Patterns and management of distant failure in locally advanced rectal cancer: a cohort study

Purpose

To determine the long-term outcomes of locally advanced rectal cancer (LARC) treated with neoadjuvant chemoradiation (CRT) and surgery, and to analyze the management and survival once distant failure has developed.

Methods

Data from LARC patients treated from 2000 to 2010 were retrospectively reviewed. CRT protocols were based on fluoropirimidines ± oxaliplatin. Follow-up consisted of physical examination, carcinoembryonic antigen levels, and chest-abdominal-pelvic CT scan.

Results

The study included 228 patients with a mean age of 59 years. Forty-eight (21.1 %) patients had distant recurrence and 6 patients (2.6 %) had local recurrence. Median follow-up was 49 months. The 5- and 10-year actuarial disease free survival was 75.3 and 65.0 %, respectively. The 5- and 10-year actuarial overall survival (OS) was 89.6 and 71.2 %, respectively. Patients were classified as having liver (14 patients) or lung (27 patients) relapse according to the organ firstly metastasized. The variables significantly associated by univariate Cox analysis to survival were the achievement of an R0 metastases resection and the Köhne risk index, while the metastatic site showed a statistical trend. By multivariate Cox analysis, the only variable associated with survival was a R0 resection (HR = 16.3, p < 0.001). Median OS for patients undergoing a R0 resection was 73 months (95 % CI 67.8–78.2) compared to 25 months (95 % CI 5.47–44.5) in those non-operated patients (p < 0.001).

Conclusions

Combined treatment for LARC obtains a 5-year OS rounding 90 %. Follow-up based on thoracic-abdominal CT scan allows an early diagnosis of metastatic lesions. Surgical resection of metastases, regardless of their location, greatly increases the patient’s survival rate.

     

Brown-Séquard syndrome and cervical post-traumatic subarachnoid hematoma

Cervical Traumatic SSH are very rare in literature. They are usually caused by cardiopulmonary diseases that increase vascular pressure causing spinal vessels rupture.In thoracolumbar spine, the spinal puncture is the most common cause. The ventrolateral position is even more unusual.In traumatic brain injury (TBI), an abrupt extension–flexion movement could have caused the rupture of subarachnoid vessels. This, accompanied by the slowed blood “wash out” (probably due to the previous osteoarthrosis and spinal canal stenosis), led to the formation of an organized clot, which caused an acute spinal cord compression syndrome.Cervical subarachnoid spinal hematoma can present as Brown-Séquard syndrome. The treatment is prompt surgical removal and decompression. The posterior approach (partial hemilaminectomy with or without laminoplasty) with microsurgical technique is feasible, fast and simple to evacuate the hematoma with good results. Surgical nuances in posterior approach are: small spinal canal, difficulty in mobilizing the cervical cord, these haematomas are wrapped and attached to the spinal cord or nerve roots by multiple arachnoid bands, requiring techniques of Microdissection for its evacuation unlike the epidural and subdural haematomas that are easily aspirated.Here, we report a unique case of a ventrolateral SSH due to TBI.     

Bioaccumulation and maternal transfer of PBDE 47 in the marine medaka (Oryzias melastigma) following dietary exposure

The bioaccumulation and maternal transfer of 2,2',4,4'-tetrabromodiphenyl ether (PBDE 47) were investigated in the marine medaka (Oryzias melastigma) following dietary exposure, in which PBDE 47 was bioencapsulated into brine shrimp (Artemia sp.) and fed daily to male-female pairs of medaka. In the accumulation experiment, each 2-month-old (pre-breeding) medaka were provided with dietary PBDE 47 at 1.3±0.2 μg/day for 21 days. Growth-corrected concentrations of PBDE 47 in the medaka increased over the 21 days of exposure and there were no significant differences between males and females at any of the sampling times. Final concentrations were similar for males and females after 21 days (230±30 and 250±30 μgg(-1) wet weight, respectively), accounting for 84-100% of the PBDE 47 provided in the diet. In the maternal transfer experiment, 3-month-old (breeding) medaka were provided with dietary PBDE 47 at 1.2±0.2 μg/day for 18 days, and reached body concentrations of 76±3 (males) and 61±6 (females)μgg(-1) wet weight. Female growth-corrected PBDE 47 concentrations were significantly lower than males by day 12 (P<0.05), and egg PBDE 47 concentrations were up to 25 ng/egg by day 18. Our results showed that maternal transfer is an important offloading mechanism for female fish. The fact that lipid normalized egg:female PBDE ratios did not significantly deviate from 1 further indicated that the maternal transfer of PBDE 47 is associated with lipid mobilization during egg production.     

High levels of hsCRP are associated with carbohydrate metabolism disorder

Aim: To determine risk parameters associated with high values of high sensitive C‐reactive protein (hsCRP) in subjects with different glucose fasting levels. Methods: Anthropometric parameters, arterial pressure, glycemia, lipid profile, uric acid, and hsCRP were studied in a population of 513 individuals between 40 and 65 years. Results: In total, 349 (68.0%) were normoglycemic (NG); 113 (22.0%) had impaired fasting glucose (IFG); and 51 (9.9%) were diabetic subjects. A multivariate linear regression analysis showed that the natural logarithm of hsCRP was associated significantly with glycemia levels (P = 0.009), uric acid (P = 0.001), diastolic blood pressure (P = 0.011), smoking habit (P = 0.021), BMI (P<0.001), and sex (P<0.001). One‐third of the NG subjects had high hsCRP levels. A multiple logistic regression analysis showed that sex and BMI were variables related to high levels of hsCRP in subjects with IFG and NG. In NG subjects, uric acid levels were associated with risk of presenting high hsCRP levels and were higher in women than men. In NG women, ROC curves analysis identified a uric acid level of 3.9 mg/dl as a cut‐off point to predict a high value of hsCRP. Those individuals with uric acid values higher than 3.9 mg/dl and normal glycemia had 3.5‐fold more risk of having hsCRP levels over 3.0 mg/l. Conclusions: We sustain that high levels of hsCRP are associated with disturbance in carbohydrate metabolism. In addition, we believe that in low cardiovascular risk population, such as NG women, uric acid levels above 3.9 mg/dl might represent a signal of possible pro‐inflammatory state and cardiovascular risk. J. Clin. Lab. Anal. 25:375–381, 2011. © 2011 Wiley Periodicals, Inc.     

Molecular detection of cryptic Y-chromosomal material in patients with Turner syndrome

A systematic search for a hidden Y-chromosome mosaicism, in Turner syndrome (TS) patients is justified by the evaluation of the risk of development of germ cell tumors. In this study, we analyzed cryptic Y-chromosome derivatives by polymerase chain reaction (PCR) coupled with fluorescence in?situ hybridization (FISH) using Y-specific sequences in patients with TS, and validated this methodology. Unrelated patients with TS (n=32) of Mexican mestizo ethnic origin were diagnosed using cytogenetic analysis. Clinical assessment, endocrine evaluation, karyotyping, FISH and PCR analysis of the Y-chromosomal loci were performed. We found that 9.4% (3 out of 32) patients with TS had Y-chromosome material. Two patients showed Y-chromosome by conventional cytogenetics. One patient had no Y-chromosome by initial karyotyping (45,?X) but was positive by lymphocyte PCR?DNA analysis of the Y-sequence-specific sex-determining region Y (SRY) gene. Our results suggest that the detection of the Y-chromosome material using sensitive methods, such as PCR coupled with FISH, should be carried out in all patients with TS and should not be limited to TS patients with cytogenetically identifiable Y-chromosome and/or virilization.     

Equity, governance and financing after health care reform: lessons from Mexico

To determine, from the perspective of providers, community leaders and users of health services, equity, governance and health financing outcomes of the Mexican health system reform.Cross-sectional study oriented towards the qualitative analysis of financing, governance and equity indicators for the uninsured population. Taking into account feasibility, as well as political and technical criteria, six Mexican states were selected as study populations and a qualitative research was conducted during 2004-2006. Two hundred and forty in-depth interviews were applied, in all selected states, to 60 decision-makers, including medical and administrative personnel; 60 service providers at health centres; 60 representatives of civil organizations, including municipal representatives and, finally, 60 members of health committees and users of services at second and first levels of care units. The analysis of interviews was performed using ATLAS-Ti software. An outcome mapping of health reform was developed. For political actors, Mexican health system reform has not modified dependence on the central level; ignorance about reform strategies and lack of participation in the search for financial resources to finance health systems were evidenced. Also, in all states under study, community leaders and users of services reported the need to improve an effective accountability system at both municipal and state levels. Health strategies for equity, governance and financing do not have adequate mechanisms to promote participation from all social actors. Improving this situation is a very important goal in the Mexican health democratization process, in the context of health care reform. There are relevant positive and negative effects of the reform on equity, governance and financing in health. Special emphasis is placed on the analysis of lessons learned in Mexico and the usefulness of the main strengths and weaknesses, as relevant evidences for other middle-income countries which are designing, implementing and evaluating reform strategies in order to achieve equity in resource allocation, good levels of governance and a greater financial protection in health.     

Elementary school practices and children's objectively measured physical activity during school

Objective

To examine the relation of physical activity practices covering physical education (PE), recess, and classroom time in elementary schools to children's objectively measured physical activity during school.

Methods

Participants were 172 children from 97 elementary schools in the San Diego, CA and Seattle, WA USA regions recruited in 2009–2010. Children's moderate-to-vigorous physical activity (MVPA) during school was assessed via accelerometry, and school practices were assessed via survey of school informants. Multivariate linear mixed models were adjusted for participant demographics and unstandardized regression coefficients are reported. The 5 practices with the strongest associations with physical activity were combined into an index to investigate additive effects of these practices on children's MVPA.

Results

Providing ≥ 100 min/week of PE (B = 6.7 more min/day; p = .049), having ≤ 75 students/supervisor in recess (B = 6.4 fewer min/day; p = .031), and having a PE teacher (B = 5.8 more min/day; p = .089) were related to children's MVPA during school. Children at schools with 4 of the 5 practices in the index had 20 more min/day of MVPA during school than children at schools with 0 or 1 of the 5 practices (p < .001).

Conclusions

The presence of multiple school physical activity practices doubled children's physical activity during school.