BACKGROUND: Scalp cooling has been shown in several studies to be an effective method in preventing chemotherapy-induced alopecia (CIA). Data on the use of scalp cooling in Asian countries are ...limited, and evidence for its use and efficacy among our patients are not available. OBJECTIVE: The aim of this study was to assess the effectiveness and tolerability of scalp cooling among breast cancer patients in our study population. METHODS: Consecutive breast cancer patients receiving FE75C, FE100C, FE100C-D, docetaxel75 or docetaxel, and cyclophosphamide (TC) at our treatment center were recruited and allocated to the treatment (scalp cooling, DigniCapTM system) or control group in this prospective nonrandomized controlled study. The assessment of alopecia was carried out using the World Health Organization grading system and clinical photographs. RESULTS: Seventy patients were recruited, but only 25 completed the study and were evaluable for analysis. Five of 12 patients (42%) in the scalp cooling group managed to preserve hair. Two of three patients who received FE75C and TC regimens had minimal hair loss. All patients treated with FE100C had severe hair loss. Half of all patients who received scalp cooling throughout chemotherapy rated the treatment as reasonably well tolerated. The most common reason for discontinuing scalp cooling was intolerance to its side effects. CONCLUSION: Scalp cooling is potentially effective in reducing CIA caused by docetaxel, TC, and FE75C chemotherapy regimen. However, it was not well tolerated by our study population. The dropout rate was high, and this needs to be taken into consideration when pursuing further trials in a similar setting.
Acute chest pain suggestive of acute coronary syndrome is a frequent complaint in the emergency department. Acute coronary syndromes include myocardial infarction and unstable angina. Being able to ...establish the diagnosis rapidly and accurately may be lifesaving. A cardiac workup is indicated in this subset of patients in the acute setting, even if there are no ischemic changes on electrocardiography. If the clinical examination and initial cardiac workup suggest that a patient is having myocardial ischemia, the patient will usually be urgently referred for invasive coronary angiography and revascularization. In stable patients without evidence of ST elevation and ongoing myocardial ischemia, an initially conservative approach is sometimes considered. Cardiac risk stratification of this subgroup of patients who are at low and intermediate risk for coronary artery disease is recommended before discharge, and imaging is necessary to exclude ischemia as an etiology. Noninvasive cardiac imaging modalities include chest radiography, single photon-emission CT myocardial perfusion imaging, echocardiography, multidetector CT, PET, and MRI. Noncardiac etiologies of chest pain include aortic dissection, aortic aneurysm, pulmonary embolism, pericardial disease, and lung parenchymal disease. Noninvasive cardiac imaging in patients who are at low and intermediate risk for coronary artery disease may improve confidence regarding the safety of discharge from the emergency department. In addition to risk stratification, noncoronary etiologies for chest pain can be established with imaging.
Histologically assessed liver fibrosis stage has prognostic significance in patients with non-alcoholic fatty liver disease (NAFLD) and is accepted as a surrogate endpoint in clinical trials for ...non-cirrhotic NAFLD. Our aim was to compare the prognostic performance of non-invasive tests with liver histology in patients with NAFLD.
This was an individual participant data meta-analysis of the prognostic performance of histologically assessed fibrosis stage (F0–4), liver stiffness measured by vibration-controlled transient elastography (LSM-VCTE), fibrosis-4 index (FIB-4), and NAFLD fibrosis score (NFS) in patients with NAFLD. The literature was searched for a previously published systematic review on the diagnostic accuracy of imaging and simple non-invasive tests and updated to Jan 12, 2022 for this study. Studies were identified through PubMed/MEDLINE, EMBASE, and CENTRAL, and authors were contacted for individual participant data, including outcome data, with a minimum of 12 months of follow-up. The primary outcome was a composite endpoint of all-cause mortality, hepatocellular carcinoma, liver transplantation, or cirrhosis complications (ie, ascites, variceal bleeding, hepatic encephalopathy, or progression to a MELD score ≥15). We calculated aggregated survival curves for trichotomised groups and compared them using stratified log-rank tests (histology: F0–2 vs F3 vs F4; LSM: <10 vs 10 to <20 vs ≥20 kPa; FIB-4: <1·3 vs 1·3 to ≤2·67 vs >2·67; NFS: <–1·455 vs –1·455 to ≤0·676 vs >0·676), calculated areas under the time-dependent receiver operating characteristic curves (tAUC), and performed Cox proportional-hazards regression to adjust for confounding. This study was registered with PROSPERO, CRD42022312226.
Of 65 eligible studies, we included data on 2518 patients with biopsy-proven NAFLD from 25 studies (1126 44·7% were female, median age was 54 years IQR 44–63), and 1161 46·1% had type 2 diabetes). After a median follow-up of 57 months IQR 33–91, the composite endpoint was observed in 145 (5·8%) patients. Stratified log-rank tests showed significant differences between the trichotomised patient groups (p<0·0001 for all comparisons). The tAUC at 5 years were 0·72 (95% CI 0·62–0·81) for histology, 0·76 (0·70–0·83) for LSM-VCTE, 0·74 (0·64–0·82) for FIB-4, and 0·70 (0·63–0·80) for NFS. All index tests were significant predictors of the primary outcome after adjustment for confounders in the Cox regression.
Simple non-invasive tests performed as well as histologically assessed fibrosis in predicting clinical outcomes in patients with NAFLD and could be considered as alternatives to liver biopsy in some cases.
Innovative Medicines Initiative 2.
Abstract Purpose To assess the current status of diabetes teaching in Canadian medical schools. Methods Faculty primarily responsible for teaching undergraduate diabetes education were identified at ...all 17 Canadian medical schools and were asked to provide their undergraduate diabetes curricula. The curricula were analyzed by method of teaching. Results Reponses were obtained from14 of 17 (82%) medical schools. The average number of teaching hours in the entire undergraduate program was 15.4 and ranged from 7 to 22.5 hours. Formats included lectures, small groups, workshops, assigned readings, problem-based learning and laboratory studies. Lectures made up 48% of the curriculum, followed by small groups at 26%. Conclusions There has been an increased use of small group sessions in undergraduate diabetes education, in keeping with generalized changes in medical school curricula. Future study is warranted in assessing the impact of differing undergraduate teaching methods on eventual competency.
The population of adults with congenital heart disease is increasing in North America. Radiologic imaging is critical for the initial assessment and for surveillance in this population. Chest ...radiography and echocardiography are valuable first-line tools for evaluation. However, magnetic resonance imaging and computed tomography are often necessary, particularly for assessment of extracardiac anatomy or specific vascular connections or relationships, which may be complex in postoperative patients. Although magnetic resonance imaging and computed tomography can provide volumetric data for more comprehensive evaluation of cardiac anatomy and function, magnetic resonance imaging does not require patient exposure to ionizing radiation or nephrotoxic iodinated contrast media. Magnetic resonance imaging also can measure blood flow for quantification of left-to-right shunts, regurgitant fractions, and pressure gradients. Although noninvasive imaging techniques have limitations, they can evaluate most lesions and preclude the need for cardiac catheterization. Noninvasive imaging is particularly useful for serial evaluation of patients with surgically corrected congenital heart disease, because nearly one half of these patients will require two or more surgeries.
Abstract There are limited data to guide the choice of high-dose therapy (HDT) regimen before autologous hematopoietic cell transplantation (AHCT) for patients with Hodgkin (HL) and non-Hodgkin ...lymphoma (NHL). We studied 4917 patients (NHL, n = 3905; HL, n = 1012) who underwent AHCT from 1995 to 2008 using the most common HDT platforms: carmustine (BCNU), etoposide, cytarabine, and melphalan (BEAM) (n = 1730); cyclophosphamide, BCNU, and etoposide (CBV) (n = 1853); busulfan and cyclophosphamide (BuCy) (n = 789); and total body irradiation (TBI)–containing treatment (n = 545). CBV was divided into CBVhigh and CBVlow based on BCNU dose. We analyzed the impact of regimen on development of idiopathic pulmonary syndrome (IPS), transplantation-related mortality (TRM), and progression-free and overall survival. The 1-year incidence of IPS was 3% to 6% and was highest in recipients of CBVhigh (hazard ratio HR, 1.9) and TBI (HR, 2.0) compared with BEAM. One-year TRM was 4% to 8%, respectively, and was similar between regimens. Among patients with NHL, there was a significant interaction between histology, HDT regimen, and outcome. Compared with BEAM, CBVlow (HR, .63) was associated with lower mortality in follicular lymphoma ( P < .001), and CBVhigh (HR, 1.44) was associated with higher mortality in diffuse large B cell lymphoma ( P = .001). For patients with HL, CBVhigh (HR, 1.54), CBVlow (HR, 1.53), BuCy (HR, 1.77), and TBI (HR, 3.39) were associated with higher mortality compared with BEAM ( P < .001). The impact of specific AHCT regimen on post-transplantation survival is different depending on histology; therefore, further studies are required to define the best regimen for specific diseases.
Background The optimal method for closing gastrotomies after transgastric instrumentation has yet to be determined. Objective To compare gastrotomy closure with endoscopically delivered bioabsorbable ...plugs with no closure. Design Prospective, controlled study. Setting Animal laboratory. Subjects Twenty-three dogs undergoing endoscopic transgastric peritoneoscopy between July and August 2007. Interventions Endoscopic anterior wall gastrotomies were performed with balloon dilation to allow passage of the endoscope into the peritoneal cavity. The plug group (n = 12) underwent endoscopic placement of a 4 × 6-cm bioabsorbable mesh plug in the perforation, whereas the no-treatment group (n = 11) did not. Animals underwent necropsy 2 weeks after the procedure. Main Outcome Measurements Complications related to gastrotomy closure, gastric burst pressures, relationship of burst perforation to gastrotomy, and the degree of adhesions and inflammation at the gastrotomy site. Results After the gastrotomy, all dogs survived without any complications. At necropsy, burst pressures were 77 ± 11 mm Hg and 76 ± 15 mm Hg ( P = .9) in the plug group and no-treatment group, respectively. Perforations occurred at the site of the gastrotomy in 2 of 12 animals in the plug group and in none of the 11 dogs in the no-treatment group ( P = .5). Finally, there were minimal adhesions in all dogs (11/11) in the no-treatment group and minimal adhesions in 3 and moderate adhesions or inflammatory masses in 9 of the 12 animals in the plug group ( P = .004). Limitations Small number of subjects, animal model, no randomization. Gastrotomy trauma during short peritoneoscopy may not be applicable to longer procedures. Conclusions After endoscopic gastrotomy, animals that were left untreated did not show any clinical ill effects and demonstrated adequate healing, with fewer adhesions and less inflammation compared with those treated with a bioabsorbable plug.
Abstract Purpose 5-fluorouracil (5-FU) chemotherapy is associated with severe and unpredictable toxicity in a significant proportion of patients. 5,10-methylenetetrahydrofolate (MTHF) and ...5-fluorodeoxyuridine monophosphate (FdUMP) bind to thymidylate synthase and together inhibit its function, resulting in cytotoxicity. We hypothesized that susceptibility to 5-FU toxicity might be related to individual differences in serum components of folate metabolism affecting intracellular 5,10-MTHF levels. Patients and Methods A prospective cohort of chemo-naive colorectal cancer patients planned to receive IV 5-FU and folinic acid for five consecutive days every four weeks in both the adjuvant and palliative settings were studied. Pretreatment clinical and laboratory data were collected. Biochemical data associated with folate metabolism was also collected. The primary endpoint was occurrence of > grade 3 toxicity and/or toxicity mandating dose delay or reduction. Results Of 78 eligible patients studied, multivariable analyses identified only a higher pre-treatment serum folate level as an independent predictor of toxicity > grade 3 and/or mandating schedule modification (p=0.016). Comparing patient cohorts amongst folate quartile groupings revealed increasing toxicity trends in the highest quartile with an odds ratio of 2.58 (p = 0.19) compared to combined lower quartiles as well as superior relapse-free and overall survival in patients treated in the adjuvant setting. Log-rank analysis showed significant association between higher folate levels and relapse free survival as well as overall survival. Conclusion Pretreatment serum folate level did not conclusively influence 5-FU toxicity and antitumour efficacy. However high folate levels appeared to trend towards a greater incidence of severe toxicities, but also lower rates of disease recurrence and mortality. This study provides promising hypothesis-generating data warranting further investigation. The predictive value of pretreatment folate status should be a priority for study in cancer patients receiving 5-FU-based chemotherapy, and should be considered a potentially confounding factor in clinical trials and a modifiable parameter in treatment.
Lower-extremity arteriopathy patients can be managed nonsurgically, but there is no standard algorithm for follow-up. The authors present a consensus on appropriate postangioplasty studies in the ...setting of claudication or a threatened limb. Physical examination with measurements of the ankle-brachial index should be the first step in patients with recurrent symptoms. When there is high clinical suspicion for a threatened limb, the patient should proceed directly to catheter angiography for possible reintervention. However, in the setting of claudication alone, segmental Doppler pressures and pulse volume recordings are the initial test of choice. Magnetic resonance angiography or ultrasound can be used in conjunction to further characterize lesions with more detail. Computed tomographic angiography may also be used to image lower-extremity vasculature but is limited by the presence of large amounts of vascular calcifications. Novel techniques, including dual-energy computed tomographic angiography and noncontrast magnetic resonance angiography, may provide clinicians with alternative approaches in patients with large amounts of vascular calcifications and renal insufficiency, respectively.
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