Is the measurement of sarcopenia associated with oncological disease in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

BACKGROUND

Peritoneal malignancies are challenging cancers to manage. While cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC), may offer a cure, it is a radical procedure associated with significant morbidity. Pre-emptive identification of deconditioned patients for optimization may mitigate surgical risk. However, the difficulty lies in identifying a cost-effective predictive tool. Recently, there has been interest in sarcopenia, which may occur due to malignancy. The purpose of this study was to assess the utility of sarcopenia at predicting post-operative outcomes.

METHODS

A quaternary-centre retrospective study of CRS and HIPEC patients (2017-2020), were conducted to determine the association between pre-operative sarcopenia on oncological (peritoneal carcinomatosis index (PCI)) and surgical outcomes (complications). Sarcopenia from lumbar CT-images were measured using Slice-o-matic™. Statistical differences were analysed using Mann-Whitney U and Chi-squared test.

RESULTS

Cohort analysis (n = 94) found 40% had sarcopenia, majority were female (53.2%), and average age of 55 years. The major pathologies was colorectal cancer (n = 39, 41.5%), appendix adenocarcinoma (n = 21, 22.3%), and pseudomyxoma peritonei (PMP) (n = 19, 20.2%). Sarcopenia was associated with decreased weight, 72.7 versus 82.2 kg (P = 0.014) and shorter survival, 1.4 versus 2.1 years (95% CI, 1.09-3.05, P = 0.032). Median PCI (excluding PMP) was 11 (6-18) and median PCI (only PMP) was 25 (11-32). Post-operatively, sarcopenia patients experienced more complications (72.5% vs. 64.8%, P = 0.001).

CONCLUSION

Pre-emptive identification of sarcopenia may be a useful prognostic indicator and predictor of post-operative outcomes in CRS and HIPEC. For oncological patients, sarcopenia may be an indicator of patients requiring targeted pre-operative rehabilitation, or advanced disease requiring further treatment.

Compartment syndrome as a novel complication of extended spectrum beta lactamase Escherichia coli necrotising soft tissue infection – A case report

Introduction and importance

Necrotising soft tissue infections (NSTI) encompass a group of destructive soft tissue disease processes which can involve skin, subcutaneous tissue, fascia and or muscle, associated with rapid spread along tissue planes and mortality. Clinical presentations include progressive pain, suppuration/necrosis and systemic toxicity with haemodynamic instability. While diagnosis is based on clinical findings it can be augmented with imaging. Treatment is typically in the form of resuscitation, immediate administration of broad spectrum intravenous antibiotics and urgent source control through radical surgical debridement.

Case presentation

An 82-year-old man presented with left forearm/hand pain and fevers in the context of immunocompromise. Examination found tense swelling of the left volar and dorsal forearm and hand, absent distal pulses with pain and paraesthesia over both surfaces. He underwent surgical debridement with fasciotomy and remained in intensive care with blood cultures revealing ESBL E. coli.

Clinical discussion

Compartment syndrome is a rare complication of NSTI and its clinical presentation can obscure early diagnosis. ESBL E. coli is an uncommon pathogen to cause monomicrobial infection and must be accounted for when considering broad spectrum empirical antibiotic cover.

Conclusion

Review of this case and the literature show a rare presentation of NSTI and highlights the importance of early diagnosis based on even a small index of suspicion. It also shows the key significance rationalisation of antibiotics as soon as practicable, given that even broad spectrum empirical cover can be inappropriate in the context of novel microorganisms, particularly in high risk patients.

•

First recorded case of monomicrobial ESBL E. coli compartment syndrome

•

ESBL E. coli NSTI is rare and not covered by many empirical antimicrobial guidelines.

•

Compartment syndrome secondary to NSTI is uncommon and associated with streptococci.

•

Early recognition and prompt management are essential to prognosis.

18 F-FDG PET and PET/CT as a diagnostic method for Ewing sarcoma: A systematic review and meta-analysis

PURPOSE

The aim of this study was to evaluate the diagnostic accuracy of ¹⁸ -fluorodeoxyglucose-positron emission tomography (¹⁸ F-FDG PET) and PET/computed tomography (PET/CT) in imaging primary and metastatic lesions in Ewing sarcoma (ES).

METHODS

PubMed, Cochrane, Scopus, and Web of Science were searched for relevant studies. Data concerning ¹⁸ F-FDG PET/CT diagnostic accuracy were extracted and then analyzed using Open Meta-analyst software. Reported diagnostic accuracy outcomes included sensitivity, specificity, negative likelihood ratio (NLR), positive likelihood ratio (PLR), and diagnostic odds ratio.

RESULTS

Thirty-one studies with a total of 735 patients were included in this meta-analysis. The sensitivity and specificity of ¹⁸ F-FDG PET/CT were: 92.6% and 74.1% for total ES lesions, 96.7% and 68.3% for ES primary lesions, 76.1% and 92.4% for lung metastasis, 83.9% and 93.2% for bone metastasis, and 89.9% and 92.6% for ES recurrence, respectively.

CONCLUSION

¹⁸ F-FDG PET/CT is sensitive and accurate in diagnosing, staging, and detecting the recurrence of ES compared with non-PET imaging. It has high accuracy for diagnosing recurrence of ES in bone metastases; however, CT remains a superior diagnostic method for detecting lung metastasis.

Implementation of diabetes screening in community pharmacy - factors influencing successful implementation

INTRODUCTION

Community pharmacists are increasingly providing a range of professional health services. Whilst research provides evidence of their benefits, knowledge translation into practice has been challenging both in Australia and internationally. An opportunity to develop a granular understanding of factors driving successful implementation was presented by the Pharmacy Diabetes Screening Trial (PDST), a clustered Randomised Controlled Trial (RCT) implemented in a random sample of 339 Australian community pharmacies. Its aim was to compare the clinical and cost effectiveness of three pharmacy-based diabetes screening interventions.

OBJECTIVE

To investigate the experiences of Australian community pharmacists in the implementation of the PDST and factors influencing implementation success.

METHODS

Semi-structured telephone interviews were conducted with a stratified sample of pharmacist trial participants based on screening performance (number screened relative to target), location, and trial arm. All interviews were audio-recorded and transcribed ad verbatim. Interviews were continued until saturation. Initial thematic analysis was followed by in-depth analysis to test the extent to which the data fitted with three previously described overarching themes driving successful national implementation of innovation in community pharmacy.

RESULTS

From August 2017 to October 2017, 21 interviews were conducted; 12 with high-performing and 9 with low-performing pharmacists. The key enablers and barriers were qualities of a pharmacy champion and active staff engagement, ease of implementation related to the number of working pharmacists and other staff, the external context including engagement with consumers and doctors, and consumer demand. It was also identified that attitudes/emphasis towards implementation planning and conscious prioritisation of service delivery by pharmacists may have been key differences between high- and low-performing pharmacies.

CONCLUSION

Insights into the interaction between individual, organisational, and external factors influencing successful implementation of community pharmacy innovations highlighted in this study should inform the design of future innovations to ensure their success and sustainability.