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Adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome is characterized by hypothalamus-pituitary-adrenal axis dysfunction. As the neuroendocrinological axis has been shown to react under the regulation of the central nerve system through the corticotropin-releasing factor (CRF) releasing from the hypothalamic paraventricular nucleus. Whether one of the neuromodulation therapies, vagus nerve stimulation, is able to treat this neuroendocrinological disorder remains unknown. In this study, we explored the effects of vagus nerve stimulation (VNS) on CRF-induced serum ACTH level change in normal rats. After the vagus nerve electrode placement, the ACTH and corticosterone levels were measured multiple times before and after the administration of CRF (2 μg/kg) in switched-ON and -OFF groups, respectively, compared to the control group. Our results showed that 2 h continuous stimulation on the vagus nerve inhibited CRF-induced ACTH release up to 1 h compared with the control group, while the corticosterone level was not influenced. The vagus nerve might be a potential therapeutic target in the treatment of ACTH-dependent Cushing's syndrome disorders involving hypothalamus-pituitary-adrenal axis dysfunction.

Background Cancer survivors who develop breast cancer as a second malignancy (BCa-2) are common. Yet, little is known about the prognosis of BCa-2 compared to first primary breast cancer (BCa-1). Methods Using the Surveillance, Epidemiology, and End Results database, we conducted a population-based cohort study including 883,881 patients with BCa-1 and 36,313 patients with BCa-2 during 1990–2015. Compared with patients with BCa-1, we calculated hazard ratios (HRs) of breast cancer-specific mortality among patients with BCa-2, using multivariable Cox regression. Results During the follow-up (median 5.5 years), 114,964 and 3829 breast cancer-specific deaths were identified among BCa-1 and BCa-2 patients, respectively. Patients with BCa-2 had more favorable tumor characteristics and received less intensive treatment e.g., surgery and chemo−/radio-therapy, compared to patients with BCa-1. When adjusting for demographic factors, patients with BCa-2 were at similar risk of breast cancer-specific mortality (HR 1.00, 95% CI 0.97–1.03) compared to patients with BCa-1. However, when additionally controlling for tumor characteristics and treatment modes, BCa-2 patients were at an increased risk of breast cancer-specific mortality (HR 1.11, 95% CI 1.08–1.15). The risk elevation was particularly greater when the first malignancy was lung, bladder, ovarian or blood malignancy (HRs 1.16–1.85), or when the first malignancy was treated with chemotherapy and radiotherapy (HR 1.44, 95% CI 1.28–1.63). Conclusions Overall, patients with BCa-2 have worse breast cancer-specific survival, compared with their BCa-1 counterparts, although the risk elevation is mild. High-risk subgroups based on first malignancy’s characteristics may be considered for active clinical management.

Background Multiple myeloma (MM) is a major health concern. Understanding the different burden and tendency of MM in different regions is crucial for formulating specific local strategies. Therefore, we evaluated the epidemiologic patterns and explored the risk factors for MM death. Methods Data on MM were collected from the 2019 Global Burden of Disease study. We used incidence, mortality, and disability adjusted life-years to estimate the global, regional, and national burden of MM. Results In 2019, there were 155,688 (95% UI, 136,585 – 172,577) MM cases worldwide, of which 84,516 (54.3%, 70,924 – 94,910) were of men. The age-standardized incidence rate (ASIR) was 1.72/100,000 persons (95% UI, 1.59–1.93) in 1990 and 1.92/100,000 persons (95% UI, 1.68–2.12) in 2019. The number of MM deaths increased 1.19-fold from 51,862 (95% UI, 47,710–58,979) in 1990 to 113,474 (95% UI, 99,527 – 121,735) in 2019; the age-standardized death rate (ASDR) was 1.42/100,000 persons (95% UI, 1.24–1.52) in 2019. In recent 15 years, ASDR showed a steady tendency for men, and a downward tendency for women. Countries with high social-demographic indexes exhibited a higher ASIR and ASDR. Australasia, North America, and Western Europe had the highest ASIR and ASDR, with 46.3% incident cases and 41.8% death cases. Monaco had the highest ASIR and ASDR, which was almost half as high as the second highest country Barbados. In addition, United Arab Emirates and Qatar had the largest growth multiple in ASIR and ASDR, which was twice the third country Djibouti. Conclusions Globally, incident and death MM cases have more than doubled over the past 30 years. The increasing global burden may continue with population aging, whereas mortality may continue to decrease with the progression of medical technology. The global burden pattern of MM was diverse, therefore specific local strategies based on different burden patterns for MM are necessary.

Background Previous studies have widely assessed heat-mortality relationships across global regions, while the epidemiological evidence regarding the heat effect on years of life lost (YLL) is relatively sparse. Current investigations using daily mean data cannot take hourly temperature variation into consideration and may underestimate heat effects. We developed a novel indicator, daily excess hourly heat (DEHH), to precisely evaluate the potential heat effects on mortality and YLL. Methods Hourly data on temperature and daily information, including concentrations of air pollutants, relative humidity, and records of all registered deaths were obtained in Wuhan, China during the warm seasons (May–September) of 2009–2012. DEHH, developed in this study, is defined as daily total hourly temperatures that exceed a specific heat threshold. By performing time series regression analyses, we assessed the changes in daily mortality and YLL per interquartile range (IQR) increase in DEHH across different lag days. Results The heat threshold evaluated by the Akaike Information Criterion for DEHH calculation is 30 °C (92th percentile of whole-year mean temperature distribution). Daily average DEHH was 13.9 °C, with an IQR of 19.9 °C. Linear exposure-response curves were found between DEHH and two health outcomes. Generally, heat effects lasted for 2–3 days and DEHH at lag 0–1 was most strongly associated with increased mortality and YLL. The effects were especially remarkable for stroke and ischemic heart disease mortality. Most intense effect on YLL was found in non-accidental deaths (20.11, 95% confidence interval: 8.90–31.33) at lag 0–1. More DEHH-related mortality and YLL from cardiovascular deaths were observed among males. People aged 0–74 years and males suffered more from YLL burden due to high temperatures. Conclusions Our study demonstrated that DEHH may be an alternative indicator to precisely measure heat effects on daily mortality and YLL. Further DEHH-based evidence from large scale investigations is needed so as to better understand heat-associated health burden and improve public response to extremely high temperatures.

Epidemiological studies increasingly provide evidence about the adverse health effects of temperature variability (TV), which reflects short-term intra- and inter-day temperature change. However, calculation of TV only considers the temporal variability and lacks spatial variability. This study intends to investigate whether the lack of spatial variability in TV calculations has biased the health effect estimates. We collected daily data from the fine-gridded hourly temperatures and more than 2 million all-cause mortality counts in Zhejiang province in China from 2009 to 2015. A spatiotemporal TV index was developed by calculating the standard deviation of the hourly temperatures based on records from multiple sites. This new index could be compared to the two typical temporal TV indices that are calculated based on the hourly temperatures from one-site and area-average records. The three types of TV are compared using a three-stage analytical approach: district-specific time series Poisson regression, meta-analysis, and calculation of attributable mortality fraction. We observe that both spatiotemporal and temporal TVs produce very similar TV–mortality associations, attributable mortality fractions, and model fits at the district level. For example, the mortality increase associated for every increase of 1 °C during 0–7 exposure days is 1.53% (95% CI: 1.31, 1.73) in spatiotemporal TV, whereas it is 1.48% (95% CI: 1.27, 1.68) and 1.45% (95% CI: 1.24, 1.67) in the one-site and area-average temporal TV, respectively. Thus, time series models using temporal TV index are equally good at estimating the associations between TV and mortality as spatiotemporal TV at the district level in population-based epidemiological studies in China. Epidemiological studies using temperature from one site or the averages of multiple sites in TV calculation will not bias the effect estimates of TV. Our study could provide an important guidance method for future TV-related research in China and even in other countries.

Background Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease. Methods GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden. Findings The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10.8 million (95% uncertainty interval [UI] 9.51-12.1) deaths (19.2% [16.9-21.3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8.71 million (8.12-9.31) deaths (15.4% [14.6-16.2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11.6% [10.3-13.1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older. Interpretation Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. Copyright (C) 2020 The Author(s). Published by Elsevier Ltd.

We thank all staff members working on the Breast Cancer Information Management System (BCIMS) for their contributions to data collection and management. We also thank Dr Bo Fu, Mr Yan Li and Mr Pei Liu at the University of Electronic Science and Technology of China for data cleaning and zip code mapping. Our study was supported by the Key Research and Development Project of Sichuan Province of China (grant number: 2017SZ00005) and Swedish Research Council (grant number: 2018‐00648)., Little is known about how health insurance policies, particularly in developing countries, influence breast cancer prognosis. Here, we examined the association between individual health insurance and breast cancer-specific mortality in China. We included 7436 women diagnosed with invasive breast cancer between 2009 and 2016, at West China Hospital, Sichuan University. The health insurance plan of patient was classified as either urban or rural schemes and was also categorized as reimbursement rate (ie, the covered/total charge) below or above the median. Breast cancer-specific mortality was the primary outcome. Using Cox proportional hazards models, we calculated hazard ratios (HRs) for cancer-specific mortality, contrasting rates among patients with a rural insurance scheme or low reimbursement rate to that of those with an urban insurance scheme or high reimbursement rate, respectively. During a median follow-up of 3.1 years, we identified 326 deaths due to breast cancer. Compared to patients covered by urban insurance schemes, patients covered by rural insurance schemes had a 29% increased cancer-specific mortality (95% CI 0%-65%) after adjusting for demographics, tumor characteristics and treatment modes. Reimbursement rate below the median was associated with a 42% increased rate of cancer-specific mortality (95% CI 11%-82%). Every 10% increase in the reimbursement rate is associated with a 7% (95% CI 2%-12%) reduction in cancer-specific mortality risk, particularly in patients covered by rural insurance schemes (26%, 95% CI 9%-39%). Our findings suggest that underinsured patients face a higher risk of breast cancer-specific mortality in developing countries., Vetenskapsrådet

Purpose Stereo-electroencephalography (SEEG) implantation before epilepsy surgery is critical for precise localization and complete resection of the seizure onset zone (SOZ). Combined metabolic and morphological imaging using hybrid PET/MRI may provide supportive information for the optimization of the SEEG coverage of brain structures. In this study, we originally imported PET/MRI images into the SEEG positioning system to evaluate the application of PET/MRI in guiding SEEG implantation in refractory epilepsy patients. Materials Forty-two patients undergoing simultaneous PET/MRI examinations were recruited. All the patients underwent SEEG implantation guided by hybrid PET/MRI and surgical resection or ablation of epileptic lesion. Surgery outcome was assessed using a modified Engel classification one year (13.60 ± 2.49 months) after surgery. Areas of SOZ were identified using hybrid PET/MRI and concordance with SEEG was evaluated. Logistic regression analysis was used to predict the presence of a favorable outcome with the coherence of concordance of PET/MRI and SEEG. Results Hybrid PET/MRI (including visual PET, MRI, plus MI Neuro) identified SOZ lesions in 38 epilepsy patients (90.47 %). PET/MRI showed the same SOZ localization with SEEG in 29 patients (69.05 %), which was considered to be concordant. The concordance between the PET/MRI and SEEG findings was significantly predictive of a successful surgery outcome (odds ratio = 20.41; 95 % CI = 2.75–151.4, P = 0.003**). Conclusion Hybrid PET/MRI combined visual PET, multiple sequences MRI and SPM PET helps identify epilepsy lesions particularly in subtle hypometabolic areas. Patients with concordant epileptic lesion localization on PET/MRI and SEEG demonstrated a more favorable outcome than those with inconsistent localization between modalities.

Background Magnetoencephalography (MEG) has high temporal and spatial resolution and good spatial accuracy in determining the locations of source activity among most non-invasive imaging. The recently developed technology of optically-pumped magnetometer (OPM) has sensitivity comparable to that of the superconducting quantum interference device (SQUID) used in commercial MEG system. New method Double-channel OPM-MEG system detects human photic blocking of alpha rhythm at the occipital region of skull in the magnetically shielded environment via a wearable whole-cortex 3D-printed helmet. Results The alpha rhythm can be detected by the OPM-MEG system, the MEG signals are undoubtedly caused by photic blocking and similar with the results measured by SQUID magnetometer. Comparison with existing methods Due to the dependency of current commercial whole-cortex SQUID-MEG system on the liquid helium, the separation from the liquid helium space to the human head is usually at least a few centimeters. The wearable OPM-MEG system, however, can significantly improve the detection efficiency since its sensors can be mounted close to scalp, normally less than 1 cm. Conclusions OPM-MEG system successfully detects alpha rhythm blocked by light stimulation and works well in the home-made magnetically shielded environment. OPM-MEG system shows a substitute for the traditional MEG system.

Publisher's version (útgefin grein), Background: Cancer patients have a highly increased risk of psychiatric disorders following diagnosis, compared with cancer-free individuals. Inflammation is involved in the development of both cancer and psychiatric disorders. The role of non-steroidal anti-inflammatory drugs (NSAIDs) in the subsequent risk of psychiatric disorders after cancer diagnosis is however unknown. Methods: We performed a cohort study of all patients diagnosed with a first primary malignancy between July 2006 and December 2013 in Sweden. Cox proportional hazards models were used to assess the association of NSAID use during the year before cancer diagnosis with the risk of depression, anxiety, and stress-related disorders during the first year after cancer diagnosis. Results: Among 316,904 patients identified, 5613 patients received a diagnosis of depression, anxiety, or stress-related disorders during the year after cancer diagnosis. Compared with no use of NSAIDs, the use of aspirin alone was associated with a lower rate of depression, anxiety, and stress-related disorders (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.81 to 0.97), whereas the use of non-aspirin NSAIDs alone was associated with a higher rate (HR, 1.24; 95% CI, 1.15 to 1.32), after adjustment for sociodemographic factors, comorbidity, indications for NSAID use, and cancer characteristics. The association of aspirin with reduced rate of depression, anxiety, and stress-related disorders was strongest for current use (HR, 0.84; 95% CI, 0.75 to 0.93), low-dose use (HR, 0.88; 95% CI, 0.80 to 0.98), long-term use (HR, 0.84; 95% CI, 0.76 to 0.94), and among patients with cardiovascular disease (HR, 0.81; 95% CI, 0.68 to 0.95) or breast cancer (HR, 0.74; 95% CI, 0.56 to 0.98). Conclusion: Pre-diagnostic use of aspirin was associated with a decreased risk of depression, anxiety, and stress-related disorders during the first year following cancer diagnosis., This study was supported by grants awarded to FF by Swedish Cancer Society (No. CAN 2017/322) and the Swedish Research Council for Health, Working Life and Welfare (No. 2017-00531), to KH by China Scholarship Council (No. 201806240005), to ES by National Health and Medical Research Council (GNT1147498) and National Breast Cancer Foundation (IIRS-20 to 025), and to AW by the National Breast Cancer Foundation (PF-15 to 014). The researchers were independent of the funding agencies. The funding bodies have no role in the design of the study or collection, analysis, and interpretation of data or in writing the manuscript. Open access funding provided by Karolinska Institute.

Background Current online prognostic prediction models for breast cancer, such as Adjuvant! Online and PREDICT, are based on specific populations. They have been well validated and widely used in the United States and Western Europe; however, several validation attempts in non-European countries have revealed suboptimal predictions. Objective We aimed to develop an advanced breast cancer prognosis model for disease progression, cancer-specific mortality, and all-cause mortality by integrating tumor, demographic, and treatment characteristics from a large breast cancer cohort in China. Methods This study was approved by the Clinical Test and Biomedical Ethics Committee of West China Hospital, Sichuan University on May 17, 2012. Data collection for this project was started in May 2017 and ended in March 2019. Data on 5293 women diagnosed with stage I to III invasive breast cancer between 2000 and 2013 were collected. Disease progression, cancer-specific mortality, all-cause mortality, and the likelihood of disease progression or death within a 5-year period were predicted. Extreme gradient boosting was used to develop the prediction model. Model performance was assessed by calculating the area under the receiver operating characteristic curve (AUROC), and the model was calibrated and compared with PREDICT. Results The training, test, and validation sets comprised 3276 (499 progressions, 202 breast cancer-specific deaths, and 261 all-cause deaths within 5-year follow-up), 1405 (211 progressions, 94 breast cancer-specific deaths, and 129 all-cause deaths), and 612 (109 progressions, 33 breast cancer-specific deaths, and 37 all-cause deaths) women, respectively. The AUROC values for disease progression, cancer-specific mortality, and all-cause mortality were 0.76, 0.88, and 0.82 for training set; 0.79, 0.80, and 0.83 for the test set; and 0.79, 0.84, and 0.88 for the validation set, respectively. Calibration analysis demonstrated good agreement between predicted and observed events within 5 years. Comparable AUROC and calibration results were confirmed in different age, residence status, and receptor status subgroups. Compared with PREDICT, our model showed similar AUROC and improved calibration values. Conclusions Our prognostic model exhibits high discrimination and good calibration. It may facilitate prognosis prediction and clinical decision making for patients with breast cancer in China.

Ovarian function suppression (OFS) plus other endocrine treatment was recommended to hormone receptor (HR)-positive breast cancer by some guidelines recently. We performed this study to validate the survival benefits of OFS plus aromatase inhibitors (AI) or selective estrogen receptor modulators (SERM) in the real world. All premenopausal, HR-positive breast cancer patients diagnosed between 1996 and 2017 were identified. Eligible patients were classified into three groups according to their adjuvant endocrine treatment, including OFS plus AI, OFS plus SERM and SERM alone. The primary outcome is invasive disease-free survival (iDFS), whereas the secondary outcome is overall survival (OS). Cox proportional hazards models and propensity score adjusted models were used to compare the survival benefits in three groups. We included 2838 patients, of which 246 received OFS plus AI, 175 received OFS plus SERM, and 2417 received SERM alone. Compared with SERM alone, OFS plus AI was associated with an improved iDFS (HR 0.59, 95% CI 0.36–0.96) and OS (HR 0.26, 95% CI 0.08–0.85). OFS plus SERM, however, was not significantly associated with extended iDFS or OS. Among patients older than 40 years old, OFS plus AI was more effective than OFS plus SERM (HR 0.38, 95% CI 0.17–0.88) or SERM alone (HR 0.44, 95% CI 0.23–0.84) in terms of iDFS. Our findings suggest that OFS plus AI treatment may extend both iDFS and OS among premenopausal patients with hormone receptor-positive breast cancer in the real world.

Background: Sudden temperature change may elevate short-term mortality and remains an important global health threat in the context of climate change. To date, however, little available temperature-mortality evidence has taken into account both intra- and inter-day temperature variability (TV), thus largely limiting the comprehensive understanding of mortality burden due to unstable weather. Moreover, seasonal and temporal patterns in TV-mortality associations were sparsely discussed, nationally and regionally. Objectives: We aimed to assess the nationwide association of all-cause mortality with hourly temperature variability (HTV), quantify HTV-attributable mortality, and further explore the temporal and seasonal variations of mortality burden due to HTV in United Kingdom. Methods: Fourteen-year time-series data on temperature and mortality were collected from 10 regions in England and Wales during 1993–2006, totally including 7,573,716 all-cause deaths. HTV was calculated from the standard deviation of hourly temperature records within two neighboring days. A three-stage analytic approach was adopted to assess HTV-associated mortality burden. We first applied a time-series quasi-Poisson regression to estimate region-specific HTV-mortality associations, then pooled these associations at the national level using a multivariate meta-analysis, and finally estimated the HTV-attributable mortality fraction and illustrated its seasonal and temporal variations by conducting season- and period-specific analyses based on time-varying distributed lag models. Results: We found strong evidence that large HTV exposure elevated short-term mortality risk in England and Wales, with a pooled estimate of 1.13% (95% confidence interval (CI): 0.88, 1.39) associated with a 1-°C increase in HTV. During the whole study period, HTV accounted for a national average attributable fraction of 2.52% (95% empirical confidence interval (eCI): 2.27, 2.76) of the total deaths. This HTV-attributable mortality estimate showed a significant temporal decrease (p

This meta-analysis aimed to determine whether prophylactic probiotics in combination with antibiotics are superior to antibiotics alone in the prevention of surgical site infection (SSI) after colorectal surgery. Fourteen trials involving 1524 participants were included. Compared with antibiotics alone, prophylactic probiotics in combination with antibiotics reduced the risk of SSI as well as other complications, shortened the cumulative duration of antibiotic therapy. Current evidence suggested that probiotics in combination with antibiotics could be recommended.

Objective: To conduct a meta-analysis of prospective and retrospective studies to reveal the relationship between the Glasgow prognostic score (GPS) and overall survival (OS) or progression-free survival (PFS) in patients with lung cancer. Methods: Correlative studies were included by searching the databases of PubMed, Web of Science, Embase, and PubMed Cochrane Library until April 16, 2017. We combined the hazard ratios (HRs) and 95% confidence intervals (CIs) to assess the correlation between GPS and OS or PFS in patients with lung cancer. Results: Ten studies involving 5,369 participants from several regions were identified through searching databases. In a pooled analysis of all studies, elevated GPS was associated with poorer OS (HR = 2.058; 95% CI, 1.51-2.80; pConclusions: Increased level of GPS may have a prognostic value in lung cancer. We detected a statistical difference in the association of elevated GPS and poorer OS, though the association was not significant in PFS settings. However, further studies are warranted to draw firm conclusions.

Background Despite ongoing progress in our understanding of long-term outcomes after neuromodulation procedures, acute adverse outcomes shortly after deep brain stimulation (DBS) treatment have remained remarkably limited. Objective To identify risk factors associated with acute 30-day outcomes after DBS treatment in patients with Parkinson disease (PD). Methods We evaluated patients who underwent DBS treatment for PD from 2005 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program database. We used bivariate analysis and multivariate logistic regression to identify short-term postoperative outcomes, including 30-day complication, discharge destination, and unplanned readmission. Results Overall, 650 patients with PD underwent DBS procedures and complications were identified in 32 patients (4.9%). Of 481 patients who had complete discharge data, 18 patients (3.7%) were discharged to a facility and 16 patients (3.3%) experienced an unplanned readmission. Patients with PD who were obese ( P = 0.045), who had preoperative anemia ( P = 0.008), and who experienced longer operative durations ( P = 0.01) had increased odds of postoperative complications. Inpatient status ( P = 0.001), dependent functional status ( P P = 0.043) were all associated with discharge to a facility other than home. Longer operative duration ( P = 0.013), anemia ( P = 0.036), and dependent functional status ( P = 0.03) were significantly associated with unplanned readmission. As expected, complications increased the likelihood of unplanned readmission ( P Conclusions This study provides individualized estimates of the risks associated with short-term adverse outcomes based on patient demographics and comorbidities. These data can be used as an adjunct for short-term risk stratification of patients with PD being considered for DBS treatment.

Background With the tremendous advances in the field of brain–computer interfaces (BCI), the literature in this field has grown exponentially; examination of highly cited articles is a tool that can help identify outstanding scientific studies and landmark papers. This study examined the characteristics of 100 highly cited BCI papers over the past 10 years. Methods The Web of Science was searched for highly cited papers related to BCI research published from 2006 to 2015. The top 100 highly cited articles were identified. The number of citations and countries, and the corresponding institutions, year of publication, study design, and research area were noted and analyzed. Results The 100 highly cited articles had a mean of 137.1(SE: 15.38) citations. These articles were published in 45 high-impact journals, and mostly in TRANSACTIONS ON BIOMEDICAL ENGINEERING (n = 14). Of the 100 articles, 72 were original articles and the rest were review articles. These articles came from 15 countries, with the USA contributing most of the highly cited articles (n = 52). Fifty-seven institutions produced these 100 highly cited articles, led by Duke University (n = 7). Conclusions This study provides a historical perspective on the progress in the field of BCI, allows recognition of the most influential reports, and provides useful information that can indicate areas requiring further investigation.

Background: Temperature-related mortality risks have mostly been studied in urban areas, with limited evidence for urban–rural differences in the temperature impacts on health outcomes. Objectives: We investigated whether temperature–mortality relationships vary between urban and rural counties in China. Methods: We collected daily data on 1 km gridded temperature and mortality in 89 counties of Zhejiang Province, China, for 2009 and 2015. We first performed a two-stage analysis to estimate the temperature effects on mortality in urban and rural counties. Second, we performed meta-regression to investigate the modifying effect of the urbanization level. Stratified analyses were performed by all-cause, nonaccidental (stratified by age and sex), cardiopulmonary, cardiovascular, and respiratory mortality. We also calculated the fraction of mortality and number of deaths attributable to nonoptimum temperatures associated with both cold and heat components. The potential sources of the urban–rural differences were explored using meta-regression with county-level characteristics. Results: Increased mortality risks were associated with low and high temperatures in both rural and urban areas, but rural counties had higher relative risks (RRs), attributable fractions of mortality, and attributable death counts than urban counties. The urban–rural disparity was apparent for cold (first percentile relative to minimum mortality temperature), with an RR of 1.47 [95% confidence interval (CI): 1.32, 1.62] associated with all-cause mortality for urban counties, and 1.98 (95% CI: 1.87, 2.10) for rural counties. Among the potential sources of the urban–rural disparity are age structure, education, GDP, health care services, air conditioners, and occupation types. Conclusions: Rural residents are more sensitive to both cold and hot temperatures than urban residents in Zhejiang Province, China, particularly the elderly. The findings suggest past studies using exposure–response functions derived from urban areas may underestimate the mortality burden for the population as a whole. The public health agencies aimed at controlling temperature-related mortality should develop area-specific strategies, such as to reduce the urban–rural gaps in access to health care and awareness of risk prevention. Future projections on climate health impacts should consider the urban–rural disparity in mortality risks. https://doi.org/10.1289/EHP3556

Key Points Question During the hot season, is timing of heat exposure associated with varied risk of hospitalization in the Brazilian population? Findings In this time-stratified case-crossover study, the association between heat exposure and hospitalization was greatest in the early hot season, particularly for residents living in the northeast and central west regions of Brazil. Exposure to early heat was associated with the highest risk of hospitalization for children and elderly individuals, and for admissions for endocrine, nutritional, and metabolic diseases. Meaning Preventive strategies to mitigate the association of high temperature with population health should focus on extreme high temperatures occurring early in the hot season., This time-stratified case-crossover study examines the association between timing of heat exposure and risk of hospitalization in the Brazilian population., Importance The onset of the hot season is known to be adversely associated with a range of health outcomes. However, little is known about whether the association is constant over the course of the hot season. Objective To quantify the change in the association between heat exposure and hospitalization from the early to late hot season in the Brazilian population. Design, Setting, and Participants This time-stratified case-crossover study used daily data on hospitalization and weather conditions during the 2000 to 2015 hot seasons in 1814 Brazilian cities. There were 49 145 997 admissions during the study period. Data analysis was conducted between May 12, 2018, and July 2, 2018. Exposures Increase in daily mean temperature. Main Outcomes and Measures Daily hospitalizations were recorded. Conditional quasi-Poisson regression with time-varying constrained distributed lag model was used to examine the city-specific association between heat and hospitalization in the early or late hot season. City-specific estimates were then pooled at the national level using random-effect meta-analysis. Stratified analyses were conducted by 5 regions, sex, 10 age groups, and 7 cause-specific categories. Results Of the 49 145 997 admissions (59% women), the median (interquartile range) age was 33.3 (19.8-55.7) years. At the national level, the risk of hospitalization increased by 4.6% (95% CI, 4.3%-4.9%) and 2.3% (95% CI, 1.9%-2.6%) for every 5°C increase in daily mean temperature in the early and late hot season, respectively. Exposure to early heat was associated with greater risk of hospitalization for residents in the northeast (6.4%; 95% CI, 5.5%-7.3%) and central west (7.1%; 95% CI, 6.1%-8.2%) compared with other regions. Children aged 0 to 9 years and elderly individuals (aged ≥80 years) were most susceptible. Admissions due to endocrine, nutritional, and metabolic diseases were most strongly associated with heat exposure. There was an attenuation in the heat-associated risk of hospitalization from the early to late hot season for all subgroups except young children and patients with hospitalization caused by respiratory illness. Conclusions and Relevance In this study, the association between heat exposure and hospitalization attenuated temporally for most of the Brazilian population. Preventive strategies to mitigate the association of high temperature with population health should focus in particular on the first few days of heat exposure.

Background Percutaneous kyphoplasty (PKP) is a procedure performed by a spine surgeon who undergoes either orthopedic or neurosurgical training. The relationship between short-term adverse outcomes and spine specialty is presently unknown. To compare short-term adverse outcomes of single-level PKP when performed by neurosurgeons and orthopedic surgeons in order to develop more concretely preventive strategies for patients under consideration for single-level PKP. Methods We evaluated patients who underwent single-level PKP from 2012 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We used univariate analysis and multivariate logistic regression to assess the association between spine surgeon specialty and short-term adverse events, including postoperative complication and unplanned readmission, and to identify different independent risk predictors between two specialties. Results Of 2248 patients who underwent single-level PKP procedure, 1229 patients (54.7%) had their operations completed by a neurosurgeon. There were no significant differences in the development of the majority of postoperative complications and the occurrence of unplanned readmission between the neurosurgical cohort (NC) and the orthopedic cohort (OC). A difference in the postoperative blood transfusion rate (0.7% NS vs. 1.7% OC, P = 0.039) was noted and may due to the differences in comorbidities between patients. Multivariate regression analysis revealed different independent predictors of postoperative adverse events for the two spine specialties. Conclusions By comparing a large range of demographic feature, preoperative comorbidities, and intraoperative factors, we find that short-term adverse events in single-level PKP patients does not affect by spine surgeon specialty, except that the OC had higher postoperative blood transfusion rate. In addition, the different perioperative predictors of postoperative complications and unplanned readmissions were identified between the two specialties. These findings can lead to better evidence-based patient counseling and provide valuable information for medical evaluation and potentially devise methods to reduce patients’ risk.

Background: Limited evidence is available regarding the association between heat exposure and morbidity in Brazil and how the effect of heat exposure on health outcomes may change over time. Objectives: This study sought to quantify the geographic, demographic and temporal variations in the heat–hospitalization association in Brazil from 2000–2015. Methods: Data on hospitalization and meteorological conditions were collected from 1,814 cities during the 2000–2015 hot seasons. Quasi-Poisson regression with constrained lag model was applied to examine city-specific estimates, which were then pooled at the regional and national levels using random-effect meta-analyses. Stratified analyses were performed by sex, 10 age groups, and 11 cause categories. Meta-regression was used to examine the temporal change in estimates of heat effect from 2000 to 2015. Results: For every 5°C increase in daily mean temperature during the 2000–2015 hot seasons, the estimated risk of hospitalization over lag 0–7 d rose by 4.0% [95% confidence interval (CI): 3.7%, 4.3%] nationwide. Estimated 6.2% [95% empirical CI (eCI): 3.3%, 9.1%] of hospitalizations were attributable to heat exposure, equating to 132 cases (95% eCI: 69%, 192%) per 100,000 residents. The attributable rate was greatest in children

Background Temperature variability (TV) is closely associated with climate change, but there is no unified TV definition worldwide. Two novel composite TV indexes were developed recently by calculating the standard deviations of several days’ daily maximum and minimum temperatures (TVdaily), or hourly mean temperatures (TVhourly). Objectives This study aimed to compare the mortality risks and burden associated with TVdaily and TVhourly using large time-series datasets collected from multiple locations in China, United Kingdom and United States. Methods We collected daily mortality and hourly temperature data through 1987 to 2012 from 63 locations in China (8 communities, 2006–2012), United Kingdom (10 regions, 1990–2012), and USA (45 cities, 1987–2000). TV-mortality associations were investigated using a three-stage analytic approach separately for China, UK, and USA. First, we applied a time-series regression for each location to derive location-specific TV-mortality curves. A second-stage meta-analysis was then performed to pool these estimated associations for each country. Finally, we calculated mortality fraction attributable to TV based on above-described location-specific and pooled estimates. Results Our dataset totally consisted of 23, 089, 328 all-cause death cases, including 93, 750 from China, 7,573,716 from UK and 15, 421, 862 from USA, respectively. In despite of a relatively wide uncertainty in China, approximately linear relationships were consistently identified for TVdaily and TVhourly. In the three countries, generally similar lag patterns of TV effects were consistently observed for TVdaily and TVhourly. A 1 °C rise in TVdaily and TVhourly at lag 0–7 days was associated with mortality increases of 0.93% (95% confidence interval [CI]: 0.12, 1.74) and 0.97% (0.18, 1.77) in China, 0.33% (0.15, 0.51) and 0.41% (0.21, 0.60) in UK, and 0.55% (0.41, 0.70) and 0.51% (0.35, 0.66) in USA, respectively. Larger attributable fractions were estimated using TVdaily than those using TVhourly, with estimates at 0–10 days of 3.69% (0.51, 6.75) vs. 2.59% (0.10, 5.01) in China, 1.14% (0.54, 1.74) vs. 0.98% (0.55, 1.42) in UK, and 2.57% (1.97, 3.16) vs. 1.67% (1.15, 2.18) in USA, respectively. Our meta-regression analyses indicated higher vulnerability to TV-induced mortality risks in warmer locations. Conclusions Our study added multi-country evidence for increased mortality risk associated with short-term exposure to large temperature variability. Daily and hourly TV exposure metrics produced generally comparable risk effects, but the attributable mortality burden tended to be higher using TVdaily instead of TVhourly.

Motor deficit is among the most debilitating aspects of injury to the central nervous system. Despite ongoing progress in brain-machine interface (BMI) development and in the functional electrical stimulation of muscles and nerves, little is understood about how neural signals in the brain may be used to potentially control movement in one’s own unconstrained paralyzed limb. We recorded from high-density electrocorticography (ECoG) electrode arrays in the ventral premotor cortex (PMv) of a rhesus macaque and used real-time motion tracking techniques to correlate spatial-temporal changes in neural activity with arm movements made towards objects in three-dimensional space at millisecond precision. We found that neural activity from a small number of electrodes within the PMv can be used to accurately predict reach-return movement onset and directionality. Also, whereas higher gamma frequency field activity was more predictive about movement direction during performance, mid-band (beta and low gamma) activity was more predictive of movement prior to onset. We speculate these dual spatiotemporal signals may be used to optimize both planning and execution of movement during natural reaching, with prospective relevance to the future development of neural prosthetics aimed at restoring motor control over one’s own paralyzed limb.

Purpose Postmastectomy radiation therapy (PMRT) had heterogeneous effects on survival outcome of patients with T1-2N1 breast cancer. A reliable model to estimate individuals’ risk of locoregional recurrence (LRR) and the potential benefit derived from PMRT is needed. Methods and Materials We retrospectively analyzed 1141 patients with T1-2N1 breast cancer who underwent mastectomy between January 2001 and December 2012. Based on the Fine and Gray competing risks regression in 623 unirradiated patients, a nomogram predicting LRR was conducted for risk quantification. Decision tree analysis was performed for patient grouping. The impact of PMRT was evaluated among 3 subgroups. Results With a median follow-up of 74.9 months, the 5-year cumulative incidence of LRR, distant recurrence (DR) and breast cancer mortality (BCM) were 3.9%, 8.8%, and 6.0%, respectively, for the entire cohort. Based on nomogram scores, patients were classified into 3 risk groups in decision tree analysis. In the high-risk group, PMRT was found to be associated with a 12.7% risk reduction of 5-year LRR, 9.2% risk reduction of 5-year DR, and 7.0% risk reduction of 5-year BCM, whereas it was not significantly associated with LRR, DR, or BCM in low- and intermediate-risk groups. Conclusions The nomogram performed individualized risk quantification of LRR in patients with T1-2N1 breast cancer. A newly identified patient subgroup with high risk of LRR were found to derive survival benefit from PMRT.

Restoration of digital flexion after brachial plexus injury or forearm injury has been a great challenge for hand surgeons. Nerve transfer and forearm donor muscle transfer surgeries are not always feasible. The present study aimed at evaluating the effectiveness of restoring digital flexion by brachialis muscle transfer. Ten lower brachial plexus- or forearm-injured patients were enrolled. After at least 12 months following surgery, the middle-finger-to-palm distance was less than 2.5 cm in six patients. In the other four patients with less satisfactory results, secondary tenolysis surgery was performed and the middle-finger-to-palm distances were reduced to 2.0–4.0 cm. The average grasp strength was 20 ± 4 kg. Elbow flexion was not adversely affected. In conclusion, brachialis muscle transfer is an effective method for reconstructing digital flexion, not only in lower brachial plexus injury, but also in forearm injury patients. Level of evidence: IV

Studies have shown that vitamin D could have a role in breast cancer survival; however, the evidence of the relationship between patients’ vitamin D levels and their survival has been inconsistent. This meta-analysis explores possible dose-response relationships between vitamin D levels and overall survival by allowing for differences in vitamin D levels among populations of the various studies. Studies relating vitamin D (25-OH-D [25-hydroxyvitamin D]) levels in breast cancer patients with their survival were identified by searching PubMed and Embase. A pooled HR (hazard ratio) comparing the highest with the lowest category of circulating 25-OH-D levels were synthesized using the Mantel-Haenszel method under a fixed-effects model. A two-stage fixed-effects dose-response model including both linear (a log-linear dose-response regression) and nonlinear (a restricted cubic spline regression) models were used to further explore possible dose-response relationships. Six studies with a total number of 5984 patients were identified. A pooled HR comparing the highest with the lowest category of circulating 25-OH-D levels under a fixed-effects model was 0.67 (95% confidence interval = 0.56-0.79, P < .001). Utilizing a dose-response meta-analysis, the pooled HR for overall survival in breast cancer patients was 0.994 (per 1 nmol/L), Pfor linear trend < .001. At or above a 23.3 nmol/L threshold, for a 10 nmol/L, 20 nmol/L, or 25 nmol/L increment in circulating 25-OH-D levels, the risk of breast cancer overall mortality decreased by 6%, 12%, and 14%, respectively. There was no significant nonlinearity in the relationship between overall survival and circulating 25-OH-D levels. Our findings suggest that there is a highly significant linear dose-response relationship between circulating 25-OH-D levels and overall survival in patients with breast cancer. However, better designed prospective cohort studies and clinical trials are needed to further confirm these findings.

We reported a rare peripheral nerve case, a patient developed carpal tunnel syndrome with a history of floating thumb in right hand. The median nerve was found expanded and spindle-shaped and a plexiform neurofibroma was diagnosed. Our case sheds light on anatomy and possible etiological association which may help clinical management.

Objective: We aimed to identify and analyze the characteristics of the 100 most highly-cited papers in the research field of deep brain stimulation (DBS). Methods: The Web of Science was searched for highly-cited papers related to DBS research. The number of citations, countries, institutions of origin, year of publication, and research area were noted and analyzed. Results: The 100 most highly-cited articles had a mean of 304.15 citations. These accrued an average of 25.39 citations a year. The most represented target by far was the subthalamic nucleus (STN). These articles were published in 46 high-impact journals, with Brain (n = 10) topping the list. These articles came from 11 countries, with the USA contributing the most highly-cited articles (n = 29); however, it was the University of Toronto (n = 13) in Canada that was the institution with the most highly-cited studies. Conclusions: This study identified the 100 most highly-cited studies and highlighted a historical perspective on the progress in the field of DBS. These findings allow for the recognition of the most influential reports and provide useful information that can indicate areas requiring further investigation.

Objective To perform a meta-analysis of prospective and retrospective studies exploring the association of the modified Glasgow prognostic score (mGPS) with overall survival (OS) in patients with lung cancer. Methods Relevant studies were identified by searching the Cochrane Library, Web of Science, Embase and PubMed until April 16, 2017. We combined hazard ratios (HRs) and 95% confidence intervals (CIs) to assess the correlation between mGPS and OS in patients with lung cancer. Results Eleven studies involving 5817 participants from several countries were included in the meta-analysis. In a pooled analysis of all studies, elevated mGPS predicted poorer OS (HR = 1.77; 95% CI: 1.35–2.31; P

Background To our knowledge, no study has assessed the association between heatwaves and risk of hospitalization and how it may change over time in Brazil. We quantified the heatwave–hospitalization association in Brazil during 2000–2015. Methods and findings Daily data on hospitalization and temperature were collected from 1,814 cities (>78% of the national population) in the hottest five consecutive months during 2000–2015. Twelve types of heatwaves were defined with daily mean temperatures of ≥90th, 92.5th, 95th, or 97.5th percentiles of year-round temperature and durations of ≥2, 3, or 4 consecutive days. The city-specific association was estimated using a quasi-Poisson regression with constrained distributed lag model and then pooled at the national level using random-effect meta-analysis. Stratified analyses were performed by five regions, sex, 10 age groups, and nine cause categories. The temporal change in the heatwave–hospitalization association was assessed using a time-varying constrained distributed lag model. Of the 58,400,682 hospitalizations (59% women), 24%, 34%, 21%, and 19% of cases were aged, Qi Zhao and colleagues reveal the association between heatwaves and hospital admissions between 2000 and 2015 in Brazil, with young children and the elderly most affected., Author summary Why was this study done? Brazil has a rapidly growing morbidity burden and is experiencing some of the most severe effects of global warming. However, there is no national evidence regarding the heatwave–hospitalization associations. What did the researchers do and find? Using a data set covering >78% of the national population (>160 million residents), we performed a nationwide time series study to examine the relationship between heatwaves and risk of all-cause and cause-specific hospitalizations and how it varied over time among the Brazilian population. Exposure to heatwaves characterized by high temperatures and long durations was associated with higher risk of hospitalization compared with moderate heatwaves. The duration of severe heatwaves was additively associated with risk of hospitalization in the cooler south and southeast regions. Children and the elderly were most vulnerable to heatwaves. Hospital admissions for perinatal conditions were most strongly associated with heatwaves. Over the study period, the risk of hospitalization associated with moderate heatwaves declined substantially in Brazil (especially in the south), with the notable exception of an apparent increase in the southeast region. What do these findings mean? To the best of our knowledge, this is the first national study to explore the geographic, demographic, cause-specific, and temporal variations in the association between heatwaves and risk of hospitalization in Brazil. Considering the projected increase in the frequency, duration, and intensity of heatwaves, future strategies for the forecasting of healthcare utilization in the Brazilian population should take into account the association between heatwaves and hospitalizations, especially among the most vulnerable population subgroups. Given the unique location of Brazil and its climatic and geographic diversity, our findings may be of relevance for other South American countries.

We read with interest the milestone work in the Annals of the Rheumatic Diseases by Mahler and colleagues1 on the effectiveness of low-dose radiation therapy (LDRT) on symptoms in patients with knee osteoarthritis (OA). The authors have conducted a series of studies to investigate the effects of LDRT on OA, which compensate the lack of high-level evidence in the medical literature, and inevitably forcing us to re-examine the true effectiveness of LDRT on OA in real-world clinical practice.1–3 The group should be applauded for their accomplishments. In this well-designed and well-conducted randomised, double-blinded, sham-controlled trial, they found no substantial beneficial effect on symptoms and …

It is largely unclear that whether or not surgical resection of the primary tumors could confer survival benefit among patients with metastatic breast cancer at initial presentation. We thoroughly reviewed the up-to-date evidence on surgical resection of the primary lesion in metastatic breast cancer, including comparative studies (of particular interest in risk modifiers, the type, and timing of surgical procedures), Chinese and international guidelines, as well as the progress of clinical trials. Partial modified radical mastectomy and breast-conserving surgery are by far the most common choices for patients with metastatic breast cancer. Patients with certain characteristics, for example, younger than 45 years of age or with oligo-metastasis, might benefit from the surgery. The type and timing of surgical procedures are still in debate according to the guidelines from different countries. Forthcoming evidence from the ongoing clinical trials might help close the knowledge gaps in surgical treatment for patients with metastatic breast cancer and aid the decision-making in clinical practice.

This study aims to evaluate the predictive value of left testicular volume (LTV) and right testicular volume (RTV) for testicular function respectively. Men who requested fertility testing for any reason were enrolled from December 2012 to November 2015. Subjects with primary scrotal diseases or a condition interfering reproductive system were excluded. Testicular volume (TV) was evaluated by scrotal ultrasound. Sex hormone and semen analysis including sperm concentration (SC) and sperm motility rate (SMR) were performed. Statistical analysis including comparison, stepwise linear regression and logistic regression was used. Two hundred and seventy-four patients with oligoasthenozoospermia/low testosterone and 27 control subjects were enrolled. Both LTV and RTV positively correlated with testicular function, and no differences were found between bilateral TV. RTV is the best independent factor associated with testicular function determined by SC (β=.292, p < .001), SMR (β=.227, p < .001) and total testosterone (TT) (β=.245, p < .001). Using a RTV value of 15.47 ml, the highest discriminating sensitivity and specificity were 66.7% and 62.4% respectively. RTV (

Purpose This study evaluated functional outcomes and safety after endoscopic and open bilateral carpal tunnel syndrome release in opposite hands of the same patients through a meta-analysis of randomized controlled trial data. Materials and Methods Randomized controlled trials involving both methods in opposite hands of patients with bilateral carpal tunnel syndrome were identified via a systematic review of PUBMED and EMBASE. Results Relative risks (RRs) and 95% confidence intervals (CIs) from five randomized controlled trials involving 142 patients with bilateral carpal tunnel syndrome were calculated using fixed- or random-effect methods, with a length of follow-up from 24 to 52 weeks after surgery. Compared with open release, endoscopic carpal tunnel release was associated with significantly better Boston Carpal Tunnel Questionnaire functional status scores (mean difference [MD] = 0.13, 95% confidence interval [CI] [0.02 – 0.25]; P = 0.02), but not symptom severity scores (RR = 0.06, 95% CI [−0.15 to 0.04]; P = 0.25). Endoscopic release required a longer operative time, but the procedures did not differ significantly in visual analog scale pain scores (MD = 0.02, 95% CI [−0.08 to 0.11]; P = 0.75), handgrip strength (MD = 0.17, 95% CI [−2.03 to 2.37]; P = 0.88), digital sensibility static two-point discrimination (MD = 0.34, 95% CI [−0.03 to 0.70]; P = 0.07), or complication rates (MD = 0.01, 95% CI [−0.02 to 0.05], P = 0.47). Conclusion From intraindividual evidence, endoscopic release promoted better recovery of daily life functions than open release, but required a longer operative time. The procedures provided similar symptom relief and hand strength and sensibility recovery, and were safe for patients with carpal tunnel syndrome.

The International Consensus Guidelines for advanced breast cancer (ABC) considers that the surgery of the primary tumor for stage IV breast cancer patients does not usually improve the survival. However, studies have showed that resection of the primary tumor may benefit these patients. The correlation between surgery and survival remains unclear.The impact of surgery and other clinical factors on overall survival (OS) of stage IV patients is investigated in West China Hospital. Female patients diagnosed with stage IV breast cancer between 1999 and 2014 were included (N = 223). Univariate and multivariate analysis assessed the association between surgery and OS.One hundred seventy-seven (79.4%) underwent surgery for the primary tumor, and 46 (20.6%) had no surgery. No significant differences were observed in age at diagnosis, T-stage, N-stage, histological grade, molecular subtype, hormone receptor (HR), and number of metastatic sites between 2 groups. Patients in the surgery group had dramatically longer OS (45.6 vs 21.3 months, log-rank P < .001). In univariate analysis, survival was associated with surgical treatment, residence, tumor size, lymph node, HR status, hormonal therapy, and radiotherapy. In multivariate analysis, surgery was an independent prognostic factor for OS [hazard ratio (HR), 0.569; 95% confidence interval (CI) 0.329-0.984, P = .044]. Additional independent prognostic factors were hormonal therapy (HR, 0.490; 95% CI 0.300-0.800) and radiotherapy (HR, 0.490; 95% CI 0.293-0.819). In addition, a favorable impact of surgery was observed by subgroup analysis.Our study showed that surgery of the primary breast tumor has a positive impact on OS in with stage IV breast cancer patients.