Specific Patient Groups Research Articles

Insights from a Veterans Health Administration Database Analysis: Immune-Related Adverse Effects of Immunotherapy in Relapsed/Refractory Classical Hodgkin Lymphoma

Introduction: Despite the high success rates in treating Classical Hodgkin lymphoma (cHL), a specific group of patients still experience relapsed or refractory (R/R) disease, affecting approximately 10-20% of cases. The use of immunotherapy with checkpoint inhibitors (CPIs) has emerged as a promising approach, demonstrating impressive efficacy in R/R cHL patients [2,3]. However, there is a lack of real-world evidence regarding the immune-related adverse effects (irAEs) associated with immunotherapy in this relatively rare patient population. To address this gap, this study leverages the Veterans Health Administration (VHA) database to investigate irAEs, providing valuable insights to optimize treatment decisions. Methods: A retrospective analysis was conducted on Hodgkin lymphoma patients who received immunotherapy from the VHA Corporate Data Warehouse from 2014-2022. Patients came from all 18 Veterans Integrated Service Networks, spanning all 50 states and US territories. Data was collected to determine the baseline characteristics, disease factors, detailed AE occurrence as well as outcomes in this cohort. Results: The analysis included 68 cHL patients who received immunotherapy. The cohort had a mean age of 62.2 years (SD=15.9) and a median age of 66 years (IQR 54-72). The majority of the patients were male (97%) and White (80%) and only 6% of patients had a history of autoimmune disease. The distribution of patients across stages was as follows: Stage 1 (5%), Stage 2 (15%), Stage 3 (40%), and Stage 4 (40%). Additionally, 20% of patients underwent autologous stem cell transplantation (ASCT), with 10% receiving immunotherapy before transplantation and the remaining 10% receiving it post-transplant. In our cohort, 31% had documented adverse effects related to immunotherapy. The most common adverse events observed were hematological/cytopenias (8%), dermatologic/rash (6%), endocrine-related (6%), pneumonitis (5%), hepatitis (2%), myocarditis (2%), and other adverse events (8%). Discontinuation of therapy due to irAEs occurred in 12% of patients. These findings align with prior literature, which has consistently reported thyroid gland dysfunction (such as hypothyroidism and thyroiditis) and rash as the most frequently observed immune-related adverse events [2]. The most common management of irAEs were holding therapy followed by use of corticosteroids. Kaplan-Meier survival analysis revealed a median overall survival of 55.4 months (IQR=37.2-59.2), with a median follow-up time of 36.4 months (IQR=21.6 -58.6). Conclusion: This study, utilizing the VA database, provides a distinctive and valuable perspective on irAEs associated with immunotherapy in cHL patients. By leveraging a comprehensive database on a large scale, this study significantly enhances our comprehension of immunotherapy in the context of cHL, thereby offering crucial guidance for treatment decisions concerning relapsed/refractory Hodgkin lymphoma patients. The findings of this study strongly indicate the sustained benefits of immune checkpoint inhibitors (ICI) in this population, emphasizing the importance of close patient monitoring to detect and manage immune-related adverse events at an early stage, thereby preventing life-threatening complications.

Atrial Fibrillation Patients with Immune Thrombocytopenia: A Review of Management Options and Bleeding Risks

Aim : The objective of this research is to review the bleeding risks in patients with atrial fibrillation (Afib) and immune thrombocytopenia (ITP) and explore various management strategies to formulate an optimal therapeutic approach that improves the prognosis of these patients. Methods: In this study, we devised our search approach by utilizing PubMed's Medical Subject Headings (MeSH) terms and incorporating pertinent keywords extracted from article titles and abstracts. To ensure a comprehensive scope, we integrated terms associated with immune thrombocytopenia purpura, such as “Immune Thrombocytopenia,” and similar expressions. Additionally, terms related to atrial fibrillation, including “atrial fibrillation,” were included to identify articles discussing atrial fibrillation in the context of immune thrombocytopenia. To adapt the initial search strategy for Embase, Web of Science, and Scopus databases, we employed a polyglot translator. All identified studies resulting from the search strategy were imported into EndNote, where duplicate articles were meticulously removed. The remaining studies were then transferred to Rayyan for further duplicate elimination and to initiate the screening process. The study incorporates full-text articles, submitted abstracts, and conference abstracts. Excluded from this analysis were studies falling into the following categories: (1) animal studies, (2) reviews or non-original articles, and (3) non-English articles. Results: A total of 1891 articles were retrieved from four databases, and after careful selection, 14 relevant full-text articles were analyzed. Among these, 12 studies investigated the efficacy of anticoagulants in managing cases of concurrent Afib and ITP as well as their bleeding risks. Comparing bleeding risk between groups was usually done through measuring by CHA 2DS 2 VASc or HAS BLED scoring systems and survival was also compared by using Kaplan-Meier curves A few of them also compared the efficacy and safety of warfarin against Non-Vitamin K Antagonists which has shown that Non-Vitamin K Antagonists have a lower event rate of major bleeding, lower hazard ration of systemic embolism and higher survival rate compared to warfarin The remaining two papers explored the efficacy and safety of surgical interventions, specifically left atrial appendage closure. Many studies reported that anticoagulant therapies were associated with reduced bleeding risk and have shown promising outcomes in managing patients with Afib and ITP. Additionally, percutaneous left atrial appendage closure has been reported to be a potentially safe management option for atrial fibrillation in patients with primary hemostatic disorders, including thrombocytopenia. Conclusion: In essence, this review focused on investigating the bleeding risk associated with atrial fibrillation (Afib) in patients with immune thrombocytopenia (ITP) and examining available management strategies. While the precise pathophysiological mechanisms linking atrial fibrillation and ITP remain incompletely understood, the review emphasized the intricate interplay between thromboembolic risk and bleeding complications in this specific patient group. The findings suggest that certain anticoagulation regimens and also left atrial appendage closure have shown promising safety and effectiveness in Afib patients with thrombocytopenia. Nevertheless, further research with larger sample sizes and diverse populations is needed to enhance our understanding of the Afib-ITP relationship. Such studies will yield more definitive conclusions and valuable insights into optimal anticoagulation approaches and alternative therapies for patients with both Afib and ITP.

Transportation Cost Is a Significant Barrier to Quality Care for Hematologic Malignancy Patients in a Minority-Rich, Socioeconomically Disadvantaged Population

Background Transportation to and from clinics is a barrier to care for cancer patients. Depending on treatment regimen, patients' clinic visits could be frequent, and this could lead to cumulative financial toxicity. We aim to study transportation costs as a barrier to care in hematologic malignancy patients with new cancer diagnosis and in patients referred for cellular therapy at a tertiary care academic Medical Center located in Bronx, NY. A deeper understanding of the role of financial toxicity in relation to transportation will help to understand the effect this may have on health outcomes and ways to overcome this barrier to medical care that predominantly affects minorities from low socioeconomic backgrounds. Methods This is an ongoing prospective survey-based study carried out at Montefiore Medical center, Bronx NY. Adult patients with either a newly diagnosed (ND) hematologic malignancy (HM) or those undergoing cellular therapy (CT), such as autologous, allogeneic stem cell transplant or CAR-T therapy are identified at Montefiore Oncology clinics. Patients who agree to participate are given a research team generated 5-question survey to gauge their concerns surrounding transportation for oncology visits. Responses are grouped according to cohort (ND vs CT). Sociodemographic information was collected, and race and ethnicity were self-identified. For patients with long-term follow-up, we also capture no-show rates. The study is approved by the local IRB. Results There were 72 patients across groups at the time of analysis. Forty-one patients completed surveys for the ND group and 31 for the CT group. Twelve (29%) and three (7%) patients identified their race as Black and White respectively in ND group with 8 (26%) and 4 (13%) as Black and White in the CT group, respectively. In ND, 22 (54%) patients identified their ethnicity as Hispanic/Latino with 17 (55%) in CT. The median distances between Montefiore Hospital and the patient's homes according to zip code were 3.59 miles (mi) with range 0-81.42 mi for ND and 3.47 mi with range 0-50.35 mi in the CT group. Nearly 50% of patients in ND and CT groups reported concerns about access and cost of transportation to the oncology clinic. Insurance paid for transportation for only 12.5 and 17.9% of patients in ND and CT groups, respectively. Across groups, over half of patients (52.5%) used a personal vehicle to get to appointments in the ND group with 46.5% in the CT group. Many of patients in the ND (18%) and CT (17%) group reported missing their appointments due to transportation issues. Ten percent of patients in ND and 13% in CT groups reported missing appointments due to caregiver issues. Fifty-nine percent of patients in ND and 47% in CT groups reported feeling comfortable with phone/video visits. Of patients with long term follow up and >10% no-show rates, 60% in ND and 50% in CT groups use a personal vehicle. Conclusion We report preliminary results from an ongoing prospective study evaluating transportation barriers to care for hematologic malignancy patients in an underserved population in Bronx. Even in a well-connected city such as New York City, half of patients with new hematologic cancer and those referred for cell therapy are worried about access and cost of transportation to and from medical appointments. Although the distance between clinic and home is less than 5 miles for over half of patients, patients are still missing appointments due to transportation and caregiver issues. Patients who travel using personal vehicles may also have difficulty driving due to chemotherapy or being accompanied for visits due to caregiver issues. As many novel cellular therapies recently approved are only available at tertiary centers, transportation is expected to be a bigger factor affecting social determinants of health. One potential solution is to incorporate more tele-visits as nearly half our patients are amenable to them. More information including follow-up surveys and the number of missed appointments is being collected to identify specific groups of patients who will benefit from interventions.

Does cardiovascular risk matter in IBD patients?

Cardiovascular and thromboembolic risks are increasing in the population as a whole and therefore also in inflammatory bowel disease (IBD) patients. Obesity is a worldwide challenge also affecting the IBD population, and a causal association with Crohn's disease may exist. IBD itself, particularly when active, is also associated with a significant risk of thromboembolic and cardiovascular events such as myocardial infarction and stroke. Cardiovascular risk is also a significant consideration when using Janus kinase (JAK) inhibitors and sphingosine 1 phosphate (S1P) receptor modulators to treat IBD. JAK inhibitors - such as tofacitinib - are associated with several cardiovascular and venous thromboembolic risks, including hypertension and alterations in lipid profiles - specifically, increased LDL cholesterol and triglycerides - which may contribute to atherosclerosis and cardiovascular disease. S1P receptor modulators pose a slightly different set of cardiovascular risks. Initially, these drugs can cause transient bradycardia and atrioventricular (AV) block, leading to bradycardia. Moreover, they may induce QT interval prolongation, which increases the risk of life-threatening arrhythmias such as torsades de pointes. Some patients may also experience hypertension as a side effect. In this context, IBD healthcare providers need to be alert to the assessment of cardiovascular risk - particularly as cardiovascular events appear to be confined to specific patient groups with pre-existing risk factors. In addition, the potential for S1P modulator drug interactions requires a higher level of vigilance in patients with polypharmacy compared to biologics. Cardiovascular risk is not static, and updated assessment will need to become part of the routine in many IBD units.

Prognostic significance of PNI, SIRI and LIPI in non small-cell lung cancer

Aim: Non-small cell lung cancer (NSCLC) is one of the 3 most common and deadly cancers. The aim of the current study is to investigate whether Prognostic Nutritional Index /PNI), Systemic Immune-Inflammation Index (SIRI), Lung Immune Prognostic Index (LIPI) has a prognostic significance in patients with metastatic NSLCL. Methods: Patients diagnosed with pathologically confirmed metastatic NSCLC in 5 different hospitals in Turkey between 2016-2022 were included in our study and analyzed retrospectively. overall survival (OS) and progression-free survival (PFS) were recorded. Results: The median PFS was 5.50 months, while the median OS was 16.03 months. Median OS was 14.86 months for the PNI-Low group and 17.2 months for the PNI-High group (p: <0.121). The median OS of the PNI-Low group was shorter than the PNI-High group, but there was no statistically significant difference between the groups. Median OS was 19.86 months for the SIRI-Low group and 14.23 months for the SIRI-High group (p: <0.112). Median OS was 17.76, 15.13, 13.73 months for the LIPI-Low, LIPI-intermediate group and LIPI-high group, there was no statistically significant difference between the groups (p: <0.391) Conclusion: In conclusion, PNI and SIRI may be significant in a prospective study in a specific patient group to be performed with a larger number of patients to predict the prognosis of patients with metastatic NSCLC.

No major differences in perinatal and maternal outcomes between uninterrupted embryo culture in time-lapse system and conventional embryo culture.

Is embryo culture in a closed time-lapse system associated with any differences in perinatal and maternal outcomes in comparison to conventional culture and spontaneous conception? There were no significant differences between time-lapse and conventional embryo culture in preterm birth (PTB, <37 weeks), low birth weight (LBW, >2500 g) and hypertensive disorders of pregnancy for singleton deliveries, the primary outcomes of this study. Evidence from prospective trials evaluating the safety of time-lapse incubation for clinical use show similar embryo development rates, implantation rates, and ongoing pregnancy and live birth rates when compared to conventional incubation. Few studies have investigated if uninterrupted culture can alter risks of adverse perinatal outcomes presently associated with IVF when compared to conventional culture and spontaneous conceptions. This study is a Swedish population-based retrospective registry study, including 7379 singleton deliveries after fresh embryo transfer between 2013 and 2018 from selected IVF clinics. Perinatal outcomes of singletons born from time-lapse-cultured embryos were compared to singletons from embryos cultured in conventional incubators and 71 300 singletons from spontaneous conceptions. Main perinatal outcomes included PTB and LBW. Main maternal outcomes included hypertensive disorders of pregnancy (pregnancy hypertension and preeclampsia). From nine IVF clinics, 2683 singletons born after fresh embryo transfer in a time-lapse system were compared to 4696 singletons born after culture in a conventional incubator and 71 300 singletons born after spontaneous conception matched for year of birth, parity, and maternal age. Patient and treatment characteristics from IVF deliveries were cross-linked with the Swedish Medical Birth Register, Register of Birth Defects, National Patient Register and Statistics Sweden. Children born after sperm and oocyte donation cycles and after Preimplantation Genetic testing cycles were excluded. Odds ratio (OR) and adjusted OR were calculated, adjusting for relevant confounders. In the adjusted analyses, no significant differences were found for risk of PTB (adjusted OR 1.11, 95% CI 0.87-1.41) and LBW (adjusted OR 0.86, 95% CI 0.66-1.14) or hypertensive disorders of pregnancy; preeclampsia and hypertension (adjusted OR 0.99, 95% CI 0.67-1.45 and adjusted OR 0.98, 95% CI 0.62-1.53, respectively) between time-lapse and conventional incubation systems. A significantly increased risk of PTB (adjusted OR 1.31, 95% CI 1.08-1.60) and LBW (adjusted OR 1.36, 95% CI 1.08-1.72) was found for singletons born after time-lapse incubation compared to singletons born after spontaneous conceptions. In addition, a lower risk for pregnancy hypertension (adjusted OR 0.72 95% CI 0.53-0.99) but no significant difference for preeclampsia (adjusted OR 0.87, 95% CI 0.68-1.12) was found compared to spontaneous conceptions. Subgroup analyses showed that some risks were related to the day of embryo transfer, with more adverse outcomes after blastocyst transfer in comparison to cleavage stage transfer. This study is retrospective in design and different clinical strategies may have been used to select specific patient groups for time-lapse versus conventional incubation. The number of patients is limited and larger datasets are required to obtain more precise estimates and adjust for possible effect of additional embryo culture variables. Embryo culture in time-lapse systems is not associated with major differences in perinatal and maternal outcomes, compared to conventional embryo culture, suggesting that this technology is an acceptable alternative for embryo incubation. The study was financed by a research grant from Gedeon Richter. There are no conflicts of interest for all authors to declare. N/A.

Association of Chronic Hyperglycemia With the Risk of Urolithiasis.

Background The incidence of urolithiasis is increasing along with elevated rates of chronic hyperglycemia. Therefore, this study aimed to assess the association between high hemoglobin Alc (HbAlc) levels, in the form of type 2 diabetes mellitus (T2DM), and the risk of kidney stone formation among those living in the Eastern Province of Saudi Arabia. Methodology We conducted a cross-sectional study on a total of 501 patients with known cases of urolithiasis who visited King Fahad University Hospital (Khabar, Saudi Arabia). We calculated odds ratios (ORs) of having stones with respect to three parameters, namely, fasting blood glucose level, random blood glucose level, and glycosylated HbA1c testing. Results Of the 501 cases with urinary stones included in this study, the majority (223, 44.5%) were 41-59 years of age, and 350 (69.9%) were males. Our results showed that T2DM was significantly associated with high stone burden, with increased fasting plasma glucose, increased random blood glucose, and increased HbA1c being strong predictors. The significant associations between glycemic control measures and the risk of urolithiasis remained even after adjusting for factors related to insulin resistance. Conclusions According to our results, glycemiccontrol can be an independent risk factor for urolithiasis. This critical finding demonstrates the need for further studies to investigate this particular group of patients.

Radiological Characteristics of Immunization Adenitis in the Axilla Following the Covid-19 Vaccine

It was aimed to investigate the ultrasonography (US) features of axillary COVID-19 immunization adenitis. Patients with axillary COVID-19 immunization adenitis detected between April 2021 and January 2022 were included. US features of the lymph nodes identified at the patient's initial US were all recorded. Radiological follow-up information and if exists pathology results were investigated. 104 immunization adenitis in the axilla following Covid-19 vaccine were detected. Only 18.3 percent had axillary pain or edema. Biopsy was recommended for 4 patients and follow-up was recommended for the other 100 patients. Core biopsy results were lymphoid tissue with focal micro-abscess formations, reactive lymphoid hyperplasia and plasma cell increase. All of the patients had a history of vaccination in the last 3 months. After immunization, initial US imaging was conducted mean 24-days later. The mean long and short axis were 22-mm and 13-mm, respectively. The mean long-short axes ratio was 2.2. The mean thickness of the cortex was 4.8-mm. The long and short axes of the lymph nodes in the first US and control examinations were compared statistically and they decreased in time. The hilum existed (96%). Elastography revealed soft features. The majority of the immunization adenitis are just enlarged benign-appearing lymph nodes. The majority were found during the extensive immunization campaign and were asymptomatic. Patients and their physicians should be aware of the vaccination and imaging evaluation of specific patient groups considering that these vaccinations will continue to be used for a while in the next years.

Artificial intelligence for dementia prevention.

A wide range of modifiable risk factors for dementia have been identified. Considerable debate remains about these risk factors, possible interactions between them or with genetic risk, and causality, and how they can help in clinical trial recruitment and drug development. Artificial intelligence (AI) and machine learning (ML) may refine understanding. ML approaches are being developed in dementia prevention.We discuss exemplar uses and evaluate the current applications and limitations in the dementia prevention field. Risk-profiling tools may help identify high-risk populations for clinical trials; however, their performance needs improvement. New risk-profiling and trial-recruitment tools underpinned by ML models may be effective in reducing costs and improving future trials. ML can inform drug-repurposing efforts and prioritization of disease-modifying therapeutics. ML is not yet widely used but has considerable potential to enhance precision in dementia prevention. Artificial intelligence (AI) is not widely used in the dementia prevention field. Risk-profiling tools are not used in clinical practice. Causal insights are needed to understand risk factors over the lifespan. AI will help personalize risk-management tools for dementia prevention. AI could target specific patient groups that will benefit most for clinical trials.

Gastrointestinal cancers in lean individuals with non-alcoholic fatty liver disease: A systematic review and meta-analysis.

Obesity and non-alcoholic fatty liver disease (NAFLD) are known risk factors for gastrointestinal (GI) cancers. However, GI carcinogenesis in lean NAFLD patients remains unclear. This systematic review and meta-analysis aims to investigate the association between lean NAFLD and GI cancer risk. PubMed, Embase and Cochrane Library databases were systematically searched (from inception date to April 2023) for cohort studies assessing GI cancers in lean (body mass index [BMI] < 25 kg/m2 or < 23 kg/m2 in Asians) and non-lean (BMI ≥25 kg/m2 or ≥ 23 kg/m2 in Asians) NAFLD individuals. Data from eligible studies were extracted, and meta-analysis was carried out using a random effects model to obtain risk ratios (RRs) with 95% confidence intervals (CIs). Subgroup analyses, meta-regressions and sensitivity analyses were also performed. This study was registered in PROSPERO (CRD42023420902). Eight studies with 56,745 NAFLD individuals (11% were lean) and 704 cases of incident GI cancers were included. Lean NAFLD was associated with higher risk of hepatic (RR 1.77, 95% CI 1.15-2.73), pancreatic (RR 1.97, 95% CI 1.01-3.86) and colorectal cancers (RR 1.53, 95% CI 1.12-2.09), compared to non-lean NAFLD. No significant differences were observed for oesophagus, gastric, biliary and small intestine cancers. This study shows that lean NAFLD patients have an increased risk of liver, pancreatic and colorectal cancers compared to non-lean NAFLD patients, emphasizing the need to explore tailored cancer prevention strategies for this specific patient group. Further research is required to explore the mechanisms underlying the association between lean NAFLD and specific GI cancers.

Oral microbiota study of the patients after hospitalisation for COVID-19, considering selected dental indices and antibiotic therapy using the next generation sequencing method (NGS)

ABSTRACT Background Poor oral hygiene and the increased incidence and severity of periodontitis may exacerbate SARS-CoV-2 infection. The aim was to evaluate the oral microbiota of 60 participants divided into groups: COVID-19 convalescents who received antibiotics during hospitalization (I), COVID-19 convalescents without antibiotic therapy (II) and healthy individuals (III). Materials and Methods Dental examination was conducted, and oral health status was evaluated using selected dental indexes. Clinical samples (saliva, dorsal swabs, supragingival and subgingival plaque) were collected and used for metagenomic library to the next-generation sequencing (NGS) preparation. Results Each of the clinical materials in particular groups of patients showed a statistically significant and quantitatively different bacterial composition. Patients from group I showed significantly worse oral health, reflected by higher average values of dental indexes and also a higher percentage of Veillonella, Tannerella, Capnocytophaga and Selenomonas genera in comparison to other groups. Additionally, a statistically significant decrease in the amount of Akkermansia type in both groups with COVID-19 was observed for all materials. Conclusions The primary factor affecting the composition of oral microbiota was not the SARS-CoV-2 infection itself, but the use of antibiotic therapy. The increased percentage of pro-inflammatory pathogens observed in COVID-19 patients underscores the importance of preventing periodontal disease and improving oral hygiene in the future.

Molecular Anatomy of Prostate Cancer and Its Implications in Active Surveillance and Early Intervention Strategies

Understanding prostate carcinogenesis is crucial not only for identifying new treatment targets but also for developing effective strategies to manage the asymptomatic form of the disease. There is a lack of consensus about predicting the indolent form of the disease prostate cancer, leading to uncertainties regarding treatment initiation. This review aims to enhance the assessment and management of early prostate cancer by providing a comprehensive picture of the molecular anatomy of the prostate, synthesising current evidence, highlighting knowledge gaps, and identifying future directions. It presents evidence for the efficacy of active surveillance as an alternative treatment strategy and its potential benefits in specific patient groups through androgen receptor disruption. Overall, an improved understanding of prostate carcinogenesis and its molecular underpinnings can pave the way for tailored and precise management approaches for this common cancer. Further development and validation of molecule-based assessment tools are needed. Integrating genomic, proteomic, and phenotypic models, as well as functional approaches, can help predict outcomes. This facilitates selecting candidates for active surveillance and targeting interventions for higher-risk cases, contributing to more precise management strategies.

Personalized acute kidney injury treatment.

Acute kidney injury (AKI) is a complex syndrome that might be induced by different causes and is associated with an increased morbidity and mortality. Therefore, it is a very heterogeneous syndrome and establishing a "one size fits all" treatment approach might not work. This review aims to examine the potential of personalized treatment strategies for AKI. The traditional diagnosis of AKI is based on changes of serum creatinine and urine output, but these two functional biomarkers have several limitations. Recent research identified different AKI phenotypes based on clinical features, biomarkers, and pathophysiological pathways. Biomarkers, such as Cystatin C, NGAL, TIMP2∗IGFBP7, CCL14, and DKK-3, have shown promise in predicting AKI development, renal recovery, and prognosis. Biomarker-guided interventions, such as the implementation of the KDIGO bundle, have demonstrated an improvement in renal outcomes in specific patient groups. A personalized approach to AKI treatment as well as research is becoming increasingly important as it allows the identification of distinct AKI phenotypes and the potential for targeted interventions. By utilizing biomarkers and clinical features, physicians might be able to stratify patients into subphenotypes, enabling more individualized treatment strategies. This review highlights the potential of personalized AKI treatment, emphasizing the need for further research and large-scale clinical trials to validate the efficacy of these approaches.

The Relationship Between the Presence of Distal Collateral Lymphatic Flows and Obesity in Patients with Bilateral Lower Extremity Edema

Objective: This study aimed to comprehensively assess radionuclide imaging findings to aid in the clinical diagnosis of early-stage lower extremity lymphedema. Methods: Our retrospective study included 135 patients who underwent lymphoscintigraphy for bilateral lower extremity edema (BLEE) between 2017 and 2022. Of these patients, 117 (86.7%) were female. Lymphoscintigraphic images were acquired at the 10th, 40th, and 2nd hours post-injection of radiopharmaceuticals. Bilateral lower extremity lymphatic congestion (MLC) was observed in the 2nd-hour images of radionuclide imaging (RI), with an associated accumulation of activity in the inguinal lymph nodes. All patients presented with lower extremity edema. Results: Among our patients, 55 (40.7%) were classified as obese. Bilateral distal collateral flows (BDCF) were identified in 60 (44.4%) of our patients, all of whom were female. Within this group, 13 (21.7%) were obese, and 11 (18.3%) exhibited distal and direct muscle lymphatic congestion (DDMLC). DDMLC was present in 63 (46.7%) patients. Unilateral distal collateral flow (UDCF) was detected in 75 (55.6%) of the patients with BLEE, with 67 (89.3%) of them being obese. Obese patients exhibited a significantly higher prevalence of both UDCF and DDMLC (p: 0.0005). Detailed results can be found in Table 1-4 and Figures 3 and 4. Conclusion: Functional bilateral radionuclide imaging methods provide valuable data for physicians, enabling bilateral and comparative assessments. However, particular attention should be paid to the interpretation of asymmetric images, especially in specific patient groups.

Incidence and predictors of hepatocellular carcinoma in patients with autoimmune hepatitis

Autoimmune hepatitis (AIH) is a rare chronic liver disease of unknown aetiology; the risk of hepatocellular carcinoma (HCC) remains unclear and risk factors are not well-defined. We aimed to investigate the risk of HCC across a multicentre AIH cohort and to identify predictive factors. We performed a retrospective, observational, multicentric study of patients included in the International Autoimmune Hepatitis Group Retrospective Registry. The assessed clinical outcomes were HCC development, liver transplantation, and death. Fine and Gray regression analysis stratified by centre was applied to determine the effects of individual covariates; the cumulative incidence of HCC was estimated using the competing risk method with death as a competing risk. A total of 1,428 patients diagnosed with AIH from 1980 to 2020 from 22 eligible centres across Europe and Canada were included, with a median follow-up of 11.1 years (interquartile range 5.2-15.9). Two hundred and ninety-three (20.5%) patients had cirrhosis at diagnosis. During follow-up, 24 patients developed HCC (1.7%), an incidence rate of 1.44 cases/1,000 patient-years; the cumulative incidence of HCC increased over time (0.6% at 5 years, 0.9% at 10 years, 2.7% at 20 years, and 6.6% at 30 years of follow-up). Patients who developed cirrhosis during follow-up had a significantly higher incidence of HCC. The cumulative incidence of HCC was 2.6%, 4.6%, 5.6% and 6.6% at 5, 10, 15, and 20 years after the development of cirrhosis, respectively. Obesity (hazard ratio [HR] 2.94, p=0.04), cirrhosis (HR 3.17, p=0.01), and AIH/PSC variant syndrome (HR 5.18, p=0.007) at baseline were independent risk factors for HCC development. HCC incidence in AIH is low even after cirrhosis development and is associated with risk factors including obesity, cirrhosis, and AIH/PSC variant syndrome. The risk of developing hepatocellular carcinoma (HCC) in individuals with autoimmune hepatitis (AIH) seems to be lower than for other aetiologies of chronic liver disease. Yet, solid data for this specific patient group remain elusive, given that most of the existing evidence comes from small, single-centre studies. In our study, we found that HCC incidence in patients with AIH is low even after the onset of cirrhosis. Additionally, factors such as advanced age, obesity, cirrhosis, alcohol consumption, and the presence of the AIH/PSC variant syndrome at the time of AIH diagnosis are linked to a higher risk of HCC. Based on these findings, there seems to be merit in adopting a specialized HCC monitoring programme for patients with AIH based on their individual risk factors.

Predictors of mortality in elderly patients in emergency abdominal surgery: A retrospective single-center study

Background/Aim: Advancements in medical technologies and prolonged life expectancy have increased the number of surgical interventions for elderly patients. Despite this however, emergency surgical interventions remain associated with a high mortality rate. Managing an emergency abdominal surgery in elderly patients poses great challenges for both the surgeon and the anesthesiologist. However, knowing the risk factors that increase mortality may offer advantages to the clinician managing the treatment process. There are studies in the literature examining the mortality of emergency surgeries in elderly patients. However, there are very few studies that work with a specific patient group such as abdominal surgery and then analyze laboratory test results. Here, we aimed to identify the risk factors that can be used to predict mortality in elderly patients undergoing emergency abdominal surgery. Methods: The study was designed retrospectively in a single center; 100 patients over the age of 80 who underwent emergency abdominal surgery were included in the study. The patients were divided into two groups as survivor and non-survivor. Demographic, surgical, and anesthetic characteristics, laboratory tests, American Society of Anesthesiologists (ASA) physical status scores, postoperative intensive care needs, and treatments of the groups were compared using the chi-squared and Mann Whitney U-test. Determining factors were investigated with logistic regression analysis. Results: In multivariate analysis, ASA 3 and major surgery significantly increased mortality (P=0.041, P=0.011). Receiver operating characteristic (ROC) curve analysis showed that C-reactive protein with a cut-off value of &gt;84 mg/L had a sensitivity of 58.8% and a specificity of 71.2% (AUC=0.636, P=0.004), while lactate with a cut-off value of &gt;3.6 mmol/L had a sensitivity of 50% and a specificity of 95.5% in predicting mortality (AUC=0.776, P&lt;0.001). Conclusion: The magnitude of surgery and the ASA score were the best predictors of mortality in elderly patients undergoing emergency abdominal surgery.

Populations particulières : patients de performance status 2 ou plus: Special populations: patients with performance status 2 or higher

Performance status (PS) is a measure of the patient’s overall condition. Karnofsky and ECOG (Eastern Cooperative Oncology Group) are the most widely used scales. A three-point conversion scale allows a strong correlation between both scores: ECOG 0-1 = Karnofsky 100-80 %, ECOG 2 = Karnofsky 60-70 %, ECOG 3-4 = Karnofsky 50-10 %. Numerous factors, whether linked to cancer or to comorbidities, can affect PS. PS remains a major independent prognostic factor in NSCLC (non small cell lung cancer) and SCLC (small cell lung cancer), despite its flawed reproducibility and the heterogeneity of cancer patients with poor PS. As a matter of fact, PS should be regarded as a stratification factor in research. All guidelines take PS into account as a therapeutic decision making tool, especially in the case of chemotherapy for metastatic NSCLC. Targeted therapy should be considered in case of metastatic disease with molecular targets regardless of PS, for its high effectiveness and good safety profile. Data regarding immunotherapy are rather sketchy. Tolerance seems to be fine. Findings regarding efficacy warrant careful selection of patients who might benefit from this therapy. In light of the European Medicines Agency call, let us build studies dedicated to patients as frail as they come and enroll them in clinical trials in such a way that they benefit, among others, from therapeutic advances. In order to apply clinical research findings to the general population, specific groups of patients should be more involved.1877-1203/© 2023 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Continuous Serratus - Intercostal Plane Block for Perioperative Analgesia in Upper Abdominal Surgeries: A Prospective Randomized Controlled Study.

Acute pain management after open abdominal surgeries is an essential goal in perioperative management.. Recently, serratus-intercostal plane block (SIPB) was suggested as an analgesic technique for upper abdominal surgeries. This prospective, randomized, controlled study included sixty adult patients scheduled for open upper abdominal surgeries. Patients were allocated into two equal groups: SIPB group (S group, n = 30) and control group (the C group, n = 30). In the S group, SIPB was performed in the midaxillary line at the eighth rib level followed by continuous infusion of local anaesthetic for the first postoperative day. In the C group, no block was done. The primary objective of the study was to control postoperative pain on the first postoperative day as assessed by the numerical rating scale (NRS). Secondary outcomes included perioperative hemodynamics, total postoperative analgesic consumption, number of analgesic requests, and incidence of postoperative nausea and vomiting. The mean postoperative NRS reported in group S was statistically lower than that in group C (2.4±0.7, 3.9±0.31, P < 0.001). The postoperative morphine consumption was lower in the S group than in the C group [(0 (0-4), 3 (1-4), respectively, P < 0.001]. The incidence of PONV was significantly lower in the S group than in the C group (16.7% and 40%, P < 0.045). SIPB was associated with a better analgesic profile compared with the control group after upper abdominal surgeries. Further studies are recommended to determine block safety in special patient groups, including bariatric and laparoscopic surgeries.

Performance of the race-free CKD-EPI creatinine-based eGFR equation in a Danish cohort with measured GFR.

In 2021, an updated Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation for estimated glomerular filtration rate (eGFR) without a coefficient for race (CKD-EPI21) was developed. The performance of this new equation has yet to be examined among specific patient groups. We compared the performances of the new CKD-EPI21 equation and the 2009 equation assuming non-Black race (CKD-EPI09-NB) in patients with GFR measured by chromium-51-EDTA plasma clearance at Aarhus University Hospital in Denmark during 2010-18. We examined bias, accuracy, precision and correct classification of chronic kidney disease (CKD) stage using chromium-51-EDTA clearance as the reference standard. We assessed the performance in the total cohort, cancer patients and potential living kidney donors. We also assessed the performance stratified by CKD stage in the total cohort. In this predominantly white population, the CKD-EPI21 equation performed slightly better than the CKD-EPI09-NB equation in both the total cohort (N=4668), and in cancer patients (N=3313) and potential living kidney donors (N=239). In the total cohort, the CKD-EPI21 equation demonstrated a slightly lower median absolute bias (-0.2 versus -4.4mL/min/1.73 m2), and a similar accuracy, precision and correct classification of CKD stage compared with the CKD-EPI09-NB equation. When stratified by CKD stage, the CKD-EPI09-NB equation performed slightly better than the CKD-EPI21 equation among patients with a measured GFR (mGFR) <60mL/min/1.73 m2. In a selected cohort of Danish patients with mGFR, the CKD-EPI21 equation performed slightly better than the CKD-EPI09-NB equation except for patients with a mGFR <60mL/min/1.73 m2, where CKD-EPI09-NB performed slightly better although the differences were considered clinically insignificant.

Pretreatment Modified Glasgow Prognostic Score for Predicting Prognosis and Survival in Elderly Patients with Gastric Cancer Treated with Perioperative FLOT.

The adverse effects of chemotherapy are more apparent in elderly patients and lead to worse prognosis and mortality. Identifying immunonutritional risk factors is of great importance in terms of treatment effectiveness, prognosis, and mortality in geriatric oncology. The modified Glasgow prognostic score (mGPS) is an immunonutritional index based on serum CRP and albumin levels. In this study, we aimed to investigate the role of mGPS in predicting prognosis and survival in elderly patients with gastric cancer receiving perioperative FLOT treatment. We retrospectively enrolled 71 patients aged over 65 years and grouped them according to their pretreatment mGPS score. Kaplan-Meier and Cox regression analysis showed overall survival was significantly worse in the mGPS 1 and mGPS 2 groups than in the mGPS 0 group (p = 0.005 and p < 0.001, respectively). Compared to the mGPS 0 group, the mGPS 1 group had a 6.25 times greater risk of death (95% CI: 1.61-24.28, p = 0.008), and the mGPS 2 group had a 6.59 times greater risk of death (95% CI: 2.08-20.85, p = 0.001). High BMI was identified as a significant risk factor for being in the mGPS 2 group (OR: 1.20, 95% CI: 1.018-1.425, p = 0.030). In conclusion, elevated pretreatment mGPS was associated with poor overall survival in elderly patients with gastric cancer treated with perioperative FLOT therapy. As such, pretreatment mGPS can be a simple and useful tool to predict mortality in this specific patient group.