no documentation of major complications. Conclusions Our results provide evidence that office-based percutaneous biopsy can be administered safely and yield accurate, clinically useful results when performed by a fellowship-trained musculoskeletal oncologist.

Analysis of the Variability of Abstract Structures in Medical Journals

The abstract is typically the most widely read section of articles, and sometimes the only section that is read. It provides readers with an overview of the article without having to read the entire paper. Thus, abstracts should be presented in a manner that will most efficiently deliver the article’s major messages to the reader. This is especially relevant in the medical field, since physicians are required to keep up with the burgeoning literature as it pertains to their chosen specialty or subspecialty. In 1987, theAdHocWorkingGroup for Critical Appraisal of the Medical Literature proposed a seven-heading format for structured abstracts in clinical articles. Their proposal was further supported by several studies that suggested that structured abstracts were superior to unstructured abstracts, in terms of both quality and the ability to allow readers to select articles more quickly. However, several subsequent studies questioned the superiority of structured abstracts over unstructured ones. Nevertheless, many journals quickly adopted the structured abstract concept soon after it was introduced in 1987. No large-scale data currently exist on specific abstract format requirements required by individual medical journals for published research articles. This information could be valuable in determining the current trends in abstract structure to help tailor the abstract format to the preference of their readers. Thus, our studywas performed to evaluate the abstract format requirements for all English medical journals that publish original articles.

Transabdominal robot-assisted diaphragmatic plication: a 3.5-year experience

OBJECTIVES Diaphragmatic paralysis, a known cause of dyspnoea, can drastically reduce breathing efficiency, diminishing quality of life. We report our 3.5-year experience with 22 consecutive patients who underwent transabdominal, robot-assisted diaphragmatic plication for diaphragmatic paralysis. METHODS We retrospectively reviewed 22 consecutive patients who underwent this procedure by a single surgeon from 5 September 2012 to 12 May 2016. The primary outcome measure was change in dyspnoea severity, which was measured with the 5-point Medical Research Council dyspnoea scale (a score of 5 indicates breathlessness so severe, the individual is homebound). RESULTS Of the 22 patients who underwent robotic diaphragmatic plication, 17 (77.3%) patients were male. Median body mass index was 30 kg/m2 (range 24.2-42.17 kg/m2). Most plications (13 of 22, 59.1%) were left sided; one (4.6%) was bilateral. Median operating time was 161 min (range 107-293 min), but this time was higher for the first 3 procedures (255 min, range 239-293 min). Median length of stay was 2 days, and median time to chest tube removal was 1 day. At follow-up, 20 of the 22 (91%) patients reported improved breathing and 2 reported no change. No patient reported worsened dyspnoea. The median Medical Research Council score changed from 4.0 preoperatively to 2.0 postoperatively (P = 0.001). CONCLUSIONS Transabdominal robotic diaphragmatic plication involves small incisions but improves surgical dexterity. Surgical times are reasonable, and this surgical technique can be adopted with a quick but steep learning curve. Early results show good functional outcomes.