Pretherapy metabolic tumour volume is an independent predictor of outcome in patients with diffuse large B-cell lymphoma

Purpose

We investigated the prognostic value of total metabolic tumour volume (TMTV) in diffuse large B-cell lymphoma (DLBCL).

Methods

TMTV was measured in 114 patients with newly diagnosed DLBCL who underwent ¹⁸F-FDG PET/CT at baseline before immunochemotherapy. TMTV was computed by summing the volumes of all lymphomatous lesions after applying the local SUVmax threshold of 41 % using semiautomatic software. Prognostic value was assessed by Kaplan-Meier estimates of progression-free survival (PFS) and overall survival (OS).

Results

Median follow-up was 39 months. Average pretherapy TMTV was 509?±?568 cm³. The 3-year estimates of PFS were 77 % in the low metabolic burden group (TMTV ≤550 cm³) and 60 % in the high metabolic burden group (TMTV >550 cm³, p?=?0.04), and prediction of OS was even better (87 % vs. 60 %, p?=?0.0003). Cox regression showed independence of TMTV for OS prediction (p?=?0.002) compared with other pretherapy indices of tumour burden, such as tumour bulk and the International Prognostic Index.

Conclusion

Pretherapy TMTV is an independent predictor of outcome in patients with DLBCL.     

Embolization of Life-Threatening Arterial Rupture in Patients with Vascular Ehlers–Danlos Syndrome

Purpose

To evaluate the safety and efficacy of transarterial embolization of life-threatening arterial rupture in patients with vascular Ehlers–Danlos syndrome (vEDS) in a single tertiary referral center.

Methods

We retrospectively analyzed transarterial embolization for vEDS performed at our institution from 2000 to 2012. The indication of embolization was spontaneous arterial rupture or pseudoaneurysm with acute bleeding. All interventions used a percutaneous approach through a 5F or less introducer sheath. Embolic agents were microcoils and glue in 3 procedures, glue alone in 2, and microcoils alone in 2.

Results

Five consecutive vEDS patients were treated by 7 embolization procedures (4 women, mean age 29.8 years). All procedures were successfully performed. Two patients required a second procedure for newly arterial lesions at a different site from the first procedure. Four of the five patients were still alive after a mean follow-up of 19.4 (range 1–74.7) months. One patient died of multiple organ failure 2 days after procedure. Minor procedural complications were observed in 3 procedures (43 %), all directly managed during the same session. Remote arterial lesions occurred after 3 procedures (43 %); one underwent a second embolization, and the other 2 were observed conservatively. Puncture site complication was observed in only one procedure (14 %).

Conclusion

Embolization for vEDS is a safe and effective method to manage life-threatening arterial rupture.     

A prospective study comparing diathermy and scalpel incisions in tension-free inguinal hernioplasty

Although still controversial, the use of diathermy instead of scalpel for skin incision and underlying tissue dissection is gradually gaining wide acceptance. This is due to the observation that no change in wound complication rates or postoperative pain are reported with the use of electrocautery. However, these studies include operations without the use of prosthetic materials during abdominal wall closure. The purpose of this study was to investigate the hypothesis that a) application of extreme heat may result in significant postoperative pain and poor wound healing because of excessive tissue damage and scarring respectively, and b) skin incision with the use of diathermy entails increased risk of wound infection in the presence of an underlying prosthetic material. One hundred twenty-five consecutive patients submitted to inguinal hernioplasty using the tension-free technique and fulfilling the inclusion criteria for the study were allocated alternately to either scalpel (n = 60), or diathermy (n = 57) groups. Eight patients had bilateral hernias. Five of them were allocated to the scalpel group and three to the diathermy group. According to the study protocol, they received both approaches for skin and underlying tissues incision, thus resulting in a total of 68 scalpel and 65 diathermy individual hernioplasties. Parameters measured included blood loss during the skin incision and underlying tissue dissection, postoperative pain and requirements for analgesics, the presence of wound dehiscence in the absence of infection, and postoperative wound infection on the day of discharge, on the day staples were removed, and 1 month after surgery. The two groups of patients were similar in relation to patient demographics, type of hernias, and operation details. Blood loss was minimal, and the amount of blood lost did not differ between the two groups. Diathermy group patients required less parenteral analgesics on the first postoperative day. A higher proportion of patients in the scalpel group continued to need oral analgesics on the second postoperative day compared to patients in the diathermy group. There was no difference between the two groups in terms of wound strength. Infectious complications were totally absent. The use of diathermy for skin incision during inguinal hernioplasty is as safe as the use of scalpel in terms of wound healing and reduces the analgesics requirements in the postoperative period.     

Peroxisome proliferator-activated receptor beta/delta exerts a strong protection from ischemic acute renal failure

Ischemic acute renal failure is characterized by damages to the proximal straight tubule in the outer medulla. Lesions include loss of polarity, shedding into the tubule lumen, and eventually necrotic or apoptotic death of epithelial cells. It was recently shown that peroxisome proliferator-activated receptor beta/delta (PPARbeta/delta) increases keratinocyte survival after an inflammatory reaction. Therefore, whether PPARbeta/delta could contribute also to the control of tubular epithelium death after renal ischemia/reperfusion was tested. It was found that PPARbeta/delta+/- and PPARbeta/delta-/- mutant mice exhibited much greater kidney dysfunction and injury than wild-type counterparts after a 30-min renal ischemia followed by a 36-h reperfusion. Conversely, wild-type mice that were given the specific PPARbeta/delta ligand L-165041 before renal ischemia were completely protected against renal dysfunction, as indicated by the lack of rise in serum creatinine and fractional excretion of Na+. This protective effect was accompanied by a significant reduction in medullary necrosis, apoptosis, and inflammation. On the basis of in vitro studies, PPARbeta/delta ligands seem to exert their role by activating the antiapoptotic Akt signaling pathway and, unexpectedly, by increasing the spreading of tubular epithelial cells, thus limiting potentially their shedding and anoikis. These results point to PPARbeta/delta as a remarkable new target for preconditioning strategies.     

IGL-1 solution in kidney transplantation: first multi-center study

Abstract:  IGL-1 solution is characterized by inversion of K+ and Na+ concentrations in the University Wisconsin (UW) solution and polyethylene glycol 35 (PEG 35) substitution for hydroxy ethyl starch. In this prospective study, 121 patients transplanted with kidneys preserved in IGL-1 solution were compared to 102 patients grafted with kidneys preserved in UW solution. Serum creatinine and creatinine clearance, delayed graft function (DGF) and rejection episodes, patient and graft survival were evaluated in the first post-transplant year. Groups were comparable regarding to donor and recipient characteristics. Median creatinine levels were significantly lower in IGL-1 group from day 6 to day 14 and it decreased more rapidly in the IGL-1 group (from day 4 to day 15: p < 0.05). Creatinine clearance values were usually higher in the IGL-1 group for the first 15 d. During the follow-up period serum creatinine concentrations were lower in IGL-1 group at one, three, six and 12 months after transplantation (p = 0.04; p = 0.06, p = 0.01 and p = 0.08, respectively) while creatinine clearance values were similar during the follow-up. No significant difference in DGF and rejection rates as well as in patient and graft survival was shown between the two groups. Kidneys preserved in IGL-1 solution showed to have the same function as kidneys preserved in UW solution.     

Performance of the Cockcroft-Gault and MDRD equations in adult Nigerians with chronic kidney disease

Background  Estimation of the glomerular filtration rate (GFR) is required in the assessment of patients with chronic kidney disease (CKD) in order to provide information regarding the functional status of the kidneys. Current guidelines advocate the use of prediction equations, such as the Cockcroft-Gault (CG) formula and the Modification of Diet in Renal Disease (MDRD) study-derived equations, over clearance of endogenous creatinine (Ccr) in achieving this aim. We were interested in knowing the accuracy of these equations in predicting the GFR in adult Nigerians with CKD. Methods  We conducted a review of records of patients who were evaluated for CKD at the Nephrology Clinic of the Jos University Teaching Hospital between 2001 and 2003. We compared the CG and MDRD equations against the Ccr in predicting the GFR in 130 patients (88 males and 42 females) with CKD. Results  The means ± standard deviation (SD) for the measured and predicted GFR by the CG and MDRD equations were similar (17.6 ± 25.8 ml/min, 19.9 ± 24.0 ml/min and 21.5 ± 28.2 ml/min, respectively; analysis of variance [ANOVA], F = 0.68, P = 0.5). The mean difference between CG and Ccr was −2.2 ± 14.8 ml/min, with discordance at Ccr values >25 ml/min. The mean difference between MDRD and Ccr was −3.9 ± 18.1 ml/min, with discordance at Ccr values >40 ml/min. Conclusion  The CG and MDRD equations provide reliable alternatives to measured Ccr in the estimation of the GFR in Nigerian patients with CKD.     

Bariatric Surgery Outcomes in Sarcopenic Obesity

Background

Sarcopenic obesity is the combination of low muscle mass and strength with increased fat mass. This condition is associated with negative health outcomes. We hypothesized that sarcopenia could be a pejorative factor on surgical weight loss.

Objective

The objectives of the study are to determine the influence of sarcopenic obesity on gastric bypass and sleeve gastrectomy results regarding weight loss and comorbidities resolution at 3, 6, and 12 months.

Setting

The study was conducted at the University Hospital.

Methods

Sixty-nine obese patients who benefited from bariatric surgery were included. Skeletal muscle mass was determined by the Janssen’s equation. Physical performance and muscle strength were determined using the 6-min walk test and the wall sit test. Obese subjects from the lowest tertile of the Skeletal Muscle mass Index (SMI) of Baumgartner were set as sarcopenic.

Results

Weight loss outcomes and rate of weight loss failure were not influenced by sarcopenia. At 1 year, mean EBMIL% was 75.4 %?±?5 in sarcopenic subjects vs 67.8 % ±4 in the non-sarcopenic subjects (p?=?0.242). Improvement rates of co-morbidities were similar between groups. Skeletal muscle mass was no more different between groups at 1 year after surgery. There was no patient lost to follow-up.

Conclusions

Bariatric surgery remains effective in achieving weight loss target in sarcopenic patients, with similar remission rates of main comorbidities and similar safety profile than in the non-sarcopenic group. Whether bariatric surgery could result in improvement or deterioration of daily living activities disabilities and functional autonomy in sarcopenic obese patients still have to be evaluated.

     

Stage does not predict survival after resection of hilar cholangiocarcinomas promoting an aggressive operative approach

Introduction

Staging systems have been developed to predict survival after resection of hilar cholangiocarcinoma. Notably, they have not been validated nor compared for relative predictive ability.

Methods

Forty-two patients underwent resection of hilar cholangiocarcinoma and have been followed through a prospectively collected database. The tumors were staged using the Bismuth-Corlette, Blumgart, and American Joint Committee on Cancer (AJCC) systems, and a significant relationship with survival was sought.

Results

Eleven patients were treated by extrahepatic biliary resection alone, while 31 required extrahepatic biliary resections with in-continuity hepatic resections. All patients underwent adjuvant therapy. To date, 30 patients have died with a mean survival time of 30 months ± 35.0 (SD). Twelve patients are alive with a mean survival of 90 months ± 61.8. By regression analysis, none of the staging systems had a significant relationship with survival (Bismuth: P = .64; Blumgart: P = .66; AJCC: P = .31).

Conclusions

Most patients with hilar cholangiocarcinoma require in-continuity hepatic resections. Survival after resection promotes an aggressive approach, with cure in as many as 30%. Staging systems should not impact the decision to operate or postoperative management, as all tumors should be aggressively resected and all patients should receive adjuvant treatment.     

Transforming growth factor-β1 in the urine of young children with urinary tract infection

Urinary tract infection (UTI) is a frequent cause of morbidity during the first years of life and may lead to renal insufficiency. Transforming growth factor-1 (TGF-) is both immunoregulatory and an important mediator of interstitial fibrosis. TGF- was detected in the urine of 52% of 48 children aged 1–24 months with a first episode of UTI (94% due to Escherichia coli) and no obstructive nephropathy compared with 0 of 20 healthy young children (P<0.001). TGF- was detected in the urine only during the early stage (<1 day) after initiation of treatment. It was detected more frequently (P=0.06) and in significantly higher concentrations (P=0.046) in children with a normal ^99m Tc-dimercaptosuccinic acid scan compared with those with abnormal scans performed 3–14 days after the diagnosis of UTI, suggesting a regulatory role in fibrogenesis and outcome of pyelonephritis in childhood.