Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study

BACKGROUND

Limited research exists regarding the impact of neuroimaging on endovascular thrombectomy (EVT) decisions for late-window cases of large vessel occlusion (LVO) stroke.

OBJECTIVE

T0 assess whether perfusion CT imaging: (1) alters the proportion of recommendations for EVT, and (2) enhances the reliability of EVT decision-making compared with non-contrast CT and CT angiography.

METHODS

We conducted a survey using 30 patients drawn from an institutional database of 3144 acute stroke cases. These were presented to 29 Canadian physicians with and without perfusion imaging. We used non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG).

RESULTS

The percentage of EVT recommendations differed by 1.1% with or without perfusion imaging. Individual decisions changed in 21.4% of cases (11.3% against EVT and 10.1% in favor). Inter-rater agreement (κG) among the 29 raters was similar between non-perfusion and perfusion CT neuroimaging (κG=0.487; 95% CI 0.327 to 0.647 and κG=0.552; 95% CI 0.430 to 0.675). The 95% CIs overlapped with moderate agreement in both. Intra-rater agreement exhibited overlapping 95% CIs for all 28 raters. κG was either substantial or excellent (0.81-1) for 71.4% (20/28) of raters in both groups.

CONCLUSIONS

Despite the minimal difference in overall EVT recommendations with either neuroimaging protocol one in five decisions changed with perfusion imaging. Regarding agreement we found that the use of automated CT perfusion images does not significantly impact the reliability of EVT decisions for patients with late-window LVO.

Multi-Laboratory Evaluation of Prototype Dried Blood Spot Quality Control Materials for Creatine Kinase-MM Newborn Screening Assays

Pilot studies to detect newborns with Duchenne Muscular Dystrophy (DMD) by newborn bloodspot screening (NBS) have been conducted under the New York State Newborn Screening Program (NYS) and are currently in progress as part of the Early Check Program at Research Triangle Institute (RTI) International. The Newborn Screening Quality Assurance Program (NSQAP) at the U.S. Centers for Disease Control and Prevention (CDC) produced a set of seven prototype dried blood spot (DBS) reference materials spiked with varying levels of creatine kinase MM isoform (CK-MM). These DBS were evaluated over a 3-week period by CDC, NYS, and RTI, all using the same CK-MM isoform-specific fluoroimmunoassay. Results from each laboratory were highly correlated with the relative proportion of CK-MM added to each of the six spiked pools. Based on reference ranges established by NYS and RTI for their pilot studies, these contrived DBS collectively spanned the CK-MM ranges found in typical newborns and the elevated ranges associated with DMD. This set allows quality assessment over the wide range of fluctuating CK-MM levels in typical and DMD-affected newborns.

Development of a Universal Second-Tier Newborn Screening LC-MS/MS Method for Amino Acids, Lysophosphatidylcholines, and Organic Acids

First-tier MS-based newborn screening by flow injection analysis can have high presumptive positive rates, often due to isomeric/isobaric compounds or poor biomarker specificity. These presumptive positive samples can be analyzed by second-tier screening assays employing separations such as liquid chromatography-mass spectrometry (LC-MS/MS), which increases test specificity and drastically reduces false positive referrals. The ability to screen for multiple disorders in a single multiplexed test simplifies workflows and maximizes public health laboratories' resources. In this study, we developed and validated a highly multiplexed second-tier method for dried blood spots using a hydrophilic interaction liquid chromatography (HILIC) column coupled to an MS/MS system. The LC-MS/MS method was capable of simultaneously detecting second-tier biomarkers for maple syrup urine disease, homocystinuria, methylmalonic acidemia, propionic acidemia, glutaric acidemia type 1, glutaric acidemia type 2, guanidinoacetate methyltransferase deficiency, short-chain acyl-CoA dehydrogenase deficiency, adrenoleukodystrophy, and Pompe disease.

20 Comparison of Six Frailty Screening Tools in Patients Aged 65+ with An Arm Fragility Fracture

Introduction

Frailty is associated with an increased risk of falling and fracture, but not routinely assessed in fracture clinic. Early identification and management of frailty among older people with arm fragility fracture could help avoid further falls and fractures, especially of the hip. We evaluated the feasibility of assessing frailty in a busy fracture clinic.

Methods

People aged 65+ years with an arm fracture in one acute trust were recruited. Frailty was assessed in fracture clinics using six tools: Fried Frailty Phenotype (FFP), FRAIL scale, PRISMA-7, electronic Frailty Index (e-FI), Clinical Frailty Score (CFS), and Study of Osteoporotic Fracture (SOF). The sensitivity and specificity of each tool was compared against FFP as a reference. Participants identified as frail by 2+ tools were referred for Comprehensive Geriatric Assessment (CGA).

Results

100 patients (mean age 75 years±7.2; 20 men) were recruited. Frailty prevalence was 9% (FRAIL scale), 13% (SOF), 14% (CFS > 6), 15% (FFP; e-FI > 0.25), and 25% (PRISMA-7). Men were more likely to be frail than women. Data were complete for all assessments and completion time ranged from one minute (PRISMA-7; CFS) to six minutes for the FFP which required most equipment. Comparing with FFP, the most accurate instrument for stratifying frail from non-frail was the PRISMA-7 (sensitivity = 93%, specificity = 87%) while the remaining tools had good specificity (range 93%–100%) but average sensitivity (range 40%–60%). Twenty patients were eligible for CGA. Five had recently had CGA and 11/15 referred were assessed. CGA led to 3–6 interventions per participant including medication changes, life-style advice, investigations, and onward referrals.

Conclusion

It was feasible to assess frailty in fracture clinic and to identify patients who benefitted from CGA. Frailty prevalence was 9%—25% depending on the tool used and was higher among men. PRISMA-7 could be a practical tool for routine use in fracture clinics.

Effect of dietary supplementation with essential oils and a Bacillus probiotic on growth performance, diarrhoea and blood metabolites in weaned pigs

Context Dietary supplementation of essential oils or in combination with a Bacillus probiotic was investigated as an antibiotic growth promoter for weaned pigs. Aims To evaluate the effect of essential oils (i.e. thymol and carvacrol mixture) or in combination with a probiotic strain (i.e. Bacillus subtilis PB6) on the growth performance, diarrhoea incidence, ammonia emission and serological profiles of weaned pigs. Methods A total of 96 crossbred ([Yorkshire × Landrace] × Duroc) weaned pigs were randomly allotted to one of six treatments based on sex and initial bodyweight. Each group was distributed into four replicates with four pigs each according to a randomised complete block design. The treatments were: (i) positive control, basal diet supplemented with colistin 150 g/tonne and amoxicillin 200 g/tonne; (ii) negative control, basal diet without supplementation; (iii) T3, basal diet supplemented with essential oils 300 g/tonne; (iv) T4, basal diet supplemented with essential oils 600 g/tonne; (v) T5, basal diet supplemented with essential oils 1000 g/tonne; and (vi) T6, basal diet supplemented with essential oils 300 g/tonne diet and Bacillus probiotics 1000 g/tonne. Key results The piglets fed with supplements had a significantly higher average daily gain and lower incidence of diarrhoea than the piglets in the negative control (P = 0.001). Feeding the essential oils alone or in combination with probiotics significantly reduced faecal ammonia emission (P = 0.027) and blood urea nitrogen (P = 0.039), while markedly increasing the serum immunoglobulin G concentration of weaned pigs compared with the negative control treatment (P = 0.014). The difference in time of blood collection had significant effects on blood urea nitrogen and immunoglobulins (P = 0.001). However, no significant differences emerged in average daily feed intake, gain: feed ratio, feed efficiency and antibody against swine fever among the treatments. Conclusions Diet supplementation with essential oils or in combination with probiotics improved growth performance and immunity, and lowered ammonia emissions and diarrhoea incidence of weaned pigs. Implications These findings provide a basis for the application of phytogenic compounds and probiotics as antibiotic growth promoter alternatives in post-weaning diets for pigs.

Provision of Virtual Outpatient Care during the COVID-19 Pandemic and Beyond: Enabling Factors and Experiences from the UBC Pharmacists Clinic

The COVID-19 pandemic has generated an unprecedented level of interest in, and uptake of, technology-enabled virtual health care delivery as clinicians seek ways to safely care for patients with physical distancing. This paper describes the UBC Pharmacists Clinic's technical systems and lessons learned using enabling technology and the provision of virtual patient care by pharmacists. Of 2036 scheduled appointments at the clinic in 2019, only 1.5% of initial appointments were conducted virtually which increased to 64% for follow-up appointments. Survey respondents (n = 18) indicated an overall high satisfaction with the format, quality of care delivery, ease of use and benefits to their overall health. Other reports indicate that the majority of patients would like the option to book appointments electronically, email their healthcare provider, and have telehealth visits, although a small minority (8%) have access to virtual modes of care. The Clinic team is bridging the technology gap to better align virtual service provision with patient preferences. Practical advice and information gained through experience are shared here. As the general population and health care providers become increasingly comfortable with video conferencing as a result of COVID-19, it is anticipated that requests for video appointments will increase, technological barriers will decrease and conditions will enable providers to increase their virtual care capabilities. Lessons learned at the Clinic have application to pharmacists in both out-patient and in-patient care settings.

Locating fish bomb blasts in real-time using a networked acoustic system

Results are presented of a demonstration of real-time fish blast location in Sabah, Malaysia using a networked hydroacoustic array based on the ShotSpotter gunshot location system. A total of six acoustic sensors - some fixed and others mobile - were deployed at ranges from 1 to 9 km to detect signals from controlled test blasts. This allowed the blast locations to be determined to within 60 m accuracy, and for the calculated locations to be displayed on a map on designated internet-connected computers within 10 s. A smaller three-sensor system was then installed near Semporna in Eastern Sabah that determined the locations of uncontrolled blasts set off by local fishermen. The success of these demonstrations shows that existing technology can be used to protect reefs and permit more effective management of blast fishing activity through improved detection and enforcement measures and enhanced community engagement.

Inflammatory bowel disease in patients with Hirschsprung's disease: a systematic review and meta-analysis

AIM AND OBJECTIVES

Hirschsprung-associated enterocolitis (HAEC) continues to be an important cause of morbidity in patients with Hirschsprung's disease (HSCR). HAEC can occur at any time during the course of the disease. The reported incidence of HAEC before surgery ranges from 6 to 50%, and after surgery, it ranges from 2 to 35%. HAEC and inflammatory bowel disease (IBD) have similar clinical presentation including diarrhea, hematochezia, and abdominal pain. In recent years, isolated cases of IBD have been reported in patients who had surgical treatment for HSCR. The exact pathogenesis of HAEC or IBD is not known. However, both conditions are characterized by an abnormal intestinal mucosal barrier function, which may be a common pathway. The purpose of this meta-analysis was to determine the clinical presentation and outcome in patients with HSCR who developed IBD after pull-through operation.

MATERIALS AND METHODS

A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "inflammatory bowel disease", "Crohn/Crohn's disease", "ulcerative colitis", and "Hirschsprung disease/Hirschsprung's disease" for studies published between 1990 and 2017. The relevant cohorts of HSCR associated with IBD were systematically searched for clinical presentation and outcomes.

RESULTS

14 studies met defined inclusion criteria, reporting a total of 66 patients who had HSCR associated with IBD. Mean age at first operation for HSCR was 5.8 months, mean age at diagnosis of IBD was 7.7 years, and the majority of patients were male (73%). The extent of aganglionosis was total colonic aganglionosis in 41% of patients, long segment in 45%, and rectosigmoid in 14%. The majority of patients underwent a Duhamel procedure (84%) for HSCR. The distribution of IBD was Crohn's disease in 72.3% of patients, ulcerative colitis in 16.9%, and others in 10.8%. Eight articles (47 patients) reported about HAEC, and 22 patients (47%) had experienced HAEC after surgery for HSCR.

CONCLUSION

Male patients with extensive colonic aganglionosis who continue to suffer from postoperative HAEC after a Duhamel procedure are more susceptible to develop IBD. Recognition of IBD may be important in the long-term follow-up of HSCR patients who have had postoperative HAEC.

Crystal growth and piezoelectric characterization of mechanically stable ZnO nanostructure arrays

The highest piezoelectric performance of ZnO can be achieved by utilizing the piezoelectric operation along the c-axis due to its anisotropic permanent dipole moment.

Grading system for migrated lumbar disc herniation on sagittal magnetic resonance imaging: an agreement study

PURPOSE

Migrated lumbar disc herniations (LDHs) in the sagittal plane are common. Disc migration grading can be applied as a useful measurement tool in the diagnosis, treatment, and outcome evaluation of migrated LDH. No study has evaluated the reliability of migrated LDH grading. We evaluated the reliability and functionality of the current magnetic resonance imaging (MRI) grading system for migrated LDH.

METHODS

We assessed a six-level grading system developed based on sagittal MRI and graded according to the direction (rostral and caudal) and degree (low, high, and very high) of disc migration. One-hundred and one migrated LDHs treated with minimally invasive endoscopic discectomy were analyzed independently by two experienced radiologists. Intraobserver and interobserver agreements were assessed by kappa statistics.

RESULTS

The most common migrated LDH grade was grade 4 (30.94%; caudal, low-grade migration). Rostral and caudal migrations were more common in the upper and lower lumbar levels, respectively. Interobserver agreement in the grading of migrated LDH was good at both the first (kappa = 0.737) and second assessment (kappa = 0.657). The intraobserver agreement for reader 1 was very good (kappa = 0.827) and for reader 2 was good (kappa = 0.620).

CONCLUSIONS

The current grading system for migrated LDH was found to be reliable and functional with good interobserver and intraobserver agreement. It may be useful in the interpretation of disc migration patterns and outcomes of various minimally invasive surgical procedures.

Financial and environmental costs of reusable and single-use anaesthetic equipment

BACKGROUND.

An innovative approach to choosing hospital equipment is to consider the environmental costs in addition to other costs and benefits.

METHODS.

We used life cycle assessment to model the environmental and financial costs of different scenarios of replacing reusable anaesthetic equipment with single-use variants. The primary environmental costs were CO 2 emissions (in CO 2 equivalents) and water use (in litres). We compared energy source mixes between Australia, the UK/Europe, and the USA.

RESULTS.

For an Australian hospital with six operating rooms, the annual financial cost of converting from single-use equipment to reusable anaesthetic equipment would be an AUD$32 033 (£19 220), 46% decrease. In Australia, converting from single-use to reusable equipment would result in an increase of CO 2 emissions from 5095 (95% CI: 4614-5658) to 5575 kg CO 2 eq (95% CI: 5542-5608), a 480 kg CO 2 eq (9%) increase. Using the UK/European power mix, converting from single-use (5575 kg CO 2 eq) to reusable anaesthetic equipment (802 kg CO 2 eq) would result in an 84% reduction (4873 kg CO 2 eq) in CO 2 emissions, whilst in the USA converting to reusables would have led to a 2427 kg CO 2 eq (48%) reduction. In Australia, converting from single-use to reusable equipment would more than double water use from 34.4 to 90.6 kilolitres.

CONCLUSIONS.

For an Australian hospital with six operating rooms, converting from single-use to reusable anaesthetic equipment saved more than AUD$30 000 (£18 000) per annum, but increased the CO 2 emissions by almost 10%. The CO 2 offset is highly dependent on the power source mix, while water consumption is greater for reusable equipment.

Work-exacerbated asthma in a workers' compensation population

BACKGROUND

Asthma is becoming more prevalent with large numbers of individuals suffering from work-exacerbated asthma.

AIMS

To examine the characteristics of workplace exposures and working days lost in relation to work-exacerbated asthma (WEA) in a workers' compensation population.

METHODS

An analysis of accepted workers' compensation asthma claims in Ontario over a 5-year period. Claims among the top three industry groups were categorized based on working time lost of 1 day or less, 2-5 days and 6 days or more. Attributable agents were subdivided into dusts, smoke, chemicals and sensitizers.

RESULTS

Among the asthma claims, 72% (645) fulfilled criteria for WEA from their history. The commonest industry groups were services, education and health care, with 270 claims that met our analysis requirements. Within these industry groups, education had a lower proportion of workers with short exacerbations (missing 1 day or less: 27%) while the health care industry had a higher than expected proportion of short exacerbations (55%). The agents to which WEA was attributed differed across the groups, with dusts having the highest proportion in the education group (65%), smoke in the service industry (34%) and sensitizers in health care (41%). Those agents more commonly attributed to exacerbations tended to have lower rates of prolonged exacerbation compared with less commonly involved agents.

CONCLUSIONS

The morbidity of WEA and the type of agents to which it was attributed varied between industry groups.

Flagella overexpression attenuates Salmonella pathogenesis

Flagella are cell surface appendages involved in a number of bacterial behaviors, such as motility, biofilm formation, and chemotaxis. Despite these important functions, flagella can pose a liability to a bacterium when serving as potent immunogens resulting in the stimulation of the innate and adaptive immune systems. Previous work showing appendage overexpression, referred to as attenuating gene expression (AGE), was found to enfeeble wild-type Salmonella. Thus, this approach was adapted to discern whether flagella overexpression could induce similar attenuation. To test its feasibility, flagellar filament subunit FliC and flagellar regulon master regulator FlhDC were overexpressed in Salmonella enterica serovar Typhimurium wild-type strain H71. The results show that the expression of either FliC or FlhDC alone, and co-expression of the two, significantly attenuates Salmonella. The flagellated bacilli were unable to replicate within macrophages and thus were not lethal to mice. In-depth investigation suggests that flagellum-mediated AGE was due to the disruptive effects of flagella on the bacterial membrane, resulting in heightened susceptibilities to hydrogen peroxide and bile. Furthermore, flagellum-attenuated Salmonella elicited elevated immune responses to Salmonella presumably via FliC's adjuvant effect and conferred robust protection against wild-type Salmonella challenge.

Uterine leiomyosarcoma in asian patients: validation of the revised Federation of gynecology and obstetrics staging system and identification of prognostic classifiers

BACKGROUND

In 2008, the Federation of Gynecology and Obstetrics (FIGO) revised their 1988 staging system for uterine leiomyosarcomas. In this article, we compare performance of the 2008 and 1988 FIGO systems.

METHODS

Individual case data were manually culled. Staging was retrospectively assessed according to revised and 1998 FIGO criteria. Overall survival distribution was assessed by the Kaplan-Meier method. Harrell's concordance index was used to assess the discriminative ability of a fitted Cox model to predict overall survival.

RESULTS

A total of 110 cases of uterine leiomyosarcomas were reviewed and data from 88 patients were analyzed. In all, 71% of cases were classified as stage I, 7% as stage II, 3% as stage III, and 19% as stage IV under the revised FIGO staging system. Nine patients (10.2%) were downstaged and none were upstaged. The revised FIGO system did not show a significant improvement over the 1988 FIGO system in the ability to discriminate the risk of death of patients between stages, with concordance indexes of 0.70 and 0.71, respectively. Most patients were classified as stage I with age, tumor grade, tumor size, and lymphovascular invasion as prognostic factors.

CONCLUSION

The 2008 revised FIGO staging system for uterine leiomyosarcomas does not perform better than the 1988 system for uterine endometrial carcinomas. A better staging system is needed for these cases.

Role of overexpressed CFA/I fimbriae in bacterial swimming

Enterotoxigenic Escherichia coli CFA/I is a protective antigen and has been overexpressed in bacterial vectors, such as Salmonella Typhimurium H683, to generate vaccines. Effects that overexpressed CFA/I may engender on the bacterial host remain largely unexplored. To investigate, we constructed a high CFA/I expression strain, H683-pC2, and compared it to a low CFA/I expression strain, H683-pC, and to a non-CFA/I expression strain, H683-pY. The results showed that H683-pC2 was less able to migrate into semisolid agar (0.35%) than either H683-pC or H683-pY. Bacteria that migrated showed motility halo sizes of H683-pC2 < H683-pC < H683-pY. In the liquid culture media, H683-pC2 cells precipitated to the bottom of the tube, while those of H683-pY did not. In situ imaging revealed that H683-pC2 bacilli tended to auto-agglutinate within the semisolid agar, while H683-pY bacilli did not. When the cfaBE fimbrial fiber encoding genes were deleted from pC2, the new plasmid, pC2(-), significantly recovered bacterial swimming capability. Our study highlights the negative impact of overexpressed CFA/I fimbriae on bacterial swimming motility.

Vulnerabilities in Yersinia pestis caf operon are unveiled by a Salmonella vector

During infection, Yersinia pestis uses its F1 capsule to enhance survival and cause virulence to mammalian host. Since F1 is produced in large quantities and secreted into the host tissues, it also serves as a major immune target. To hold this detrimental effect under proper control, Y. pestis expresses the caf operon (encoding the F1 capsule) in a temperature-dependent manner. However, additional properties of the caf operon limit its expression. By overexpressing the caf operon in wild-type Salmonella enterica serovar Typhimurium under a potent promoter, virulence of Salmonella was greatly attenuated both in vitro and in vivo. In contrast, expression of the caf operon under the regulation of its native promoter exhibited negligible impairment of Salmonellae virulence. In-depth investigation revealed all individual genes in the caf operon attenuated Salmonella when overexpressed. The deleterious effects of caf operon and the caf individual genes were further confirmed when they were overexpressed in Y. pestis KIM6+. This study suggests that by using a weak inducible promoter, the detrimental effects of the caf operon are minimally manifested in Y. pestis. Thus, through tight regulation of the caf operon, Y. pestis precisely balances its capsular anti-phagocytic properties with the detrimental effects of caf during interaction with mammalian host.

Expression of Escherichia coli virulence usher protein attenuates wild-type Salmonella

Generation of a live attenuated vaccine for bacterial pathogens often requires prior knowledge of the pathogen's virulence factors. We hypothesized an alternative approach of heterologous gene expression would make a wild-type (wt) pathogen more susceptible to host cell killing, thus, resulting in immunization. As proof of concept, the heterologous expression of enterotoxigenic E. coli (ETEC) colonization factor antigen I (CFA/I) was tested to attenuate Salmonella. The overexpression of CFA/I resulted in significant attenuation of wt Salmonella. In-depth studies revealed the attenuation depended on the co-expression of chaperone (CfaA) and usher (CfaC) proteins. Remarkably, the CfaAC-attenuated Salmonella conferred protection against wt Salmonella challenge. Mechanistic study indicated CfaAC made Salmonella outer membranes permeable, causing Salmonella to be vulnerable to host destruction. Thus, enhancing bacterial permeability via CfaAC represents an alternative method to attenuate pathogens despite the presence of unknown virulence factors.

PlasmaKinetic™ (bipolar) transurethral resection of prostate: a prospective trial to study pathological artefacts, surgical parameters and clinical outcomes

INTRODUCTION

The aims of the study were to compare the degree of cautery artefacts in prostatic chips between monopolar and PlasmaKinetic™ transurethral resection of prostate (TURP), and to determine if there is any difference in the intraoperative and post surgical parameters between them.

METHODS

After institutional review board approval, patients were prospectively enrolled to undergo PlasmaKinetic™ TURP. Their parameters were compared with those of the historical monopolar TURP controls. All histological specimens were reviewed by a single senior pathologist.

RESULTS

46 patients were recruited to undergo PlasmaKinetic™ TURP. The resection time was significantly longer for the bipolar group compared to the monopolar group (50.2 versus 36.7 min, p-value is 0.001). The speed of resection (resection weight/time) was lower for the bipolar group (0.45 versus 0.56 g/min, p-value is 0.017). More irrigant was used for the bipolar group (21.2 versus 15.6 litres, p-value is 0.001) intraoperatively. There was no statistically significant difference in terms of intraoperative drop in haemoglobin and serum sodium change between the two groups. There seems to be a lesser degree of cautery artefacts in the PlasmaKinetic™ group than the monopolar group (42.17 versus 45.07 microns); however, this was not statistically significant (p-value is 0.452).

CONCLUSION

Bipolar TURP seems to result in a lesser degree of cautery artefacts when compared to conventional monopolar TURP, albeit statistically insignificant, compared to monopolar TURP. TURP also resulted in a longer resection time and increased irrigant use, but no difference in blood loss and serum sodium levels.

Updated survival results of the randomized phase II study comparing cisplatin/capecitabine (CX) with epirubicin plus CX (ECX) in advanced gastric cancer (AGC)

46

Background: We previously reported results of a randomized study showing that CX is equally active to ECX in terms of progression-free survival (PFS) (Yun et al. Eur J Cancer. 2010). Here we report updated overall survival (OS) results with an additional 12 months' follow-up.

Methods: Ninety-one chemotherapy-naïve patients with histologically-confirmed, measurable AGC were randomized to receive CX (cisplatin 75 mg/m2 iv on day 1 and capecitabine 1,000 mg/m2 bid po on days 1-14, n=45) or ECX (epirubicin 50 mg/m2 plus CX, n=44) every 3 weeks. After CX or ECX had failed, second-line chemotherapy (SLC) was recommended for all patients if their performance status was preserved.

Results: Treatment duration was similar for both arms (4.4 for CX v 4.2 months for ECX). There was no relevant difference in the occurrence of overall grade 3 or 4 toxicities between the CX and ECX arms (80% v 78%, respectively; p=0.516). However, none in the CX and 12% in the ECX arm discontinued treatment because of toxicity. There were no significant differences in therapeutic efficacy between CX and ECX with respect to the response rate (38% v 37%, respectively), PFS (6.4 v 6.5 months), as well as OS (12.7 v 13.8 months; p=0.51). After failure, 60% of patients (26 CX and 28 ECX patients) received SLC. However, OS was not differed whether a patient was treated with SLC or not (13.1 v 11.2 months; p=0.94).

Conclusions: The present analysis confirms previous findings that both CX and ECX appear to be comparatively active as first-line chemotherapy for AGC. Furthermore, the role of SLC in AGC warrants further evaluation.

No significant financial relationships to disclose.

Elevated LDH and paranasal sinus involvement are risk factors for central nervous system involvement in patients with peripheral T-cell lymphoma

Background: The incidence and risk factors of central nervous system (CNS) involvement in peripheral T-cell lymphomas (PTCLs) are still unclear.

Patients and methods: We analyzed 228 patients with PTCLs, excluding cases of extranodal natural killer/T-cell lymphoma and primary cutaneous T-cell lymphoma, by retrospectively collecting the clinical features and outcomes of the patients.

Results: Twenty events (8.77%, 20/228) of CNS involvement were observed during a median follow-up period of 13.9 months (range 0.03–159.43). Based on univariate analysis, elevated serum lactate dehydrogenase (LDH) level [P = 0.019, relative risk (RR) 5.904, 95% confidence interval (CI) 1.334–26.123] and involvement of the paranasal sinus (P = 0.032, RR 3.137, 95% CI 1.105–8.908) adversely affect CNS involvement. In multivariate analysis, both were independently poor prognostic factors for CNS relapse [elevated LDH level: P = 0.011, hazard ratio (HR) 6.716, 95% CI 1.548–29.131; involvement of the paranasal sinus: P = 0.008, HR 3.784, 95% CI 1.420–10.083]. The survival duration of patients with CNS involvement was significantly shorter than that of the patients without CNS involvement (P = 0.009), with median overall survival of 7.60 months (95% CI of 4.92–10.28) versus 27.43 months (95% CI of 0.00–57.38), respectively.

Conclusions: Elevated LDH level and involvement of the paranasal sinus are two risk factors for CNS involvement in patients with PTCLs. Considering the poor prognoses after CNS relapse, prophylaxis should be considered with the presence of any risk factor.