Immunosuppressive treatment results in patients with primary IgA nephropathy in Turkiye; the data from TSN-GOLD working group

BACKGROUND

Immunoglobulin A (IgA) nephropathy (IgAN) treatment consists of maximal supportive care and, for high-risk individuals, immunosuppressive treatment (IST). There are conflicting results regarding IST. Therefore, we aimed to investigate IST results among IgAN patients in Turkiye.

METHOD

The data of 1656 IgAN patients in the Primary Glomerular Diseases Study of the Turkish Society of Nephrology Glomerular Diseases Study Group were analyzed. A total of 408 primary IgAN patients treated with IST (65.4% male, mean age 38.4 ± 12.5 years, follow-up 30 (3-218) months) were included and divided into two groups according to treatment protocols (isolated corticosteroid [CS] 70.6% and combined IST 29.4%). Treatment responses, associated factors were analyzed.

RESULTS

Remission (66.7% partial, 33.7% complete) was achieved in 74.7% of patients. Baseline systolic blood pressure, mean arterial pressure, and proteinuria levels were lower in responsives. Remission was achieved at significantly higher rates in the CS group (78% vs. 66.7%, p = 0.016). Partial remission was the prominent remission type. The remission rate was significantly higher among patients with segmental sclerosis compared to those without (60.4% vs. 49%, p = 0.047). In the multivariate analysis, MEST-C S1 (HR 1.43, 95% CI 1.08-1.89, p = 0.013), MEST-C T1 (HR 0.68, 95% CI 0.51-0.91, p = 0.008) and combined IST (HR 0.66, 95% CI 0.49-0.91, p = 0.009) were found to be significant regarding remission.

CONCLUSION

CS can significantly improve remission in high-risk Turkish IgAN patients, despite the reliance on non-quantitative endpoints for favorable renal outcomes. Key predictors of remission include baseline proteinuria and specific histological markers. It is crucial to carefully weigh the risks and benefits of immunosuppressive therapy for these patients.

Are deep learning classification results obtained on CT scans fair and interpretable?

Following the great success of various deep learning methods in image and object classification, the biomedical image processing society is also overwhelmed with their applications to various automatic diagnosis cases. Unfortunately, most of the deep learning-based classification attempts in the literature solely focus on the aim of extreme accuracy scores, without considering interpretability, or patient-wise separation of training and test data. For example, most lung nodule classification papers using deep learning randomly shuffle data and split it into training, validation, and test sets, causing certain images from the Computed Tomography (CT) scan of a person to be in the training set, while other images of the same person to be in the validation or testing image sets. This can result in reporting misleading accuracy rates and the learning of irrelevant features, ultimately reducing the real-life usability of these models. When the deep neural networks trained on the traditional, unfair data shuffling method are challenged with new patient images, it is observed that the trained models perform poorly. In contrast, deep neural networks trained with strict patient-level separation maintain their accuracy rates even when new patient images are tested. Heat map visualizations of the activations of the deep neural networks trained with strict patient-level separation indicate a higher degree of focus on the relevant nodules. We argue that the research question posed in the title has a positive answer only if the deep neural networks are trained with images of patients that are strictly isolated from the validation and testing patient sets.

Machine Learning Based Prediction of Distant Metastasis in Rectal Cancer Patients with Complete Response following Neoadjuvant Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

Distant metastasis (DM) is the leading cause of disease recurrence in rectal cancer patients with clinical or pathological complete response (CR) following neoadjuvant chemoradiotherapy (nCRT). Identifying these patients may help to tailor the treatment approach. The aim of this study was to predict the rectal cancer patients with high risk of DM following CR with nCRT, using machine learning (ML), based on patient, disease and treatment related clinical factors.

MATERIALS/METHODS

Data of the rectal cancer patients treated with nCRT at three academic centers between 2010-2022 were collected. Patients with secondary malignancies were excluded. 157 patients with CR were included in the analysis. Median age was 63 (31-85). Female/male ratio was 59/98. Tumor location was proximal-, mid- and distal-rectum in 9, 65 and 83 patients, respectively. cT stage was T2, T3 and T4 in 14, 120 and 23 patients, respectively. 122 patients had cN (+). Median tumor and regional lymph nodes doses were 50.4 (45-56) Gy and 45 (45-50.4) Gy, respectively, in 25-28 fractions, concurrently with capecitabine. 63 patients had clinical CR and were followed up without surgery, and 94 had pathological CR. Median RT-surgery interval was 11 (3.4-59) weeks. 41 patients were managed with total neoadjuvant treatment and 52 received adjuvant systemic treatment. Median follow up time was 37 (3-143) months. DM was detected in 18 patients at median 14 (2-87) months and local tumor recurrence/progression was seen in 9. A ML model was used to predict DM based on patient, disease and treatment related 37 clinical factors. Statistical analysis was conducted using Python (v.3.7). P<0.05 was accepted as statistically significant. Multiple Linear Regression was used to analyze the relationship between DM and independent continuous variables. Chi-square test was used to analyze the difference between the observed frequency distribution of a categorical variable and the expected frequency distribution. Confusion matrix algorithm was used to evaluate the performance of the model. Logistic regression algorithm (LRA) was selected as the best performing algorithm for the ML model that used 37 variables from 157 patients. The model was trained using 75% of the data and the remaining 25% was used for testing.

RESULTS

CEA, ratio of post- to pre-RT tumor SUVmax, tumor dose, RT-surgery interval, pre-RT weight loss, smoking history, cN status, and gender were significant parameters to predict DM, based on the LRA of the ML model. Accuracy score of the model was 92% and AUC of the ROC was 74%. Precision (positive predictive value) and recall (sensitivity) of the model were 67% and 50%, respectively.

CONCLUSION

Machine learning has a high rate of correctly classifying patients and good performance in predicting those with DM. Further studies with larger patient numbers are needed.

Effect of drought on aquaporin expression in grafted and ungrafted grapevine cultivars

Drought stress severely affects growth, development and productivity in most agricultural crops. Since ancient times, rootstocks have been used to enable crop cultivation in unsuitable soil conditions. In the present study, three factors were evaluated: 1) cultivar: Vitis vinifera L. cv. ‘Horozkarası’ (drought-tolerant) and cv. ‘Kabarcık’ (drought-sensitive) were used; 2) rootstock: each cultivar was self-rooted and grafted onto ‘Rupestris du Lot’ rootstock; 3) drought stress: half of each cultivar/rootstock combination underwent drought stress and the other half was irrigated at field capacity for seven days. In order to estimate the responses of the cultivars, relative water content, proline content and aquaporin isoform expression levels (VvPIP2;1, VvPIP2;2, VvTIP1;1, and VvTIP2;1) were quantified. The results revealed that drought stress caused more reduction in relative water content (RWC) in ‘Kabarcık’ cultivar (drought-sensitive) than in ‘Horozkarası’ cultivar (drought-tolerant). Proline content increased in both cultivars in response to drought stress but to a relatively greater extent in the grafted ‘Kabarcık’ cultivar. Considering expression levels of genes, VvPIP2;1, VvPIP2;2, and VvTIP2;1 were downregulated whilst VvTIP1;1 was upregulated in the leaf. Both ‘Horozkarası’ and ‘Kabarcık’ cultivars showed similar trends in terms of their responses to drought stress. Grafting significantly increased the proline content in both cultivars exposed to drought stress. The rootstock conferred better drought protection to ‘Kabarcık’ cultivar than to ‘Horozkarası’ cultivar.

Second look hysteroscopy following hysteroscopic septum resection improves reproductive outcomes in patients undergoing ICSI

The aim of this study was to compare the reproductive outcomes between infertile women who underwent hysteroscopic uterine septum resection and those who required a second look hysteroscopy due to residual septum prior to intracytoplasmic sperm injection (ICSI) cycles with selective single 'Grade A' embryo transfer (ET). All second look hysteroscopies were performed due to partial remnant septum in a control three dimensional transvaginal ultrasonography (3D TVUSG) after the first hysteroscopic resection. Miscarriage and biochemical pregnancy rates were not different between the groups while clinical pregnancy and live birth rates were significantly higher in Group 2 than in Group 1. Second look hysteroscopic metroplasty performed to restore remnant septum significantly improves live birth rate as well as clinical pregnancy rates while it appears not to alleviate abortion and biochemical pregnancy rates in women undergoing ICSI-ET.IMPACT STATEMENTWhat is already known on this subject? The effect of hysteroscopic septum resection on reproductive outcomes in IVF treatment in infertile patients with uterine septum is not clearly known.What do the results of this study add? With the selective single ET strategy, complete or partial hysteroscopic correction of the uterine septum before ICSI and subsequent resection of the residual septum with control hysteroscopy significantly increases the live birth rates in the infertile population.What are the implications of these findings for clinical practice and/or further research? In the group of infertile patients with uterine septum, second control hysteroscopy should be performed 1 month later for residual septum or adhesions after hysteroscopic septum resection performed once.

Prognostic nutritional index is a predictor of mortality in elderly patients with chronic kidney disease

PURPOSE

Prognostic nutritional index (PNI), a composite indicator of inflammation and nutritional status, has recently been recognized as an independent prognostic marker for chronic kidney disease (CKD). We aimed to investigate PNI and its relationship with mortality in elderly patients with CKD.

METHODS

Three hundred and fifty-nine patients over the age of 80 years with stage 3-4 CKD were enrolled in this retrospective study. PNI was used to assess the nutritional status of the patients. Patients were divided into two different groups as deceased and survived and as low PNI (< 39) and high PNI (≥ 39) according to median value of PNI.

RESULTS

The mean age of the patients was 85.7 ± 3.7 years. One hundred and ninety-five (54.3%) patients died during follow-up. Multivariate analysis revealed that male gender, PNI, proteinuria, and diabetes mellitus (DM) were independent predictors of mortality in elderly patients with CKD. When patients with low PNI were compared to those with high PNI, initiation of dialysis and mortality rate were significantly higher whereas albumin, hemoglobin and lymphocyte count were lower. Pearson correlation analysis showed that PNI was significantly correlated with albumin (r = 1.000, p < 0.001), hemoglobin (r = 0.340, p < 0.001) and eGFR (r = 0.123, p = 0.020). Hemoglobin was an independent predictor of PNI in multivariate analysis.

CONCLUSION

In this study, we observed that PNI was significantly associated with mortality over the age of 80 years in patients with CKD and can be used to monitor nutritional status in this patient population.

Hemoptysis and massive focal alveolar hemorrhage after successful biventricular pacemaker implantation

During and after cardiac resynchronization therapy (CRT) implantation, many adverse events may occur. We present an interesting and important patient with hemoptysis and massive focal alveolar hemorrhage in a patient after a successful CRT implantation. CRT implantation was completed without any problems. In the follow-up, complaints of cough and hemoptysis began 1 h after the procedure. On the PA chest X-ray, a ground glass image was found in the left upper zone. Thorax CT revealed focal alveolar hemorrhage in the left upper lobe anterior segmental lung parenchyma. The patient was followed up with medical treatment and discharged in good health.

The role of melatonin in preventing radiation-induced intestinal injury

PURPOSE

Despite the therapeutic effects of radiotherapy on tumor cells, it has potential severe adverse effects on the surrounding normal tissues. Acute or chronic intestinal adverse effects that are likely to occur in patients undergoing radiotherapy for pelvic and abdominal cancers lead to increased morbidity, significant impairment of the quality of life, and economic losses. Various biological, chemical and pharmacological agents are being tested to protect from and to treat radiation enteritis. This experimental study aimed to investigate the protective effects of melatonin against radiation-induced intestinal injury when administered before radiation exposure in rats.

METHODS

In the present study, villus height and the number of villi in the ileum and jejunum of rats receiving two different doses of intraperitoneal melatonin (5 and 10 mg/kg) prior to a single fraction of radiation given at a dose of 8 Gy to the abdominal region, was evaluated by histopathological examination 3 and 7 days after radiation exposure.

RESULTS

At a dose of 5 mg/kg, melatonin was found to be effective in preventing radiation-induced injury to villus height in the jejunum and the number of villi in the ileum and jejunum, and at a dose of 10 mg/kg it was also effective in preventing radiation-induced injury to villus height in the ileum.

CONCLUSIONS

Melatonin is effective for the prevention of radiation-induced intestinal injury. This outcome can be considered an evidence to test melatonin in clinical trials.

Baseline carotid intima-media thickness is associated with cardiovascular morbidity and mortality in peritoneal dialysis patients

Carotid intima-media thickness (CIMT) is an early marker of atherosclerosis and is increased in peritoneal dialysis (PD) patients. Association of CIMT with cardiovascular disease (CVD) or mortality is less clear. Fibroblast growth factor-23 (FGF-23) is a hormone associated with vascular calcification, atherosclerosis, and mortality in the hemodialysis population. We investigated whether baseline CIMT and FGF-23 are associated with CVD and mortality in PD patients. Fifty-five PD patients were included. CVD was defined as ischemic heart disease, stroke, or peripheral artery disease. Intact FGF-23 was measured in plasma. CIMT was measured by ultrasonography. Twenty-one patients developed CVD and 12 died over 47.1 ± 33.8 months. Patients with CVD were older (55.9 ± 10.5 vs. 42.5 ± 12.9 years, P < .01), had lower albumin (3.8 ± 0.5 vs. 4.2 ± 0.3 g/dL, P < .01) and higher CIMT (0.87 ± 0.22 vs. 0.61 ± 0.11 mm, P < .01). Patients with mortality were also older (53.5 ± 11.5 vs. 45.8 ± 13.8 years, P = .05), had lower albumin (3.7 ± 0.6 vs. 4.1 ± 0.3 g/dL, P < .01), higher CRP (15.0 ± 8.5 vs. 7.6 ± 8.4 mg/L, P < .01) and CIMT (0.9 ± 0.3 vs. 0.6 ± 0.1 mm, P < .01). Albumin and CIMT were associated with CVD and CIMT >  0.75 mm was associated with cardiovascular mortality. FGF-23 did not show any correlations. CIMT at baseline is associated with CVD and mortality in PD patients.

P0377THE RELATIONSHIP BETWEEN SEVERITY OF INTERSTITIAL FIBROSIS AND ANEMIA IN PATIENT WITH PRIMARY GLOMERULONEPHRITIS: THE DATA FROM TSN-GOLD WORKING GROUP

Background and Aims

Anemia is one of the most important complications in chronic renal disease and inadequate erythropoietin production is the most important reason for anemia. Fibrosis of renal interstitium may be associated with inadequate synthesis of erythropoietin and anemia. In our study, we investigated the relationship between the severity of interstitial fibrosis (IF) in patients with primary glomerulonephritis (PGN) and anemia parameters.

Method

A total of 2794 patients who were recorded to the database of the Turkish Society of Nephrology, Glomerular Diseases (TSN-GOLD) Working Group between May 2009 and June 2019 were included in our national multicenter (44 centers) study. Patients aged 16 years or more with documented biopsy were included in the study. Patients were divided into four groups according to IF severity. IF was not detected in the interstitial area, was defined as none, if fibrosis was present in less than 25% of the area, defined as mild, if fibrosis was present in 25-50%, defined as moderate and if more than 50%, defined as severe. Anemia was defined as hemoglobin &lt;12 g/dl in adult female patients and &lt;13 g/dl in adult male patients, according to Clinical Practice Guidelines for anemia of CKD published by The Kidney Disease: Improving Global Outcomes Foundation. The relationship between IF severity and anemia parameters at the time of biopsy was investigated.

Results

In the study, 57% of the patients were male and their mean age was 41.0 ± 14.3 years. The mean eGFR was 82.7 ± 36.9 ml / min / 1.73 m2 and the hemoglobin level was 13.1 ± 1.9 g/dl. General characteristics of patients with and without anemia are given in Table 1. While 41.1% of patients had no IF, 41.2% had mild, 14.1% had moderate and 3.5% had severe IF. When the patients were divided into four groups according to the severity of IF, the mean hemoglobin and hematocrit levels were significantly different between the groups (Figure 1). Anemia was present in 960 patients (34.4%) (Figure 2). Anemia rate was significantly higher in the patients with IF than patients without IF (36.8% vs 30.9%, p = 0.001). Anemia rate was %25.1 in patients with eGFH≥60 ml/min/1.73m2 and 56% in patients with eGFR&lt;60 ml/min/1.73m2. Gender, serum albumin, eGFR, proteinuria, presence of diabetes, presence of nephrotic syndrome, and presence of IF were the independent variables in the regression analysis of hemoglobin-related factors (Table 2).

Conclusion

Approximately one-third of PGN patients had anemia at the time of biopsy and the frequency of anemia increases in patients with IF. The presence of IF is an independent risk factor associated with the development of anemia in PGN. The elucidation of the etiopathogenesis of anemia in PGN patients may play an important role in the follow-up and treatment of patients. Studies on IF can play a critical role.

Do adipofascial flaps affect the mechanical properties of a repaired tendon? A biomechanical rat model study

The aim of this study was to evaluate the effect of vascularized and non-vascularized fascial flaps on tendon healing, specifically the maximum strain, maximum stress, elasticity and resistance of the repaired tendon. Rats were randomly divided into 3 groups: Group 1 - primary repair; Group 2 - vascularized pedicled fascial graft; Group 3 - non-vascularized free fascial graft. The rats were euthanized after 2 weeks and 40mm-long samples were taken from the Achilles tendon and gastrocnemius muscle. To evaluate the mechanical properties of the tendons, maximum load, maximum deformation, energy stored until yield point and stiffness on the load-deformation curve were measured. Based on this mechanical testing, the best group in terms of tissue strength and quality was the primary repair group. When the samples were examined individually, the two samples with the highest breaking force after the control group were in the pedicled graft group. The worst results overall were in the free graft group. We believe that if the blood flow is preserved for the fascial flap in the pedicled graft group, the tendon's breaking force would be higher.

Which one predicts mortality better? Hemogram and ST elevation myocardial infarction

Objective

The aim of this study was to determine the effectiveness of hematological parameters measured at the moment of admission to the emergency room in predicting in-hospital mortality and to determine cut-off values of strongly predictive values.

Subjects and Methods

The study began with approval of the ethics committee. In total, 1,929 patients over 18 years of age, whose date could be obtained, were included in the study. From the hemogram parameters, white blood cells (WBC), red cell distribution width, mean platelet volume, and ratio of neutrophils to lymphocytes (NLR) values were determined and recorded. CK-MB and high-sensitive Troponin T values were recorded as cardiac markers. For statistical analysis, "SPSS for Windows Version 21" package program was used.

Findings

About 71.7% (n = 1384) of the patients were male and 28.3% (n = 545) of the patients were female. About 92.5% of the patients (n = 1785) were discharged from the hospital, whereas the remaining 144 patients (7.5%) were exitus in the hospital. When the efficacy of hematological parameters and cardiac markers in predicting mortality was examined by receiver operating charecteristics analysis, NLR was found to be the strongest predictor (area under the curve [AUC], 0.772, standard deviation [SD] = 0.022, 95% confidence interval [CI]). It was found that the WBC value came in second place after NLR as a strong predictor of mortality (AUC, 0.749, SD = 0.024, % 95 CI).

Conclusion

The use of predictors for the prediction of mortality for ST elevation myocardial infarction patients is of great importance for faster implementation of treatment modalities. We found that WBC and especially NLR values obtained with a simple method can be used as powerful predictors.

Evaluation of the radioprotective effects of thymoquinone on dynamic thiol-disulphide homeostasis during total-body irradiation in rats

Ionizing radiation-induced free radicals cause functional and structural harmful effects. Thiol, an important antioxidant, plays a major role in the eradication of reactive oxygen molecules. Thiol/disulphide homeostasis is a marker of oxidative stress. The objective of this study was to assess the potential radioprotective effects of thymoquinone (TQ) on the dynamic thiol/disulphide homeostasis of rats receiving total-body irradiation (IR). Twenty-two rats were divided into three groups to test the radioprotective effectiveness of TQ. The sham control group did not receive TQ or IR. The IR group received only total-body IR. The TQ + IR group received IR plus TQ. Following IR, blood samples were taken. The thiol/disulphide homeostasis parameters were analysed by a newly established method. In the IR group, native thiol and the native thiol/total thiol ratio were significantly decreased (P = 0.003 and P = 0.003, respectively), whereas the disulphide/native thiol and disulphide/total thiol ratios were significantly increased when compared with those of the sham control group (P = 0.003 and P = 0.003, respectively). In the TQ + IR group, the mean disulphide, native thiol and total thiol levels and the disulphide/native thiol, disulphide/total thiol and native thiol/total thiol ratios were not found to be significantly different when compared with those of the sham control group (P > 0.05 for all). Thiol/disulphide homeostasis was found to be disturbed after IR exposure. The results showed that TQ had antioxidant effects and reduced the IR-induced oxidative stress, which was demonstrated through the dynamic thiol/disulphide homeostasis. Thus, the use of TQ before radiation treatment helped protect the rats from oxidant side effects.

Prognostic value of pre-treatment 18F-FDG PET uptake for nasopharyngeal carcinoma

PURPOSE

To evaluate the prognostic value of maximal standardized uptake values (SUVmax) from serial fluor-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Fifty-two patients with NPC who underwent 18F-FDG PET/CT scan before radiotherapy with/without chemotherapy were reviewed retrospectively. Twenty-seven patients (52%) were applied 3-D conformal radiotherapy and 25 patients (48%) applied intensity-modulated radiotherapy (IMRT). Fourteen (27%) patients were given neoadjuvant chemotherapy and forty-four (84.6%) patients were given concomitant and adjuvant chemotherapy.

RESULTS

Median follow-up time was 34 months (range 5.6-66.4 months). Forty-four (84.6%) patients were alive at last follow-up and eight (15.4%) had died. The best cut-off value of the SUVmax for the primary tumor site (SUVmax-PT) was 13 and 9 for the lymph nodes (SUVmax-LN). Patients with SUVmax-PT ≥ 13.0 and SUVmax-LN ≥ 9 had a significantly higher risk for the development of the distant metastases (p = 0.044 and p = 0.038). DFS was affected in patients with SUVmax-PT ≥ 13 (log rank χ 2 = 2.54, p = 0.017) and was significantly lower in patients with SUVmax-LN ≥ 9 for the lymph nodes (log rank χ 2 = 5.81, p = 0.013). OS was not affected by SUV levels. A multivariate Cox proportional hazard model of DFS included age (≥ 40), SUVmax-LN (< 9), T stage (T1-2) and neoadjuvant chemotherapy are significantly better prognosis for the DFS.

CONCLUSION

18F-FDG PET/CT uptake before treatment, as determined by SUVmax, may be a valuable tool to evaluate prognosis in NPC patients.

Crab claw pattern on corneal topography: pellucid marginal degeneration or inferior keratoconus?

PurposeTo evaluate the topographic, tomographic, and densitometric properties of patients with pellucid marginal degeneration (PMD) and inferior keratoconus.Patients and methodsRetrospective, comparative case series. Forty-seven eyes of 32 patients with crab claw patterns were identified from 2751 patients with corneal ectasia. They were divided into two groups, inferior keratoconus and PMD, based on clinical findings. The topographic, tomographic, and densitometric measurements were analyzed.ResultsPMD was detected in 11 eyes of eight patients (mean age 50.2±11.1 years), and inferior keratoconus was detected in 36 eyes of 24 patients (mean age 34.7±10.1 years). The control group consisted of 40 patients (33.1±4.6 years). The thinnest corneal point and maximum anterior and posterior elevation points were located lower in the PMD than in the inferior keratoconus (P<0.01). In the PMD, all deviation indices were higher than the controls (P<0.01), whereas the deviation indices, except Dt (P=0.960), were lower than the inferior keratoconus (P<0.01). The densitometry values of PMD were significantly higher than those of the controls in all zones and layers (P<0.01) and significantly higher than the densitometry values of inferior keratoconus in the 6-10 and 10-12 mm zones (P<0.05).ConclusionThere is a higher probability of a patient with crab claw pattern on the topography of having inferior keratoconus than having PMD. Therefore, analyzing only the anterior corneal surface is not sufficient in differential diagnosis. Tomographic and densitometric evaluations may facilitate the differential diagnosis.

Prognostic value of pre-treatment 18F-FDG-PET uptake in small-cell lung cancer

PURPOSE

Small-cell lung cancer (SCLC) is an aggressive disease, despite an initially favorable response to treatment, and its prognosis is still poor. Multiple parameters have been studied as possible prognostic factors, but none of them are reliable enough to change the treatment approach. ¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) is a novel imaging technique for staging of SCLC. The aim of this study was to evaluate the prognostic value of pre-treatment FDG-PET parameters on clinical outcome in limited stage (LS) SCLC patients treated with curative thoracic radiotherapy (RT) and chemotherapy.

METHODS

Clinical records of 46 LS-SCLC patients with pre-treatment FDG-PET imaging were retrospectively reviewed. Patients were treated with definitive RT for a total dose of 50-60 Gy and chemotherapy. The clinical endpoints were progression-free survival (PFS) and overall survival (OS).

RESULTS

The median age was 59 (range 30-82) years, and median follow-up time was 23.2 months (range 5-82.8 months). Median OS was 30.9 months for pre-treatment tumor maximum standardized uptake value (SUV_max) <9.3 and 20.6 months for SUV_max ≥9.3 (p = 0.027) and PFS was 55.6 months for SUV_max <9.3 and 38.6 months for SUV_max ≥9.3 (p = 0.16). Median OS was 73 months for pre-treatment lymph node SUV_max <5.8 and 21 months for ≥5.8 (p = 0.01) and PFS was 38.6 months (range 6.8-70.3 months) for SUV_max-LN ≥5.8; all patients with SUV_max-LN <5.8 were alive (p = 0.07). Median survival time was 28.2 months (range 21.7-34.7 months) for patients younger than 65 and 8.7 months (range 5.7-11.8 months) for those ≥65 years (p = 0.00).

CONCLUSIONS

Pre-treatment FDG-PET uptake may be a valuable tool to evaluate prognosis in SCLC patients. Patients with a higher pre-treatment FDG uptake may be considered at increased risk of failure and may benefit from more aggressive treatment approaches.

Unplanned irradiation of internal mammary lymph nodes in breast cancer

AIMS

To evaluate the incidental dose to the internal mammary chain (IMC) in patients treated with three-dimensional conformal radiotherapy, to estimate the predictors affecting the magnitude of IMC receiving dose and to determine the predictive role of clinical parameters on survival.

MATERIALS AND METHODS

Between 2009 and 2015, 348 patients undergoing RT for breast cancer were retrospectively analyzed. All patients underwent our department's routine procedure for breast cancer. The internal mammary lymph nodes were contoured according to Radiation Therapy Oncology Group (RTOG) concensus. Based on each patient's dose-volume histograms, the mean doses (D _mean) to internal mammary gland were analyzed. Overall survival and disease-free survival were also evaluated.

RESULTS

The median follow-up time was 38 (range 3-80) months. The D _mean to IMC was 32.8 Gy and the dose delivered to IMC showed a greater coverage in modified radical mastectomy (MRM) group compared with breast conserving surgery (34.6 vs 26.7 Gy). The T-stage of tumor and the N-stage of tumor affected the incidental dose to IMC. The tumor size, the number of involved lymph nodes, the percentage of involved lymph nodes, hormonal status, advanced T-stage and advanced N-stage were the prognostic factors that affect survival.

CONCLUSION

The IMC received meaningful incidental irradiation dose when treated with two opposite tangential fields and ipsilateral supraclavicular fossa with a single anterior field. The real effect of incidental dose on survival and the hypothesis about the benefit of incidental irradiation of IMC should be examined in clinical studies.

Thoracic Re-irradiation for Locally Recurrent Lung Cancer

Background: Patients with recurrent or progressive lung cancer experience a significant symptom burden, negatively affecting quality of life and reducing life expectancy. Thoracic re-irradiation can be used for palliative treatment to relieve symptoms or as a curative treatment. Methods: Using patient charts, we identified and reviewed 28 cases that had received palliative thoracic re-irradiation for recurrent lung cancer. Results: Before re-irradiation, 32% of patients had stage III non-small cell lung cancer and six had small cell lung cancer. The median interval between treatments was 18.7 months. Median follow-up was 31.2 months from the initial radiotherapy and 5 months after re-irradiation. A better performance status before re-irradiation (<80 vs >80, p=0.09) and a lower overlap 90% isodose (<70 vs >70, p=0.09) showed trends toward improved survival. Grade 1-2 toxicity from re-irradiation was recorded in 12/28 patients, and no grade 3 or 4 acute toxicity was encountered. Conclusion: The role of palliative treatment in survival is not clear but it can provide symptomatic relief in patients, with no high grade toxicity. Further studies with greater patient numbers and longer follow-up times should facilitate determination of the role of this treatment in toxicity and effects on survival.

Solid Gastric Emptying after Highly Selective Vagotomy and Pyloroplasty in Patients with Obstructing Duodenal Ulcer

Before being superseded by medical management, highly selective vagotomy (HSV) without drainage was the procedure of choice for uncomplicated duodenal ulcer. It is also justified for complications, including perforation and bleeding in selected cases. This prospective study evaluated the effects of HSV plus drainage on solid gastric emptying in 20 patients with chronic duodenal ulcer and pyloric stenosis. Patients were treated with HSV plus pyloroplasty (Heineke-Mikulicz pyloroplasty in five patients, Finney pyloroplasty in six patients and Jaboulay gastroduodenostomy in nine patients) and underwent solid-phase gastric emptying scintigraphic studies pre-operatively and 2 months and 6 months post-operatively. Results were compared with those from 10 controls. No significant differences were observed between the different types of pyloroplasty, although emptying was slightly faster in the gastroduodenostomy group. Gastric emptying returned to normal by 6 months post-operatively. In conclusion, HSV plus pyloroplasty is effective and can be used for the relief of stenosis in selected cases of duodenal ulcer.

An Old Friend in the Treatment of Drive Line Infection After Left Ventricular Assist Device Implantation: Omentoplasty--A Case Report

INTRODUCTION

In this report, we share our omentoplasty experience in a patient with recurrent left ventricular assist device (LVAD) drive line infection. Drive line infection is a life-threating complication for the patient and a difficult problem for surgeons to resolve.

CASE REPORT

In our patient, after LAVD implantation recurrent drive line infection episodes occurred and standard therapeutic strategies failed to cure the infection. Therefore, we performed an old, well-known omentoplasty plasty technique to heal the abscess.

CONCLUSIONS

After omentoplasty and appropriate antibiotic therapy, the drive line infection healed uneventfully. The patient is still under control for 14 months without any signs of infection. Omentoplasty may be kept in mind for patients with resistant drive line infections.

Regular exercise alleviates renovascular hypertension-induced cardiac/endothelial dysfunction and oxidative injury in rats

The importance of physical activity in the management of renovascular diseases is well-known, but lacks evidence of underlying mechanisms. The purpose of the study was to elucidate the protective/therapeutic effects of regular exercise on experimental renovascular hypertension (RVH)-induced oxidative stress and cardiac dysfunction. Wistar albino rats underwent a RVH surgery (2K1C, Goldblatt). Three weeks later half of the rats started swimming exercise for 9 weeks (n = 15), while the sedentary RVH group (n = 15) had no exercise during that period. Sham-operated control rats (n = 10), had the similar surgical procedures but the left renal artery was left unclipped. Body weights were monitored, and blood pressures were measured weekly using tail-cuff. Echocardiographic evaluation was performed on the 3(rd) week and on the 12(th) week of the experiment before the rats were decapitated. Heart and thoracic aorta were removed and serum was collected, while aortic samples were put in a 10% formaldehyde solution for immunochemistry. Cardiac tissue samples obtained from each animal were used for the determination of tissue myeloperoxidase (MPO) and catalase (CAT) activities, malondialdehyde (MDA), and glutathione (GSH) levels. In the sedentary RVH group, aortic contractile response (contraction/relaxation in isolated organ bath), left ventricular diastolic and systolic dimensions, and immunohistochemical staining of aortic inducible nitric oxide synthase (iNOS) were increased, while ejection fraction and aortic endothelial nitric oxide synthase (eNOS) staining were decreased. RVH in the sedentary rats resulted in increased pro-inflammatory cytokines (TNF-α, IL-2, IL-6), lipid peroxidation (malondialdehyde) and neutrophil infiltration (myeloperoxidase activity) along with reductions in antioxidant glutathione and catalase levels in the cardiac tissue. Exercise after RVH increased the immunohistochemical staining of aortic eNOS, decreased iNOS staining and reversed the alterations in echocardiographic and oxidative parameters. Regular exercise commenced after RVH surgery alleviated renovascular hypertension-induced oxidative injury, by modulating oxidant-antioxidant balance via the involvement of the endothelial NO system.

Outcomes of reirradiation in the treatment of patients with multiple brain metastases of solid tumors: a retrospective analysis

BACKGROUND

Patients with multiple brain metastases are often treated with whole brain radiation therapy (WBRT). Second course of WBRT is an important treatment option for patients with clinical or radiological intracranial disease progression. This study examines the outcomes in patients with multiple brain metastases who underwent reirradiation.

METHODS

We examined the medical records of 34 patients with multiple brain metastases who were treated WBRT. The median dose for the first course of WBRT was 30 Gy (range, 25-30 Gy) and for the second course 25 Gy (range, 20-30 Gy). Statistical analyses were performed with using Cox regression analyses, log-rank test and Kaplan-Meier method.

RESULTS

The median Karnofsky performance status (KPS) was 80 (range, 50-100) before reirradiation. Patients with KPS of >70 had a median survival of 11.4 months, compared to 2.2 months with KPS of ≤70 (P=0.012) and patients who have severe symptoms at the time of reirradiation with median survival 2.2 months while those with mild symptoms had a median of 4.8 months survival (P=0.08). The median overall survival for all patients after diagnosis of metastases was 24.7 months, after the re-irradiation WBRT (re-WBRT) it was 5.3 months (95% CI, 4.08-6.62) and from the diagnosis of primary tumor was 27.1 months (95% CI, 17.75-37.04).

CONCLUSIONS

In select patients who have good performance status and who do not have severe symptoms might benefit from re-WBRT and re-WBRT seems to be associated with minimal toxicity in patients treated with lower palliation doses.

The effects of intraperitoneal chemotherapeutic agents on adhesion formation

PURPOSE

Intra-abdominal adhesions are a major complication of healing. Furthermore these adhesions may cause morbidity and sometimes mortality for patients, and also are a financial burden to the health system.

MATERIALS AND METHODS

Cecum abrasion was performed in all rats and solutions containing saline to group 1, 5-fluorouracil to group 2, cisplatin to group 3, paclitaxel to the group 4, and mitomycin-C were administered into the abdomen of the groups, respectively. The intra-abdominal adhesions were scored after the macroscopic evaluation.

RESULTS

Among the chemotherapeutic drugs, paclitaxel significantly increases occurring of intra-abdominal adhesions in comparison with the control group and the other drugs according to the evaluation of scoring and statistical studies.

CONCLUSION

It is suggested to use the drugs which have a proven anti-adhesion feature or barriers to the patients who are going to be applied intraperitoneal chemotherapy with paclitaxel.

Survival following reirradiation using intensity-modulated radiation therapy with temozolomide in selected patients with recurrent high grade gliomas

BACKGROUND

High grade gliomas often recur after initial treatment. Despite so many treatment options, there is no standard treatment for recurrent gliomas. The aim of this study is to offer survival following reirradiation (re-RT) using intensity-modulated radiation therapy (IMRT) with temozolomide in selected patients with recurrent high grade gliomas.

METHODS

We examined the medical records of 21 adult patients with recurrent high grade gliomas who were reirradiated with IMRT at the time of tumor recurrence or progression. Tumor recurrence was shown by gadolinium-enhanced magnetic resonance imaging (MRI) and diagnosis was established by pathology review. Statistical analyses were performed with SPSS version 18.0.1 using Cox regression analyses, log-rank test and Kaplan-Meier method.

RESULTS

Eighteen patients presented by localized recurrence, three patients with diffuse recurrence. Median radiotherapy (RT) dose was 54 Gy. About 81% patients received temozolomide with re-RT. The time interval between two courses RT was median 39.3 months (range, 9.6-140.8 months). The response was checked by MRI. About 24% patients achieved complete response (CR) and 29% patient partial response (PR). Stable disease (SD) was observed in 47% patients. Median follow-up time from diagnosis was 41.4 months (range, 16.6-145.4 months) and 12.3 months (range, 2-27.6 months) from re-RT. Median time to recurrence was 39.3 months (range, 9.6-140.8 months). Median survival after re-RT was 18 months for anaplastic astrocytoma (AA), 14.1 months for glioblastoma multiforme (GBM) (range, 11-17.2 months) (P=0.1) and 7.1 months for patients with Karnofsky performance status (KPS) <70 before re-RT and 17.4 months for KPS >70 (P=0.02).

CONCLUSIONS

re-RT is one of the treatment options for recurrent high grade gliomas and IMRT can be an effective treatment modality for recurrent high grade brain tumors with only mild side effects. Survival is better in patients with good performance status and in recurrent anaplastic tumors after re-RT.

Two cases of gastrointestinal stromal tumor of the small intestine with liver and bone metastasis

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors most commonly occur in the stomach (60%), jejunum and ileum (30%). Metastasis is characteristically the malignant behavior of the GISTs. GISTs most frequently metastasize to the liver and peritoneum, whereas bone and lung metastases are uncommon sites. Here, we described two cases of bone and liver metastases in patients with advanced GISTs. Both of them showed liver metastasis at disease presentation and bone metastasis in early time after the diagnosis. Bone metastases involved the lumber spine and right femur in first patient and L2 vertebral body in the second case. All of the lesions presented a lytic pattern. These cases are presented because of the rare incidence of bone metastasis to femur and vertebral bodies. More attention should be paid to the diagnosis of bone metastases from GISTs in clinical practice despite the shortage of available data on the sensitivity and specificity of bone scintigraphy and PET-CT.

Circulating endothelial cell number and markers of endothelial dysfunction in previously preeclamptic women

OBJECTIVE

Patients with preeclampsia (PE) have endothelial dysfunction and an increased future risk of cardiovascular (CV) mortality. The number of circulating endothelial cells (CECs) is markedly increased in conditions associated with a high degree of endothelial cell activation/injury including PE. We hypothesized that the number of CECs continues to be increased in women with a history of PE, reflecting ongoing endothelial cell activation/injury.

STUDY DESIGN

CECs, flow-mediated vasodilation, levels of adhesion molecules and soluble vascular endothelial growth factor receptor-1 (sVEGFR1), and urine albumin/creatinine ratio were determined in 21 healthy women with ongoing normal pregnancy, 24 healthy currently nonpregnant women with a history of normal pregnancy, a total of 17 women with currently active mild (n = 11) or severe (n = 6) PE without hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and 16 currently nonpregnant women with a history of mild (n = 10) or severe (n = 6) PE.

RESULTS

Blood samples from women with active preeclampsia had higher CECs (9.9 ± 7.9 cells/mL) than healthy pregnant women (3.0 ± 4.1 cells/mL; P < .001), healthy nonpregnant women with a history of normal pregnancy (3.4 ± 4.0 cells/mL; P < .001), or women with a history of preeclampsia (2.4 ± 2.0 cells/mL; P < .001). The number of CECs were similar between women with a history of preeclampsia and healthy nonpregnant women with a history of normal pregnancy. Patients with active preeclampsia had significantly higher soluble vascular cell adhesion molecule-1, soluble E-selectin, sVEGFR1, and urinary albumin/creatinine ratio than healthy pregnant women. However, soluble vascular cell adhesion molecule-1, soluble E-selectin, urinary albumin/creatinine ratio were similar in women with a history of preeclampsia and healthy nonpregnant women with a history of normal pregnancy. However, women with a history of preeclampsia had higher sVEGFR1 levels than women with a history of normal pregnancy (P < .05).

CONCLUSION

Markers of endothelial activation, dysfunction, and damage were increased in patients with PE. After the delivery, this activation status is similar to the age-matched nonpregnant women with a history of normal pregnancy. However, sVEGFR-1 levels remain higher in women with a history of preeclampsia compared with women without a history of preeclampsia.