Impact of stereotactic body radiation therapy on geriatric assessment and management for older patients with head and neck cancer using G8

PurposeManagement of head and neck cancers (HNC) in older adults is a common but challenging clinical scenario. We assess the impact of Stereotactic Body Radiation Therapy (SBRT) on survival utilizing the Geriatric-8 (G8) questionnaire.Materials and methods171 HNC patients, deemed medically unfit for definitive treatment, were treated with SBRT ± systemic therapy. G8 questionnaires were collected at baseline, at 4–6 weeks, and at 2–3 months post-treatment. Patients were stratified according to their baseline G8 score: <11 as ‘vulnerable’, 11–14 as ‘intermediate’, and >14 as ‘fit’. Overall survival (OS) was assessed through univariate Kaplan Meier analysis. Repeated measures ANOVA was used to determine if baseline characteristics affected G8 score changes.ResultsMedian follow-up was seventeen months. 60% of patients presented with recurrent HNC, 30% with untreated HNC primaries, and 10% with metastatic non-HNC primaries. Median age was 75 years. Median Charlson Comorbidity Index score was 2. 51% of patients were ‘vulnerable’, 37% were ‘intermediate’, and 12% were ‘fit' at baseline, with median survival of 13.2, 24.3, and 41.0 months, respectively (p = .004). Patients who saw a decrease in their follow-up G8 score (n = 69) had significantly lower survival than patients who had stable or increased follow-up G8 scores (n = 102), with median survival of 8.6 vs 36.0 months (p < .001).ConclusionThe G8 questionnaire may be a useful tool in upfront treatment decision-making to predict prognosis and prevent older patients from receiving inappropriate anti-cancer treatment. Decline in follow-up G8 scores may also predict worse survival and aid in goals of care following treatment.     

Pharmacological therapy of vascular malformations of the gastrointestinal tract.

Vascular malformation (AVM) in the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and iron deficiency anemia, especially in an aging population. While endoscopic coagulative therapy is the method of choice for controlling bleeding, a substantial number of cases require additional therapy. Adjunctive or even primary phamacotherapy may be indicated in recurrent bleeding. However, there is little evidence-based proof of efficacy for any agent. The bulk of support is derived from anecdotal reports or case series. The present review compares the outcome of AVM after no intervention, coagulative therapy or focus on pharmacological agents. Most of the literature encompasses two common AVMs, angiodysplasia and hereditary hemorrhagic telangiectasia. Similarly, the bulk of information evaluates two therapies, hormones (estrogen and progesterone) and the somatostatin analogue octreotide. Of these, the former is the only therapy evaluated in randomized trials, and the results are conflicting without clear guidelines. The latter therapy has been reported only as case reports and case series without prospective trials. In addition, other anecdotally used medications are discussed.     

The anesthetic management of ventricular septal defect (VSD) repair in a child with mitochondrial cytopathy

PURPOSE: To present the anesthetic management for the correction of a ventricular septal defect (VSD) in a patient with multiple acyl CoA dehydrogenase deficiency (glutaric aciduria type II; GAII). A review of the literature about anesthetic management of patients with mitochondrial diseases undergoing cardiopulmonary bypass (CPB) is also included. Clinical features: An 11-yr-old girl with GAII manifested as severe hypoglycemia since she was a newborn and generalized muscle weakness. She underwent open-heart surgery for VSD correction with CPB. The anesthetic management avoided inhalational anesthetics, maintained the blood sugar within normal limits and continued normothermia during CPB in order to avoid the stress of hypothermia for her abnormal mitochondria. The patient tolerated the procedure well and experienced a good recovery. CONCLUSION: The anesthetic management of patients with any mitochondrial disease requires normoglycemia, normothermia and the avoidance of metabolic stress in order to preserve energy production by the diseased mitochondria.     

Tissue Doppler assessment of left ventricular diastolic function in rheumatic mitral stenosis

BackgroundLeft ventricular systolic and diastolic functions are reported to be altered in mitral stenosis. Although conventional Doppler ultrasound recording of transmitral flow is used in the assessment of left ventricular diastolic function, yet, in patients with mitral stenosis, it is altered by mitral stenosis itself and thus precludes the proper assessment of LV diastolic function.Aim of the workThe aim of this work is to assess LV diastolic function using pulsed tissue Doppler interrogation of mitral annulus motion in patients with rheumatic mitral stenosis.Patients and methodsTwelve patients with established diagnosis of rheumatic mitral stenosis in normal sinus rhythm were obtained from outpatient clinic of Cardiology Department in Mansura specialized hospital. Thirteen age and sex matched controls with completely normal echo-Doppler study were taken for comparison. All patients were subjected to thorough history taking including dyspnea grading according to NYHA score, clinical examination, 12 lead surface electrocardiogram and most importantly echo-Doppler study.ResultsWe found statistically significant higher peak mitral annular E_a velocity from septal, anterior, inferior and lateral portions of the mitral annulus in controls compared with mitral stenosis patients as well as their averaged values. There is no statistically significant difference regarding peak mitral annular A_a velocity from septal, anterior, inferior and lateral portions of the mitral annulus between both groups as well as their averaged values. The ratio of early to late mitral annular velocities from all recorded sites was statistically significantly higher in the controls compared with mitral stenosis patients.ConclusionsTDI of mitral annulus may provide potential diagnostic role for assessment of LV diastolic function in patients with mitral stenosis.     

Congestive heart failure as a rare cause of unilateral breast edema: A case report & review of the literature

Reported cases encountered difficulty in differentiating between inflammatory carcinoma and breast edema caused by congestive heart failure especially if the breast edema is unilateral. Our presented case is an elderly woman with unilateral breast edema due to congestive heart failure that was initially suspected to have breast cancer based on clinical findings. However imaging studies showed breast edema pattern with no definite underlying mass. This edema was resolved with standard treatment of heart failure. Congestive heart failure may be a possible cause of unilateral breast edema especially in a patient with background of congestive heart failure.     

Serum vitamin D status in type 2 diabetic patients from Gaza Strip

ObjectiveTo assess serum vitamin D status and its relations to other biochemical parameters in type 2 diabetic patients from Gaza Strip.Materials and methodsThis case-control study included 58 type 2 diabetic patients as well as 58 non-diabetic controls. Patients and controls were matched for age and gender. Data were obtained from questionnaire interview, and biochemical analysis of blood samples.ResultsSerum vitamin D was significantly lower in diabetic patients compared to non-diabetic controls (25.9 ± 11.0 versus 34.6 ± 13.8 ng/dl, % difference = 28.8%, P < 0.001). The number of patients having vitamin D deficient, insufficient and sufficient were 6 (10.4%), 35 (60.3%) and 17 (29.3%) compared to controls of 3 (5.2%), 16 (27.6%) and 39 (67.2%), respectively (χ² = 14.672, P < 0.001). Serum glucose, glycated hemoglobin (HbA1c), serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and triglycerides were significantly higher in patients than in controls whereas serum insulin, high density lipoprotein cholesterol (HDL-C) and calcium were significantly lower in patients. Serum vitamin D showed significant negative correlations with HbA1c (r = ? 0.186, P = 0.046), ALT (r = ? 192, P = 0.040) and AST (r = ? 0.188, P = 0.044) whereas significant positive correlations were found with HDL-C (r = 0.188, P = 0.044) and calcium (r = 0.239, P = 0.010).ConclusionThe significant negative and positive correlations of vitamin D with HbA1c and calcium, respectively suggests that vitamin D supplementation would be of potential therapeutic value in clinical settings for controlling of type 2 diabetes and more importantly its complications. However, a well-designed clinical trials are needed to define the contribution of vitamin D status and therapy in the global diabetes problem.     

Geospatial blockchain: promises,challenges, and scenarios in health and healthcare

A PubMed query run in June 2018 using the keyword ‘blockchain’ retrieved 40 indexed papers, a reflection of the growing interest in blockchain among the medical and healthcare research and practice communities. Blockchain’s foundations of decentralisation, cryptographic security and immutability make it a strong contender in reshaping the healthcare landscape worldwide. Blockchain solutions are currently being explored for: (1) securing patient and provider identities; (2) managing pharmaceutical and medical device supply chains; (3) clinical research and data monetisation; (4) medical fraud detection; (5) public health surveillance; (6) enabling truly public and open geo-tagged data; (7) powering many Internet of Things-connected autonomous devices, wearables, drones and vehicles, via the distributed peer-to-peer apps they run, to deliver the full vision of smart healthy cities and regions; and (8) blockchain-enabled augmented reality in crisis mapping and recovery scenarios, including mechanisms for validating, crediting and rewarding crowdsourced geo-tagged data, among other emerging use cases. Geospatially-enabled blockchain solutions exist today that use a crypto-spatial coordinate system to add an immutable spatial context that regular blockchains lack. These geospatial blockchains do not just record an entry’s specific time, but also require and validate its associated proof of location, allowing accurate spatiotemporal mapping of physical world events. Blockchain and distributed ledger technology face similar challenges as any other technology threatening to disintermediate legacy processes and commercial interests, namely the challenges of blockchain interoperability, security and privacy, as well as the need to find suitable and sustainable business models of implementation. Nevertheless, we expect blockchain technologies to get increasingly powerful and robust, as they become coupled with artificial intelligence (AI) in various real-word healthcare solutions involving AI-mediated data exchange on blockchains.     

Diagnostic efficiency of selected biochemical variables to predict the clinical outcome of exertional rhabdomyolysis in Egyptian draft horses

As little is known about redox status in horses with rhabdomyolysis, the present study was carried out to evaluate the diagnostic efficiency of oxidative stress markers as well as selected biochemical variables to predict the clinical outcome of exertional rhabdomyolysis (ER) in Egyptian draft horses. ER was tentatively diagnosed based on the competent case history and physical examination findings and confirmed by elevation of plasma creatine kinase (CK) levels. According to the clinical outcome, the diseased horses were categorized into two groups: survivors (n?=?21) and non-survivors (n?=?10). The analysis of receiver operating characteristic curve (ROC) showed high sensitivity and specificity of CK, lactate dehydrogenase (LDH), aspartate aminotransferase (AST), alanine aminotransferase (ALT), lipid peroxides (LPO), malondialdehyde (MDA), nitric oxide (NO), total antioxidant capacity (TAC), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px) and Vitamin C. Their cutoff points were >127,778?U/L, >16,100?U/L, >3,433?U/L, >1,294?U/L, >6.8?nmol/L, >14.0?μmol/L, >9.30?μmol/L, <0.62?mmol/L, <2.21?×?10³?IU/g Hb, <60.5?IU/g Hb, and <68.5?mg/dL, respectively. Of the tested variables, CK, LDH, AST, LPO, MDA, and vitamin C appear to have higher sensitivity (100%) and specificity (91%) to predict non-survivorship in examined horses. Our findings suggest that estimation of oxidative stress markers as well as CK, LDH, ALT, and AST not only have diagnostic significance in Egyptian horses with rhabdomyolysis but also can help predict clinical outcomes of such a clinical condition.     

Relationship between HLA-DRB1*0101, DRB1*0301 alleles and interleukin-12 in haemophilic patients and hepatitis C virus positive hepatocellular carcinoma patients

The immune system can effectively eliminate hepatitis C virus (HCV) in 15 % of acute hepatitis cases. It is assumed that certain HLA-DR alleles present HCV epitopes more effectively to CD4 helper T cells than do others resulting in vigorous proliferative response to these epitopes and probably HCV recovery. So, we aimed at investigating the frequency of HLA-DRB1*0101 and DRB1*0301 alleles in child and adult haemophilics and in HCV positive hepatocellular carcinoma (HCC) patients in a trial to predict patients who require early therapeutic intervention. We also evaluated interleukin (IL)-12 levels in these patients since IL-12 induces interferon (IFN)-gamma production. This study was conducted on 50 antiHIV negative male patients subdivided into: 25 HCV negative haemophilics (group I), 10 HCV positive haemophilics (group II) and 15 HCV positive HCC (group III). Fifteen healthy persons of matched age and free of HCV and HIV infections were chosen as controls (group IV). All patients and controls were subjected to thorough history taking and clinical examination, routine and diagnostic investigations, viral markers, DRB1*0101 and DRB1*0301 amplification by polymerase chain reaction and plasma IL-12 quantitation by enzyme linked immunosorbent assay (ELISA). The frequencies of DRB1*0101 and DRB1*0301 were 20% and 30% respectively in HCV positive haemophilics and 13.3% and 40%, respectively in HCC. IL-12 levels were significantly lower in HCC cases than in HCV positive haemophilics. Among the haemophilics, IL-12 levels were non-significantly higher in children than in adults and were associated with the given number of blood product bags. DRB1*0101 and DRB1*0301 may have a role in HCV clearance and persistence in Egyptian patients with haemophilia and HCC. Low IL-12 levels encountered in HCV positive haemophilics suggest its relation to immunopathogenesis and outcome of HCV infection.