AngioVac system for infective endocarditis: A new treatment for an old disease

Three different patients presented to our institution with right-sided infective endocarditis (IE). All three were found to have vegetation on the tricuspid valve. These patients were started on appropriate antimicrobial therapy according to their blood cultures sensitivities. Despite this management, the patients' clinical status did not improve solely on antimicrobials. Surgery was, therefore, indicated to remove the vegetations. Traditionally, the appropriate management would have been invasive surgery. However, these patients were subjected to a novel treatment in our institution for right-sided IE: percutaneous mechanical vegetation debulking with an AngioVac system. After this procedure, all three patients' clinical status improved drastically. This new less invasive approach seems to offer the same results as the traditional invasive surgery, with faster recovery time. More comparative studies are needed to confirm this idea.

A Rare Case of Pulmonic and Aortic Valve Infective Endocarditis: A Case Report

Infective endocarditis (IE) is a microbial infection affecting cardiac valves. IE most often affects the aortic valve and is commonly caused by community-acquired, penicillin-sensitive streptococcus that enters through the oral cavity. In this report, we present a case of a 66-year-old man with a medical history of congenital pulmonic stenosis status after pulmonic valve (PV) repair. The patient underwent a transesophageal echocardiogram showing a 1 cm × 0.7 cm mobile vegetation attached to the ventricular aspect of the right coronary aortic cusp and a 1.1 cm × 0.5 cm mobile vegetation attached to the arterial aspect of the PV cusp. In conclusion, concomitant right- and left-sided IE is an exceedingly rare condition. Due to its rarity and complexity of presentation, pulmonic valve endocarditis (PVE) requires a multidisciplinary approach to its perioperative management to prevent systemic complications.

Atypical Neuroleptic Malignant Syndrome in a COVID-19 Intensive Care Unit

Neuroleptic malignant syndrome (NMS) has been defined as a life-threatening neurologic emergency related to the use of antipsychotic medications. It is most often seen with high-potency (first-generation) antipsychotic medications and may occur after a single dose. There have been conflicting reports in the literature of an atypical NMS (ANMS) presentation, associated with lower-potency agents (second generation) antipsychotic medications. NMS is usually diagnosed with a tetrad of clinical symptoms although none of the tetrads is needed for diagnosis. We report a case of a patient admitted for severe acute syndrome coronavirus 2 (SARS-CoV2) pneumonia who developed probable ANMS. SARS-CoV2 also referred to as coronavirus disease 2019 (COVID-19) added another dimension of complication to patient care as we have, at this time, an incomplete understanding of the pathogenesis. We feel critical care clinicians should maintain broad differentials to clinical findings, during the use of multiple medications and not simply attribute the various presentations to COVID-19.

Tracking and Assessing Oil Spill Toxicity to Aquatic Organisms: A Novel Approach

An in situ exposure and effects bioassay system was developed for assessing the toxicity of oil spills to aquatic organisms. The assessment tool combines components of 2 previously developed systems, the sediment ecotoxicity assessment ring (SEA Ring) and the drifting particle simulator. The integrated drifting exposure and effects assessment ring (DEEAR) is comprised of a Global Positioning System (GPS) float, a drifter drogue, the SEA Ring, and the Cyclops-7 fluorescent sensor. Polyethylene passive sampling devices (PED) were mounted for an additional means to characterize water quality conditions and exposures. The DEEAR is optimized for evaluating oil exposure and toxicity in the shallow surface mixing layer of marine waters. A short-term preliminary test was conducted in San Diego, California, USA, to verify the operation of the GPS tracking, the iridium communications, and the integrated SEA Ring exposure system. Further, a proof-of-concept demonstration was conducted offshore in the Santa Barbara Channel, where natural oil seeps produce surface slicks and sheens. Two DEEAR units were deployed for 24 h-one within the oil slick and one in an area outside observable slicks. An aerial drone provided tracking of the surface oil and optimal sites for deployment. The DEEAR proof-of-concept demonstrated integrated real-time tracking and characterization of oil exposures by grab samples, PED, and fluorescent sensors. Oil exposures were directly linked to toxic responses in fish and mysids. This novel integrated system shows promise for use in a variety of aquatic sites to more accurately determine in situ oil exposure and toxicity. Environ Toxicol Chem 2021;40:1452-1462. © 2021 SETAC.

Modern Management of High-risk Soft Tissue Sarcoma With Neoadjuvant Chemoradiation: A Single-center Experience

OBJECTIVE

Neoadjuvant chemoradiation (NA-CRT), followed by resection of high-risk soft tissue sarcoma (STS), may offer good disease control and toxicity outcomes. We report on a single institution's modern NA-CRT experience.

MATERIALS AND METHODS

Delay to surgical resection, resection margin status, extent of necrosis, tumor cell viability, presence of hyalinization, positron emission tomography (PET)/computed tomography data, and treatment toxicities were collected. Using the Kaplan-Meier survival analysis, 5-year overall survival, disease-free survival, distant metastasis-free survival, and local control (LC) were estimated. Clinicopathologic features and PET/computed tomography avidity changes were assessed for their potential predictive impact using the log-rank test.

RESULTS

From 2011 to 2018, 37 consecutive cases of localized high-risk STS were identified. Twenty-nine patients underwent ifosfamide-based NA-CRT to a median dose of 50 Gy before en bloc resection. At a median follow-up of 40.3 months, estimated 5-year overall survival was 86.1%, disease-free survival 70.2%, distant metastasis-free survival 75.2%, and LC 86.7%. Following NA-CRT, a median reduction of 54.7% was observed in tumor PET avidity; once resected, median tumor necrosis of 60.0% with no viable tumor cells was detected in 13.8% of the cases. Posttreatment resection margins were negative in all patients, with 27.6% having a margin of ≤1 mm. Delays of over 6 weeks following the end of radiation treatment to surgical resection occurred in 20.7% cases and was suggestive of inferior LC (92.8% vs. 68.6%, P=0.025).

CONCLUSIONS

This single-institution series of NA-CRT demonstrates favorable disease control. Delay in surgical resection was associated with inferior LC, a finding that deserves further evaluation in a larger cohort.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Glycopyrrolate and Post-Operative Urinary Retention: A Narrative Review

The use of non-depolarizing neuromuscular blockade (NDNMB) necessitates the use of reversal agents. Glycopyrrolate, an anticholinergic agent, is commonly used in combination with neostigmine, an anticholinesterase, for the reversal of neuromuscular blockade medications. Glycopyrrolate is known to effect on the genitourinary system adversely with an inhibitory effect on bladder contraction, bladder hypotonia, and increase in the frequency of urinary retention. Many studies analyzing the association between glycopyrrolate and urinary retention are outdated and published over a decade ago. The decade old studies were retrospective and did not consider post-operative urinary retention (POUR) as a primary outcome. The purpose of this manuscript is to review the association between glycopyrrolate administration and post-operative urinary retention in the perioperative setting.

Public Response to Suicide News Reports as Reflected in Computerized Text Analysis of Online Reader Comments

Previous research has documented the rise in rates of suicidal behaviors following media reports of celebrity suicide. Whereas most research has focused on documenting and analyzing suicide rates, little is known about more subtle psychological effects of celebrity suicide on the public, such as despair and feelings of abandonment. The Internet has revolutionized the responses to news reports, enabling immediate and anonymous responses potentially reflecting these psychological processes. Thus, the current study explored the unique psychological impact of a celebrity suicide on the public by analyzing the big data of readers' comments to suicide news reports, using computational linguistics methods. Readers' comments (N = 14,506) to suicide news reports were retrieved from 4 leading online news sites. The comments were posted in response to 1 of 1 types of reports: a celebrity suicide (Robin Williams), a non-celebrity suicide, and general reports of suicide as a social phenomenon. LIWC software for computerized linguistic analysis was used to calculate the frequency of the various types of words used. Comparison of the responses to the 3 types of suicide reports revealed higher frequency of first-person pronouns and for emotionally charged words on comments to a celebrity suicide, compared with comments to the other types of suicide reports. The findings suggest that celebrity suicide news reports evoke the expression of positive emotions, possibly related to the venerated celebrity, alongside negative, internalized emotions, and feelings of social isolation. Theoretical, practical, and methodological implications are discussed.

Evaluating the efficacy of DGT to quantify copper in stormwater at end-of-pipe

In many cases, stormwater compliance monitoring is labor intensive, expensive, and largely unsuccessful in providing the data needed to support stormwater management goals. To help address these issues, diffusive gradients in thin film (DGTs), time-integrative passive samplers for metals, were evaluated to monitor copper in stormwater runoff. DGTs were co-located with traditional autosamplers within the stormwater conveyance systems at Naval Base San Diego (NBSD) to provide a direct comparison with composite sampling. DGTs were exposed in the laboratory to flow-averaged composite samples from NBSD stormwater conveyance systems. These experiments showed increasing uptake over time (range = 1.5-24 h) for copper, with positive, linear correlations (r² > 0.980) between exposure duration and copper mass accumulated. However, it appears that the corresponding calculations of the DGT-labile fraction (C_DGT) relative to the dissolved fraction fluctuated across the different exposure durations. In general, trends observed for C_DGT measurements from the field were consistent with trends in the lab DGT exposures and traditional dissolved metal measurements from composite samples. Finally, time-weighted average copper concentrations from DGTs deployed for the first and second phases of storm events were within 30% of measurements from DGTs that were deployed for the entire storm event in the same stormwater vault. Cumulatively, these results show promise for continuous monitoring with DGTs as an approach that produces data more representative of exposure to the receiving environment during episodic events than data from traditional grab or composite chemistry sampling, and can represent significant cost savings.

Improving labour progression among women with epidural anesthesia following use of a birthing ball: a review of recent literature

Epidural anaesthesia is an effective form of pain relief during vaginal deliveries. However, neuraxial anaesthesia may slow the progression of labour. The assumption that epidurals lead to increased caesarean sections is also a topic of current debate. A holistic approach with the use of a birthing ball has been advocated as a potential modality to decrease labouring times and, therefore, reduce progression to caesarean section. Birthing balls aim to increase pelvic outlet opening, which facilitates labouring. Our aim is to review recent literature pertaining to birthing balls and their role in improving quality and outcomes of vaginal deliveries in patients with epidurals.IMPACT STATEMENTWhat is already known on the subject? Epidural anaesthesia may slow the progression of labour. It has been hypothesised that slowing progression of labour is associated with increased rates of vacuum and forceps delivery. Most common clinical indication for caesarean section is failure to progress during labour. Birthing Balls have been shown to quicken the progression of labour, theoretically reducing caesarean sections with those with epidurals.What do the results of the study add? Several studies have demonstrated a reduced duration of first and second stage of labour among women with epidural anaesthesia, but the existing literature is limited, and interpretation of results may be restricted by generalizability and inherent study biases. The objective of this article is to review existing literature and highlight the potential clinical utility of birthing balls in current obstetric practice.What are the implications of these findings for clinical practice and further research? Use of birthing balls has been advocated to decrease labouring time and therefore reduce progression to caesarean section. Larger studies or meta-analysis would be required to confirm potential benefits of birthing ball use.

Right Atrial, Right Ventricular, Superior Vena Cava Dissection Caused by Swan-Ganz Catheter Placement

This case involves Swan-Ganz catheter placement in a patient who developed cardiogenic shock, possibly due to the catheter dissecting the intimal lining of the superior vena cava and endocardium.

Quadricuspid aortic valve associated with aortic insufficiency contributors

A 51-year-old male presented with a wound in his right hand that was suspicious for possible septic emboli of cardiac origin. With transesophageal echocardiography, the patient was found to have a rare quadricuspid aortic valve. This quadricuspid valve can present with variable symptoms and physical exam findings. Due to embryological defects, this pathology is associated with several other anatomical defects that are important to recognize prior to surgical intervention. Transesophaegeal echocardiography remains the gold standard in detection of quadricuspid aortic valve and identification of other possible cardiac lesions.

Response to anti-PD1 therapy with nivolumab in metastatic sarcomas

BACKGROUND

Manipulation of immune checkpoints such as CTLA4 or PD-1 with targeted antibodies has recently emerged as an effective anticancer strategy in multiple malignancies. Sarcomas are a heterogeneous group of diseases in need of more effective treatments. Different subtypes of soft tissue and bone sarcomas have been shown to express PD-1 ligand.

METHODS

We retrospectively analyzed a cohort of patients (pts) with relapsed metastatic/unresectable sarcomas, who were treated with nivolumab provided under a patient assistance program from the manufacturer. Pts underwent CT or PET/CT imaging at baseline and after at least four doses of nivolumab; RECIST 1.1 criteria were used for response assessment.

RESULTS

Twenty-eight pts with soft tissue (STS, N = 24) or bone sarcoma (N = 4), received IV nivolumab 3 mg/kg every 2 weeks from July 2015. Median age was 57 (24-78), male:female ratio was 14:14; the median number of nivolumab cycles was eight. Eighteen pts concomitantly received pazopanib at 400-800 mg daily. The most common side effect was grade 1-2 LFT elevations; grade 3-4 toxicity occurred in five patients (colitis, LFT elevations, pneumonitis). Twenty-four pts received at least four cycles. We observed three partial responses: one dedifferentiated chondrosarcoma, one epithelioid sarcoma and one maxillary osteosarcoma (last two patients on pazopanib); nine patients had stable disease including three leiomyosarcomas; 12 patients had progression of disease including 4 leiomyosarcoma. Clinical benefit (response + stability) was observed in 50% of the evaluable patients.

CONCLUSIONS

These data provide a rationale for further exploring the efficacy of nivolumab and other checkpoint inhibitors in soft tissue and bone sarcoma.

Palliative CT-Guided Cordotomy for Medically Intractable Pain in Patients with Cancer

Palliative cervical cordotomy can be performed via percutaneous radiofrequency ablation of the lateral C1-2 spinothalamic tract. This rare procedure can be safe, effective, and advantageous in mitigating medically intractable unilateral extremity pain for selected patients with end-stage cancer. This report reviews the indications, techniques, risks, and potential benefits of cordotomy. We describe our recent experience treating 3 patients with CT-guided C1-2 cordotomy and provide the first characterization of spinal cord diffusion MR imaging changes associated with successful cordotomy.

Nickel and Copper Toxicity to Embryos of the Long-Spined Sea Urchin, Diadema savignyi

The sensitivity of long-spined sea urchins (Diadema savignyi) collected from Guam (Northern Marianas Islands), USA, to nickel and copper in seawater was explored using 48-h embryo-larval development toxicity tests. The median effective concentrations (EC50) averaged 94 µg L(-1) for nickel, and 19 µg L(-1) from a single exposure to copper, and suggest relatively high sensitivity of this species to nickel compared with other sea urchin genera, but similar sensitivity to copper. Ambient nickel and copper concentrations concurrently sampled from 16 near-shore locations around Guam were one to two orders of magnitude lower than those that would be expected to result in adverse effects to D. savignyi embryos. Although nationally recommended chronic ambient water quality criteria, currently 8.2 and 3.1 µg L(-1) for nickel and copper, respectively, were not exceeded, recently derived qualifying toxicity data should be considered for updating these criteria to ensure protectiveness of sensitive tropical species.

Progress in the treatment of Ewing sarcoma: are the rumors of the demise of cytotoxic chemotherapy premature?

In this issue, Bollling et. al. review the development of treatment of Ewing sarcoma as it evolved over the past 30 years of clinical trials in Europe, largely under the leadership of Heribert Jurgens to whom this review is dedicated. The 44 authors were teachers, colleagues, students and co-investigators of Jurgens. The authors attribute the ability to make progress in the treatment of Ewing sarcoma through the establishment of larger and still larger cooperative studies in order to demonstrate statistically significant advances in the treatment of this rare disease.

The effects of dexamethasone on sleep in young children with acute lymphoblastic leukemia

PURPOSE

Corticosteroids, which are a mainstay in the treatment of acute lymphoblastic leukemia (ALL), have a well-documented adverse effect on sleep. We sought to characterize the effects of dexamethasone on sleep over an entire 28-day treatment cycle using actigraphy, an objective measure of sleep.

METHODS

The sleep of 25 children aged 2-9 years (mean 4.5 years) with ALL treated with dexamethasone were evaluated during maintenance chemotherapy using a within-subject experimental design, actigraphy, and standardized questionnaires to assess sleep, sleep problems, and fatigue.

RESULTS

During the five days of dexamethasone treatment, sleep time increased during the night (535 vs. 498 min; p = 0.004) and daytime napping increased the following day (14 vs. 0 min; p = 0.002), and the number of wake episodes during the night was lower (14 vs. 20; p =  ≤ 0.001). However, when assessed individually, sleep-onset time, efficiency, and wake after sleep onset during the night were unchanged during dexamethasone treatment; when the cumulative effect of all of these factors was assessed, there was a statistically and clinically significant increase in nighttime sleep duration during dexamethasone treatment.

CONCLUSIONS

During the five days of treatment with dexamethasone, an increase in nighttime sleep as well as daytime napping was observed in young children with ALL. The increases in sleep duration return to baseline one day after the discontinuation of dexamethasone.

Reducing blood utilization by implementation of a type-and-screen transfusion policy a single-institution experience

OBJECTIVES

The Blood Utilization Committee implemented a standardized protocol for the preoperative blood order for cardiac patients. The aim of our study was to assess the improvement in blood utilization using the crossmatch to transfusion ratio (C:T).

METHODS

Four months of retrospective data were collected, which included all RBC crossmatch requests and all RBC units transfused. Similar data were gathered for the period of the intervention. The difference in C:T was calculated.

RESULTS

The retrospective group had 166 patients for whom blood products were ordered. There were 560 crossmatch requests and 237 transfused RBC units with a C:T of 2.36. The prospective group had 127 patients with 297 crossmatch requests, 190 transfused units, and a C:T of 1.56. There was a statistically significant difference in the C:T. The cost difference was $12,244.00.

CONCLUSIONS

Implementing exact guidelines, with the introduction of a type-and-screen concept, allowed more efficient blood usage.

An in vivo method for measuring the adsorption of plasma proteins to titanium in humans

A novel method of collecting in vivo plasma proteins of humans from osteotomies prepared during insertion of an oral implant is described. A rod containing a collecting portion with a predetermined surface is introduced into the osteomy, removed, and transferred for enzyme-linked immunosorbent assay analysis. Two experiments were used to examine the feasibility of the method. In the first, titanium (Ti) rods with different roughness were exposed for 10 min to the blood. Blasted and acid-etched surfaces adsorbed four times more and acid-etched surfaces adosorbed two times more plasma proteins as compared to machined surfaces. In the second experiment, blasted and acid-etched rods were wetted for 10 s prior to the insertion. The adsorption for fibronectin, albumin, fibrinogen, and IgG was enhanced significantly compared with nonwetted rods. These results are discussed in the light of previous methods used in studies on adsorption. Thus, use of the collecting instrument enables aspects of human plasma-implant interface to be studied in a more realistic manner.

Recurrent retroperitoneal liposarcoma in a patient with neurofibromatosis type I

INTRODUCTION

Liposarcoma complicating neurofibromatosis is very rare. Only a few cases have been described until now. We present a case of recurrent dedifferentiated retroperitoneal liposarcoma in a patient with neurofibromatosis type I (NF-1).

CASE PRESENTATION

A 47-year-old Caucasian woman with NF-1 presented to the hospital initially complaining of left lumbar pain irradiating to the anterior thigh and knee. Physical examination showed atrophy of the lower extremities bilaterally and decreased motor strength on the left lower extremity. Radiological studies demonstrated an enhancing lesion in the left paraspinal region, suggesting malignancy. The patient underwent local resection of tumour with safety margins. Pathological examination was consistent with dedifferentiated liposarcoma (DDLS) with positivity for MDM2 and CDK4 markers. No evidence of metastasis was noted on the radiological studies. The final diagnosis was DDLS, high-grade (G3), pT2bN0M0, stage III. After 6 weeks post-tumour resection, the patient experienced recurrence of malignancy. Chemotherapy with cisplatin and doxorubicin was initiated in the patient.

CONCLUSIONS

Liposarcoma in the context of neurofibromatosis is very rare. To the best of our knowledge, only six cases have been reported until now in the literature. We are presenting this case to underline the possibility of recurrence in the case of retroperitoneal DDLSs despite local tumour resection. Also, although the role of chemotherapy is controversial we decided to start treatment with cisplatin and doxorubicin given the success of chemotherapy in similar case presentations.

Dcdc2 knockout mice display exacerbated developmental disruptions following knockdown of doublecortin

The dyslexia-associated gene DCDC2 is a member of the DCX family of genes known to play roles in neurogenesis, neuronal migration, and differentiation. Here we report the first phenotypic analysis of a Dcdc2 knockout mouse. Comparisons between Dcdc2 knockout mice and wild-type (wt) littermates revealed no significant differences in neuronal migration, neocortical lamination, neuronal cilliogenesis or dendritic differentiation. Considering previous studies showing genetic interactions and potential functional redundancy among members of the DCX family, we tested whether decreasing Dcx expression by RNAi would differentially impair neurodevelopment in Dcdc2 knockouts and wild-type mice. Consistent with this hypothesis, we found that deficits in neuronal migration, and dendritic growth caused by RNAi of Dcx were more severe in Dcdc2 knockouts than in wild-type mice with the same transfection. These results indicate that Dcdc2 is not required for neurogenesis, neuronal migration or differentiation in mice, but may have partial functional redundancy with Dcx.

Did CDM particles of mass 2.47 x 10(-3) eV interact with precursor biopolymers and nucleic acids to initiate and boost lifeforms on Earth?

Recent observations and theoretical studies have shown that non-baryonic Cold Dark Matter (CDM), which constitutes about 84% of all matter in the Universe, may feature a complex-scalar-field that carries particles of mass ≅ 2.47 x 10(-3)eV with the associated Compton range m(-1) ≅8.02 x 10(-3) cm, a distance on the scale of extended bionucleic acids and living cells. Such a complex-scalar-field can enter a weak-isospin Lorentz-invariant interaction that generates the flow of right-handed electrons and induces a chirality-imbued quantum chemistry on the m (-1) scale. A phenomenological Volterra-type equation is proposed for the CDM-impacted time development of N, the number of base pairs in the most advanced organism at Earth-age t. The solution to this equation suggests that the boosts in N at t ≅ 1.1 Gyr (advent of the first living prokaryotic cells), at t ≅ 2.9 Gyr (advent of eukaryotic single-celled organisms) and finally at t ≅ 4.0 Gyr (the Cambrian explosion) may be associated with three multi-Myr-duration cosmic showers of the complex-scalar-field CDM particles. If so, the signature of the particles may be detectible in Cambrian rocks.

The association between the embolic load and atrial size in acute pulmonary embolism

BACKGROUND

Early identification by computed tomography pulmonary angiography (CTPA) of patients with acute pulmonary embolism (PE) who have signs associated with a high embolic burden would be highly desirable.

OBJECTIVES

To investigate whether an increased obstruction of the pulmonary vasculature is associated with reduced left atrial (LA) and increased right atrial (RA) areas.

METHODS

We retrospectively analyzed a consecutive series of CTPA studies of 137 patients with acute PE and 38 controls without PE between October 2004 and March 2006. Left and right atrial areas and longitudinal and short axis diameters were measured and correlated with the pulmonary arterial obstruction index (PAOI) divided into tertiles (obstruction of < 12.5%, 12.5%-42.5% and ≥ 42.5%).

RESULTS

There was a significant negative age- and gender-adjusted correlation between the PAOI and LA measurements, particularly the LA area (r = -0.259) and the LA short axis diameter (r = -0.331). All RA measurements had positive correlations (RA area, r = 0.279; RA short axis diameter, r = 0.313). The LA/RA area ratio correlated negatively with the PAOI (r = -0.447). All above-mentioned correlations had P < 0.002. All the LA measurements were the largest in the controls and gradually decreased with higher PAOIs. A receiver operating characteristic curve analysis demonstrated that the RV/LV diameter, LA/RA area and LA/RA short axis diameter ratios had comparable discriminative ability for higher PAOI tertiles.

CONCLUSIONS

The higher the clot load in the pulmonary arteries, the smaller the LA area and the larger the RA area. Atrial area measurements by CTPA may serve as a real-time parameter in assessing the severity of PE upon diagnosis.

Duration of exposure and the dose-response model of PTSD

A dose-response model underlies posttraumatic stress disorder (PTSD) and posits a relationship between event magnitude and clinical outcome. The present study examines whether one index of event magnitude--duration of exposure--contributes to risk of PTSD among female victims of sexual assault. Findings support a small but significant contribution of event duration to clinical status in the immediate aftermath of trauma but not at 3-month follow-up. The opposite pattern is obtained for subjective appraisals of threat. These findings add to a growing literature that suggests that a simple application of the dose-response model to objective event characteristics may be insufficient to explain the risk of PTSD.

Long-term follow-up (>20 years) for one of the original randomized prospective trials evaluating adjuvant chemotherapy in patients with high-grade operable osteosarcoma

10514

Background: Neoadjuvant and adjuvant chemotherapy is now standard practice for patients who present with localized osteosarcoma. We present the long-term follow-up (>20years) for one of the original prospective randomized trials that compared adjuvant chemotherapy to no treatment in patients with high-grade operable osteosarcoma. Methods: The original study was performed at UCLA from 1981 to 1984. During this time, 59 patients with high-grade, operable, non-metastatic osteosarcoma were randomized to receive adjuvant chemotherapy (MSKCC T-10B protocol)(N=32; 24 men, 8 women, median age 15 yrs) vs. expectant management (N=27; 20 men, 7 women, median age 18 yrs). All patients received one neoadjuvant course of intra-arterial doxorubicin hydrochloride (90mg) and radiation (1750cGy). At a median follow-up of 2 years, there was a statistically significant improvement in both disease-free (55% vs. 20%, p<.01) and overall survival (80% vs. 48%, p<.01) for those who received immediate adjuvant chemotherapy. Upon recurrence, patients in the T-10B arm received salvage chemotherapy with doxorubicin hydrochloride and cisplatin while those in the expectant arm received the T-10B protocol. 27 years after the initiation of the trial, long-term follow-up was obtained on all patients. Results: Median follow-up time for survivors was 24 years. 18 patients in the adjuvant chemotherapy arm died of disease (DOD) while 14 have no evidence of disease (NED). 22 patients in the control arm DOD, 1 died of other causes and 4 have NED. The 5, 10, and 20 year disease specific survival (DSS) for the treatment arm (47%, 43%, 43% respectfully) was significantly better than that of the control arm (30%, 26%, 17% respectfully) (p=0.0254). Conclusions: Early administration of chemotherapy in patients with high-grade operable osteosarcoma provides a significant survival benefit that is maintained with long-term (>20 years) follow-up. These results support the idea that early systemic treatment offers the best opportunity to cure patients with this high-risk malignancy.

No significant financial relationships to disclose.

Deconvolving an Estimate of Breath Measured Blood Alcohol Concentration from Biosensor Collected Transdermal Ethanol Data

Biosensor measurement of transdermal alcohol oncentration in perspiration exhibits significant variance from subject to subject and device to device. Short duration data collected in a controlled clinical setting is used to calibrate a forward model for ethanol transport from the blood to the sensor. The calibrated model is then used to invert transdermal signals collected in the field (short or long duration) to obtain an estimate for breath measured blood alcohol concentration. A distributed parameter model for the forward transport of ethanol from the blood through the skin and its processing by the sensor is developed. Model calibration is formulated as a nonlinear least squares fit to data. The fit model is then used as part of a spline based scheme in the form of a regularized, non-negatively constrained linear deconvolution. Fully discrete, steepest descent based schemes for solving the resulting optimization problems are developed. The adjoint method is used to accurately and efficiently compute requisite gradients. Efficacy is demonstrated on subject field data.

Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea

OBJECTIVES

Positive airway pressure therapy (PAP) is frequently used to treat children who have obstructive sleep apnea syndrome and do not respond to adenotonsillectomy. However, no studies have evaluated objectively adherence to PAP in children, and few studies have evaluated objectively the effectiveness of PAP. The objective of this study was to determine adherence and effectiveness of PAP (both continuous [CPAP] and bilevel [BPAP] pressure) in children with obstructive apnea.

METHODS

A prospective, multicenter study was performed of children who were randomly assigned in a double-blind manner to 6 months of CPAP versus BPAP. Adherence was measured objectively using the equipment's computerized output. Effectiveness was evaluated using polysomnography.

RESULTS

Twenty-nine children were studied. Approximately one third of children dropped out before 6 months. Of the 21 children for whom 6-month adherence data could be downloaded, the mean nightly use was 5.3 +/- 2.5 (SD) hours. Parental assessment of PAP use considerably overestimated actual use. PAP was highly effective, with a reduction in the apnea hypopnea index from 27 +/- 32 to 3 +/- 5/hour, and an improvement in arterial oxygen saturation nadir from 77 +/- 17% to 89 +/- 6%. Results were similar for children who received CPAP versus BPAP. Children also had a subjective improvement in daytime sleepiness.

CONCLUSIONS

Both CPAP and BPAP are highly efficacious in pediatric obstructive apnea. However, treatment with PAP is associated with a high dropout rate, and even in the adherent children, nightly use is suboptimal considering the long sleep hours in children.

Hemolysis during percutaneous mechanical thrombectomy can mimic a hemolytic transfusion reaction

BACKGROUND

Interventional radiologists have developed percutaneous mechanical thrombectomy (PMT) devices to remove intravascular thrombi. Hemolysis, secondary to thrombus destruction from these devices, has been described in radiology journals, but similar reports appear to be lacking in the transfusion medicine literature. Two cases of hemolysis after PMT are described that involved the transfusion service, one of which was reported as a hemolytic transfusion reaction.

CASE REPORTS

The first patient received 4 units of red cells (RBCs) during a thrombectomy and subsequent placement of a transjugular intrahepatic portosystemic shunt. The patient developed hemoglobinuria, and it was reported to the blood bank as a possible hemolytic transfusion reaction. After RBC mismatch and bacterial contamination were excluded, the hemolysis was attributed to thrombectomy-related mechanical hemolysis. In the second case, a hemolyzed sample was sent to the blood bank for a type and cross-match. Upon requesting that the sample be redrawn, it was learned that the sample was obtained after PMT.

CONCLUSION

Patients who have undergone PMT can have clinical and laboratory findings suggestive of hemolytic transfusion reactions. Although interventional radiologists are familiar with these side effects, the blood bank profession needs to be aware that these procedures cause nonimmune hemolysis and must consider this possibility when evaluating transfusion reactions in these patients.

Evaluation of the Patient Who Has Sleep Complaints: A Case-Based Method Using the Sleep Process Matrix

There are four sleep symptoms that patients can have: difficulty with sleep onset, problems occurring during sleep, difficulty awakening from sleep, and daytime sleepiness. These symptoms develop when there is a problem in one or more of the nine fundamental process domains that control sleep. These fundamentalsleep process domains are: circadian, homeostatic, ultradian, developmental, cardiorespiratory, neurological, psychiatric/behavioral,drugs/alcohol, and other medical problems. Successful treatment of the sleep problems depends on the correct identification of the underlying sleep processes that are causing the sleep symptom. The sleep process matrix is a way of organizing one's thinking to accomplish this task.