Robotic cholecystectomy for acute cholecystitis: Three case reports Introduction: Nowadays laparoscopic cholecystectomy is considered as criterion standard for surgical treatment of acute calculous cholecystitis. During the last few years, there has been growing interest about the robotic approach. Several authors have reported the superiority of robotic cholecystectomy, associated with a lower percentage of conversion especially in patients with intraoperative diagnosis of acute or gangrenous cholecystitis. We report 3 case reports of moderate acute cholecystitis successfully treated by robotic cholecystectomy. Patient Concerns: Three patients presented moderate acute calculous cholecystitis with leukocytosis, fever, nausea, vomiting, and pain. Diagnosis: Three patients of our study population had clinical and laboratory suspicion of moderate acute calculous cholecystitis verified by abdominal ultrasound examination, which found out cholelitiasis in all 3 cases. Final diagnosis was confirmed by intraoperative findings and histopathological examination, with two empyematous cholecystitis and one perforated cholecystitis. Interventions: All patients underwent robotic cholecystectomy with the da Vinci Robotic Surgical System. The entire procedure required a mean operation time of 128 minutes and the average blood loss was 60 mL, without any intraoperative complications. Outcomes: In all 3 cases postoperative period was uneventfull. All the patients were discharged within 24 hours and no readmissions were reported during a 30 days’ follow-up. Conclusions: Robotic cholecystectomy for ACC is feasible and safe. Several studies have demonstrated that robotic approach reduces the risk of conversion to open surgery in case of acute or gangrenous cholecystitis. Our results are in line with current literature. In fact, we have successfully treated 2 patients with empyematous acute cholecystitis and 1 with gangrenous cholecystitis with a totally robotic approach, without any complications or need of conversion to open surgery. In conclusion, our results confirm that it is the time to include robotic surgery in the emergency setting.

Rationale and methods of a randomized clinical trial to compare specific exercise programs versus home exercises in patients with subacromial impingement syndrome Background Subacromial impingement syndrome (SIS) is a common clinical condition with a multifactorial etiology. Currently, there is a great variety of therapeutic exercise modalities aimed at treating SIS. Based on alterations of the glenohumeral and/or dysfunctional scapular kinematics associated with SIS, we hypothesize that the implementation of a specific exercise program with special focus on the correction of muscle deficits should be more effective than nonspecific exercises performed at home. This article describes the rationale and methods of study aimed at testing the effectiveness of specific exercise programs versus home exercises in patients with SIS. Method/Design Ninety-four patients between the ages of 18 and 50 years referred to the Physical Therapy department of the Clinical Hospital San Borja Arriaran in Chile will be randomized to 2 treatment arms. The intervention group will receive a program of specific exercises with a duration of 12 weeks, taking as a reference the algorithm of clinical decision proposed by a panel of experts. The control group will receive a program of nonspecific exercises to perform at home. Three evaluations will be performed: before the initiation of treatment, and at the 12-week and 1-year follow-up. The primary outcome measure will be the shoulder function by the Constant-Murley questionnaire, and the secondary outcome measures will be the upper extremity function by the Disabilities of the Arm, Shoulder and Hand questionnaire, and pain by the visual analog scale. Discussion This article reports the design of a randomized clinical trial aimed at assessing the effectiveness of a specific exercise program versus home exercises in patients with SIS. Trial registration Brazilian registry of clinical trials UTN number U1111-1204-0268. Registered 27 September 2017.

Effective therapeutic options for elderly patients with hepatocellular carcinoma: A nationwide cohort study We evaluated the post-treatment overall survival (OS) of elderly hepatocellular carcinoma (HCC) patients. The archived records of 10,578 HCC patients registered at the Korean Central Cancer Registry from 2008 through 2014 were retrospectively analyzed. In this registry, we selected Barcelona Clinic Liver Cancer (BCLC) 0, A, or B staged HCC patients (n = 4744) treated by surgical resection (SR), local ablation therapy (LAT), or locoregional therapy (LRT). OSs in nonelderly (<70 years) and elderly (≥70 years) patients were compared after propensity score matching (PSM). In BCLC 0-A staged HCC, the cumulative OS rates of elderly patients were poorer than those of nonelderly patients after PSM (P < .001), but not in those with BCLC stage B (P > .05). In BCLC 0-A staged elderly patients, OS after SR was significantly better than after LAT (P = .005) or LRT (P < .001). In BCLC B staged elderly patients, SR achieved better OS than LRT (P = .006). Multivariable analysis showed that LAT (hazard ratio [HR] 1.52, P = .048) or LRT (HR, 2.01, P < .001) as compared with SR, and large (>3 cm) tumor size (HR1.49, P = .018) were poor predictors of OS for elderly patients with BCLC stage 0-A, and that LRT (HR, 2.64, P = .042) was a poor predictor for those with BCLC stage B. SR provided a better OS rate than LAT or LRT in elderly HCC patients with BCLC stage 0–A, than LRT in those with BCLC stage B. SR should be considered the first therapeutic option even in elderly HCC patients with these stages.

Can the prognosis of mantle cell lymphoma be predicted by simple CBC counts? Mantle cell lymphoma (MCL) exhibits a heterogenous clinical course. The MCL International Prognostic Index (MIPI) is the most commonly used risk classification system in MCL. However, it does not contain a parameter associated with the tumor microenvironment. The aim of this study was to develop a more powerful prognostic index by evaluating the absolute monocyte count (AMC), neutrophil/lymphocyte ratio (NLR), and platelet/lymphocyte ratio (PLR) at diagnosis in conjunction with the clinical and laboratory parameters. The data of 96 MCL patients with newly diagnosed from January 2014 to December 2018 were retrospectively evaluated in this study. The AMC, NLR, and PLR cut-off values were determined using the receiver operating characteristic (ROC) analysis. The clinical behavior and results of the disease exhibited significant variation in high and low value groups at the time of diagnosis. In univariate analysis, the AMC ≥ 580, NLR ≥ 2.43, and PLR ≥ 120.85 were determined as negative prognostic factors for 5-year progression free survival (PFS) (AMC: PFS, P < .001; NLR: PFS, P < .001; PLR: PFS, P < .001) and for 5-year overall survival (OS) (P < .001, P < .001, P < .001, respectively). Beta-2 microglobulin (B2-MG), and MIPI for PFS, and for OS were found to be independent risk factors in the multivariate analysis (for PFS: P = .006, P = .002, respectively; and for OS: P = .007, P = .001, respectively). The 5-year OS was 20% in the group with B2-MG ≥ 3.5. The patients in high-risk MIPI group had poorer 5-year OS (median OS: 40 months, P < .001). The results stated that the use of B2-MG in conjunction with MIPI was a more sensitive method in determining the prognosis in MCL (median OS: 12 months in high-risk MIPI group with a B2-MG ≥3.5, P < .001). Additionally, it was found that parameters reflecting the tumor microenvironment such as AMC, NLR, and PLR increased the risk of progression in MCL. In view of these findings, in addition B2-MG to the MIPI to create a more sensitive prognostic scoring system may provide an insight into personalization of treatment with early recognition of patients with poor prognosis.

E-cadherin expression is associated with susceptibility and clinicopathological characteristics of thyroid cancer: A PRISMA-compliant meta-analysis Background: Recently, many studies have been carried out to investigate the clinicopathological significance of E-cadherin expression in thyroid cancer. However, the results remained inconsistent. In the present study, we performed a meta-analysis to evaluate the associations of E-cadherin expression with susceptibility and clinicopathological characteristics of thyroid cancer. Methods: Eligible studies were searched from Medicine, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang databases. The strength of associations between E-cadherin expression and susceptibility and clinicopathological features of thyroid cancer were assessed by pooled odds ratios (ORs) and 95% confidence intervals (CIs). Results: Forty-six studies with 1700 controls and 2298 thyroid cancer patients were included for this meta-analysis. Pooled results indicated that E-cadherin expression was significantly associated with susceptibility of papillary cancer and follicular cancer (papillary cancer, ORs = 14.31, 95% CIs = 3.42–59.90; follicular cancer, ORs = 10.14, 95% CI = 4.52–22.75). Significant association between E-cadherin expression and thyroid cancer risk was also observed in the subgroup analysis based on control group (normal thyroid tissue, ORs = 28.28, 95% CI = 8.36–95.63; adjacent thyroid tissue, ORs = 8.83, 95% CI = 3.27–23.85; benign thyroid tissue, ORs = 43.96, 95% CI = 9.91–194.95). In addition, E-cadherin expression was significantly correlated with lymph node metastasis, differentiation, and tumor-node-metastasis (TNM) stage of thyroid cancer (lymph node metastasis, ORs = 3.21, 95% CI = 1.98–5.20; differentiation, ORs = 0.25, 95% CI = 0.07–0.82; TNM stage, ORs = 4.85, 95% CI = 2.86–8.25). Conclusions: The present study showed that E-cadherin expression was significantly associated with susceptibility and clinicopathological characteristics of thyroid cancer, which suggested that E-cadherin expression might be a potential predictive factor for clinical progression of thyroid cancer.

Comparative effectiveness of 3 Traditional Chinese Medicine treatment methods for idiopathic pulmonary fibrosis: A systematic review and network meta-analysis protocol Introduction: The morbidity of idiopathic pulmonary fibrosis (IPF) was found in an increasing trend, progressive worsening of symptoms and deterioration in lung function tend to trigger off a lower quality of life (QoL). Only pirfenidone and nintedanib have been recommended in the guidelines, which can modify the disease process. However, no evidence was verified to significantly alleviate the main clinical manifestations of IPF. At present, Chinese herbal formula (CHF) is widely prescribed as an adjunct to western medicine to treat the disease, and have shown promising benefits on clinical symptoms and QoL. There are mainly 3 Traditional Chinese Medicine (TCM) treatment methods guiding the composition of CHFs, which are devoting to comfort the common symptoms of IPF. Nevertheless, the paucity of direct comparative evidence of them posed a challenge for clinicians to determine the relative merits options. Therefore, we formulate this protocol, which is described for a systematic review to investigate relative advantages among different TCM treatment method and provide more reliable evidence for clinical decision-making. Methods and analysis: A systematic literature search will be employed in 10 electronic databases. Inclusion criteria are randomized control trials of CHFs composed based on the 3 TCM treatment methods, which act as an adjuvant treatment with routine drugs, compared with routine drugs alone. The primary outcomes we focus on include St George's Hospital Respiratory Questionnaire (SGRQ) scores, TCM symptom (dyspnea, cough) scores. The research screening, data extraction, and methodological quality assessment will be conducted by 2 individuals separately, and dispute will be adjudicated by a third senior reviewer. We will employ network meta-analysis (NMA) in a Bayesian framework with vague priors and the surface under the cumulative ranking curve (SUCRA) to obtain the comprehensive rank for the 3 TCM treatment methods. Results: This systematic review will provide an evidence of CHFs composed under the guidance by 3 TCM treatment methods with routine drugs, compared with routine drugs alone for IPF, and will submit to a peer-reviewed journal for publication. Conclusion: The conclusion of this systematic review will provide evidence for relative advantages among the 3 TCM treatment methods.

A case report of cholangiocarcinoma combined with moderately differentiated gastric adenocarcinoma Rationale: Multiple primary carcinoma (MPM) refers to simultaneous or successive occurrence of ≥2 types of primary malignant tumors in a single organ or in different organs of the same individual. It is rarely seen in clinical practice. Among the various types of MPM, hilar cholangiocarcinoma combined with gastric cancer is extremely rare. Patient concerns: The patient was a 61-year-old man who was admitted to our hospital due to upper abdominal discomfort and yellow-stained skin mucosa for 9 days. Diagnoses: Preoperative diagnosis: Considering the typical preoperative painless jaundice as well as his clinical imaging report, the patient received the following preoperative diagnosis: obstructive jaundice, type IV hilar cholangiocarcinoma based on Bismuth-Corlette classification, and no intrahepatic distant metastasis. Intraoperative diagnosis: The results of intraoperative snap freezing and laboratory examination indicated gastric adenocarcinoma. Therefore, the patient received an intraoperative diagnosis of obstructive jaundice, hilar cholangiocarcinoma, and gastric cancer. Postoperative pathological diagnosis: Postoperative pathological examination of the gastric lesion revealed the following results: ulcerative, moderately differentiated gastric adenocarcinoma and intestinal type in the Lauren classification of stomach cancer; moderately differentiated adenocarcinoma of the bile duct. Interventions: Surgical resection operation was carried out and the patient received chemotherapy after operation. But we could not strictly follow the relevant clinical guidelines to perform standardized operations and provide comprehensive treatment because of his economic situation, psychological factors, and the current medical environment in China. Outcomes: The patient did not receive standardized postoperative therapy. Although he lived and worked normally for 8 months after the operation, he died 10 months after surgery. Lessons: This report reminds us to pay close attention to the likelihood of MPM and other low-incidence diseases. The physicians and imaging clinicians should explore all clinical possibilities to avoid misdiagnosis of this rare disease and formulate effective treatment plans to maximize the therapeutic benefits for the patient.

Evaluation of PTEN and CD4+FOXP3+ T cell expressions as diagnostic and predictive factors in endometrial cancer: A case control study To evaluate the potential role of Pten and CD4+FOXP3+ T cells in prognosis from endometrial cancer. Tissue samples and clinical data were collected from 200 patients with endometrial cancer and 100 control patients with benign uterine diseases. The expressions of Pten and CD4+FOXP3+ T cells were quantified by immunohistochemistry and immunofluorescence. After surgery, all patients were followed up for an average of 56.3 months. Surgical effects were evaluated based on the patients’ symptoms and signs. A two-sided P value < .05 was considered significant. Pten diminished and CD4+FOXP3+ T cells significantly accumulated with the progression of endometial cancer, in comparison to the controls. Moreover, Pten expression was negatively correlated with the count of CD4+FOXP3+ T cells. Pten and CD4+FOXP3+ T cells were correlated with clinical characteristics, including tumor stage, differentiation and associated with patients’ disease-free survival. Limited data were available between the expressions of Pten and CD4+FOXP3+ T cells in patients with endometrial cancer. Our study findings suggested that the expressions of Pten and CD4+FOXP3+ T cells might become possible biomarkers for the diagnosis and prediction in endometrial cancer.

Thyroid cartilage loci and hyoid bone analysis using a video fluoroscopic swallowing study (VFSS) Introduction: Hyoid bone movement can be useful for diagnosing oropharyngeal dysphagia. In most clinical settings, the movement can be evaluated by a video fluoroscopic swallowing study (VFSS) that induces radiation exposure. In contrast with the hyoid bone, the thyroid cartilage is easily seen through the anterior neck surface. We hypothesized that the movement of thyroid cartilage correlates with hyoid bone movement in various axis and can be used as a parameter to evaluate swallowing. The purpose of this study was to investigate whether thyroid cartilage and hyoid bone movement were correlated and to collect basic data to determine if thyroid cartilage can be used as a parameter to evaluate swallowing. Methods: A total of 25 subjects were included, and the VFSS image with normal swallowing function was collected retrospectively. The VFSS image was analyzed by specially developed semi-automatic software. Laryngeal prominence and anterior-superior margins of the hyoid were automatically extracted during swallowing. Two-point sets of the loci during swallowing were obtained in all VFSS frames. The X-coordinates showed an anterior-posterior axis, and the Y-coordinates showed a superior-inferior axis. Pearson correlation coefficients for each X- and Y-coordinate component were computed. Results: X- and Y-coordinates of the thyroid cartilage and hyoid bones in all subjects showed movement in similar patterns, although each subject's movement differed. Pearson correlation coefficients of X- and Y-coordinate components of all subjects ranged from 0.611 to 0.981, which indicated that thyroid cartilage and hyoid bone movement was strongly correlated in anterior-posterior and superior-inferior axes, respectively. Conclusion: We analyzed thyroid cartilage and hyoid bone movement using a specifically developed semi-automatic software and concluded that the movement of thyroid cartilage and hyoid bone was strongly correlated in anterior-posterior and superior-inferior axes, respectively, during swallowing. The present study implies that analysis of thyroid cartilage movement can be used as a parameter for swallowing evaluation.

A group-focused rational emotive behavior coaching for management of academic burnout among undergraduate students: Implications for school administrators Background: High-stress level affects students’ health and many of them experiencing high levels of stress are at risk of burnout. School administrators are often concerned about the experiences and negative effects of burnout among students and staff. Burnout is described as a psychological reaction to chronic stress. The aim of the current study was to investigate the effect of a group-focused intervention (rational emotive behavior coaching, REBC) on academic burnout among undergraduate students attending public universities in Southeast Nigeria. Methods: A group randomized controlled trial design was adopted for this study. A total of 52 convenient samples of undergraduate students (with a high degree of burnout symptoms) took part in the research. We used a group REBT program manual for the management of burnout which was complemented with REBC techniques. Data were gathered with the aid of the perceived stress scale (PSS-10) and Oldenburg Burnout inventory-student (OLBI-S). Data were analyzed using ANOVA and paired t test at .05 probability level. Results: Results showed that the group-focused REBC program significantly alleviated burnout symptoms among students in the treatment group compared to students in the control group as measured by OLBI-S subscales: exhaustion (F(1,51) = 41.789, P = .000, JOURNAL/medi/04.02/00005792-201907260-00010/math_10MM1/v/2019-07-25T170432Z/r/image-tiff , ΔR2 = 0.634, SE = 1.00), and disengagement (F(1,51) = 196.036, P = .000, JOURNAL/medi/04.02/00005792-201907260-00010/math_10MM2/v/2019-07-25T170432Z/r/image-tiff , ΔR2 = 0.869, SE = 0.69). The students who benefitted from the group-focused REBC program maintained reduced symptoms of burnout after three months when the researchers conducted a follow-up as measured by OLBI-S subscales: exhaustion (F(1,51) = 34.012, P = .000, JOURNAL/medi/04.02/00005792-201907260-00010/math_10MM3/v/2019-07-25T170432Z/r/image-tiff , ΔR2 = 0.467, SE = 1.21), and disengagement (F(1,51) = 108.941, P = .000, JOURNAL/medi/04.02/00005792-201907260-00010/math_10MM4/v/2019-07-25T170432Z/r/image-tiff , ΔR2 = 0.765, SE = 0.85). Conclusion: This research indicates that group-focused REBC can be applied to reduce burnout symptoms among undergraduate students. The group-focused REBC intervention may be adapted to overcome employee burnout and school administrators’ burnout. Researchers may need to investigate the possibility of storing and harnessing data from studies on REBC and burnout and delivering computer-based/internet REBC program following evidence-based computing strategies and principles.