Low Pelvis Research Articles

Intravenous Injection of Tranexamic Acid in Patients with Pelvis or Acetabulum Fractures to Reduce Blood Loss: A Double-Blind, Randomized, Controlled Trial

Background: Despite their low incidence, pelvis and acetabular fractures have a high mortality rate due to extensive hemorrhage. Tranexamic acid (TXA) is an antifibrinolytic drug that inhibits the production of plasminogen. The aim of the current study is to evaluate the safety and efficacy of TXA use for blood loss reduction and the need for blood transfusion in patients with fractures of the pelvis or acetabulum.
 Methods: 108 patients were recruited from two tertiary care hospitals and assigned evenly either to the intervention (TXA) or the control group. TXA group received 15 mg/kg TXA 30 minutes before the fracture reduction and fixation surgery. The number of transfused blood units before, during, and after the surgery was recorded. Blood loss was assessed by calculation of estimated blood loss (EBL), collected blood with drain, collected blood with suction, and weight of the used gauzes during the surgery. The time between fracture occurrence and the surgery, the duration of the surgery, and the days of admission were assessed.
 Results: The mean age was 39.49 ± 15.81 years, and 69.4% were women. 6 patients had pelvic, and 102 patients had acetabulum fractures. The duration of the surgery was not significantly different. The time gap between the reconstructive surgery and fracture occurrence was significantly higher in the TXA group (P = 0.032). The mean postoperative hospitalization time was significantly lower among TXA group patients (P = 0.037). The mean hemoglobin (Hb) in the TXA group was significantly higher, postoperatively (P = 0.028). The mean EBL, the blood volume collected by suction or drain, the weight of the consumed gauze during the surgery, and the number oftransfused blood units were significantly lower in the TXA group. The transfusion rate was significantly lower in patients with a shorter time gap between fracture occurrence and reduction surgery (P = 0.021).
 Conclusion: TXA can decrease blood loss, the transfused blood units during and after the operation, and hospital admission days. Moreover, it did not increase the chance of pulmonary thromboembolism (PTE) or deep vein thrombosis (DVT) in the patients receiving TXA; thus, it can be assumed as a safe and efficient drug in patients with acetabulum or pelvis fractures.

Проявление дисфункции в крестцово-подвздошном суставе при боли в нижней части спины

The aim of the study was to identify the sacroiliac joint dysfunction in patients with various manifestations of vertebrogenic pain in the low back and pelvis and to determine the regimen ofmanual therapy techniques. A comprehensive assessment of examination and treatment of patients with the sacroiliac joint syndrome was carried out. The positive role of the combined treatment including drug therapy and manual therapy was noted. A decrease in the pain syndrome intensity was found in 79.5% of cases, in all groups of patients, already at the beginning of treatment.

A retrospective evaluation of supine pelvic radiography image quality using centring points and anatomical axial rotation, including reliability of measurements (ARLEX-P STUDY)

IntroductionPelvic radiographs are commonly used for the investigation of a variety of conditions. Comparison between examinations requires a consistent radiographic technique but variations in image quality and radiographic centring points are frequently reported in the literature. The aim of this study was to establish the amount of variation in the radiographic centring point (RCP) and pelvic axial rotation (PAR), with a secondary aim of reporting the reliability of such measures. MethodsUsing a previously acquired imaging archive, 633 adult pelvis/hip radiographs were identified on a Picture Archiving and Communication System (PACS). Radiographs with bilateral prostheses, evidence of acute pelvic trauma, projections acquired on a stretcher/trolley and those demonstrating large discontinuity between the detector and X-ray field centre were excluded. To determine centring point variation (+ values denote superior variations) and axial rotation multiple measurements were obtained from each radiograph. A video was used to train five observers and each of these reviewed ten random cases to determine inter- and intra-rater reliability. One of the five observers then performed the measurements on all remaining radiographs. ResultsFollowing exclusions 380 radiographs were evaluated. The median (IQR) RCP deviation from the inter-acetabular line was +22 (+2 to +43) mm where both iliac crests were present and −29 (−45 to −12) mm where they were not. Eleven (3%) cases demonstrate RCP variation from the midline of greater than 25 mm (no bias towards the left or right side). The median (IQR) PAR was 0.0 (−1.5 to 1.4) degrees with greater variance in PAR for male participants (p = 0.004). Almost 60% of inter-rater ICC measurements were categorised as excellent, good or moderate. ConclusionVariations in RCP and PAR exist when evaluating a sample of routinely acquired pelvis radiographs. Some initial factors, such as sex and sub-examination type (full pelvis [XPEL] or low centred pelvis [XHIPB]) have been identified as having a statistical affect on variability. Further research and methods to standardise radiographic techniques is required and must be multidimensional in nature. Implications for practiceSelection of radiographic technique, including RCP, appears to influence components of the pelvis radiograph. Given the increasing clinical requirements for pelvic radiography further standardisation alongside individual optimisation is warranted.

Intraoperative Techniques for Gaining Ileoanal Pouch Reach.

Ileal pouch-anal anastomosis allows for reestablishing gastrointestinal continuity in patients after proctocolectomy. The technical elements of pouch creation and gaining reach into the pelvis are demanding and require a variety of surgical maneuvers to achieve a tension-free anastomosis. We present a brief review of the literature discussing various approaches aimed at improving ileal pouch reach into the low pelvis. Although these techniques are used with different frequencies, they serve as important adjuncts to the gastrointestinal surgeons' armamentarium.

The Profile of Belgian Osteopaths: A Cross-Sectional Survey.

This study gives an update on the characteristics of Belgian osteopaths five years after the Benelux Osteosurvey. Additional new data were collected on their professional identity and views on the profession. All Belgian osteopaths who could be contacted (n = 1473) were invited to complete a voluntary, online-based, closed-ended survey distributed between May and September 2018. The survey, composed of 52 questions and seven sections, was formally translated from English to Dutch and French and adapted from the original version. Adult, self-defined osteopaths working in Belgium were eligible. Recruitment of participants was performed through all professional associations and the InterMutualistic Agency. Descriptive statistics were used to analyse the data. The survey was completed by 332 osteopaths. Thirty-one per cent of the respondents were female. Almost all the respondents were self-employed (99.4%); half of them worked as part of a team (47.6%). Most respondents had a 5-year part-time training, and the majority had a previous academic degree, mainly in physical therapy (65.8%). According to respondents, most patients seek care for lumbar non-specific low back, pelvis and neck pain. Most respondents strongly define themselves as osteopaths and advertise themselves exclusively as osteopaths. This survey provided an update of the current characteristics of Belgian osteopathic practitioners and added new information on their professional identity and views on the profession. The information provided could contribute to the body of evidence used by stakeholders and policymakers in the future regulation of the profession in Belgium.

Robotic Surgery for the Ileal Pouch.

A robotic approach to total colectomy/proctectomy and ileal pouch reconstruction would seem to be a sensible use of the platform's enhanced reach, visualization, and dexterity. The study aimed to discuss current published data for robotic ileal pouch surgery. The study selection included a paucity of published data to date, representing early learning curves and case series with small numbers. Current robotic platforms may offer advantages, particularly in the low pelvis beyond what is found with a laparoscopic approach.

Pelvic pain in Maigne\u2019s syndrome\u2014a multi-segmental approach

BackgroundMaigne’s syndrome is a poorly understood condition that affects the thoracolumbar junction. The symptoms can range from pain in the low back, pelvis, hip, lower abdomen, and groin. These symptoms can have bio-mechanical and neurophysiological attributions due to the complexity of spinal mechanics. Thoraco-lumbar junction (T12-L1) is a transitional zone with a higher degree of mean angular motion and a mean translation motion than T10-T11 and T11-T12. This higher degree of translational and rotation mobility predisposes these segments to a higher degree of stress, making them more prone to biomechanical faults such as dysfunctions and positional faults. These altered static and dynamic mechanics can create a cascade of problems along the biomechanical chain. The co-existence of thoracolumbar junction problems with pelvic pain and dysfunctions strengthens the idea of regional interdependence.Case presentationThe patient is a 44-year-old Caucasian male who reported pain in the low back with symptoms radiating to the right hip, iliac region, lower abdomen, and gluteal region. The patient tested positive for Sacroiliac joint dysfunction with both Laslett’s cluster testing and palpatory sacroiliac examination. In addition, the segmental examination showed restriction in thoracolumbar junction with positive skin rolling test and hypomobility in manual segmental testing. Thus, the manual therapy treatment targeted the thoracolumbar junction and sacroiliac joint to address the underlying biomechanical dysfunctions.ConclusionsThe manual therapy targeting both sacroiliac and thoracolumbar spine can improve pelvic and thoracic spine mobility. In addition, therapeutic exercises can focus on enhancing anterior and posterior chain force generation capacity. This combined approach helped improve functional outcomes with a significant decrease in the Modified Oswestry Disability index and significant improvement on Visual analog scale.

Robotic Versus Laparoscopic Surgery for Rectal Cancer: A Comprehensive Review of Oncological Outcomes.

The treatment of rectal cancer is complex and involves specialized multidisciplinary care, although the tenet is still rooted in a high-quality total mesorectal excision. The robotic platform is one of many tools in the arsenal to assist dissection in the low pelvis. This article is a comprehensive review of the oncological outcome comparing robotic vs laparoscopic rectal cancer resection, with a particular focus on total mesorectal excision. There is no statistical difference in total mesorectal grade, circumferential margin, distal margin, and lymph node harvest. Survival data are less mature, but there is also no difference in disease-free or overall survival between the two techniques. Although additional randomized trials are still needed to validate these findings, both techniques are currently acceptable in the minimally invasive treatment of rectal cancer, and surgeon preference is paramount to safe and optimal resection.

Therapeutic Radiation in Genetically Engineered Mouse Models of Cancer

Some drugs that target tumor metabolism are minimally effective in vitro but limit proliferation in vivo. Our goal was to develop a preclinical platform enabling us to test drugs that target cancer cell metabolism in combination with radiation therapy in vivo. Here we report the initial results of preclinical studies in autochthonous mouse models of prostate and colorectal cancer using radiation as monotherapy.A dose escalation study was performed in C57BL/6 wild-type mice using 1-5 fraction regimens with a BED of 90, 130, 180, and 250 (a/b = 3). Flank xenograft models of prostate cancer (22Rv1 and PC3 cells) were treated with 24 Gy in 4 fractions or sham irradiated (n = 10 animal per group, 40 animals total). Pb-Cre;Ptenfl/fl;p53fl/fl mice (autochthonous prostate cancer model) age 5 months were randomly assigned to two dose regimens (37.5 Gy in 5 fractions or 45 Gy in 5 fractions) or sham irradiation (n = 11-14 per group). Survival was estimated by Kaplan-Meier Analysis. Colorectal tumors were induced in male and female Villin-CreER;Apcfl/fl mice by intramucosal tamoxifen injection. Mice were assigned 2:1 to 37.5 Gy or sham irradiation (n = 10-15 per group). Treatment effect was measured as percent survival 6 months after tumor induction. In all cases pathologic response rate was determined using serial histologic sections and proliferation by Ki-67 immunohistochemistry.For a 2 cm field directed at the low abdomen and pelvis of mice, the maximum tolerated dose of radiation was 45 Gy delivered in 5 fractions. The intestinal tract was identified as the dose limiting organ for abdominopelvic radiation. In irradiated flank xenografts, growth delay was observed for all tumors compared with 100% progression in unirradiated controls. Pathologic complete response was observed in 1 of 10 (10%) 22Rv1 xenografts and 4 of 10 (40%) PC3 xenografts. In the autochthonous prostate cancer model, median survival was significantly improved in the 45 Gy (236 days, P < 0.0001) and 37.5 Gy (227 days, P = 0.0007) arms relative to control (206 days). Irradiated tumors were also smaller relative to control (mean difference -2.637 grams [95% CI -4.617 to -0.6563, P = 0.0153); however, all mice eventually died of local tumor progression. In the autochthonous colorectal cancer model, survival at 6 months was significantly improved in the radiation group relative to control (100% vs 40%, P = 0.0012). In both prostate and colorectal cancer autochthonous models the proliferation index at time of death (prostate) or 6 months after tumor induction (colorectal) was similar in irradiated and control cohorts.Hypofractionated radiation therapy can be safely administered to the abdominopelvic region in mice and improves survival in autochthonous mouse models of prostate and colorectal cancer. Radiation can induce pathologic complete responses in flank xenografts, but not autochthonous tumors, suggesting the presence of radioresistant persister cells in these models.

Reproducibility and Accuracy of Pelvic Tilt in Predicting the Difference Between Pelvic Incidence and Lumbar Lordosis Value

We investigated the pelvic morphologic factors that determine the degree of pelvic incidence (PI)-lumbar lordosis (LL) mismatch. Overall, 306 patients were included. The regional and global sagittal parameters were measured. Linear regression analyses were performed for 4 pelvic parameters and PI-LL mismatch. E1 and E2 were defined as linear regression equations between pelvic tilt (PT) and PI-LL mismatch and PI and PI-LL mismatch, respectively. The patients were categorized by cluster analysis using the hierarchal method for the 4 pelvic parameters. E1 and E2 showed statistical significance; however, the coefficient of determination of E1 was higher than that of E2 (R2= 0.675 vs. 0.238; P < 0.01). Sex, LL, E1, and E2 showed significant differences in the regional parameters. The T1 pelvic angle (TPA), spinosacral angle (SSA), and incidence angle of inflection points (IAIPs) showed significant differences in global parameters (P < 0.01). The IAIPs and TPA were low in the anteverted pelvis group and high in the retroverted pelvis group (P < 0.001). The SSA was low inthe small pelvis group and high in the large pelvis group (P< 0.001). The proportion of women in the large pelvis group (93%) was significantly higher than that in the other groups (P < 0.01). The individual differences between the PI and LL values can be more accurately determined using the individual PT, and the optimal PT amount will differ depending on the pelvis shape. The increase in the TPA and IAIPs corresponded to the PT, and the SSA increased in accordance with the pelvic size.

Transanal total mesorectal excision outcomes for advanced rectal cancer in a complex surgical population.

Total mesorectal excision (TME) is the gold standard for oncologic resection in low and mid rectal cancers. However, abdominal approaches to TME can be hampered by poor visibility, inadequate retraction, and distal margin delineation. Transanal TME (taTME) is a promising hybrid technique that was developed to mitigate the difficulties of operating in the low pelvis and to optimize the circumferential resection and distal margins. The objective of this study was to characterize our experience implementing taTME at our institution in a technically challenging patient population. We performed a retrospective review of consecutive patients who underwent taTMEs between November 2013 and May 2019 for rectal cancer at a tertiary community cancer center. Outcome measures included pathologic grading of TME specimen, post-operative complications, and oncologic outcomes. Forty-four patients with mid and low rectal cancer underwent low anterior resection via taTME. The most common staging modality was rectal MRI which demonstrated T3 or T4 tumors in 89% of our patients prior to neoadjuvant. Eighty-six percent of patients underwent neoadjuvant chemoradiation. The initial cases were performed sequentially as a single team, but we later transitioned to a synchronous, two-team approach. Ninety-one percent of TME grades were complete or near complete. Only one patient (2.3%) had a positive circumferential margin. Six patients developed anastomotic leaks with an overall anastomotic complication rate of 18.2%. Two patients (4.5%) with primary rectal cancer developed local recurrence, one of which developed multifocal local recurrence. Using the taTME approach on selected locally advanced low rectal cancers, especially in technically complex irradiated and obese male patients, has yielded comparably safe and effective outcomes to laparoscopic proctectomy.

Serious adverse events following lumbar spine mobilization or manipulation and potential associated factors: a systematic review protocol.

The objectives of this review are to describe the serious adverse events reported in the literature following lumbopelvic mobilization and manipulation, and identify patient, provider, and/or treatment factors that may be associated with serious adverse events after these interventions. Spinal mobilization and manipulation are types of conservative care commonly used to treat people with low back pain and other musculoskeletal conditions of the lumbar spine and pelvis. Although most adverse events following these interventions are benign and transient, serious adverse events have been reported mostly following spinal manipulative therapy. Given the significant impact serious adverse events can have on patients' lives, identifying factors that may be associated with serious adverse events following spinal mobilization and manipulation of the low back and pelvis would allow for a more specific pre-treatment screening, potentially reducing the occurrence of serious adverse events following these popular interventions and contributing to a safer treatment delivery. This review will consider interventional and observational studies that report serious adverse events following lumbopelvic spinal mobilization or manipulation experienced by people of any age. Examples of serious adverse events include disc herniation, cauda equina syndrome, and vertebral fracture. MEDLINE, Embase, CINAHL, PubMed, The Cochrane Database of Systematic Reviews/Central Register of Controlled Trials, and Index to Chiropractic Literature (ICL) databases will be searched as well as OpenGrey and ProQuest Dissertations and Theses. Two independent reviewers will screen titles and abstracts of identified references as well as the full text of identified studies, and extract data following a standardized data extraction form. Data will be summarized, categorized, and a comprehensive narrative summary will be presented. PROSPERO CRD42019122339.

Morphology of the Greater Trochanter: An Assessment of Anatomic Variation and Canal Overhang

BackgroundVarus malposition is a risk of early failure in total hip arthroplasty. The degree to which the tip of the greater trochanter (GT) overhangs the canal can increase this risk. Although we know proximal femoral anatomy is variable, no study has addressed variations in medial overhang of the GT on plain radiographs. MethodsAll low anteroposterior pelvis radiographs more than 1 year were reviewed 3 times by 2 orthopaedic surgeons and one radiologist. The canal width (CW) was measured 10 cm below the lesser trochanter. Canal overhang (CO) was defined by the distance between the lateral medullary canal and a parallel line beginning at the most medial aspect of the GT. The overhang index (OI) is defined as the percentage of the canal overhung by the GT. ResultsThe mean CW was 13.5 mm, mean CO 16.4 mm, and mean OI 1.22. Hips were then classified as the following: (A) OI < 0.5 (n = 8), (B) OI 0.5-1.0 (n = 78), (C) OI 1.0-1.5 (n = 191), and (D) OI > 1.5 (n = 68). Intraobserver reliability was excellent for all measures: 0.89 (confidence interval: 0.87-0.91) for CW, 0.96 (0.95-0.97) for CO, and 0.97 (0.97-0.98) for OI. Interobserver reliability was good for CW 0.75 (0.70-0.79) and excellent for CO 0.90 (0.88-0.92) and OI 0.95 (0.94-0.96). ConclusionsVariations in the morphology of the proximal femur can predispose to varus component malposition. The degree to which the GT overhangs the canal can be quantified and classified based on plain films. This can aid in preoperative planning and help guide intraoperative proximal femoral preparation.

Lower extremity kinetics and muscle activation during gait are significantly different during and after pregnancy compared to nulliparous females

BackgroundLow back, pelvic, and lower extremity pain are common during and after pregnancy. Understanding differences in mechanics between pregnant and non-pregnant females is a first step toward identifying potential pathological mechanisms. The primary purpose of this study was to compare joint kinetics and muscle activation during gait between females during and after pregnancy to nulliparous females. MethodsTwenty pregnant females completed testing on three occasions (second trimester, third trimester, and post-partum), while 20 matched, nulliparous controls were tested once. Motion capture, force data, and surface electromyography were averaged across seven trials during gait. Lower extremity kinematics, lower extremity moments and work normalized to pre-pregnancy body mass, work distribution, and peak and average muscle activation amplitude were calculated. Independent t-tests were conducted between pregnant and nulliparous females at each time point. ResultsCompared to controls, peak hip abductor moments were greater throughout and after pregnancy. Females in second trimester also demonstrated greater sagittal negative ankle work and greater percent contribution of the ankle and smaller percent contribution of the hip to negative work. Compared to controls, during third trimester there were greater knee abductor, ankle plantarflexor, and ankle dorsiflexor moments and greater work at the ankle and total work. Several moment and work variables continued to be elevated post-partum compared to controls. Gluteus maximus muscle activation amplitude was smaller in second trimester and post-partum compared to controls. SignificanceWhile overall joint demands were greater during and after pregnancy, there was a smaller relative sagittal utilization of the hip early in pregnancy and smaller gluteus maximus muscle amplitude during second trimester and post-partum. Because the gluteus maximus muscle contributes to force closure and dynamic stability of the low back and pelvis, relative gluteus maximus disuse, concurrent with increased joint loads, could potentially contribute to pain during and after pregnancy.

Transanal Total Mesorectal Excision: Description of the Technique.

Surgery remains the gold standard for the treatment of locally advanced rectal cancer. The most effective approach to reduce locoregional recurrence is total mesorectal excision (TME). However, obtaining an optimal TME is demanding, especially in low rectal tumors and anatomically unfavorable pelvis. Transanal TME (taTME) was developed to facilitate low pelvis dissection and potentially provide optimal outcomes for oncologic resection. Current studies have reported satisfactory short-term outcomes. However, taTME is a technically challenging procedure and must be learned in an appropriate training process to allow for a safe implementation. Previous experience in laparoscopic and transanal surgery is strongly recommended. In this work, we provide a detailed discussion of the technique, based on the realization of more than 400 taTME interventions.

Efficacy of Menthol Infused Kinesiotaping in Forward Bending (Flexion) of Lumbar Spine in Mechanical Low Back Pain Patients: Interventional Study

Background: In all developed countries low back pain (LBP) is a considerable health problem which is thecommonest problem treated in primary healthcare setting. It is defined as pain, muscle tension, or stiffnesslocalized above the inferior gluteal folds and below the costal margin, with or without sciatica. The majorsymptoms of nonspecific LBP are disability and pain.Aims & Objectives: To evaluate the effect of menthol infused kinesiotaping and conventional therapyin forward bending (flexion) of the lumbar spine in mechanical low back pain patients. Sample size:138Subjects Group A -69 Subjects & Group B – 69 Subjects Study Design: Interventional Study setting: RaviNair Physiotherapy College, Datta Meghe Institute of Medical Sciences (Deemed University), Sawangi(Meghe), Wardha Sample and Sampling Method: 138 Subjects were randomly selected and assigned in 2groups, as Group 1(control group), Group 2 (Interventional group) in equal numbers. The Patients havingmechanical low back pain, with the age group between 18-50 both genders & Willing to participate wereincluded & the patients who were having PIVD with instability and radicular symptoms,Operated casesof spine, Lumbar spondylosis, lumbarcanal stenosis, spondylolisthesis, sensory deficits, Malignancy,Tuberculosis, Any infection or tumour around low back and pelvis were excluded.Result: Mean pain on VAS in group A it was 3.52 ± 0.75 and in group B it was 5.53±0.76, Mean M-schoberstest score in group A was 4.209±0.48 and in group B it was 3.653±0.25.Conclusion: The inferences from the present study suggest that Menthol infused Kinesiotaping is moreeffective than Conventional therapy in management of Low back pain.

Regular Physical Exercise for Prevention and Treatment of Low Back Pain: A Systematic Review

Introduction: Low back pain is one among the main health problems during life time with a high prevalence, which causes functional loss and reduced productivity. Low back pain specifically affects the lumbar region of the spine. The pain is usually related with mostly muscle tension, and often limits our range of movement. Low back pain (LBP) is a common problem involving the muscles, nerves, and bones of the back. Objective: The purposes of this review study are to describe about low back pain and to examine the most recommended exercise for prevention and management of low back pain, to review scientific evidence on the effect of physical exercise on low back pain and to review the risk factors which lead to develop low back pain. Methods: The review of related literature search strategy were used the terms in relation with LBP and exercise, exercise prescription for LBP, exercise testing for LBP, recommended exercise for LBP, the effect of exercise on back pain and etc. A search was conducted in the following databases: online research databases, web of knowledge, and science direct, sport discus, Google scholar and from other relevant citations. Results: Based on LBP analysis and outcome functions, can be categorized as acute (<6 wk), sub-acute (6-12 wk), and chronic. Risk factors associated with low-back pain include age greater than 34 years, degenerative diseases such as arthritis or osteoporosis, a family or personal history of back pain or trauma, a sedentary lifestyle, low job satisfaction, and low socioeconomic status, excess body weight, psychological stress or depression and physically hard work. Common symptoms of LBP: pain that is dull or achy, contained to the low back, stinging, burning pain that moves from the low back to the backs of the thighs, sometimes into the lower legs or feet, muscle spasms and tightness in the low back, pelvis, and hips, pain that worsens after prolonged sitting or standing, difficulty standing up straight, walking, or going from standing to sitting and pain that worsens with bending, lifting, standing or walking. Regular exercise particularly endurance and stretching exercises such as walking, biking, and swimming, has the good evidence of efficacy among exercise regimen, whether for whom with acute, sub-acute, or chronic low back pain. Generally, to reduce and manage LBP following low-impact endurance, strength and stretching regular exercises are advised.

Bone mineral density at different sites and 5 years mortality in end-stage renal disease patients: A cohort study.

Bone disease with osteoporosis and renal osteodystrophy is common in end stage renal disease (ESRD) patients and associates with cardiovascular disease (CVD) and increased morbimortality. We investigated associations of low bone mineral density (BMD) at various bone sites with five year all-cause and CVD mortality in ESRD patients. In a post hoc analysis of 426 ESRD patients (median age 56 years, 62% men) starting dialysis, BMD (whole-body dual-energy X-ray absorptiometry, DXA), body composition, nutritional status (subjective global assessment, SGA), handgrip strength (%HGS), Framingham CVD risk score (FRS) and biochemical biomarkers of nutrition and inflammation were assessed. We used the Fine and Gray competing risk regression analysis to assess survival analysis. In multivariate logistic regression analysis, %HGS and intact parathyroid hormone associated with low tertile of: BMDtotal, BMDhead and BMDpelvis, after adjusting for FRS, SGA, %HGS, s-albumin, hsCRP, lean body mass index and year of recruitment. Patients with high FRS had low BMDhead (p<0.001). Low tertile of BMDtotal (sHR, 1.53), BMDhead (sHR 1.54) and BMDpelvis (sHR 1.60) associated with increased all-cause mortality whereas no such associations were found for the trabecular bone rich sites BMD arm, leg, trunk, rib or spine. Low tertile of BMDtotal (sHR 1.94), BMDhead (sHR 1.68), BMDleg (sHR 2.25) and BMDpelvis (sHR 2.45) associated with increased CVD mortality whereas BMD at other sites did not associate with CVD mortality. Low head and pelvis BMD, and low total BMD, as assessed by whole-body DXA, were independent predictors of increased risk of all-cause and CVD mortality. Cortical BMD appeared to have stronger association to survival in ESRD than trabecular BMD.

Multi-Institutional Observational Study of Prophylactic Extended-Field Concurrent Chemoradiotherapy Using Weekly Cisplatin for Patients with Pelvic Node-Positive Cervical Cancer in East and Southeast Asia

This multi-institutional observational study conducted among 11 Asian countries aimed to assess the clinical outcomes of prophylactic extended-field concurrent chemoradiotherapy using weekly cisplatin for patients with locally advanced cervical cancer in East and Southeast Asia. Uterine cervical cancer is among the most common cancers in East and Southeast Asia, and the mortality rate remains high in these countries because many patients present at a relatively advanced stage. It is necessary to develop new treatment methods for locally advanced cervical cancer suitable for developing countries. The pattern of spread in cervical cancer appears to be orderly, initially involving the low pelvis and then progressing to high pelvic lymph nodes (PLN) and para-aortic lymph nodes (PALN). To control occult PALN metastasis, extended-field radiation therapy including the para-aortic region and PLN region may be one of the effective treatments. Between October 2007 and May 2016, 106 patients with untreated squamous cell carcinoma of the cervix were enrolled in the present study. Radiotherapy consisted of pelvic irradiation (total dose, 50 Gy/25 fractions including central shielding), prophylactic para-aortic regional irradiation (36-40 Gy/20 fractions), and either high- or low-dose-rate intracavitary brachytherapy (ICBT) according to institutional practice. The planned Point A dose was 21-28 Gy in 3-4 fractions for high-dose-rate ICBT and 40-41 Gy in 1-2 fractions for low-dose-rate ICBT. Five cycles of weekly cisplatin (40 mg/m2) were administered during the radiotherapy course. A total of 106 patients were enrolled. Of these, 10 had major protocol violations and 2 did not receive treatment because of worsened general condition. Thus, 95 patients were evaluable. The median follow-up was 56 months. Of the 95 patients, 76 (80%) received four or five cycles of chemotherapy. Acute grade 3 leukopenia was observed in 20 (21%) of the patients, and late grade 3 gastrointestinal toxicity was observed in 3%. The 2-year local control, progression-free survival, and overall survival rate for all patients were 96%, 78%, and 90%, respectively. The results indicated that prophylactic extended-field concurrent chemoradiotherapy using weekly cisplatin is feasible and effective for patients with locally advanced cervical cancer in East and Southeast Asia.

Control of PET-Positive Lymph Nodes Treated with Definitive Chemoradiation in Locally Advanced Cervical Cancer

Pelvic and/or para-aortic lymph node (LN) involvement at diagnosis is a significant prognostic factor for cervical cancer. The optimal treatment technique for nodal disease has not been well established. We retrospectively reviewed the treatment and outcomes of patients with PET-positive LN metastases treated with definitive chemoradiation at our institution. Cervical cancer patients with PET-positive nodes treated with curative intent at our institution from 2006 to 2017 were identified. All patients received external beam radiotherapy with concurrent weekly cisplatin followed by brachytherapy. Patients with no follow-up imaging were excluded. Nodal treatment techniques (no boost [NB] vs. sequential boost [SEB] vs. simultaneously integrated boost [SIB]) were recorded. Total dose to each LN was converted to equivalent of 2-Gy (EQD2). Nodal control was assessed using follow-up PET/CT and/or CT imaging. Nodal failure was defined as persistence or increase in PET avidity or increase in size on CT. Nodal failure free rates were calculated using the maximum likelihood method. A total of 136 positive nodes from 43 patients were included in the analysis. Nodal distribution was as follows: 93 low pelvis (external iliac, internal iliac, obturator), 22 common iliac, 20 para-aortic, and 1 inguinal. The involved LN had a median pre-treatment size of 1.3 cm (range: 0.5-4.5 cm) and median standardized uptake value (SUV) of 7.8 (range: 2.3-19.2). A majority of the nodes were treated with intensity modulated radiation therapy with an SEB (45.6%) or SIB (45.6%) to a median cumulative EQD2 of 5448 cGy (range: 4425-6549 cGy). At a median follow up of 763 days, 9 of the 136 (6.6%) treated nodes in 6 of the 43 (14.0%) patients experienced failure: 6 low pelvic, 2 common iliac, and 1 para-aortic. The failed LN had a median size of 1.5 cm (range: 0.9-3.2 cm) and median SUV of 6.1 (range: 2.3-14.3). Median time from treatment initiation to nodal failure was 113 days (range: 85-447 days). The 1- and 2-year nodal failure free rates were 86.5% and 76.9% in the cohort of 43 patients, and 95.0% and 87.3% for all 136 metastatic LN. Crude control rates were 95.2% (59/62) in LN treated with SEB compared to 91.9% (57/62) in LN treated with SIB. There were no acute grade 3+ non-hematologic toxicities. Nine patients experienced late grade 3-5 toxicities, including fistula formation (n=4), small bowel obstruction (n=2), rectal bleeding (n=2), ureteral stricture (n=1), and vaginal stenosis (n=1). Concurrent chemoradiotherapy using either a sequential or simultaneous integrated boost provides excellent local control of PET-positive LN in cervical cancer patients and is well tolerated.