Radioimmunotherapy versus autologous hematopoietic stem cell transplantation in relapsed/refractory follicular lymphoma: a Fondazione Italiana Linfomi multicenter, randomized, phase III trial

BACKGROUND

Optimal consolidation for young patilents with relapsed/refractory (R/R) follicular lymphoma (FL) remains uncertain in the rituximab era, with an unclear benefit of autologous stem cell transplantation (ASCT). The multicenter, randomized, phase III FLAZ12 (NCT01827605) trial compared anti-CD20 radioimmunotherapy (RIT) with ASCT as consolidation after chemoimmunotherapy, both followed by rituximab maintenance.

PATIENTS AND METHODS

Patients (age 18-65 years) with R/R FL and without significant comorbidities were enrolled and treated with three courses of conventional, investigator-chosen chemoimmunotherapies. Those experiencing at least a partial response were randomized 1 : 1 to ASCT or RIT before CD34+ collection, and all received postconsolidation rituximab maintenance. Progression-free survival (PFS) was the primary endpoint. The target sample size was 210 (105/group).

RESULTS

Between August 2012 and September 2019, of 164 screened patients, 159 were enrolled [median age 57 (interquartile range 49-62) years, 55% male, 57% stage IV, 20% bulky disease]. The study was closed prematurely because of low accrual. Data were analyzed on 8 June 2023, on an intention-to-treat basis, with a 77-month median follow-up from enrollment. Of the 141 patients (89%), 70 were randomized to ASCT and 71 to RIT. The estimated 3-year PFS in both groups was 62% (hazard ratio 1.11, 95% confidence interval 0.69-1.80, P = 0.6662). The 3-year overall survival also was similar between the two groups. Rates of grade ≥3 hematological toxicity were 94% with ASCT versus 46% with RIT (P < 0.001), and grade ≥3 neutropenia occurred in 94% versus 41%, respectively (P < 0.001). Second cancers occurred in nine patients after ASCT and three after radioimmunotherapy (P = 0.189).

CONCLUSIONS

Even if prematurely discontinued, our study did not demonstrate the superiority of ASCT versus RIT. ASCT was more toxic and demanding for patients and health services. Both strategies yielded similar, favorable long-term outcomes, suggesting that consolidation programs milder than ASCT require further investigation in R/R FL.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Delayed emergence from anesthesia caused by an intraoperative cerebral embolism of a malignant peripheral nerve sheath tumor in a neurofibromatosis type 1 patient: a case report

BACKGROUND

Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas which commonly arise from neurofibromatosis type 1. Lung metastases of the tumors are well-known, but intraoperative cerebral tumor embolisms of MPNSTs have not been reported in literature.

CASE PRESENTATION

A 52-year-old female patient with neurofibromatosis type 1 underwent a right lung partial resection for lung tumors. She was extubated after adequate recovery of spontaneous breathing; however, she could not respond to verbal commands. In the intensive care unit, her neurological examination revealed conjugate eye deviation, right hemiparalysis, and aphasia. Magnetic resonance imaging revealed acute cerebral ischemia, so she underwent an endovascular thrombectomy. The histopathological diagnosis of emboli was a MPNST, which was identical with that of the resected lung tumor.

CONCLUSION

We report the first case of delayed emergence caused by a cerebral tumor embolism of MPNST during partial lung resection.

Therapeutic plasma exchange in postpartum HELLP syndrome: a case report

BACKGROUND

Postpartum hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is more difficult to treat than HELLP syndrome during pregnancy. We describe a case of postpartum HELLP syndrome that responded to plasma exchange (PE) therapy.

CASE PRESENTATION

A 30-year-old primipara woman was hospitalized for gestational hypertension at 33 weeks of gestation and underwent an emergent cesarean section at 36 weeks and 6 days of gestation due to rapidly progressing pulmonary edema. After delivery, liver dysfunction and a rapid decrease in platelet count were observed, and the patient was diagnosed with severe HELLP syndrome. She experienced multiple organ failure despite intensive care, and PE therapy was initiated. Her general condition dramatically stabilized within a few hours of PE therapy.

CONCLUSION

It is controversial whether PE therapy should be used primarily in the management of HELLP syndrome, but early initiation of PE therapy could be effective for severe HELLP syndrome.

First assessment of root biomass and root carbon and nitrogen stocks in Turkish floodplain forests

Estimation of whole root biomass including coarse and larger roots and root balls can provide better understanding of carbon and nitrogen stocks in floodplain forests. Whole root systems of nine ash trees (Fraxinus angustifolia Vahl.) and six alder trees (Alnus glutinosa L.) trees ranging in diameter breast height (dbh) from 29.1 to 72.0 cm for ash and from 29.1 to 44.3 cm for alder were excavated, and their small < 1 cm, medium 1-4 cm, larger > 4 cm and root-ball biomass, and root carbon and nitrogen stocks were determined in Karacabey floodplain forest in Bursa, Turkey. In addition, for the method comparison, small root biomass (< 1 cm) was also determined using soil-core method. The whole root biomass of ash trees varied from 167.7 to 186.8 Mg ha^-1. Alder trees had lower whole root biomass than ash trees ranging from 49.0 to 63.6 Mg ha^-1. The determination of small root biomass by soil excavation method was nearly two-fold higher than by soil core method. Both root carbon and nitrogen stocks showed an increase with increasing root diameter. Among the tree characteristics (dbh, age, height, and volume), the dbh showed the highest correlation with whole root biomass and root carbon and nitrogen stocks for both tree species. It is concluded that young trees can have higher small, medium, and large root biomass and store more C and N in those roots, whereas older trees can have higher root-ball biomass and root-ball carbon and nitrogen stocks in Karacabey floodplain forests.

The Importance of F-Wave Patterns in a Patient with Cerebrovascular Disease Characterized by a Markedly Increased Tone of the Thenar Muscles

F-waves are used to measure the excitability of spinal motor nerve function. This study aimed to investigate the F-wave patterns in a patient with cerebrovascular disease who had no voluntary movement of the hand, particularly the thumb, caused by a considerably increased tone of the thenar muscles. A patient with right hemiplegia caused by left cerebral hemorrhage (putamen) showed a considerably increased tone of the thumb flexors and no voluntary movements. F-waves were recorded from the affected thenar muscles with median nerve stimulation in the supine lying position during the first trial. Exercise therapy that included stretching of the affected thenar muscles was performed twice a week for 20 min for 8 months. Subsequent changes in the F-wave waveform were examined and considered as second trial. The latency and persistence of the F-wave and F-wave conduction velocity did not show any significant change between the two trials. Compared with the first trial, the F/M amplitude ratio in the second trial was increased. Following 8 months of exercise therapy, muscle tone improved slightly, and minimal voluntary movements of the affected thumb were noted. Since motor function of the affected thumb improved with exercise therapy but there was no improvement in F-wave data, it was determined that the main factor underlying the hypertonicity of the thenar muscles in this patient was more likely due to secondary muscle shortening than to spasticity. Unclear waves that possibly were F-waves were also observed approximately 20 ms after the appearance of the M-wave in the first trial but not in the second trial. Because exercise therapy showed muscle tone improvement and did not result in the appearance of unclear waves, F-wave patterns should be monitored for evaluating spasticity, which markedly increases muscle tone in patients with cerebrovascular disease.

Noncollinear electro-optic sampling detection of terahertz pulses in a LiNbO3 crystal while avoiding the effect of intrinsic birefringence

We propose and experimentally prove efficient high-resolution electro-optic sampling measurement of broadband terahertz waveforms in a LiNbO₃ crystal in the configuration with the probe laser beam propagating along the optical axis of the crystal. This configuration allows one to avoid the detrimental effect of strong intrinsic birefringence of LiNbO₃ without any additional optical elements. To achieve velocity matching of the terahertz wave and the probe beam, the terahertz wave is introduced into the crystal through a Si prism at the Cherenkov angle to the probe beam. The workability of the scheme at different wavelengths of the probe optical beam (800 and 1550 nm) is demonstrated.

Veno-venous extracorporeal membrane oxygenation in the management of refractory bilateral bronchial dehiscence after lung transplant: a case report

Background

Bronchial dehiscence is a life-threatening complication after lung transplant. If it is not treated by placement of stent or reanastomosis, the chance of survival will depend on the availability of a new graft. However, retransplant is not a practical management option in Japan, where waiting time for lung transplant is extensive. We described a case of refractory bilateral bronchial dehiscence managed by veno-venous extracorporeal oxygenation membrane (VV ECMO) while allowing the dehiscence to heal.

Case presentation

A 25-year-old man with idiopathic pulmonary arterial hypertension underwent a bilateral lung transplant. The patient developed bilateral bronchial dehiscence. Open reanastomosis was not successful, and air leakage recurred under low positive pressure ventilation. VV ECMO was established to maintain oxygenation with spontaneous breathing until both dehiscence were closed by adhesions.

Conclusion

In a patient with refractory bilateral bronchial dehiscence, VV ECMO may provide bronchial rest and serve as a bridge therapy to recovery.

Correlation of foetal body weight by coronet width measurement using ultrasonography in prepartum cows: a pilot study

This study aimed to clarify the effectiveness of foetal body weight estimation by measuring foetal coronet width using transrectal ultrasonography in beef cows during near-term pregnancy. A characteristic 'gull wing' pattern was obtained from the foetal coronet cross-section from the dewclaw side using ultrasonography. This pattern was matched to the bone surface of the distal part of the middle phalanx. Then, the relationship between coronet width and body weight at birth of 22 Japanese Brown calves was analysed and a high correlation coefficient of 0.8965 (P < 0.001) was obtained. In conclusion, the coronet width of the fetus is depicted as a 'gull wing' hyperechoic structure and can be measured by ultrasonography per rectum during near-term pregnancy. This technique may be a useful tool to identify high-risk cows with dystocia before calving. High foetal coronet values may predispose cattle to dystocia.

Two cases of intraoperative hemodynamic instability during combined thoracoscopic-laparoscopic surgery for esophagogastric junction carcinoma

Background

Intraoperative complications during combined thoracoscopic-laparoscopic surgery for esophagogastric junction (EGJ) carcinoma have not been reported as compared to those during surgery for esophageal carcinoma. We present two cases which had surgery-related hemodynamic instability during laparoscopic proximal gastrectomy and intra-mediastinal valvuloplastic esophagogastrostomy (vEG) with thoracoscopic mediastinal lymphadenectomy for EGJ carcinoma.

Case presentation

In case 1, the patient fell into hypotension with hypoxemia during laparoscopic vEG due to pneumothorax caused by entry of intraabdominal carbon dioxide. In case 2, ventricular arrythmia and ST elevation occurred during laparoscopic vEG. Pericardium retraction to secure surgical field during reconstruction compressed the coronary artery, which caused coronary malperfusion. These two events were induced by the surgical procedure, characterized by the following: (1) connection of the thoracic and abdominal cavities and (2) cardiac displacement during vEG.

Conclusion

These cases indicated tension pneumothorax and coronary ischemia are possible intraoperative complications specific to combined thoracoscopic-laparoscopic surgery for EGJ carcinoma.

Associations between Dietary Variety and Frailty in Community-Dwelling Older People Who Live Alone: Gender Differences

OBJECTIVES

This study aimed to investigate the influences of living arrangements on the association between dietary variety and frailty by gender in community-dwelling older people.

DESIGN

A cross-sectional study.

SETTING

Nishinomiya city, Hyogo prefecture, Japan.

PARTICIPANTS

A total of 4,996 randomly selected community-dwelling older people aged 65 years and older and living in Nishinomiya City.

MEASUREMENTS

Survey questionnaires were distributed via mail. The frailty score was evaluated by the 5-item frailty screening index. Dietary variety was assessed using the dietary variety score developed for the general older Japanese population.

RESULTS

A total of 2,764 community-dwelling participants aged ≥ 65 years responded to the questionnaires. After excluding missing data, 1,780 participants were included in the study analysis. The frailty scores in older men living alone were significantly higher than those in older men living with someone (P < 0.001). The dietary variety scores in older men living alone were significantly lower than those in older men living with someone (P < 0.001). However, differences in the frailty and dietary variety scores between living alone and living with someone were not were observed in older women (P = 0.360 and P = 0.265, respectively). In the multivariable regression analysis, the associations between dietary variety score and frailty score in living alone (β= -0. 271, P = 0.011) were stronger than those in living with someone in the case of older men (β= -0.131, P = 0.045). Similar associations between dietary variety and frailty were presented in older women living alone than in those living with someone (β -0.114, P = 0.002; β -0.088, P = 0.012, respectively).

CONCLUSIONS

Older men who live alone had higher frailty score and lower dietary variety. The associations between dietary variety and frailty were different according to living arrangements in both older men and older women.

Successful treatment with positive airway pressure ventilation for tension pneumopericardium after pericardiocentesis in a neonate: a case report

BACKGROUND

Pneumopericardium in neonates is often associated with respiratory diseases, of which positive pressure ventilation (PPV) is an exacerbating factor. Here, we present a neonate case of pneumopericardium after cardiac surgery which was resolved after applying PPV.

CASE PRESENTATION

A 28-day-old neonate with left recurrent nerve palsy after aortic reconstruction for interrupted aortic arch developed pericardial effusion. Pericardiocentesis was performed under general anesthesia, and a drainage tube was left in the pericardium. After extubation, stridor gradually exacerbated, following hemodynamic deterioration. A chest X-ray demonstrated pneumopericardium. Upper airway stenosis due to recurrent nerve palsy developed excessive negative pleural pressure, and air was drawn into pericardium via the insertion site of the drainage tube. After tracheal intubation and applying PPV, the pneumopericardium improved.

CONCLUSION

PPV does not always exacerbate pneumopericardium. In a patient with pericardial-atmosphere communication, increased inspiration effort can cause pneumopericardium, and PPV is a therapeutic option to alleviate the pneumopericardium.

Anesthetic management of lung transplantation: Results from a multicenter, cross-sectional survey by the society for advancement of transplant anesthesia

BACKGROUND

Current protocols for the perioperative care of lung transplant (LTX) recipients lack rigorous evidence and are often empiric, based upon institutional preferences. We surveyed LTX anesthesiologists to determine the most common practices.

METHODS

We developed a survey of 40 questions regarding perioperative care of LTX recipients using Qualtrics software. The survey was sent out to members of the Society of Cardiovascular Anesthesiologists performing LTX at geographically diverse sites to facilitate data collection for as many practices as possible.

RESULTS

The responses were center-weighed (127 responses, 85% from academic settings). The clamshell approach was commonly used (70%). Cardiopulmonary bypass was preferred by 56%, ex vivo lung perfusion utilized by 43%, and 49.4% indicated they use lungs from donation after circulatory determination of death. Most (69%) used oximetric pulmonary artery catheters, 60% used tissue oximetry, and 89.3% utilized transesophageal echocardiography. Inhaled nitric oxide was preferred by 48%, restrictive fluid management by 48%, and systemic analgesia advocated by 49% of participants. Inspired oxygen concentration <30% was applied to the new lung on reperfusion by 28% of the respondents.

CONCLUSION

Variations in healthcare delivery and utilization for LTX recipients indicate gaps in knowledge and potential opportunities to improve the quality of care.

Elastocapillary adhesion of a soft cap on a rigid sphere

We study the capillary adhesion of a spherical elastic cap on a rigid sphere of a different radius. Caps of small area accommodate the combination of flexural and in-plane strains induced by the mismatch in curvature, and fully adhere to the sphere. Conversely, wider caps delaminate and exhibit only partial contact. We determine the maximum size of the cap enabling full adhesion and describe its dependence on experimental parameters through a balance of stretching and adhesion energies. Beyond the maximum size, complex adhesion patterns such as blisters, bubbles or star shapes are observed. We rationalize these different states in configuration diagrams where stretching, bending and adhesion energies are compared through two dimensionless parameters.

Nonellipsometric electro-optic sampling of terahertz waves in GaAs

We report efficient high-resolution electro-optic sampling detection of broadband terahertz radiation by measuring direct intensity modulation of a femtosecond fiber laser beam induced by terahertz field in a 1-cm thick GaAs crystal.

Non-overt disseminated intravascular coagulation scoring for critically ill patients: The impact of antithrombin levels

Validation of a scoring algorithm for non-overt disseminated intravascular coagulation (DIC) proposed by the International Society on Thrombosis and Haemostasis (ISTH) is still incomplete. It was the objective of this study to assess the impact of including AT to non-overt DIC scoring on the predictability for intensive care unit (ICU) death and the later development of overt-DIC defined by the Japanese Ministry of Health and Welfare (JMHW) or the ISTH. We performed a retrospective observational study conducted in 364 patients in critical care. Coagulation parameters obtained daily for DIC screening were utilised for scoring. There were 194 and 196 patients scored as positive non-overt DIC with and without AT, respectively; diagnostic agreement between the two was 78%. As compared with patients without non-overt DIC, these non-overt DIC patients had significantly higher mortality. In 37 ICU non-survivors, positive non-overt DIC scoring with AT preceded ICU death by a median of 6.8 days, which was significantly earlier as compared with a median of 5.4 days for non-overt DIC without AT (p=0.022). In patients who developed overt-DIC after admission, the time period from positive non-overt DIC to positive overt-DIC was significantly longer when AT was utilised (overt-DIC ISTH; 1.3 days vs. 0.1 days, p=0.004, overt-DIC JMHW; 2.5 days vs. 2.0 days, p=0.04, with AT vs. without AT, respectively). Non-overt DIC scoring predicted a high risk of death in critically ill patients. When information on AT levels was included, non-overt DIC scoring was found to predict development of overt-DIC significantly earlier than non-overt DIC scoring without AT.

[Differences between Anesthesiology Residency Education Programs in Japan and the USA]

New anesthesiology residency education program requirements were launched in Japan. The main change was to specify which anesthesia cases a resi- dent must experience during the training period. We believe that comparing the educational requirements between anesthesiology specialty certification programs in Japan and the USA is a timely undertaking. This detailed comparison study is aimed to identify compo- nents to improve the current educational systems in each country. Three educational components are required in the USA, but not in Japan: daily clinical evaluations based on well-defined criteria, regular lectures and nation- wide annual achievement tests, and national board- accredited subspecialty fellowships. Conversely, in Japan, scholarly presentations at scientific meetings are mandatory for anesthesiology board certification, but the scholarly activity requirement in the USA is vaguely defined. These points identified through our comparison could help improve residency training programs in both Japan and in the USA.