Intraoperative electron radiation therapy as an important treatment modality in retroperitoneal sarcoma

Background

Local recurrence (LR) rates in patients with retroperitoneal sarcoma (RPS) are high, ranging from 40% to 80%, with no definitive studies describing the best way to administer radiation. Intraoperative electron beam radiation therapy (IOERT) provides a theoretical advantage for access to the tumor bed with reduced toxicity to surrounding structures. The goal of this study was to evaluate the role of IOERT in high-risk patients.

Methods

An institutional review board approved, single institution sarcoma database was queried to identify patients who received IOERT for treatment of RPS from 2/2001 to 1/2009. Data were analyzed using the Kaplan–Meier method, Cox regression, and Fisher Exact tests.

Results

Eighteen patients (median age 51 y, 25–76 y) underwent tumor resection with IOERT (median dose 1250 cGy) for primary (n = 13) and recurrent (n = 5) RPS. Seventeen patients received neoadjuvant radiotherapy. Eight high-grade and 10 low-grade tumors were identified. Median tumor size was 15 cm. Four patients died and two in the perioperative period. Median follow-up of survivors was 3.6 y. Five patients (31%) developed an LR in the irradiated field. Three patients with primary disease (25%) and two (50%) with recurrent disease developed an LR (P = 0.5). Four patients with high-grade tumors (57%) and one with a low-grade tumor (11%) developed an LR (P = 0.1). The 2- and 5-y OS rates were 100% and 72%. Two- and 5-y LR rates were 13% and 36%.

Conclusions

Using a multidisciplinary approach, we have achieved low LR rates in our high-risk patient population indicating that IOERT may play an important role in managing these patients.     

A Decrease in the Percentage of CD3+ Cells Is Correlated With Clinical Improvement During Plasmapheresis in Patients With Myasthenia Gravis

Plasmapheresis not only removes circulating antibodies but also modulates cellular immunity, including lymphocyte subsets. To investigate the effect of double‐filtration plasmapheresis (DFPP) on the ratio of lymphocyte subsets in patients with myasthenia gravis (MG), we examined the percentages of B‐cells, T‐cells, T helper (Th) cells, T suppressor (Ts) cells, natural killer (NK) cells, NKT cells, and Th/Ts ratio before and after a single DFPP session and after a course of DFPP. A total of 26 patients were recruited; their peripheral blood lymphocyte subsets were assayed using flow cytometry. After a single session of DFPP treatment, the percentages of T‐cells (P = 0.0200), Th cells (P = 0.0178), and the Th/Ts ratio (P = 0.0309) decreased significantly, whereas the percentage of NK cells (P = 0.0007) increased significantly. More importantly, after one course of DFPP treatment, the reduced clinical quantitative MG (QMG) score was correlated with the decrease of the percentage of T‐cells (r = 0.5005, P = 0.0092). Fourteen thymectomized MG patients had decreased percentages of T‐cells (P = 0.0304) and Th cells (P = 0.0444), whereas they had increased NK cells (P = 0.0197) after a single DFPP session. Here, transiently decreased percentages of T‐cells after the full DFPP course could enhance the effectiveness of plasmapheresis for MG patients.     

Low incidence of thromboembolism in relapsed/refractory myeloma patients treated with thalidomide without thromboprophylaxis in Taiwan

Thromboembolism (TE) is a common complication in patients with multiple myeloma (MM). Immunomodulatory agents, e.g., thalidomide, have expanded the therapeutic options for treating myeloma; however, Western countries report a high incidence of thrombosis in thalidomide-treated MM patients who lack thromboprophylaxis. A Korean trial reported low TE incidence in thalidomide-treated myeloma patients (39?% were given aspirin prophylactically). We aimed to elucidate the TE frequency in MM patients in Taiwan who were treated with thalidomide without TE prophylaxis. We retrospectively collected the records of MM patients who had used thalidomide from a single institute between 2004 and 2010, combined these records with two other Taiwanese studies, and compared all three with the Korean trial. In the current Taiwanese series, five of 144 patients (3.5?%) developed TE as follows: three (2.1?%) were venous and two (1.3?%) were arterial. Only 6.1?% of the patients had undergone TE prophylaxis, which is less than in the Korean trial (38.9?%, p?<?0.05). Of the patients in the relapsed/refractory cohort (n?=?114) who were given thalidomide alone, none (0/52) developed venous TE (VTE); however, two patients (2/35, 5.7?%) who were given thalidomide–dexamethasone as a salvage treatment developed VTE. In the thrombosis cohort, four patients (80?%) were treated with thalidomide plus dexamethasone. In conclusion, the frequency of thalidomide-related TE in myeloma patients without effective TE prophylaxis was low in Taiwan. In relapsed/refractory myeloma patients, the VTE frequency was slightly lower compared with Western patients irrespective of treatment with thalidomide alone or combined with dexamethasone. Even in low TE incidence areas, thalidomide combined with dexamethasone was more thrombogenic compared with others.     

A diagnostic algorithm to serologically differentiate West Nile virus from Japanese encephalitis virus infections and its validation in field surveillance of poultry and horses

The detection of West Nile virus (WNV) in areas endemic for Japanese encephalitis virus (JEV) is complicated by the extensive serological cross-reactivity between the two viruses. A testing algorithm was developed and employed for the detection of anti-WNV antibody in areas endemic for JEV. Using this differentiation algorithm, a serological survey of poultry (2004 through 2009) and horses (2007 through 2009) was performed. Among 2681 poultry sera, 125 samples were interpreted as being positive for antibodies against JEV, and 14 were suspected to be positive for antibodies against undetermined flaviviruses other than WNV and JEV. Of the 2601 horse sera tested, a total of 1914 (73.6%) were positive to the initial screening test. Of these positive sera, 132 sera (5.1%) had been collected from horses that had been imported from the United States, where WNV is endemic. These horses had WNV vaccination records, and no significant pattern of increasing titer was observed in paired sera tests. Of the remaining 1782 positive sera 1468 sera (56.4%) were also found to contain anti-JEV antibodies, and were interpreted to be JEV-specific antibodies by the differentiation algorithm developed in this study. The remaining 314 horses (12.1%) for which a fourfold difference in neutralizing antibody titer could not be demonstrated, were determined to contain an antibody against an unknown (unidentified or undetermined) flavivirus. No evidence of WNV infections were found during the period of this study.     

Differentiation of West Nile virus-infected animals from vaccinated animals by competitive ELISA using monoclonal antibodies against non-structural protein 1

Antibodies against non-structural protein 1 (NS1) are considered to be the most reliable indicator of a present or past infection by West Nile virus (WNV) in animals. In this study, an in-house competitive enzyme-linked immunosorbent assay (NS1-cELISA) utilizing baculovirus-expressed NS1 and monoclonal antibodies against NS1 was established for the detection of antibody responses to NS1 in WNV-infected animals. The assay was validated by the simultaneous detection of early antibody responses to NS1 and the structural envelope protein in animals infected with WNV, or inoculated with inactivated WNV. NS1-cELISA detected WNV antibodies at 6 days post-infection (dpi) in a WNV-infected rabbit (percent inhibition [PI] value of 84.0), and at 10 dpi in a WNV-infected chicken (PI value of 67.0). The NS1-cELISA was able to detect WNV antibodies in sera from all WNV-infected rabbits at 10 dpi (PI value of 79.2±18.0), and from three of four WNV-infected chickens at 14 dpi (PI value of 73.7±22.8). The results of this study demonstrate that the antibody response to NS1 is similar to that against envelope protein in WNV-infected rabbits and chickens, whereas animals inoculated with inactivated WNV develop antibody responses only to the envelope protein but not to NS1. The NS1-cELISA developed here has the potential to be a useful tool for monitoring WNV circulation (i.e., the prevalence of specific antibodies against WNV NS1), by assaying serum samples from regions in which an inactivated vaccine control strategy has been implemented.     

Compare the Traditional Chinese Medicine Manipulation With Rehabilitation on In-Patients After Total Knee Arthroplasty

This prospective, randomized, and controlled study was conducted to assess Traditional Chinese Medicine (TCM) for pain control, alone and in conjunction with a standard inpatient rehabilitation program, during the five days immediately following total knee arthroplasty (TKA). Forty-one patients undergoing primary unilateral TKA between February, 2010 and January, 2011 were randomly assigned to one of three groups. Levels of pain were then monitored using a Visual Analogue Scale (VAS). Significant alleviation of pain and diminution of flexion contractures were achieved using TCM, with and without standard rehabilitation. These outcomes support use of TCM immediately post-TKA to facilitate patient recovery.     

The effect of tumor location on prognosis in patients with primary ureteral urothelial carcinoma

ObjectivesTo investigate the association of tumor location on oncological outcomes in patients treated with radical nephroureterectomy (RNU) for primary ureteral urothelial carcinoma (UC).Materials and methodsFrom January 1990 to December 2007, 127 patients with primary solitary ureteral UC who underwent RNU at our institution were included. The patients were divided into 3 groups based on tumor location—proximal, middle, or distal ureter. Patients' medical records were reviewed retrospectively. The clinicopathologic data and oncologic outcomes were compared among the groups.ResultsOf the 127 patients, 40 (31.5%) had tumors in the proximal ureter, 40 (31.5%) in the middle ureter, and 47 (37.0%) in the distal ureter. Patients with distal ureteral UC were more likely to undergo open procedures to manage the bladder cuff (P = 0.005). Other clinical and histopathologic variables were not different among the 3 groups. Comparing the proximal, middle, or distal ureteral UC, bladder recurrence developed in, respectively, 25.0%, 25.0%, and 21.3% cases (P = 0.892); local retroperitoneal recurrence in 2.5%, 12.5%, and 4.3% (P = 0.141); contralateral recurrence in 0%, 0%, and 4.3%(P = 0.177); and distant metastasis in 17.5%, 10.0%, and 4.3% (P = 0.147). Recurrence-free and cancer-specific survival among the 3 groups were not different (P = 0.781 and 0.192, respectively).ConclusionsTumor location cannot be used to predict oncologic outcomes in patients treated with RNU for primary ureteral UC. Therefore, clinical decisions or follow-up protocol should not differ among patients with primary proximal, middle, or distal ureteral UC.     

Difficult fiber-optic intubation in a patient with giant neck masses: The role of McCoy laryngoscope in elevating compressed laryngeal aperture

Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.     

Gender difference in antidepressant-related sexual dysfunction in Taiwan

Objective

Sexual dysfunction accompanied by depression may be altered by antidepressants. The effects of antidepressants on sexual dysfunction among males and females remain to be investigated.

Methods

Three groups of subjects, drug-free patients with depression (N= 125), medicated patients with depression (N= 145) and healthy volunteers (N= 255), were recruited. A Chinese version of the Changes in Sexual Functioning Questionnaire was employed to assess sexual function as the primary outcome.

Results

Drug-free depressed females and medicated depressed males had more sexual dysfunction than healthy controls. The desire for sexual behaviors among healthy females and medicated depressed females was higher than that of drug-free depressed females.

Conclusion

Depression and antidepressants may have different impacts on the sexual function of males and females.