Current updates relating to treatment for interstitial cystitis/bladder pain syndrome: systematic review and network meta-analysis

BACKGROUND

Despite the publication of several meta-analyses regarding the efficacy of certain therapies in helping individuals with interstitial cystitis (IC) / bladder pain syndrome (BPS), these have not provided a comprehensive review of therapeutic strategies. The study aimed to determine the efficacy of various therapies for IC/BPS and identify potential moderating factors using randomized controlled trials (RCTs).

METHODS

We queried the PubMed, Cochrane, and Embase databases to identify prospective RCTs using inclusion criteria: 1) patients diagnosed with IC, 2) interventions included relevant treatments, 3) comparisons were a specified control or placebo, 4) outcomes were mean differences for individual symptoms and structured questionnaires. The pairwise meta-analysis and network meta-analysis (NMA) were performed to compare the treatments used in IC/BPS. Hedges' g standardized mean differences (SMDs) were used for improvement in all outcomes using random-effects models. Efficacy outcomes included individual symptoms such as pain, frequency, urgency, and nocturia, as well as structured questionnaires measuring IC/BPS symptoms.

RESULTS

A comprehensive literature search was conducted which identified 70 RCTs with 3,651 patients. The analysis revealed that certain treatments, such as instillation and intravesical injection, showed statistically significant improvements in pain and urgency compared to control or placebo groups in traditional pairwise meta-analysis. However, no specific treatment demonstrated significant improvement in all outcomes measured in the NMA. The results of moderator analyses to explore influential variables indicated that increasing age was associated with increased nocturia, while longer follow-up periods were associated with decreased frequency.

CONCLUSION

This systematic review and meta-analysis provide insights into the efficacy of various treatments for IC. Current research suggests that a combination of therapies may have a positive clinical outcome for patients with IC, despite the fact that treatment for this condition is not straightforward.

TRIAL REGISTRATION

PROSPERO CRD42022384024.

The Correlations between the Intensity of Histopathological Ubiquitin-Specific Protease 11 Staining and Progression of Prostate Cancer

BACKGROUND

Ubiquitin-specific protease 11 (USP11), one of the principal phosphatase and tensin homolog (PTEN) deubiquitinases, can reserve PTEN polyubiquitination to maintain PTEN protein integrity and inhibit PI3K/AKT pathway activation. The aim of the current study was to investigate the associations between immunohistochemical USP11 staining intensities and prognostic indicators in individuals with prostate cancer.

METHODS

Tissue microarrays (TMAs) were performed for human prostate cancer and normal tissue (control) samples. Data on patient's age, Gleason score, plasma prostate-specific antigen (PSA) titer, disease stage, and presence of seminal vesicles, lymph nodes, and surgical margin involvement were collected. A pathologist who was blinded to the clinical outcome data scored the TMA for USP11 staining intensity as either positive or negative.

RESULTS

Cancerous tissues exhibited lower USP11 staining intensity, whereas the neighboring benign peri-tumoral tissues showed higher USP11 staining intensity. The degree of USP11 staining intensity was lower in patients with a higher PSA titer, higher Gleason score, or more advanced disease stage. Patients who showed positive USP11 staining were more likely to have more optimal clinical and biochemical recurrence-free survival statistics.

CONCLUSIONS

USP11 staining intensity in patients with prostate cancer is negatively associated with several prognostic factors such as an elevated PSA titer and a high Gleason score. It also reflects both biochemical and clinical recurrence-free survival in such patients. Thus, USP11 staining is a valuable prognostic factor in patients with prostate cancer.

Long-term end-stage renal disease risks after living kidney donation: a systematic review and meta-analysis

BACKGROUND

Recent studies have shown that donor nephrectomy can induce renal function impairment. However, few meta-analysis studies about this have proceeded. Therefore, the objective of this systematic review and meta-analysis including all data of recent research studies was to determine whether living donor nephrectomy (LDN) could induce renal function impairment.

METHODS

By November 2020, comprehensive literature searches were performed on PubMed, Embase, and Cochrane databases. Inclusion criteria were: (1) observational studies with data about overall end-stage renal disease (ESRD) or chronic kidney disease (CKD) of living kidney donors, (2) control group consisted of people without donor nephrectomy, and (3) outcomes of studies included long-term end-stage renal disease risks after living kidney donation. Risk of Bias in Non-randomized Studies of interventions (ROBINS-I) assessment tool was used to evaluate our methodological quality.

RESULTS

The qualitative review included 11 studies and the meta-analysis included 5 studies. In the meta-analysis, the integrated overall ESRD risk was 5.57 (95% CI: 2.03-15.30). Regarding the overall risk of bias using ROBINS-I assessment tool, 0 studies was rated as "Low", 7 studies were rated as "moderate", 2 studies were rated as "Serious", and two studies were rated as "Critical".

CONCLUSIONS

Our study showed that LDN increased ESRD risk in LDN patients. However, in our meta-analysis, variables in included studies were not uniform and the number of included studies was small. To have a definite conclusion, meta-analyses of well-planned and detailed studies need to be conducted in the future.

Effects of Sexual Rehabilitation on Sexual Dysfunction in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis

PURPOSE

Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89%. Ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems. Therefore, sexual rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment, appropriate counseling, a multidisciplinary approach, and partner rehabilitation. In this study, systematic review and meta-analysis was performed to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD.

MATERIALS AND METHODS

Comprehensive literature searches were conducted using MEDLINE, Cochrane Library electronic database, and EMBASE through June 2022. Questionnaire scores at the end point as outcomes of the study were recorded as were standardized mean difference (SMD) with their 95% confidence intervals (CIs). Meta-regression analysis was conducted for each moderator. We performed a risk of bias evaluation for included studies using the RoB 2 tool.

RESULTS

The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226-0.633). There was a statistical difference between groups. SMD changes were 0.674 (95% CI, 0.308-1.039) at one month and 0.320 (95% CI, 0.074-0.565) at six months. The regression analysis with all variables (number of patients, study duration, and questionnaire types) revealed no significance.

CONCLUSIONS

This study indicates that sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, for clinical application, well-designed studies with many patients should be conducted in the future and the standardization of rehabilitation protocols is required.

A phase I trial of LXS196, a protein kinase C (PKC) inhibitor, for metastatic uveal melanoma

BACKGROUND

Up to 50% of patients with uveal melanoma develop metastases (MUM) with a poor prognosis and median overall survival of approximately 1 year.

METHODS

This phase I study evaluated the safety, tolerability, pharmacokinetics, pharmacodynamics and efficacy of the oral protein kinase C inhibitor LXS196 in 68 patients with MUM (NCT02601378). Patients received LXS196 doses ranging from 100-1000 mg once daily (QD; n = 38) and 200-400 mg twice daily (BID; n = 30).

RESULTS

First cycle dose-limiting toxicities (DLTs) were observed in 7/38 (18.4%) QD and 2/17 (11.8%) BID patients. Hypotension was the most common DLT, occurring at doses ≥500 mg/day, and manageable with LXS196 interruption and dose reduction. Median duration of exposure to LXS196 was 3.71 months (range: 1.81-15.28) for QD and 4.6 months (range: 0.33-58.32) for BID dosing. Clinical activity was observed in 6/66 (9.1%) evaluable patients achieving response (CR/PR), with a median duration of response of 10.15 months (range: 2.99-41.95); 45/66 had stable disease (SD) per RECIST v1.1. At 300 mg BID, the recommended dose for expansion, 2/18 (11.1%) evaluable patients achieved PR and 12/18 (66.7%) had SD.

CONCLUSION

These results suggest manageable toxicity and encouraging clinical activity of single-agent LXS196 in patients with MUM.

The correlation between the expression of ubiquitin-conjugating enzyme 2C and prostate cancer prognosis

PURPOSE

Ubiquitin-conjugating enzyme E2 C (UBE2C) is known to show a causal relationship with cancer development and advancement. The role of UBE2C is to control the mitotic spindle checkpoint. Excess UBE2C has been identified in patients with advanced prostate cancer. The objective of the present study was to examine positive connections between the expression of UBE2C and prognostic factors for prostate cancer.

METHODS

Prostate cancer patients' clinical data were analysed. Tissue microarrays (TMAs) were also performed for human prostate cancer tissues (n = 335) and adjacent non-neoplastic tissues (n = 22). TMA slides were incubated with antibodies against UBE2C. Cores were scored by a pathologist who was blind to cancer results.

RESULTS

Of 335 prostate cancer patients, 200 could be assessed for biochemical recurrence, clinical recurrence, and overall survival. Human prostate cancer tissues showed higher expression of UBE2C than adjacent non-neoplastic tissues. High expression level of UBE2C showed a strong positive relationship with a high prostate-specific antigen (PSA), Gleason's score, and pathological stage of prostate cancer. Patients with a higher UBE2C grade demonstrated greater lymphatic engagement of prostate cancer than those with a lower UBE2C grade.

CONCLUSION

The expression of UBE2C has positive correlations with several prognostic factors for prostate cancer. Thus, investigating the expression level of UBE2C staining is a promising tool for predicting prostate cancer prognosis.

Efficacy of pelvic floor muscle exercise or therapy with or without duloxetine: a systematic review and network Meta-analysis

OBJECTIVES

Postprostatectomy urinary incontinence (PPUI) is a serious complication despite surgical advances. Treatment options for PPUI include conservative care like Pelvic floor muscle exercise (PFME), which is a physiotherapy performed by the patients themselves; Pelvic floor muscle therapy (PFMT), a physiotherapy performed under the guidance of a therapist, and duloxetine treatment; and surgical interventions. In this study, network meta-analysis (NMA) was performed for direct comparison of these treatment options.

MATERIALS AND METHODS

The NMA pooled the odds ratios and 95% credible intervals using the number of patients achieving urinary continence and the total number of patients in an intention-to-treat population. The treatments were ranked based on the surface under the cumulative ranking curve (SUCRA) probabilities and the rankograms.

RESULTS

The pooled overall ORs of patients achieving urinary continence compared with no treatment was 1.73 (95% CrI: 0.657, 4.71) in PFME, 2.62 (95% CrI: 0.553, 13.5) in PFME plus Duloxetine, and 4.05 (95% CrI: 1.70, 10.2) in PFMT. The SUCRA values of ranking probabilities for each treatment showed high rates of continence in the order of PFMT, PFME plus Duloxetine, and PFME.

CONCLUSION

The results suggest that patients with PPUI should undergo PFMT and consider duloxetine as an additional treatment option.

Relationship Between Androgen Deprivation Therapy for Prostate Cancer and Risk of SARS-CoV-2 Infection: A Systematic Review and Meta-Analysis

BACKGROUND

Several cohort studies have explored the relationship between androgen deprivation therapy (ADT) and the severity of coronavirus disease 2019 (COVID-19). This study aimed to characterize the relationship between ADT and the severity of COVID-19 in patients with prostate cancer.

METHODS

A systematic search was conducted using PubMed, Embase, and Cochrane Library databases from the inception of each database until February 31, 2020. Patients with prostate cancer who were treated with ADT were assigned to treatment group while those patients who were not treated with ADT were assigned to the control group. Outcomes were severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) positivity, hospitalization, intensive care unit (ICU) admission, and death. The risk of bias was evaluated using ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) tool.

RESULTS

Three studies with qualitative synthesis were included. Finally, two studies with quantitative synthesis having a total of 44,213 patients were included for the present systematic review. There was no significant difference in SARS-CoV-2 positive rate (odds ratio [OR], 0.52; 95% confidence intervals [Cis], 0.13-2.09; P = 0.362), hospitalization (OR, 0.52; 95% CIs, 0.07-3.69; P = 0.514), ICU admission (OR, 0.93; 95% CIs, 0.39-2.23, P = 0.881), or death (OR, 0.88; 95% CIs, 0.06-12.06; P = 0.934) between ADT and non-ADT groups.

CONCLUSION

Qualitative and quantitative analyses of previous studies revealed no significant effect of ADT on COVID-19. However, more studies with higher quality that explore biochemical and immunological factors involved are needed to confirm this finding in the future.

Leveraging metabolic modeling to identify functional metabolic alterations associated with COVID-19 disease severity

OBJECTIVE

Since the COVID-19 pandemic began in early 2020, SARS-CoV2 has claimed more than six million lives world-wide, with over 510 million cases to date. To reduce healthcare burden, we must investigate how to prevent non-acute disease from progressing to severe infection requiring hospitalization.

METHODS

To achieve this goal, we investigated metabolic signatures of both non-acute (out-patient) and severe (requiring hospitalization) COVID-19 samples by profiling the associated plasma metabolomes of 84 COVID-19 positive University of Virginia hospital patients. We utilized supervised and unsupervised machine learning and metabolic modeling approaches to identify key metabolic drivers that are predictive of COVID-19 disease severity. Using metabolic pathway enrichment analysis, we explored potential metabolic mechanisms that link these markers to disease progression.

RESULTS

Enriched metabolites associated with tryptophan in non-acute COVID-19 samples suggest mitigated innate immune system inflammatory response and immunopathology related lung damage prevention. Increased prevalence of histidine- and ketone-related metabolism in severe COVID-19 samples offers potential mechanistic insight to musculoskeletal degeneration-induced muscular weakness and host metabolism that has been hijacked by SARS-CoV2 infection to increase viral replication and invasion.

CONCLUSIONS

Our findings highlight the metabolic transition from an innate immune response coupled with inflammatory pathway inhibition in non-acute infection to rampant inflammation and associated metabolic systemic dysfunction in severe COVID-19.

Changes in diagnosis rate and treatment trends of benign prostatic hyperplasia in Korea: A nationwide population-based cohort study

Purpose

This study aimed to evaluate benign prostatic hyperplasia (BPH) diagnosis rate and the changing landscape of medical and surgical management of BPH over the last decade using national population data of South Korea.

Methods

The present study analyzed data of patients diagnosed with BPH (N40) who underwent medical treatment or surgery in 3% of the national patient sample of the Health Insurance and Review Assessment database each year between 2012 and 2018. The primary outcome was the proportion of medical and surgical treatment for BPH. It was evaluated each year between 2012 and 2018. Secondary outcomes included total BPH diagnosis rate in each year of the study period. BPH diagnosis rate by age group was evaluated. The proportion of medical and surgical treatment for BPH according to the type of medical institution was investigated.

Results

The proportion of surgical treatment was 1.2% in 2012, 1.0% in 2013, 1.0% in 2014, 0.9% in 2015, 0.8% in 2016, 0.7% 2018, and 0.8% 2018, showing a progressive overall decrease from 2012 to 2018. The rate of surgical treatment for BPH increased with increasing age during the study period, showing a progressive overall increase (from 9,202 per 100,000 men in 2012 to 11,610 per 100 000 men in 2018). The number of patients with BPH was increased steadily from 2012 to 2018 in all age groups. The rate of surgical treatment in tertiary referral hospitals was the highest during the study period, followed by that in general hospitals, hospitals, and clinics.

Conclusions

In Korea, the diagnosis rate of BPH was steadily increasing during the study period. Overall surgical treatment gradually decreased compared with an increase in medical treatment among all treatments for BPH. Thus, a comprehensive treatment plan for BPH should be established considering this trend.

Prostate cancer specific mortality after 5α-reductase inhibitors medication in benign prostatic hyperplasia patients: systematic review and meta-analysis

BACKGROUND

Our study was conducted to investigate the effect of 5-ARI on the death rate from prostate cancer by means of an updated meta-analysis using related data.

METHODS

We did comprehensive literature searches using the PubMed, Embase, and Cochrane databases through July 2019. We evaluated the risk of bias in such studies using the ROBINS-I tool and analyzed deaths from cancer and deaths from all causes using HR.

RESULTS

The meta-analysis included 11 studies. The pooled overall HRs for cancer-specific deaths between 5-ARI treatment versus non-exposed groups were 0.937 (95% CI: 0.730, 1.201). In the subgroup moderator analysis, the number of patients and additional medication variables were significantly associated with deaths from all causes (p = 0.022 and p = 0.005, respectively). For detecting the publication bias or small-study effect in the included studies, we performed Begg and Mazumdar's correlation test (0.851 and 0.573) and Egger's regression coefficient test (0.035 and 0.245) and ​suggested that there was no evidence of publication bias or small-study effect in this meta-analysis.

CONCLUSIONS

Our study indicated that exposure to 5-ARI had no close association between the overall death rate or cancer-specific deaths. To confirm these results, well-designed prospective studies with large samples are required.

Efficacy of testosterone replacement therapy for treating metabolic disturbances in late-onset hypogonadism: a systematic review and meta-analysis

PURPOSE

Late onset hypogonadism (LOH) is an age-dependent reduction of testosterone associated with alterations of metabolic profile, including glucose control, insulin sensitivity, and lipid profile. The purpose of this study was to investigate the efficacy of testosterone replacement therapy (TRT) for treating metabolic disturbances through a meta-analysis of randomized clinical trials (RCTs).

METHODS

A systematic review of literature published from 1964 to November, 2019 was performed using the PubMed/Medline, Embase, and Cochrane databases. Among the 1562 articles screened, 17 articles were selected for qualitative analysis and 16 articles (n = 1373) were included for data synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Criteria for final inclusion were RCTs.

RESULTS

Sixteen studies were finally included (TRT group, n = 709; placebo group, n = 664). Among the metabolic markers, HbA1C [Mean difference (MD) = - 0.172, 95% CI - 0.329, - 0.015], HOMA IR (MD = - 0.514, 95% CI - 0.863, - 0.165), serum insulin (MD = - 12.622, 95% CI - 19.660, - 5.585), and leptin (MD = - 2.381, 95% CI - 2.952, - 1.810) showed significant improvement after TRT versus placebo. Among the lipid profiles, total cholesterol showed significant improvement (MD = - 0.433, 95% CI - 0.761, - 0.105) after TRT. However, HDL showed a decrease (MD = - 0.069, 95% CI - 0.121, - 0.018) after TRT. Among anthropometric markers, waist circumference showed significant improvement (MD = - 0.1640, 95% CI - 2.857, - 0.423).

CONCLUSION

This study demonstrated greater improvement in metabolic profiles for patients given TRT versus placebo. Further well-designed trials are needed to verify our findings and further elucidate effects of TRT on lipid profiles. This systematic review demonstrates that TRT can exert a net beneficial effect on metabolic profiles.

Long-term mortality of living kidney donors: a systematic review and meta-analysis

BACKGROUND

To date, several studies have reported inconsistent findings regarding the mortality risk faced by living kidney donors and controls. Our study assessed the methodological quality of previous studies and performed an updated meta-analysis of the mortality risk.

METHODS

Comprehensive literature searches were conducted involving the PubMed, Embase, and Cochrane databases through September 2020. The search terms used included 'living donor' and 'kidney transplantation' and 'kidney donor' and 'mortality' or 'death' or 'survival'. We evaluated the risk of bias in such studies using ROBINS-I tool. Mortality risk was analyzed using OR and HR.

RESULTS

The qualitative review involved 18 studies and the meta-analysis included nine studies. We identified 3 studies with an overall risk of bias rated as "Low", 2 studies rated as "Moderate", 8 studies rated as "Serious", and 5 studies rated as "Critical". The pooled overall mortality risk in the meta-analysis was 0.984 (95% CI: 0.743, 1.302). In the subgroup analysis of HR and OR, the summary effect estimates did not reach statistical significance. The meta-regression analysis revealed that the donor group of more than 60,000 (1.836, 95% CI: 0.371, 6.410) carried a significantly high mortality risk compared with the donor group of less than 60,000 (0.810, 95% CI: 0.604, 1.086) (P = 0.007). The number of total patients was associated with slightly elevated mortality risks (0.796 for < 10,000, 0.809 for 10,000-60,000, and 1.852 for > 60,000; P < .054).

CONCLUSIONS

Current evidence based on this systematic review suggests that the methodology of previous studies was inconsistent and also carried a high risk in several aspects. Updated meta-analysis showed that the mortality risk was not significantly different. Future studies with well-designed methodology are necessary.

Diagnostic accuracy of Raman spectroscopy for prostate cancer: a systematic review and meta-analysis

Background

Although various studies have been conducted to demonstrate the possibility of Raman spectroscopy (RS) as a diagnostic tool for prostate cancer (PC), it is difficult to use it in the real clinical area because of imitations in various research processes. Therefore, we did a systematic review and meta-analysis about the accuracy in diagnostic use of RS for PC.

Methods

A literature search was done using PubMed, Embase, and Cochrane library databases in March 2019 to analyze the accuracy of RS for diagnosis of PC. The accuracy of RS for diagnosis of PC was evaluated by means of pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC).

Results

Five studies were included for qualitative analysis by screening the remaining articles according to the inclusion and exclusion criteria by means of a systematic review. The pooled sensitivity and specificity of RS were 0.89 (95% CI: 0.87-0.91) and 0.91 (95% CI: 0.89-0.93), respectively. The overall PLR and NLR were 9.12 (95% CI: 4.15-20.08) and 0.14 (95% CI: 0.07-0.29), respectively. The DOR of RS demonstrated high accuracy (73.32; 95% CI: 18.43-291.73). The area under the curves (AUCs) of SROC curves was 0.93.

Conclusions

RS is an optical diagnostic method with high potential for diagnosis and grading of PC and has advantages of real-time and convenient use. In order to consider real-time use of RS in an actual clinical setting, more studies for standardization and generalization of RS performance and analytical method must be conducted.

Bilateral ureteral replacement using ileum in bilateral refractory ureteral stricture with renal insufficiency: a case report and review of literature

Although several studies have reported the efficacy and safety of ileal ureter in refractory ureteral strictures, reports on its long-term outcomes are still insufficient. In this case report, we present an excellent long-term outcome over three years without complication of bilateral ureteral replacement with ileum using ‘7’ shaped configuration in a woman after undergoing radical hysterectomy and radiation therapy who had renal insufficiency due to ureteral stricture. This study gave us a useful information about the feasibility and safety of bilateral ileal ureter in patients with ureteral strictures and renal insufficiency.

Association between prostate-specific antigen and serum testosterone: A systematic review and meta-analysis

BACKGROUND

Serum testosterone assays are an important tool in the clinical evaluation of a number of endocrine disorders including male hypogonadism. However, serum testosterone has a limited role in real clinical use due to its inaccuracy. We aimed to assess the association between prostate-specific antigen (PSA) and testosterone as well as the effects of various types of testosterone replacement therapy (TRT) for PSA level.

METHODS

Two electronic databases were screened: PubMed (1966 through December 2018) and Cochrane Library (1993 through December 2018). The first strategy compared the overall increase in PSA following testosterone treatment compared with placebo. The second strategy analyzed the overall association between PSA and testosterone among the observational studies.

RESULTS

In the first strategy, 22 articles were included in the final analysis. In the second strategy, 18 studies were included. Testosterone replacement therapy (TRT) showed a significant change in PSA level compared to that in the placebo group (mean difference [MD]: 0.13, 95% CI: 0.01-0.25, P = .04). Compared to placebo, only intramuscular (IM) TRT shows a significant change in PSA level group (MD: 0.16, 95% CI: 0.01-0.30, P = .04), as neither the oral nor topical type showed a significant change in PSA. In the second strategy analysis, there was no overall correlation found between PSA and testosterone (z = 0.04, 95% CI: -0.04 to 0.12, P = .04; r = 0.039). However, in the subgroup of non-BPH (benign prostate hyperplasia), a significant correlation between PSA and testosterone (z = 0.07, 95% CI: 0.01-0.13, P = .009; r = 0.089) was found.

CONCLUSIONS

We found that TRT, particularly IM TRT, significantly changed the PSA level compared with the placebo group. Furthermore, there was a significant correlation between PSA and testosterone in patients with non-BPH. According to these findings, we suggest the possibility of PSA as a surrogate marker of testosterone.

P785 Left ventricular geometry and myocardial contractility modulate impact of statins on prognosis in patients with acute heart failure

Funding Acknowledgements

N/A

Background/Introduction: The benefit of statins in patients with heart failure (HF) remains controversial and the mechanism of action is largely speculative. We investigated whether survival benefit with statins differs according to left ventricular (LV) geometry and myocardial contractility in acute HF patients.

Methods

We enrolled 1792 acute HF patients receiving statins and 2296 patients not receiving statins admitted from 2009 to 2016. The LV and right ventricular (RV) global longitudinal strain (GLS) was assessed as a measure of myocardial contractility. Patients were classified into 2 groups based on ischemic etiology of HF and further divided into 4 subgroups according to the median values of LV-GLS or RV-GLS. The primary outcome was 5-year all-cause mortality. The study protocol was approved by the ethics committee at each institute and complied with the Declaration of Helsinki. The need for written informed consent was waived.

Results

During the 5-year follow-up, 1740 (40.4%) patients died and they had more unfavorable baseline characteristics. Statin therapy was significantly associated with improved survival in overall patients and in both groups with and without ischemic etiology (all p &lt;0.001). Patients with concentric remodeling/hypertrophy and eccentric hypertrophy demonstrated survival benefit with statin therapy (P = 0.033, 0.004, and 0.008, respectively), while those with normal geometry did not (p = 0.123). In the non-ischemic HF group, survival benefit with statin therapy was confined to patients with low LV-GLS (p = 0.045) or those with low RV-GLS p = 0.003). On the contrary, in ischemic HF group, survival benefit with statin therapy was observed in all patients regardless of the values of LV-GLS or RV-GLS. Significant interactions were present between statin use and diabetes mellitus and IHD (p for interaction = 0.027 and 0.003, respectively) regarding mortality.

Conclusions

LV geometry and myocardial contractility may modulate the effects of statins in patients with acute HF. These echocardiographic measures can provide prognostic information to guide tailored statin treatment in this population. Our findings may also help to develop more well-designed prospective studies, in terms of a more homogenous study population, to confirm survival benefit with statin therapy.

Abstract P785 Figure. Multivariate Cox survival curves

A Novel Collateral Imaging Method Derived from Time-Resolved Dynamic Contrast-Enhanced MR Angiography in Acute Ischemic Stroke: A Pilot Study

BACKGROUND AND PURPOSE

Assessment of the collateral status has been emphasized for appropriate treatment decisions in patients with acute ischemic stroke. The purpose of this study was to introduce a multiphase MRA collateral imaging method (collateral map) derived from time-resolved dynamic contrast-enhanced MRA and to verify the value of the multiphase MRA collateral map in acute ischemic stroke by comparing it with the multiphase collateral imaging method (MRP collateral map) derived from dynamic susceptibility contrast-enhanced MR perfusion.

MATERIALS AND METHODS

From a prospectively maintained registry of acute ischemic stroke, MR imaging data of patients with acute ischemic stroke caused by steno-occlusive lesions of the unilateral ICA and/or the M1 segment of the MCA were analyzed. We generated collateral maps using dynamic signals from dynamic contrast-enhanced MRA and DSC-MRP using a Matlab-based in-house program and graded the collateral scores of the multiphase MRA collateral map and the MRP collateral map independently. Interobserver reliabilities and intermethod agreement between both collateral maps for collateral grading were tested.

RESULTS

Seventy-one paired multiphase MRA and MRP collateral maps from 67 patients were analyzed. The interobserver reliabilities for collateral grading using multiphase MRA or MRP collateral maps were excellent (weighted κ = 0.964 and 0.956, respectively). The agreement between both collateral maps was also excellent (weighted κ = 0.884; 95% confidence interval, 0.819-0.949).

CONCLUSIONS

We demonstrated that the dynamic signals of dynamic contrast-enhanced MRA could be used to generate multiphase collateral images and showed the possibility of the multiphase MRA collateral map as a useful collateral imaging method in acute ischemic stroke.

Moderating Effects of Prevention-Focus on the Paths from Two Insecure Attachment Dimensions to Depression

The present study investigated the moderating effects of prevention-focus on the paths from the dimensions of insecure attachment (attachment avoidance and attachment anxiety) to depression. Two hundred twenty eight Korean college students completed the Experience in Close Relationship - Revised Scale; the Regulatory Focus Strategies Scale; and the Center for Epidemiologic Studies Depression Scale. Results revealed a significant moderating effect for prevention-focus on the path from attachment avoidance to depression, but not on the path from attachment anxiety to depression. They further suggest that different interventions are needed for different combinations of persons' insecure attachment dimensions and levels of prevention-focus. Counseling implications and suggestions for future research are discussed.

Association of clinicopathological features of melanoma with total naevus count and a history of dysplastic naevi: a cross-sectional retrospective study within an academic centre

BACKGROUND

High naevus count (HNC) (≥ 50 naevi) and presence of dysplastic naevi (DN) are risk factors for malignant melanoma (MM); however, MMs also occur in patients with low naevus count (LNC) (< 50 naevi) and in patients without DN. Little is known about differences between MMs in these groups.

AIM

To characterize the clinicopathological differences between MMs in patients with HNC and those in patients with LNC, with or without biopsy-proven DN.

METHODS

This was a cross-sectional retrospective chart review of 281 patients with MM seen between April 2013 and March 2014 at an academic pigmented lesion clinic (Boston, MA, USA).

RESULTS

Patients with LNC MMs were diagnosed at an older age (51 vs. 41 years, P < 0.001, OR = 0.95, 95% CI 0.93-0.97), with more aggressive MM features, including greater Breslow thickness (1.1 vs. 0.8 mm, P = 0.01), more mitoses (2 vs. 1 mitoses/mm² , P < 0.001), lower rate of superficial spreading subtype (58 vs. 78%, P < 0.01, OR = 2.57, 95% CI 1.31-5.03) and higher MM stage (P < 0.001), compared to patients with HNC. Patients with DN had similar trends as those in patients with HNC described above, and in addition, were more likely to have a truncal MM (55 vs. 39%, P < 0.01, OR = 1.97, 95% CI 1.22-3.18) with less ulceration (13 vs. 29%, P < 0.01, OR = 0.36, 95% CI 0.19-0.71). Patients without DN were more likely to have a history of a non-MM skin cancer (32 vs. 19%, P = 0.01, OR = 0.49, 95% CI 0.28-0.85) and an amelanotic MM (33 vs 21%, P = 0.03, OR = 0.55, 95% CI 0.31-0.96).

CONCLUSIONS

Patients with LNC may develop MMs with more aggressive features at an older age than patients with HNC. A history of biopsy-proven DN reveals distinct MM differences compared to patients without DN.

Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab

Background

Anti-PD-1 antibodies (anti-PD-1) have clinical activity in a number of malignancies. All clinical trials have excluded patients with significant preexisting autoimmune disorders (ADs) and only one has included patients with immune-related adverse events (irAEs) with ipilimumab. We sought to explore the safety and efficacy of anti-PD-1 in such patients.

Patients and methods

Patients with advanced melanoma and preexisting ADs and/or major immune-related adverse events (irAEs) with ipilimumab (requiring systemic immunosuppression) that were treated with anti-PD-1 between 1 July 2012 and 30 September 2015 were retrospectively identified.

Results

One hundred and nineteen patients from 13 academic tertiary referral centers were treated with anti-PD-1. In patients with preexisting AD (N = 52), the response rate was 33%. 20 (38%) patients had a flare of AD requiring immunosuppression, including 7/13 with rheumatoid arthritis, 3/3 with polymyalgia rheumatica, 2/2 with Sjogren's syndrome, 2/2 with immune thrombocytopaenic purpura and 3/8 with psoriasis. No patients with gastrointestinal (N = 6) or neurological disorders (N = 5) flared. Only 2 (4%) patients discontinued treatment due to flare, but 15 (29%) developed other irAEs and 4 (8%) discontinued treatment. In patients with prior ipilimumab irAEs requiring immunosuppression (N = 67) the response rate was 40%. Two (3%) patients had a recurrence of the same ipilimumab irAEs, but 23 (34%) developed new irAEs (14, 21% grade 3-4) and 8 (12%) discontinued treatment. There were no treatment-related deaths.

Conclusions

In melanoma patients with preexisting ADs or major irAEs with ipilimumab, anti-PD-1 induced relatively frequent immune toxicities, but these were often mild, easily managed and did not necessitate discontinuation of therapy, and a significant proportion of patients achieved clinical responses. The results support that anti-PD-1 can be administered safely and can achieve clinical benefit in patients with preexisting ADs or prior major irAEs with ipilimumab.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome

AIM

Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms.

METHOD

A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed.

RESULTS

Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001).

CONCLUSION

Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Prospective analysis of the sealing ability of the ENSEAL® G2 Articulating Tissue Sealer and transector on human mesenteric vessels in colorectal surgery

BACKGROUND

The sealing and transection of mesenteric vessels is a crucial step in minimally invasive colorectal surgery. We examined the sealing quality of the ENSEAL^® G2 Articulating Tissue Sealer in three different articulations in mesenteric vessels.

METHODS

This was a prospective experimental study within a tertiary healthcare center, and 30 patients were recruited. Burst pressures for each specimen were measured as the primary outcome. Ten specimens at each of the three articulations were also histologically assessed for the quality of seal.

RESULTS

We evaluated 54 sets of specimens from 30 patients for bursting pressure, all of which were harvested and sealed in the operating room. No statistical difference was seen in burst pressures from seals recorded at no angulation, half-maximal angulation, or maximal angulation (1604, 1507, 1478 mmHg; p = 0.07). Histological analysis showed no statistical differences in the average vessel diameter (p = 0.57), lateral extent of thermal injury (p = 0.48), degree of vascular sclerosis, or the integrity of seal at the three articulations. No cases of intraoperative or postoperative bleeding were observed in any of the patients. Five (16.7%) of the ENSEAL^® devices developed breaks in the black, heat-shrink, polyethylene covering as a result of repeated articulation and disarticulation. Electrical arcing did not appear to have occurred as a result of the break, although this was not formally examined.

CONCLUSIONS

The maximum sustainable pressure in mesenteric vessels sealed with a bipolar electrothermal device is supraphysiological, and consequently, the device can be safely used at various articulations to seal vessels during colorectal surgery.

Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.

Learning curve analysis of colorectal endoscopic submucosal dissection (ESD) for laterally spreading tumors by endoscopists experienced in gastric ESD

BACKGROUND

Endoscopic submucosal dissection (ESD) for various colorectal neoplasms is more technically difficult than gastric ESD. We evaluated treatment outcomes and the learning curve for colorectal ESD of laterally spreading tumors (LSTs) based on the experience of a single endoscopist.

METHODS

We included 93 colorectal ESD procedures for colorectal LST that were performed between March 2009 and June 2012 by a single experienced endoscopist who previously performed hundreds of cases of gastric ESD. The cases were grouped chronologically into three periods by multi-dimensional analyses. For procedure time, the learning curve was analyzed using the moving average method, and for complication, the learning curve was analyzed using cumulative sum (cusum) method.

RESULTS

The median procedure time for 93 colorectal ESD was 45 min, and the rates of en bloc resection and R0 resection were 89.25 and 83.87 %. When results were compared among three periods in order to determine the learning curve, the procedure time and en bloc resection rates were not significantly different. However, the procedure proficiency (about 0.16 cm(2)/min) was significantly faster during the second period, after about 25 cases of colorectal ESD. In the third period (about 50 cases), the number and rate of en bloc resection (over 90 %) reached the same as that of en bloc R0 resection. When comparing outcomes based on LST subtype, the procedure proficiency of LST-granular type (LST-G) was significantly faster than that of LST-non granular type (LST-NG) (LST-NG, 0.072 cm(2)/min; LST-G, 0.157 cm(2)/min; p = 0.01).

CONCLUSION

Endoscopists fully experienced in gastric ESD need a relatively short learning period for colorectal ESD in terms of procedure time and complication. However, approximately 50 cases might be needed to acquire an adequate skill of colorectal ESD for LST in an experienced gastric ESD endoscopist. Colorectal ESD for LST-NG seems to have higher technical difficulty and a longer learning curve than LST-G.

Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection?

AIM

The aim of the study was to evaluate the value of routine intra-operative flexible sigmoidoscopy (IOFS) for left-sided anastomotic integrity and to determine the safest step after a positive leak test.

METHOD

All consecutive patients undergoing left-sided colorectal resections for benign and malignant disease between August 2005 and April 2011 were included. Data regarding procedure, type of anastomosis and outcomes of IOFS were collected. A positive intra-operative leak test resulted in redoing the anastomosis and repeating the leak test.

RESULTS

A total of 415 consecutive patients underwent hand-assisted laparoscopic colorectal resection with a colorectal/ileoanal anastomosis. All patients underwent IOFS. Seventeen patients had abnormality on IOFS. Fifteen patients had a positive air leak test. One patient had anastomotic bleeding. There was one stapler misfiring. Fourteen anastomoses were redone without diversion. One patient required diversion to protect the ileoanal anastomosis and another had already been diverted. Minor bleeding from the staple line in one patient resolved without intervention; however, he had a postoperative anastomotic leak needing surgical intervention. None of the patients who had a takedown and refashioning of the anastomosis following a positive leak on IOFS had postoperative anastomotic leakage or bleeding. Our overall anastomotic leak rate was 2.1%.

CONCLUSIONS

Intra-operative flexible sigmoidoscopy for restorative colorectal resection is safe and reliable and should be performed routinely to assess anastomotic integrity and bleeding. Refashioning the anastomosis after formal takedown would obviate the risk of leakage and is our recommended method of managing intra-operative leaks.

Prognostic factors for urachal cancer: a bayesian model-averaging approach

Purpose

This study was conducted to evaluate prognostic factors and cancer-specific survival (CSS) in a cohort of 41 patients with urachal carcinoma by use of a Bayesian model-averaging approach.

Materials and Methods

Our cohort included 41 patients with urachal carcinoma who underwent extended partial cystectomy, total cystectomy, transurethral resection, chemotherapy, or radiotherapy at a single institute. All patients were classified by both the Sheldon and the Mayo staging systems according to histopathologic reports and preoperative radiologic findings. Kaplan-Meier survival curves and Cox proportional-hazards regression models were carried out to investigate prognostic factors, and a Bayesian model-averaging approach was performed to confirm the significance of each variable by using posterior probabilities.

Results

The mean age of the patients was 49.88±13.80 years and the male-to-female ratio was 24:17. The median follow-up was 5.42 years (interquartile range, 2.8-8.4 years). Five- and 10-year CSS rates were 55.9% and 43.4%, respectively. Lower Sheldon (p=0.004) and Mayo (p<0.001) stage, mucinous adenocarcinoma (p=0.005), and larger tumor size (p=0.023) were significant predictors of high survival probability on the basis of a log-rank test. By use of the Bayesian model-averaging approach, higher Mayo stage and larger tumor size were significant predictors of cancer-specific mortality in urachal carcinoma.

Conclusions

The Mayo staging system might be more effective than the Sheldon staging system. In addition, the multivariate analyses suggested that tumor size may be a prognostic factor for urachal carcinoma.

Comparison of RECIST 1.0 and RECIST 1.1 on computed tomography in patients with metastatic colorectal cancer

OBJECTIVE

We conducted this study to compare tumor measurement by computed tomography (CT) and tumor response assessment between Response Evaluation Criteria In Solid Tumors (RECIST) 1.0 and RECIST 1.1 in patients with metastatic colorectal cancer (CRC).

METHODS

We reviewed the medical records of patients with metastatic CRC who received first-line chemotherapy between January 2004 and December 2012 and compared CT tumor measurement using two RECIST versions.

RESULTS

A total of 58 patients who had target lesions according to RECIST 1.0 were included in the study. The number of target lesions recorded by RECIST 1.1 was significantly lower than that by RECIST 1.0, with a decrease experienced in 48 patients (82.7%). Six patients had no target lesions because of the new criteria of RECIST 1.1 for lymph node size. Out of 95 lymph nodes from 58 patients, only 40% were defined as target lesions according to RECIST 1.1. The overall response rate of first-line chemotherapy according to RECIST 1.0 and 1.1 was 41.5 and 40.4%, respectively. The best tumor responses showed almost perfect agreement between RECIST 1.1 and RECIST 1.0 (ĸ = 0.913). Three patients showed disagreement of the best responses between the two RECIST versions.

CONCLUSION

RECIST 1.1 showed a highly concordant response assessment with RECIST 1.0 in metastatic CRC and its clinical impact on therapeutic decisions was minimal.

A curious case of unilateral spider nevi, cirrhosis and stroke: unilateral nevoid telangiectasia syndrome

A 55-year-old Caucasian man presented with unilateral right facial spider nevi. Relevant medical history included a right-sided cerebrovascular accident (CVA) in 1997 and decompensated alcoholic liver disease, diagnosed in 2007. The literature describes approximately 100 cases of unilateral spider nevi associated with different aetiologies, grouped under 'unilateral nevoid telangiectasia syndrome' (UNTS). This is a rare presentation of a commonly observed sign in clinical practice. This case offers an opportunity to explore the origins of spider nevi and highlights the benefit of sharing knowledge in order to help elucidate the potential mechanisms underlying common signs.

Is hybrid robotic laparoscopic assistance the ideal approach for restorative rectal cancer dissection?

AIM

While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors' preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra-operative and short-term outcomes.

METHOD

Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intra-operative and short-term outcomes were evaluated.

RESULTS

The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and nine had a coloanal pull-through procedure (mean age 60.1 years; mean body mass index 28.0 kg/m(2) ; mean operative time 327 min; conversion rate 3.9%). Three patients (3.9%) had positive resection margins (one circumferential, two distal). Five patients had an anastomotic leak (6.4%). No robot-specific complications were observed.

CONCLUSION

The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection.

Estimation of the nares-to-epiglottis distance and the nares-to-vocal cords distance in young children

BACKGROUND

Estimation of the nares-to-epiglottis and nares-to-vocal cords distances would facilitate the selection of properly sized nasopharyngeal airways and appropriate positioning of a fibreoptic bronchoscope in young children. The purposes of this study were to measure the nares-to-epiglottis and nares-to-vocal cords distances and to create an algorithm to predict these distances based on anatomical landmarks and paediatric characteristic data.

METHODS

Two hundred and eleven children, aged 1-10 yr, undergoing elective surgery were investigated. After induction of general anaesthesia, the distances from the nares to the epiglottis/vocal cords were measured using a nasogastric tube. After intubation, the distances from the lateral border of the nose to the ipsilateral mandible angle (nares-to-mandible distance) and the tragus of the ear (nares-to-tragus distance) were measured using a tape measure.

RESULTS

The nares-to-epiglottis and nares-to-vocal cords distances were significantly correlated with the age, weight, height, and external measurements (P<0.001). By stepwise multiple linear regression analysis, formulas were obtained for the nares-to-epiglottis distance (cm)=2.606+0.058×height (cm)+0.231×the nares-to-mandible distance (cm)-0.304 (gender) (r(2)=0.754) and for the nares-to-vocal cords distance (cm)=4.947+0.06×height (cm)+0.228×nares-to-mandible distance (cm)-0.283 (gender) (r(2)=0.803).

CONCLUSIONS

The nares-to-epiglottis and nares-to-vocal cords distances can be predicted using the height and the nares-to-mandible distance in young children.

CLINICAL TRIAL REGISTRATION NUMBER

Clinical Research Information Service KCT0000150.

Mucosal protective effect of PGI2 on canine small bowel auto-transplantation

PURPOSE

We designed this experimental study to assess the mucosal protective effects of continuous prostaglandin I2 (PGI2) infusion after canine small bowel autotransplantation.

MATERIALS AND METHODS

Six Mongrel dogs were randomly divided two groups: PGI2 (n = 3) and control (n = 3). The small bowel from jejunum to ileum was obtained, including the mesenteric vascular pedicle. After cold flushing ex vivo, the harvested segment was preserved in an icebox for 3 hours. Thereafter we reimplanted the harvested intestinal segment. While completing the anastomosis, PGI2 (50 μg) was slowly infused through the mesenteric artery in the PGI2 group versus the same volume of saline in the control group. At 1, 3 and 6 days after autotransplantation, we obtained blood samples, and at 6 days, small bowel segments. Endotoxin and interleukin 6 (IL-6) levels were measured and all histologic specimens stained with hematoxylin-eosin H-E were reviewed by a pathologist to grade mucosal damage as: mild (1 point), moderate (2 points), or severe (3 points) change.

RESULTS

Mean basal serum endotoxin levels were similar in both groups the PGI2 groups versus control group were 0.216 ± 0.018 versus 0.223 ± 0.040 EU/mL, respectively. However, on day 3 after the operation, the PGI2 group showed much decreased levels of serum endotoxin compared to control levels: 0.349 ± 0.196 versus 0.842 ± 0.446 EU/mL. The mean concentration of serum IL-6 on day 1 after operation among the PGI2 versus control group were 32.13 ± 7.13 pg/mL versus 36.96 ± 3.65 pg/mL. The histologic scores at 6 days after the operation were PGI2 group versus control group: 1.33 versus 1.66 (P = NS).

CONCLUSION

Continuous infusions of PGI2 through the mesenteric artery after the canine small bowel autotransplantation may protect the small bowel mucosal barrier.

Neuroimaging and cerebral palsy in children

Cerebral palsy (CP) is a description of a spectrum of central nervous system (CNS) impairments that affect mobility, communication, intellectual ability, and neurobehavior as a result of developmental brain dysfunction. CP is the most common contributor to motor disability in children with prevalence of about 2-3/1000 live births globally. Presently, no curative therapies or successful methods of prevention on a population level are available for children with one of the cerebral palsy syndromes. Despite these challenges, orthopedic, rehabilitation, neuropharmacological, and other management interventions can help maintain mobility, prevent deformity, and promote quality of life for children with CP. Typically, the diagnosis of CP is based on clinical observations and parent concerns regarding delays in attaining motor milestones (e.g., rolling, sitting, crawling, walking), not on laboratory testing or neuroimaging. However, since 2004 the American Academy of Neurology (AAN) has recommended that neuroimaging of the CNS be part of diagnostic process for cerebral palsy. Although the guideline was initially met with controversy and criticism, neuroimaging has allowed a broader appreciation of timing of lesions, extent of white matter involvement, and the complexity of the motor spectrum of disability. In this article we shall describe the major types of neuroimaging techniques and review their roles in identification and evaluation of children with one of the cerebral palsy syndromes. The authors will focus on the emerging knowledge of how brain structure can inform us about children's functioning, especially among children with prematurity, recognizing that we are only beginning to understand brain plasticity and developmental resiliency.

Combination treatment with leflunomide and methotrexate for patients with active rheumatoid arthritis

OBJECTIVE

To determine the efficacy and safety of the combination of leflunomide and methotrexate for the treatment of patients with active rheumatoid arthritis (RA) in an open, non-comparative, multicentre trial.

METHODS

Seventy-four patients with active RA were enrolled to receive concomitantly leflunomide (no loading dose, 10 mg/day) and methotrexate (starting at 7.5 mg/week and titrating up to 15 mg/week) for 20 weeks. The primary end-point was a 20% improvement in the American College of Rheumatology (ACR) criteria at 20 weeks. Safety measures included evaluation of adverse events at each visit and laboratory data, including haematology and liver function tests. Intention-to-treat analyses were conducted.

RESULTS

Sixty-five patients completed 20 weeks of treatment, and 71.6% were responders based on the ACR20 criteria. After 20 weeks, the mean changes were -16.3 for tender joint count, -12.0 for swollen joint count, -44.0 for physician global assessment, -34.3 for patient global assessment, -22.7 for erythrocyte sedimentation rate, and -0.65 for the Health Assessment Questionnaire score. Adverse events occurred in 40.5% of the patients, and were considered serious in four patients who discontinued therapy. Abnormal liver function was noted for 16 patients (21.6%). Two of these patients were withdrawn from the study; after discontinuing the medication, their liver function recovered fully.

CONCLUSION

THE combination of leflunomide and methotrexate was effective and well tolerated in the treatment of active RA patients. This combination may be a useful option as an initial treatment for active RA before starting biological agents.

Efficacy of Helicobacter pylori eradication therapy in chronic liver disease

BACKGROUND/AIMS

Peptic ulcers occur more commonly in patients with liver cirrhosis (LC). Helicobacter pylori is recognized as the most important etiology in the pathogenesis of peptic ulcers. We investigated the efficacy of proton pump inhibitor (PPI)-based triple therapy in patients with chronic liver disease and peptic ulcer.

PATIENTS AND METHODS

One hundred sixty-three patients with LC or chronic hepatitis (CH) with a peptic ulcer and proven H. pylori infection were included. The combination of PPI, amoxicillin (1.0 g), and clarithromycin (500 mg), each given twice daily, was administered for 1 or 2 weeks. The eradication of H. pylori was determined by the rapid urease test, histology, or the 13C-urea breath test at least 4 weeks after completing the treatment.

RESULTS

The eradication rate of H. pylori was similar between the LC and CH groups; 82.6% and 88.1%, respectively. In addition, there were no significant differences in eradication rates between the patients with Child-Pugh class A and Child-Pugh class B/C disease. The side effects in each group were generally mild. Only the serum ALT levels showed a significant correlation with the success of H. pylori eradication in both the LC and CH groups.

CONCLUSION

The PPI-based triple therapy achieves high eradication rates for H. pylori infection, in patients with chronic liver disease, without significant side effects.