Background and Objectives
This study aimed to compare outcomes between neoadjuvant imatinib and upfront surgery in patients with localized rectal gastrointestinal stromal tumors (GIST) patients.
...Methods
Eighty‐five patients with localized rectal GIST were divided into two groups: upfront surgery ± adjuvant imatinib (Group A, n = 33) and the neoadjuvant imatinib + surgery + adjuvant imatinib (Group B, n = 52). Baseline characteristics between groups were controlled for with inverse probability of treatment weighting (IPTW) adjusted analysis.
Results
The response rate to neoadjuvant imatinib was 65.9%. After the IPTW‐adjusted analysis, patients who underwent neoadjuvant therapy had better distant recurrence‐free survival (DRFS) and disease‐specific survival (DSS) compared with those who underwent upfront surgery (5‐year DRFS 97.8 vs. 71.9%, hazard ratio HR, 0.15; 95% CI, 0.03–0.87; p = 0.03; 5‐year DSS 100 vs. 77.1%; HR, 0.11; 95% CI, 0.01–0.92; p = 0.04). While no significant association was found between overall survival (OS) and treatment groups (p = 0.07), 5‐year OS was higher for the neoadjuvant group than upfront surgery group (97.8% vs. 71.9%; HR, 0.2; 95% CI, 0.03–1.15).
Conclusions
In patients with localized rectal GIST, neoadjuvant imatinib not only shrunk the tumor size but also decreased the risk of metastasis and tumor‐related deaths when compared to upfront surgery and adjuvant imatinib alone.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with severe hemorrhagic CRP who were admitted from ...2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life beforetreatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up.RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission(94% vs 12%), especially in control of transfusion-dependent bleeding(100% vs 0%), and offered a better control of refractory perianal pain(100% vs 0%), and a lower score of bleeding(P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding(100% vs 21.5%, P = 0.002) and severe bleeding(100% vs 0%, P < 0.001), obtained a lower score of bleeding(0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels(P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation. CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.
Mechanical thrombectomy has been proven as a standard care for moderate to severe ischemic stroke with anterior large vessel occlusion (LVO); however, whether it is equally effective in mild ischemic ...stroke (MIS) is controversial.
In this retrospective study, a total of 177 Chinese patients presenting with MIS (NIHSS ≤8) and LVO between January 2014 and September 2017 from seven comprehensive stroke centers were identified. Odds of good outcome with endovascular thrombectomy versus medical treatment were obtained by logistic regression analysis and propensity-score matching method, and a meta-analysis pooled results from six studies (n = 733).
Good outcome (mRS: 0-1) was 58.2% (46/79) in the thrombectomy and 46.9% (46/98) in the medical group, which showed no statistical significance before adjustment (P = 0.13; OR = 1.57, 95% CI: 0.86 to 2.86). The adjusted ORs of thrombectomy versus medical group were 3.23 (95% CI, 1.35 to 7.73; P = 0.008) by multivariable logistic analysis, 2.78 (1.12 to 6.89; P = 0.02) by propensity score matching analysis, and 3.20 (1.22 to 8.37; P = 0.01) by propensity score matching analysis with additional adjustments, respectively. Thrombectomy treatment did not result in excessive mortality or symptomatic intracranial hemorrhage after adjustments. The meta-analysis did not confirm the associations between good outcome and endovascular treatment.
The current study indicates that endovascular thrombectomy is associated with good functional outcome in MIS patients with LVO, and without additional risk of symptomatic intracranial hemorrhage and mortality. Although the meta-analysis failed to demonstrate its superiority compared to medical treatment, randomized clinical trials are needed.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The present study aimed to investigate early risk factors for hyperlipidemic acute pancreatitis (HLAP) in order to open up novel routes for its prevention and treatment. Demographics, laboratory data ...obtained within 48 h, enhanced computed tomography (CT) imaging data and the modified CT severity index (MCTSI) for 111 patients with HLAP who were assessed at Ordos Central Hospital (Ordos, China) between January 2015 and October 2017 were retrospectively analyzed. Of these, 17 patients progressed to infectious pancreatic necrosis (IPN) and 14 patients progressed to organ failure (OF), the occurrence of which were the study outcomes. The patients were divided into pairs groups: IPN and non-IPN, as well as OF and non-OF, and differences between the groups were determined regarding various clinicopathological parameters. Furthermore, univariate and multivariate regression analyses were performed to identify parameters associated with the risk of progression to IPN or OP. On univariate analysis, the following parameters were deemed as being significantly associated with the risk of IPN: Serum calcium ions, C-reactive protein (CRP), extent of necrosis, procalcitonin (PTC) and the MCTSI. Furthermore, calcium ions, red cell distribution width (RDW), extent of necrosis and the MCTSI were significantly associated with the risk of OF on univariate analysis. Multivariate logistic regression analysis for these parameters then indicated that CRP (P=0.014), RDW (P=0.025) and the extent of necrosis (P=0.022) were significant and independent predictors of progression; thus, these are early risk factors for patients with HLAP. Receiver operating characteristic curves were generated to evaluate the predictive value of these factors, and the area under the curve for the three parameters was 0.863 95% confidence interval (CI), 0.646-0.886, 0.727 (95% CI, 0.651-0.803) and 0.833 (95% CI, 0.739-0.936), respectively. Therefore, CRP, RDW and the extent of necrosis are early predictive indexes for the risk of progression in HLAP.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Aerosol is a critical factor affecting the atmospheric hydrological cycle and climate change. Acting as cloud condensation nuclei for cloud formation, aerosols have a significant impact on regional ...precipitation. This study uses the fully coupled chemistry module (Weather Research and Forecasting/Chem) within the Weather Research and Forecasting model to simulate convective cloud precipitation in the Yangtze River Delta of China. To investigate the impact of on precipitation, four numerical experiments are conducted. The base case uses the full emission inventory (which we call the 100% case), and the other three cases are designed based on reduced emissions for different percentages (which we call the 50% case, the 10% case, and the 1% case). Compared to the other cases, the grid point hour maximum precipitation of the 50% case is the largest, which can reach 44.1 mm/hr and has an increase of 5% over the 100% case. The strongest precipitation is delayed by about 1 hr in the 50% case, and precipitation area is increased by 6.5%. This study indicates that the influence of aerosols on regional precipitation is a nonlinear process, with a correlation coefficient of 0.52 (p<0.01) showing a strong positive correlation between cloud condensation nuclei (>250 cm−3, height of 0.5–3 km) and precipitation. Further analysis of the dynamics and microphysical processes of this convective precipitation shows that the 50% case has an area with higher rising velocity and bigger cloud water mixing ratio than the other cases but has a relatively low convective center. The formation of precipitation is mainly influenced by the accretion of snow by rain, but the role of the snow melting into rain cannot be ignored.
Key Points
Aerosols play different roles in promoting the development of convection and microphysical processes; the synthesis shows the influence of nonlinearity on precipitation, only when appropriate concentration can promote precipitation
CCN (>250 cm−3) converted from appropriate concentration aerosols can significantly enhance this precipitation
For a heavy convective precipitation system in the Yangtze River Delta, aerosols can affect precipitation by changing convective structures and microphysical processes
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Cumulative evidence has shown that the non-invasive modality of coronary computed tomography angiography (CCTA) has evolved as an alternative to invasive coronary angiography, which can be used to ...quantify plaque burden and stenosis and identify vulnerable plaque, assisting in diagnosis, prognosis and treatment. With the increasing elderly population, many patients scheduled for non-cardiovascular surgery may have concomitant coronary artery disease (CAD). The aim of this study was to investigate the usefulness of preoperative CCTA to rule out or detect significant CAD in this cohort of patients and the impact of CCTA results to clinical decision-making.
841 older patients (age 69.5 ± 5.8 years, 74.6% males) with high risk non-cardiovascular surgery including 771 patients with unknown CAD and 70 patients with suspected CAD who underwent preoperative CCTA were retrospectively enrolled. Multivariate logistic regression analysis was performed to determine predictors of significant CAD and the event of cancelling scheduled surgery in patients with significant CAD.
677 (80.5%) patients had non-significant CAD and 164 (19.5%) patients had significant CAD. Single-, 2-, and 3- vessel disease was found in 103 (12.2%), 45 (5.4%) and 16 (1.9%) patients, respectively. Multivariate analysis demonstrated that positive ECG analysis and Agatston score were independently associated with significant CAD, and the optimal cutoff of Agatston score was 195.9. The event of cancelling scheduled surgery was increased consistently according to the severity of stenosis and number of obstructive major coronary artery. Multivariate analysis showed that the degree of stenosis was the only independent predictor for cancelling scheduled surgery. In addition, medication using at perioperative period increased consistently according to the severity of stenosis.
In older patients referred for high risk non-cardiovascular surgery, preoperative CCTA was useful to rule out or detect significant CAD and subsequently influence patient disposal. However, it might be unnecessary for patients with negative ECG and low Agatston score. Trial registration Retrospectively registered.
AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with CRP who did not respond to ...previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.RESULTS: Twenty-four patients(19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo(range: 2-24 mo). Six patients(25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score(VRS) was 3 points. Nineteen patients(79.2%) received only one course of topical formalin irrigation, and five(20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in14; the effectiveness rate was 79.1%(19/24). For longterm efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula. CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.
Abstract Alzheimer’s disease (AD) is a progressive neurodegenerative disorder of the elderly accounting for the vast majority of dementia. Recently, many studies have implicated the role of ...inflammatory response, especially neuroinflammatory response in the development and progression of AD. However, the underlying mechanism of how inflammatory response induces AD is unknown. Kynurenine pathway is a major route of the amino acid tryptophan catabolism, resulting in the production of nicotine adenine dinucleotide and other neuroactive intermediates: quinolinic acid (QA) and kynurenic acid (KA). QA exerts different toxic effects, including over-activation of N-methyl- d -aspartate (NMDA) receptor and excitotoxicity, synaptic dysfunction and neuronal death. On the other hand, KA is identified as the only endogenous NMDA receptor antagonist and could modulate neurotoxic effects of QA. We hypothesize that an activated kynurenine pathway induced by inflammatory cytokines would generate more neurotoxic metabolites, which could be closely related to the pathogenesis of AD in elderly patients. Moreover, some measures, which facilitate KA synthesis and reduce the formation of QA, may emerge as a new therapeutic strategy against AD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Chronic radiation proctitis (CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, ...there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation (APC) is currently recommended as the first-choice treatment for hemorrhagic CRP, however, its indication based on long-term follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center.
To assess the long-term efficacy and safety of APC for hemorrhagic CRP.
This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment. We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas.
Forty-five patients with a median follow-up period of 24 mo (range: 12-67 mo) were enrolled. Fifteen (33.3%) patients required blood transfusion before APC. Successful treatment with APC was achieved in 31 (68.9%) patients. The mean number of APC sessions was 1.3 (1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than 50% of the surface area odds ratio (OR) = 6.53, 95% confidence interval (CI): 1.09-39.19,
= 0.04 and ulcerated area greater than 1 cm
(OR = 8.15, 95%CI: 1.63-40.88,
= 0.01). Six (13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm
(
= 0.035).
The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm
.
Severe chronic radiation proctopathy (CRP) is difficult to treat.
To evaluate the efficacy of colostomy and stoma reversal for CRP.
To assess the efficacy of colostomy in CRP, patients with severe ...hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled. Patients with tumor recurrence, rectal-vaginal fistula or other types of rectal fistulas, or who were lost to follow-up were excluded. Rectal bleeding, hemoglobin (Hb), endoscopic features, endo-ultrasound, rectal manometry, and magnetic resonance imaging findings were recorded. Quality of life before stoma and after closure reversal was scored with questionnaires. Anorectal functions were assessed using the CRP symptom scale, which contains the following items: Watery stool, urgency, perianal pain, tenesmus, rectal bleeding, and fecal/gas incontinence.
A total of 738 continual CRP patients were screened. After exclusion, 14 patients in the colostomy group and 25 in the conservative group were included in the final analysis. Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L (
< 0.001) in the conservative group. All 14 patients in the former group achieved complete remission of bleeding, and the colostomy was successfully reversed in 13 of 14 (93%), excepting one very old patient. The median duration of stoma was 16 (range: 9-53) mo. The Hb level increased gradually from 75 g/L at 3 mo, 99 g/L at 6 mo, and 107 g/L at 9 mo to 111 g/L at 1 year and 117 g/L at 2 years after the stoma, but no bleeding cessation or significant increase in Hb levels was observed in the conservative group. Endoscopic telangiectasia and bleeding were greatly improved. Endo-ultrasound showed decreased vascularity, and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall. Anorectal functions and quality of life were significantly improved after stoma reversal, when compared to those before stoma creation.
Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP. Stoma can be reversed, and anorectal functions can be recovered after reversal.
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