Clinical Features and Outcomes of 666 Cases with Therapy-Related Myelodysplastic Syndrome (t-MDS)

Therapy-related myelodysplastic syndrome (t-MDS) is a serious complication of chemoradiotherapy for primary diseases. This cohort was aimed to determine the clinical features and outcomes of t-MDS in comparison with de novo MDS. I retrieved data of 666 cases with t-MDS, and 29,703 cases with de novo MDS diagnosed between 2001 and 2012 from the database of U.S. National Cancer Institute. Survival curves were estimated, and Cox proportional hazards model was constructed. Compared with patients with de novo MDS, patients with t-MDS tended to be young (median age; 65 vs. 76 years, p < 0.001), and were more likely to be female-sex (51.4 vs. 44.7%, p = 0.001). Median overall survival (OS) and 5-year OS rate are significantly poorer in t-MDS than de novo MDS (17.2 months and 22% vs. 31 months and 32%, respectively, p < .001). In t-MDS cases, with a median follow-up of 16 months (range 1-143 months), 521 cases (78.2%) had died. Of which, 78 (15%) cases had died from acute myeloid leukemia, and 66 (12.7%) cases had died from solid cancers. Of the total 66 cases died from solid cancers; 19 cases (28.8%) died from cancer of lung/bronchus, 11 cases (16.7%) breast cancers, and 10 cases (15.2%) ovarian cancer. In a multivariate analysis adjusted for clinical features, calendar period and radiotherapy, the hazard of mortality was significantly low in de novo MDS compared with t-MDS (hazard ratio 0.59; p < .001). In conclusions, t-MDS is a distinct entity of MDS in terms of clinical characteristics and prognosis.

Differentiating Primary, Genetic, and Secondary FSGS in Adults: A Clinicopathologic Approach

FSGS describes a renal histologic lesion with diverse causes and pathogenicities that are linked by podocyte injury and depletion. Subclasses of FSGS include primary, genetic, and secondary forms, the latter comprising maladaptive, viral, and drug-induced FSGS. Despite sharing certain clinical and histologic features, these subclasses differ noticeably in management and prognosis. Without an accepted nongenetic biomarker that discriminates among these FSGS types, classification of patients is often challenging. This review summarizes the clinical and histologic features, including the onset and severity of proteinuria as well as the presence of nephrotic syndrome, that may aid in identifying the specific FSGS subtype. The FSGS lesion is characterized by segmental sclerosis and must be differentiated from nonspecific focal global glomerulosclerosis. No light microscopic features are pathognomonic for a particular FSGS subcategory. The characteristics of podocyte foot process effacement on electron microscopy, while helpful in discriminating between primary and maladaptive FSGS, may be of little utility in detecting genetic forms of FSGS. When FSGS cannot be classified by clinicopathologic assessment, genetic analysis should be offered. Next generation DNA sequencing enables cost-effective screening of multiple genes simultaneously, but determining the pathogenicity of a detected genetic variant may be challenging. A more systematic evaluation of patients, as suggested herein, will likely improve therapeutic outcomes and the design of future trials in FSGS.

Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy

OBJECTIVE

To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model.

METHODS

A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0-14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers.

RESULTS

Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4-5 vs. day 6, p = 0.01) occurred earlier with HB-EGF.

CONCLUSIONS

In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH.

LEVEL OF EVIDENCE

NA-animal studies or basic research.

Somatosensory Evoked Potentials and Central Motor Conduction Times in children with dystonia and their correlation with outcomes from Deep Brain Stimulation of the Globus pallidus internus

•

A high proportion (47%) of children with dystonia have evidence of abnormal sensory pathway function.

•

Central motor conduction times (CMCTs) and somatosensory evoked potentials (SEPs) show a significant relationship with deep brain stimulation (DBS) outcome, independent of aetiology or cranial MRI.

•

CMCTs and SEPs can guide patient selection and help counsel families about potential benefit of DBS.

Objectives

To report Somatosensory Evoked Potentials (SEPs) and Central Motor Conduction Times (CMCT) in children with dystonia and to test the hypothesis that these parameters predict outcome from Deep Brain Stimulation (DBS).

Methods

180 children with dystonia underwent assessment for Globus pallidus internus (GPi) DBS, mean age 10 years (range 2.5–19). CMCT to each limb was calculated using Transcranial Magnetic Stimulation. Median and posterior tibial nerve SEPs were recorded over contralateral and midline centro-parietal scalp. Structural abnormalities were assessed with cranial MRI. One-year outcome from DBS was assessed as percentage improvement in Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS-m).

Results

Abnormal CMCTs and SEPs were found in 19% and 47% of children respectively and were observed more frequently in secondary than primary dystonia. Of children proceeding to DBS, better outcome was seen in those with normal (n = 78/89) versus abnormal CMCT (n = 11/89) (p = 0.002) and those with normal (n = 35/51) versus abnormal SEPs (n = 16/51) (p = 0.001). These relationships were independent of dystonia aetiology and cranial MRI findings.

Conclusions

CMCTs and SEPs provide objective evidence of motor and sensory pathway dysfunction in children with dystonia and relate to DBS outcome.

Significance

CMCTs and SEPs can contribute to patient selection and counselling of families about potential benefit from neuromodulation for dystonia.

Rates and predictors of success and failure in repeat epilepsy surgery: A meta-analysis and systematic review

OBJECTIVE

Medically refractory epilepsy is a debilitating disorder that is particularly challenging to treat in patients who have already failed a surgical resection. Evidence regarding outcomes of further epilepsy surgery is limited to small case series and reviews. Therefore, our group performed the first quantitative meta-analysis of the literature from the past 30 years to assess for rates and predictors of successful reoperations.

METHODS

A PubMed search was conducted for studies reporting outcomes of repeat epilepsy surgery. Studies were excluded if they reported fewer than five eligible patients or had average follow-ups < 1 year, and patients were excluded from analysis if they received a nonresective intervention. Outcomes were stratified by each variable of interest, and quantitative meta-analysis was performed to generate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Seven hundred eighty-two patients who received repeat resective epilepsy surgery from 36 studies were included. Engel I outcome was observed in 47% (n = 369) of patients. Significant predictors of seizure freedom included congruent over noncongruent electrophysiology data (OR = 3.6, 95% CI = 1.6-8.2), lesional over nonlesional epilepsy (OR = 3.2, 95% CI = 1.9-5.3), and surgical limitations over disease-related factors associated with failure of the first surgery (OR = 2.6, 95% CI = 1.3-5.3). Among patients with at least one of these predictors, seizure freedom was achieved in 58%. Conversely, the use of invasive monitoring was associated with worse outcome (OR = 0.4, 95% CI = 0.2-0.9). Temporal lobe over extratemporal/multilobe resection (OR = 1.5, 95% CI = 0.8-3.0) and abnormal over normal preoperative magnetic resonance imaging (OR = 1.9, 95% CI = 0.6-5.4) showed nonsignificant trends toward seizure freedom.

SIGNIFICANCE

This analysis supports considering further resection in patients with intractable epilepsy who continue to have debilitating seizures after an initial surgery, especially in the context of factors predictive of a favorable outcome.

Policy Brief: Using ESSA to Improve Secondary English Learners' Opportunities to Learn through Course Taking

While the 2015 federal Every Student Succeeds Act (ESSA) allows states to adopt new measures to assess school accountability, state and district leaders must now use evidence-based interventions that address student inequities. For English learners (ELs) at the secondary level, one important measure of opportunity to learn is access to and completion of rigorous, college preparatory coursework. Drawing from ESSA's definition of "evidence-based," aligned with the Castañeda guidelines, we propose course taking as a valid and reliable statewide indicator of student success, and offer recommendations for local evidence-based interventions that would support ELs' opportunity to learn.

Comparison of the clinical characteristics and prognosis of primary versus secondary acute gastrointestinal injury in critically ill patients

BACKGROUND

This prospective study compared clinical characteristics and prognosis between primary (P) and secondary (S) acute gastrointestinal injury (AGI) (P-AGI)/(S-AGI) in critically ill patients.

METHODS

This was a prospective, single-center observational study. Patients were included if they had been hospitalized for at least 72 h before the AGI diagnosis. Patients were classified according to severity of gastrointestinal dysfunction, while P-AGI or S-AGI were defined according to whether the gastrointestinal system was directly or indirectly involved. Clinical characteristics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and Sepsis-related Organ Failure Assessment (SOFA) scores after inclusion and 28-day mortality were recorded.

RESULTS

Altogether, 282 patients were included: P and S groups enrolled 100 and 182 patients, respectively. The S group patients were older and showed increased morbidities and higher APACHE II and SOFA scores. Compared to the S group, the P group had a higher prevalence in abdominal distention and enteroparalysis and fewer patients at AGI grade I, while more patients at grade III or IV. The S group patients had the higher 28-day mortality. Multiple logistic regression analysis showed AGI grades, APACHE II score, and S-AGI independently predicted the odds of 28-day mortality.

CONCLUSIONS

Comparing to the P-AGI patients, the S group patients were older, with higher APACHE II and SOFA scores. AGI grade, APACHE II score, and S-AGI independently predicted the odds of 28-day mortality in AGI patients.

Multimodal Interventions to Enhance Adherence to Secondary Preventive Medication after Stroke: A Systematic Review and Meta-Analyses

INTRODUCTION

Nonadherence to secondary preventative medications after stroke is common and is associated with poor outcomes. Numerous strategies exist to promote adherence. We performed a systematic review and meta-analysis to describe the efficacy of strategies to improve adherence to stroke secondary prevention.

METHODS

We created a sensitive search strategy and searched multiple electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and Web of Knowledge) for studies of interventions that aimed to enhance adherence to secondary preventative medication after stroke. We assessed quality of included studies using the Cochrane tool for assessing risk of bias. We performed narrative review and performed meta-analysis where data allowed.

RESULTS

From 12,237 titles, we included seventeen studies in our review. Eleven studies were considered to have high risk of bias, 3 with unclear risk, and 3 of low risk. Meta-analysis of available data suggested that these interventions improved adherence to individual medication classes (blood pressure-lowering drugs - OR, 2.21; 95% CI (1.63, 2.98), [P < 0.001], lipid-lowering drugs - OR, 2.11; 95% CI (1.00, 4.46), [P = 0.049], and antithrombotic drugs - OR, 2.32; 95% CI (1.18, 4.56, [P = 0.014]) but did not improve adherence to an overall secondary preventative medication regimen (OR, 1.96; 95% CI (0.50, 7.67), [P = 0.332]).

CONCLUSION

Interventions can lead to improvement in adherence to secondary preventative medication after stroke. However, existing data is limited as several interventions, duration of follow-up, and various definitions were used. These findings need to be interpreted with caution.

Symptomatic congenital cytomegalovirus disease following non-primary maternal infection: a retrospective cohort study

Background

Scarce data exist about screening, diagnosis and prognosis of non-primary Cytomegalovirus (CMV) during pregnancy. We aimed to examine antenatal diagnosis of maternal non-primary CMV infection and to identify risk factors for congenial CMV disease.

Methods

Retrospective cohort of 107 neonates with congenital symptomatic CMV infection, following either primary (n = 95) or non-primary (n = 12) maternal CMV infection. We compared the groups for the manifestations and severity of congenial CMV disease, as well as for possible factors associated with the risk of developing CMV related infant morbidity.

Results

Disease severity is not similar in affected newborns, with a higher incidence of abnormal brain sonographic findings, following primary versus non-primary maternal CMV infection (76.8% vs. 8.3%, p < .001). Symptomatic congenital CMV disease following a non-primary infection is more frequent if gestational hypertensive disorders and/or gestational diabetes mellitus have ensued during pregnancy (33.3% vs. 9.9%, p <0.038), as well as if any medications were taken throughout gestation (50% vs. 16.8%, p <0.016). CMV-IgM demonstrates a low detection rate for non-primary maternal infection during pregnancy compared to primary infection (25% vs. 75.8%, p = 0.0008).

Conclusion

Non-primary maternal CMV infection has an impact on the neonate. Although not readily diagnosed during pregnancy, knowledge of risk factors may aid in raising clinical suspicion.

Extramammary Paget's Disease of Anal Canal Associated With Rectal Adenoma Without Invasive Carcinoma

Extramammary Paget's disease (EMPD) is a rare disease which is found in apocrine-rich locations such as anogenital region, axilla and rarely in other sites. Perianal EMPD is often reported as the involvement of perianal skin, but involvement of anal mucosa is very rare. Based on pathogenesis and association with either synchronous or metachronous malignancy, EMPD can be divided into primary and secondary types. Treatment approach for these two types of Paget's disease and their prognosis is different, thus it is important to make the distinction. Secondary type of Paget's disease is almost always described in association with invasive malignancy. While secondary Paget's disease arising in association with ductal carcinoma in situ of the breast is common, secondary EMPD associated with precursor lesion of the rectum without invasion is exceedingly rare. We report a very rare case of secondary Paget's disease of the anal canal in association with rectal tubular adenoma (precursor lesion) without malignancy.

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Effect of Visual Acuity on the Surgical Outcomes of Secondary Sensory Strabismus

Objectives:

To investigate the outcomes of secondary sensory strabismus surgery and to discuss the effect of visual acuity on success.

Materials and Methods:

The medical records of patients with sensory strabismus who underwent recession-resection on the eye with vision loss were reviewed. Only patients with visual acuity of ≤0.2 in the operated eye were enrolled. Data including age at surgery, visual acuity, etiology of vision loss, preoperative and postoperative deviations, follow-up duration, and surgical outcomes were recorded. Success was defined as a final deviation of ≤10 prism diopters (PD). To evaluate the effect of visual acuity on postoperative success, patients were grouped as follows according to the visual acuity of the operated eye: group 1, visual acuity <0.05; group 2, 0.05-0.1; and group 3, 0.125-0.2.

Results:

Ten females and 14 males met the inclusion criteria. The mean age at surgery was 21 years (range, 6 to 56 years). The mean preoperative deviation angle was 52.7 PD (range, 20 to 80 PD). Age at surgery, preoperative deviation and follow-up time were similar in patients with esotropia (n=7) and exotropia (n=17) (p>0.05 for all). The success rate was 62.5% at short-term and 42.1% at long-term follow-up. There was no statistically significant difference in short-term success rate among visual acuity subgroups (p=0.331), whereas the difference was statistically significant at long-term follow-up (p=0.002). The long-term success rate was higher in group 3 compared to groups 1 and 2.

Conclusion:

Better visual acuity seems to be a potential predictor for higher long-term success after strabismus surgery in patients with sensory strabismus.

Immunoglobulin A deficiency following treatment with lamotrigine

Lamotrigine (LTG) is an anti-epileptic drug and mood-stabilizing agent, whose adverse effects include skin rash and dizziness. Interactions with the immune system are rare, and only a few cases linking hypogammaglobulinemia to LTG treatment have been previously described. In this report, we describe a case in which a patient developed hypogammaglobulinemia, and a subsequent immunoglobulin A (IgA) deficiency, following LTG treatment. As a result of her immunodeficiency, the patient presented with a severe urinary tract infection and required intravenous immunoglobulin. Serum levels of immunoglobulin G and M had recovered by seven months and one month after the discontinuation of LTG, respectively; however, IgA levels remained low (less than 4mg/dL) two years post-treatment. While previous reports have demonstrated IgA deficiencies in patients prescribed other antiepileptic drugs, this is the first case of an IgA deficiency following LTG administration.

Matched comparison of primary versus salvage laparoscopic pyeloplasty

PURPOSE

To compare our experience with salvage laparoscopic pyeloplasty, using a matched control set of primary laparoscopic pyeloplasty patients.

METHODS

We retrospectively reviewed patients who underwent laparoscopic pyeloplasty from 1996 to 2014 by a single surgeon. At least 12 months of follow-up was required. Salvage patients were matched 1:3 with primary patients. Matching was based on age ±5 years, body mass index (BMI) ±5, and type of pyeloplasty (dismembered vs. non-dismembered). Primary outcome was failure as defined as re-intervention following laparoscopic pyeloplasty (does not include temporary stenting without definitive retreatment).

RESULTS

Of 128 laparoscopic pyeloplasty procedures, ten were salvage. These patients were matched to 26 patients who underwent a primary laparoscopic pyeloplasty in a 1:3 manner. One salvage pyeloplasty failed to match due to BMI, and the closest matches were made. Four salvage patients had one overlapping match, reducing the primary group to 26 patients. There were no differences in pre-, intra-, and postoperative variables between groups, except for operative time (salvage 247 min, primary 175 min, p = 0.03). With similar duration of radiologic and symptomatic follow-up, there was no significant difference in the rate of freedom from intervention.

CONCLUSION

When matching for factors that could affect success, salvage laparoscopic pyeloplasty performed as well as primary pyeloplasty except for a longer operative time. In experienced hands, salvage laparoscopic pyeloplasty for ureteropelvic junction obstruction recurrence after prior pyeloplasty is a safe and effective procedure, and should be considered an excellent alternative to the more commonly recommended endopyelotomy.

Radiosurgery for Secondary Trigeminal Neuralgia: Revisiting the Treatment Paradigm

BACKGROUND

The mechanisms by which surgery and radiation elicit pain relief in trigeminal neuralgia (TN) secondary to mass lesions vary widely. We aimed to evaluate the outcomes of radiation to the nerve rather than to the lesion in the treatment of secondary TN.

METHODS

We retrospectively reviewed all patients who underwent radiation at the University of California, Los Angeles for TN secondary to tumors. The Barrow Neurological Institute (BNI) pain score was used to evaluate pain outcomes.

RESULTS

Twelve patients were identified; 4 were male and 8 were female. Their mean age at treatment was 59.8 years (range, 47.7-84.7 years). Tumor pathologies included meningioma (n = 8), squamous cell carcinoma (n = 2), vestibular schwannoma (n = 1), and hemangiopericytoma (n = 1). No patient suffered from multiple sclerosis. Ten patients underwent initial radiation targeting their tumors-radiosurgery in 3 and fractionated radiation therapy in 7 others. Only 6 among these 10 experienced at least partial relief, which lasted a mean 6 months. Radiosurgery targeting the trigeminal nerve was eventually performed. Overall, 10 of 12 (83.3%) patients experienced good initial pain relief, complete in 6 (50%) patients. Pain recurred in 6 (60%) patients, at a mean 41 months after radiosurgery to the trigeminal nerve. Three patients experienced facial sensory dysfunction postprocedurally at a mean follow-up duration of 57 months.

CONCLUSION

In contrast to tumor radiation, radiosurgery to the trigeminal nerve root resulted in reasonable and longer pain reduction, on par with the literature regarding surgical resection, with low risk of additional complications.

Rates and Outcomes of Parathyroidectomy for Secondary Hyperparathyroidism in the United States

BACKGROUND AND OBJECTIVES

Secondary hyperparathyroidism is common among patients with ESRD. Although medical therapy for secondary hyperparathyroidism has changed dramatically over the last decade, rates of parathyroidectomy for secondary hyperparathyroidism across the United States population are unknown. We examined temporal trends in rates of parathyroidectomy, in-hospital mortality, length of hospital stay, and costs of hospitalization.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a representative national database on hospital stay regardless of age and payer in the United States, we identified parathyroidectomies for secondary hyperparathyroidism from 2002 to 2011. Data from the US Renal Data System reports were used to calculate the rate of parathyroidectomy.

RESULTS

We identified 32,971 parathyroidectomies for secondary hyperparathyroidism between 2002 and 2011. The overall rate of parathyroidectomy was approximately 5.4/1000 patients (95% confidence interval [95% CI], 5.0/1000 to 6.0/1000). The rate decreased from 2003 (7.9/1000 patients; 95% CI, 6.2/1000 to 9.6/1000), reached a nadir in 2005 (3.3/1000 patients; 95% CI, 2.6/1000 to 4.0/1000), increased again through 2006 (5.4/1000 patients; 95% CI, 4.4/1000 to 6.4/1000), and remained stable since that time. Rates of in-hospital mortality decreased from 1.7% (95% CI, 0.8% to 2.6%) in 2002 to 0.8% (95% CI, 0.1% to 1.6%) in 2011 (P for trend <0.001). In-hospital mortality rates were significantly higher in patients with heart failure (odds ratio [OR], 4.23; 95% CI, 2.59 to 6.91) and peripheral vascular disease (OR, 4.59; 95% CI, 2.75 to 7.65) and lower among patients with prior kidney transplantation (OR, 0.20; 95% CI, 0.06 to 0.65).

CONCLUSIONS

Despite the use of multiple medical therapies, rates of parathyroidectomy of secondary hyperparathyroidism have not declined in recent years.

Secondary prevention of osteoporosis following fragility fractures of the distal radius in a large health maintenance organization

A retrospective study evaluated a large health maintenance organization for secondary prevention of osteoporosis following fragility fractures of the distal radius. Our population remained undiagnosed and untreated despite the ability of the system to provide adequate care. These patients specifically should be targeted for a comprehensive multidisciplinary effort at prevention.

PURPOSE

Osteoporotic wrist fractures carry a high risk for subsequent fragility fractures. Despite therapeutic options and systems that can provide secondary prevention, patients are not always treated appropriately. Our purpose was to evaluate the treatment afforded following a distal radius fragility fracture in our health system.

METHODS

A retrospective review of fractures following surgery was performed. Radiographs and mechanism of injury defined fragility fractures. Demographic data, other fractures, and secondary prevention measures were documented.

RESULTS

Eighty-two patients were evaluated. The average age was 64 (10.2) years. The follow-up period following the index fracture was 25.2 months (SD = 4.6). Twenty-eight percent of patients had a second fragility fracture. Seven sustained a subsequent fracture within the follow-up period (8.5 %), and 16 (19.5 %) fractured prior to the index fracture. Mean time from primary to index fracture was 50 (42) months. Forty-seven percent of patients with an additional fracture carried the chart diagnosis of osteoporosis or osteopenia while 24.6 % of patients without an additional fracture carried this diagnosis (p = 0.049). No patients were referred for prevention or an endocrinologist at discharge. Twenty-one percent of patients were treated for osteoporosis at any point.

CONCLUSIONS

Patients were unlikely to receive appropriate evaluation and treatment for secondary prevention of fragility fractures in our system. A system-based treatment plan for the prevention of osteoporosis should be implemented. Since distal radius fractures occur early in osteoporosis, these fractures should be targeted for secondary prevention.

Accumulation of multiple mutations in linezolid-resistant Staphylococcus epidermidis causing bloodstream infections; in silico analysis of L3 amino acid substitutions that might confer high-level linezolid resistance

Fifty-six Staphylococcus epidermidis clinical isolates, showing high-level linezolid resistance and causing bacteremia in critically ill patients, were studied. All isolates belonged to ST22 clone and carried the T2504A and C2534T mutations in gene coding for 23SrRNA as well as the C189A, G208A, C209T and G384C missense mutations in L3 protein which resulted in Asp159Tyr, Gly152Asp and Leu94Val substitutions. Other silent mutations were also detected in genes coding for ribosomal proteins L3 and L22. In silico analysis of missense mutations showed that although L3 protein retained the sequence of secondary motifs, the tertiary structure was influenced. The observed alteration in L3 protein folding provides an indication on the putative role of L3-coding gene mutations in high-level linezolid resistance. Furthermore, linezolid pressure in health care settings where linezolid consumption is of high rates might lead to the selection of resistant mutants possessing L3 mutations that might confer high-level linezolid resistance.

Prior hypomethylating agent use lacks impact on clinical outcome in patients with secondary acute myeloid leukemia arising from myelodysplastic syndromes treated with standard induction chemotherapy

Patients with secondary acute myeloid leukemia (sAML) arising from prior myelodysplastic syndromes have poor prognosis. Anthracycline plus cytarabine (7 + 3) is a standard treatment option for patients who are fit for intensive therapy. In the present study, 22 of 96 sAML patients (23 %) were treated with 7 + 3 and achieved median overall survival (OS) of 9.8 months. Hypomethylating agents (HMA) were given for MDS in 6/22 (28 %) of the patients. When evaluating the prior HMA group, CR/CRi was 50 % for those with prior HMA exposure and 63 % for those without HMA exposure (P = 0.6). Median OS was 14 months for prior HMA exposure vs 10 months for no prior HMA (P = 0.9). The outcome of sAML patients who were treated with 7 + 3 continues to be poor. No statistical significant difference was found between response rates and mOS between prior HMA exposure or not. Additional larger studies are needed to confirm our results.

Outcomes of parathyroidectomy in renal hyperparathyroidism in patients with No access to renal transplantation in Singapore

BACKGROUND

Total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX) are considered standard surgical treatments for refractory renal hyperparathyroidism. However, there is little data available comparing their outcomes in an area with poor access to renal transplant and calcimimetics.

METHODS

Patients with renal hyperparathyroidism who underwent TPTX + AT and SPTX in a tertiary institution from 2006 to 2013 were studied. Patient characteristics, pre- and post-operative biochemical marker levels, and outcomes including recurrence rates, post-operative morbidity and mortality were analysed.

RESULTS

87 patients underwent parathyroidectomy for renal hyperthyroidism. Transplant patients were excluded in this study. 81 patients were on long-term dialysis, with a median time of 7 years from initiation of haemodialysis to parathyroidectomy. 57 patients (70.4%) underwent TPTX + AT while 24 (29.6%) underwent SPTX. Post-operatively, there was significant decrease in parathyroid hormone (PTH), calcium and phosphate levels in both groups. PTH and phosphate levels were significantly lowered with TPTX compared to SPTX (p = 0.004, 0.003). Symptomatic hypocalcaemia was seen in both groups. In a median follow-up of 4 years, 11 patients developed biochemical recurrence, with a median time of 29 months to recurrence. Median PTH at recurrence was 67.1 pmol/L. Rate of recurrence was higher in patients who underwent SPTX (20.8% vs 10.5%), with a shorter median time to recurrence (median 62.1 vs 81.3 months). 2 patients required resection of the autograft. Cohort mortality was 11 patients (13.4%), with 3 deaths secondary to cardiovascular events.

CONCLUSION

Total parathyroidectomy with autoimplantation is superior to subtotal parathyroidectomy in the short to intermediate term.

Predicting postoperative total calcium requirements after parathyroidectomy in secondary hyperparathyroidism

BACKGROUND/AIMS

To prevent hypocalcemia after parathyroidectomy (PTX), parenteral calcium is required in addition to oral calcitriol and calcium. After switching to oral calcium, patients can be discharged from the hospital. The aim of this study was to analyze the clinical characteristics and outcomes of PTX performed at a single Korean center and to investigate the associated laboratory factors used to analyze the total amount of postoperative calcium required.

METHODS

We enrolled 91 hemodialysis patients undergoing PTX from November 2003 to December 2011. We collected clinical and laboratory data preoperatively, 12 and 48 hours postoperatively, at discharge, and 3 and 6 months postoperatively.

RESULTS

In total, 59 patients underwent PTX with autotransplantation (AT), 6 underwent total PTX without AT, 11 underwent subtotal PTX, and 15 underwent limited PTX. Total PTX without AT showed the lowest recurrence rate. At all postoperative time points, the mean levels of serum calcium, phosphorus, and intact parathyroid hormone (iPTH) decreased significantly, compared with preoperative levels; however, alkaline phosphatase (ALP) increased significantly from 48 hours postoperatively to discharge (p < 0.001). On multiple linear regression analysis, the total amount of injected calcium during hospitalization showed a significant correlation with preoperative ALP (p < 0.001), preoperative iPTH (p = 0.037), and Δphosphorus at 48 hours (p < 0.001). We developed an equation for estimating the total calcium requirement after PTX.

CONCLUSIONS

Preoperative ALP, preoperative iPTH, and Δphosphorus at 48 hours may be significant factors in estimating the postoperative calcium requirement. The formula for postoperative calcium requirement after PTX may help to predict the duration of postoperative hospitalization.

Secondary stroke in patients with polytrauma and traumatic brain injury treated in an Intensive Care Unit, Karlovac General Hospital, Croatia

Traumatic brain injury (TBI) is divided into primary and secondary brain injury. Primary brain injury occurs at the time of injury and is the direct consequence of kinetic energy acting on the brain tissue. Secondary brain injury occurs several hours or days after primary brain injury and is the result of factors including shock, systemic hypotension, hypoxia, hypothermia or hyperthermia, intracranial hypertension, cerebral oedema, intracranial bleeding or inflammation. The aim of this retrospective analysis of a prospective database was to determine the prevalence of secondary stroke and stroke-related mortality, causes of secondary stroke, treatment and length of stay in the ICU and hospital. This study included patients with TBI with or without other injuries who were hospitalised in a general ICU over a five-year period. The following parameters were assessed: demographics (age, sex), scores (Glasgow Coma Score, APACHE II, SOFA), secondary stroke (prevalence, time of occurrence after primary brain injury, causes of stroke and associated mortality), length of stay in the ICU and hospital, vital parameters (state of consciousness, cardiac function, respiration, circulation, thermoregulation, diuresis) and laboratory values (leukocytes, C-reactive protein [CRP], blood glucose, blood gas analysis, urea, creatinine). Medical data were analysed for 306 patients with TBI (median age 56 years, range 18-93 years) who were treated in the general ICU. Secondary stroke occurred in 23 patients (7.5%), 10 of whom died, which gives a mortality rate of 43.4%. Three patients were excluded as the cause of the injury was missile trauma. The study data indicate that inflammation is the most important cause of secondary insults. Levels of CRP were elevated in 65% of patients with secondary brain injury; leukocytosis was present in 87% of these patients, and blood glucose was elevated in 73%. The lungs and urinary tract were the most common sites of infection. In conclusion, elevated inflammatory markers (white blood cell count and CRP) and hyperglycaemia are associated with secondary brain injury. The lack of routine use of intracranial pressure (ICP) monitoring may explain the high mortality rate and the occurrence of secondary stroke in patients with TBI.

Importance of cycles of chemotherapy and postdocetaxel novel therapies in metastatic castration-resistant prostate cancer

Purpose

With the emergence of various novel therapies including new generation taxane and androgen-targeted therapies, the optimal sequence of systemic treatment in metastatic castration-resistant prostate cancer (mCRPC) patients remains to be defined. Our aim is to investigate the impact of duration of docetaxel-based chemotherapy and postdocetaxel treatment in mCRPC patients.

Methods

The medical data of 57 Chinese mCRPC patients who received docetaxel-based chemotherapy in two oncology centers between 2003 and 2012 were reviewed. The treatment efficacy and toxicity were determined. The potential determinants of efficacy were also determined.

Results

Fifty-seven patients (median age 66 years, range 51–82 years) were given docetaxel-based chemotherapy, of whom 48 (84.2%) received 3-weekly docetaxel (52.5–75 mg/m²) and nine (15.8%) received weekly docetaxel (35 mg/m²). Postdocetaxel treatments were received by 31 (57.4%) patients, including abiraterone in 13 patients and cabazitaxel in one patient. The median follow-up time was 14.3 months. The median overall survival (OS) and progression-free survival were 20.8 months and 5.8 months, respectively. In multivariate analysis, eight cycles or more of chemotherapy [hazard ratio (HR) = 0.151, P < 0.0358], use of postdocetaxel treatment (HR = 0.346, P = 0.0005), and hemoglobin level of <10 (HR = 5.224, P < 0.0001) were independent determinants of OS. Patients who had received abiraterone and cabazitaxel as postdocetaxel treatment had significantly longer OS compared with those who received other postdocetaxel treatments (including rechallenge of docetaxel) and those who did not receive any postdocetaxel treatment (35.3 months vs. 20.8 months vs. 15.3 months, P = 0.00057).

Conclusions

The results suggest that maximizing exposure to docetaxel-based chemotherapy followed by novel therapies would have a favorable survival impact on mCRPC patients.

Comprehensive spectroscopic studies on the interaction of biomolecules with surfactant detached multi-walled carbon nanotubes

This paper investigates the interaction of ten diverse biomolecules with surfactant detached Multi-Walled Carbon Nanotubes (MWCNTs) using multiple spectroscopic methods. Declining fluorescence intensity of biomolecules in combination with the hyperchromic effect in UV-Visible spectra confirmed the existence of the ground state complex formation. Quenching mechanism remains static and non-fluorescent. 3D spectral data of biomolecules suggested the possibilities of disturbances to the aromatic microenvironment of tryptophan and tyrosine residues arising out of CNTs interaction. Amide band Shifts corresponding to the secondary structure of biomolecules were observed in the of FTIR and FT-Raman spectra. In addition, there exists an increased Raman intensity of tryptophan residues of biomolecules upon interaction with CNTs. Hence, the binding of the aromatic structures of CNTs with the aromatic amino acid residues, in a particular, tryptophan was evidenced. Far UV Circular spectra have showed the loss of alpha-helical contents in biomolecules upon interaction with CNTs. Near UV CD spectra confirmed the alterations in the tryptophan positions of the peptide backbone. Hence, our results have demonstrated that the interaction of biomolecules with OH-MWCNTs would involve binding cum structural changes and alteration to their aromatic micro-environment.

Extra middle turbinate lamellas: a suggested new classification

PURPOSE

Proper knowledge of sinonasal configurations and anatomical structural variations is essential to perform safe endoscopic sinus surgery. Although common middle turbinate variations have been well described in literature, rare variations have not. The aims of this study are to revise the nomenclature of extra middle turbinate lamellas variations and suggest an easy classification system of these lamellas.

METHOD

A retrospective charts and medical records review was performed for consecutive cases that were diagnosed with extra lamella middle turbinate based on endoscopic and stander three-dimensional reconstruction computer tomography scan at a tertiary academic center. After extensive literature review, these lamellas were classified into four types depending on the presence or absence of uncinate process and their morphological configuration.

RESULT

Twenty-two subjects (mean age 35 years; 8 men and 14 women) were identified who had thirty extra middle turbinate lamellas. Nasal obstruction and discharge were the most common presenting symptoms. Accessory middle turbinate was the most common extra lamella been observed and bifid inferior turbinate was the least common. Ten patients (45 %) had an accompanied middle turbinate anatomical variations, 9 (41 %) had nasal septum deviation, 11 (50 %) had associated maxillary or ethmoid sinusitis and 5 (23 %) had hypoplastic maxillary sinus.

CONCLUSION

Extra middle turbinate lamella is a rare type of middle turbinate anatomical variation that can be diagnosed by careful endoscopic examination and a precise computer tomography scan review. These lamellas may have a significant association with mucosa pathologies and are commonly seen with other common middle turbinate variations. Correct description and the use of common terminology can help to further evaluate the incidence of lamellas, their pathophysiological role, and to avoid any intraoperative landmark confusion.