Stand-alone intrathecal central nervous system (CNS) prophylaxis provide unclear benefit in reducing CNS relapse risk in elderly DLBCL patients treated with R-CHOP and is associated increased infection-related toxicity

Central nervous system (CNS) relapse following R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) occurs in 2–5% of patents with diffuse large B-cell lymphoma (DLBCL). Many patients aged ≥70 years are unsuitable for high-dose methotrexate (HDMTX) prophylaxis and therefore often receive stand-alone intrathecal prophylaxis. The CNS international prognostic index (CNS-IPI) is a clinical CNS relapse risk score that has not specifically been validated in elderly patients. The value of CNS prophylaxis in patients aged ≥70 years remains uncertain. Data on 690 consecutively R-CHOP-treated DLBCL patients aged ≥70 years were collected across 8 UK centres (2009–2018). CNS prophylaxis was administered per physician preference. Median age was 77·2 years and median follow-up was 2·8 years. CNS-IPI was 1–3 in 60·1%, 4 in 23·8%, 5 in 13·0% and 6 in 3·3%. Renal and/or adrenal (R/A) involvement occurred in 8·8%. Two-year overall CNS relapse incidence was 2·6% and according to CNS-IPI, 1–3:0·8%, 4:3·6%, 5:3·8% and 6:21·8%. Two-year CNS relapse incidence for R/A was 10·0%. When excluding HDMTX (n = 31) patients, there remained no change in unadjusted/adjusted CNS relapse for intrathecal prophylaxis effect according to CNS-IPI. CNS-IPI is valid in elderly R-CHOP-treated DLBCL patients, with the highest risk in those with CNS-IPI 6 and R/A involvement. We observed no clear benefit for stand-alone intrathecal prophylaxis but observed an independent increased risk of infection-related admission during R-CHOP when intrathecal prophylaxis was administered.     

Imaging of the Achilles tendon in spondyloarthritis: a comparison of ultrasound and conventional, short and ultrashort echo time MRI with and without intravenous contrast

Objectives  

To compare conventional MRI, ultrashort echo time MRI and ultrasound for assessing the extent of tendon abnormalities in spondyloarthritis.     

Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis

Background: Compared with parenteral nutrition, enteral nutrition reduces infectious complications and mortality in patients with severe acute pancreatitis (SAP). This study used clinical outcomes to investigate the association between time to initiation of distal jejunal feeding (DJF) and time to achievement of goal enteral feeding with clinical outcomes. Methods: A retrospective chart review was performed on all patients with SAP admitted to the medical intensive care unit (ICU) during a 1‐year period. Collected data included demographic information, body mass index (BMI; kg/m²), Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission, time of onset of DJF, time to goal feeding, ICU length of stay, and mortality. Results: Time to starting DJF was longer in nonsurvivors (n = 4) than in survivors (n = 12) (17 vs 7 days, P < .05). All nonsurvivors had BMI >30 kg/m² (50% had BMI > 50 kg/m²). ICU length of stay was significantly associated with achievement of goal feeding. Three patients never reached goal feeding and spent 45.3 ± 19.6 days in the ICU; 7 patients reached goal feeding within 3 days of initiating DJF and spent 18 ± 1.7 days in the ICU; and 4 patients reached goal feeding within 3 days and spent 10.5 ± 3.5 days in the ICU. APACHE II scores were not significantly different among the 3 groups (16.7 ± 1.5, 12 ± 0.7, and 16.2 ± 1.2, respectively, P > .05). Conclusions: Early initiation of DJF in the ICU was associated with reduced mortality in this cohort of patients with SAP. Early achievement of jejunal feeding goal early was associated with a shorter ICU length of stay, irrespective of the severity of SAP.     

The diagnosis of psoriatic arthritis

For over 30 years investigators have used the simple but non-validated classification criteria suggested by Moll and Wright. Several authors have suggested modifications but most remain invalid or require HLA analysis. Now, a world wide initiative has developed new criteria (the CASPAR criteria) which include both clinical, laboratory and radiological features. These will require further study before they are fully adopted for future studies but their improved performance should result in less variation between study cohorts.     

Reducing ventricular pacing in sinus node dysfunction

BACKGROUND: The use of DDIR mode has been limited since the advent of mode switch in the DDDR mode. In patients with AV block, DDDR is necessary to maintain AV synchrony. However, DDIR mode may still be beneficial for patients with intact AV conduction. The aim of this study was to compare the incidence of ventricular pacing and atrial tachyarrhythmia in DDIR and DDDR with mode switch in a randomized, single-blind, crossover study, and discuss the utility of both modes. METHODS AND RESULTS: Twenty-four patients (8 males) with bradycardia-tachycardia syndrome and no signs of AV block (mean age 70.1 +/- -9.1 years) were enrolled and randomized to DDIR or DDDR modes with the leads placed at the right atrial appendage and right ventricular apex. After 12 weeks, patients were switched to the opposite mode. During the study period, atrial high rate episodes and other pacemaker diagnostic data were collected. Significantly less ventricular pacing was observed in DDIR mode (DDIR versus DDDR; 48.9%, 76.5%, P = 0.0002) and atrial high rate episodes were significantly lower in DDIR mode (DDIR versus DDDR; 1.32, 1.85 per day, P < 0.05). CONCLUSION: In patients with sinus node dysfunction and intact AV conduction, DDIR mode may have important implications for simplifying device programming, device longevity, and to avoid atrial tachyarrhythmia.     

Hematopoietic prostaglandin D2 synthase controls the onset and resolution of acute inflammation through PGD2 and 15-deoxyDelta12 14 PGJ2

Hematopoietic prostaglandin D₂ synthase (hPGD₂S) metabolizes cyclooxygenase (COX)-derived PGH₂ to PGD₂ and 15-deoxyΔ^12–14 PGJ₂ (15d-PGJ₂). Unlike COX, the role of hPGD₂S in host defense is ambiguous. PGD₂ can be either pro- or antiinflammatory depending on disease etiology, whereas the existence of 15d-PGJ₂ and its relevance to pathophysiology remain controversial. Herein, studies on hPGD₂S KO mice reveal that 15d-PGJ₂ is synthesized in a self-resolving peritonitis, detected by using liquid chromatography–tandem MS. Together with PGD₂ working on its DP1 receptor, 15d-PGJ₂ controls the balance of pro- vs. antiinflammatory cytokines that regulate leukocyte influx and monocyte-derived macrophage efflux from the inflamed peritoneal cavity to draining lymph nodes leading to resolution. Specifically, inflammation in hPGD₂S KOs is more severe during the onset phase arising from a substantial cytokine imbalance resulting in enhanced polymorphonuclear leukocyte and monocyte trafficking. Moreover, resolution is impaired, characterized by macrophage and surprisingly lymphocyte accumulation. Data from this work place hPGD₂S at the center of controlling the onset and the resolution of acute inflammation where it acts as a crucial checkpoint controller of cytokine/chemokine synthesis as well as leukocyte influx and efflux. Here, we provide definitive proof that 15d-PGJ₂ is synthesized during mammalian inflammatory responses, and we highlight DP1 receptor activation as a potential antiinflammatory strategy.     

Criminal records of persons served in the public mental health system

OBJECTIVE: The authors examined the frequency and severity of arrests of persons served by Medicaid as well as public mental health treatment patterns before and after arrest. METHODS: A random sample of 6,624 persons was drawn from claims of the public mental health system in Los Angeles County between July 1993 and June 2001. Clients' claims were matched to criminal justice records from 1991 to 2001. Cross-tabulations and logistic regression analyses were used to examine the likelihood and seriousness of criminal involvement, as well as clients' involvement in mental health treatment around the time of the arrest. RESULTS: Twenty-four percent of the sample had at least one arrest over the ten-year period. Sixty-two percent of arrested individuals had as their most serious offense a nonviolent crime. Half of all observed arrests did not lead to conviction. There was no statistical difference in the total treatment services received between arrested and not-arrested individuals. Among those arrested, there was only a small difference in the likelihood of receiving treatment services before and after arrest. CONCLUSIONS: Almost a quarter of persons with serious mental illness were arrested at least once over ten years. More than one-third of these individuals were arrested for violent crimes, with drug crimes the second most common category. The seriousness of the offense varied with diagnosis. Arrest was not associated with meaningful increases in service use, pointing to potential missed opportunities for treatment.     

Initial fixation and cyclic loading stability of knotless suture anchors for rotator cuff repair

This study evaluated the resistance to gapping and the mode of failure for 2 knotless suture anchor systems used for rotator cuff repair compared with the performance of a conventional titanium anchor system. Eight matched pairs of fresh-frozen humeri were dissected free of all soft tissues and scanned to measure bone mineral density (BMD). The suture anchor systems tested were the TwinFix 5.0 Titanium (Smith & Nephew, Andover, MA), Bioknotless RC (DePuy Mitek, Norwood, MA), and Magnum (Opus Medical, San Juan Capistrano, CA), and each was inserted into each humerus. Cyclic, tensile loading was applied through the suture loop for 5000 cycles, or until failure, by using a servohydraulic testing machine. Gapping distances, defined as increasing elongation of the bone/anchor/suture system, were continuously measured. Total cycles to failure and mechanism of failure were documented. Mean initial (first cycle) and final (last cycle) gapping distances were 3.81 mm and 5.36 mm for the TwinFix 5.0, 4.02 mm and 5.34 mm for the Bioknotless RC, and 3.56 mm and 4.98 mm for the Magnum anchors. No significant difference was detected among mean gap openings (P > .05). However, the Bioknotless RC had more early failures (5) than the other 2 implants (1 each), approaching significance (P = .07). Trials of the Bioknotless RC that did not fail early were found to have significantly less gap opening than the other 2 systems for both initial (1.89 mm vs 3.82 mm for the TwinFix 5.0 and 3.56 mm for the Magnum) and final (2.00 mm vs 4.68 mm for the TwinFix 5.0 and 4.24 mm for the Magnum) gap opening. BMD was a significant predictor of initial (P = .029) and final (P = .008) gap opening, whereas the site of anchor insertion was a significant predictor of final displacement. The Opus Magnum was comparable with a conventional suture anchor, but the Mitek Bioknotless RC showed a trend toward early failure. Biomechanical analysis of knotless suture anchor systems can demonstrate trends among implants in an experimental setting. Knowledge of these trends could influence implant selection.