Real-World Evidence: How Long Do Our Patients Fast?—Results from a Prospective JAGO-NOGGO-Multicenter Analysis on Perioperative Fasting in 924 Patients with Malignant and Benign Gynecological Diseases

Simple Summary: The concept of ERAS (Enhanced Recovery After Surgery) was introduced to reduce perioperative morbidity through a multimodal approach. Optimized and shortened perioperative fasting is a fundamental part of this modern concept of perioperative patient management, as prolonged fasting before and after surgery is associated with unfavorable outcomes. So far, it remains unclear whether increasingly established ERAS protocols lead to adequate short fasting intervals in clinical routines. We therefore conducted this prospective multicenter study and collected real-world data from 924 patients to evaluate actual perioperative fasting behavior. Patients reported drastically prolonged perioperative fasting durations. Even longer fasting intervals were reported for oncological and extensive procedures. Our data suggest that modern optimized fasting management is poorly implemented in clinical routine practice. This study should draw attention to the need for adequate implementation of ERAS protocols and sensitize clinicians to appropriate patient education about perioperative fasting. Background: Despite the key role of optimized fasting in modern perioperative patient management, little current data exist on perioperative fasting intervals in routine clinical practice. Methods: In this multicenter prospective study, the length of pre- and postoperative fasting intervals was assessed with the use of a specifically developed questionnaire. Between 15 January 2021 and 31 May 2022, 924 gynecology patients were included, from 13 German gynecology departments. Results: On average, patients remained fasting for about three times as long as recommended for solid foods (17:02 +/- 06:54 h) and about five times as long as recommended for clear fluids (9:21 +/- 5:48 h). The average perioperative fasting interval exceeded one day (28:23 +/- 14:02 h). Longer fasting intervals were observed before and after oncological or extensive procedures, while shorter preoperative fasting intervals were reported in the participating university hospitals. Smoking, treatment in a non-university hospital, an increased Charlson Comorbidity Index and extensive surgery were significant predictors of longer preoperative fasting from solid foods. In general, prolonged preoperative fasting was tolerated well and quality of patient information was perceived as good. Conclusion: Perioperative fasting intervals were drastically prolonged in this cohort of 924 gynecology patients. Our data indicate the need for better patient education about perioperative fasting

Untersuchungen zu klinischen und biologischen Eigenschaften von medullären und extramedullären Plasmazelldyskrasien unter besonderer Berücksichtigung von Immunhistochemie und Zytogenetik

Das extramedulläre Myelom (MM-EM) ist eine seltene, aber klinisch bedeutsame Manifestation des Multiplen Myeloms (MM), die sich hinsichtlich des klinischen Verlaufs und biologischer Eigenschaften von dem ausschließlich medullärem/fokal-ossärem MM unterscheidet. Von dem MM-EM ist das solitäre Plasmozytom abzugrenzen, welches in Form eines primär extramedullären Plasmozytoms (pEMP) oder eines solitär ossären Plasmozytoms (SOP) auftreten kann. Trotz der großen Unterschiede im klinischen Verlauf, der Therapie und der Prognose sind zytogenetische sowie immunhistochemische Eigenschaften von MM, MM-EM und pEMP/SOP bisher wenig erforscht. Methoden: Wir analysierten 87 Patienten mit klassischem medullärem/fokal-ossärem MM (n=18), MM-EM (n=49) und pEMP/SOP (n=20) mittels Immunhistochemie (IHC) hinsichtlich der Expression der Zelloberflächenmarker (CXCR4, CD31, CD44 und CD81). Zusätzlich untersuchten wir Proben von medullären und extramedullären Plasmazellneoplasien mittels Fluoreszenz-in-situ-Hybridisierung (FISH) in Kombination mit zytoplasmatischer Immunglobulinfärbung („clg-FISH“) hinsichtlich der genetischen Aberrationen del(17p), del(13q), C-MYC-Amplifikation, t(4;14), t(11;14), t(14;16) und 1q21-Amplifikation. Ergebnisse: Während beim pEMP/SOP mehrheitlich die Kopf-Hals-Region (60%) betroffen war, zeigte sich beim MM-EM am häufigsten (40%) eine disseminierte Lokalisation der Extramedullärmanifestationen. Das mediane Gesamtüberleben war bei pEMP/SOP signifikant länger (nicht erreicht) als bei Patienten mit MM mit oder ohne Extramedullärmanifestation bei Diagnose (72 versus 60 Monate, p=0,01). Proben von Patienten mit MM-EM zeigten signifikant häufiger eine moderate/starke CD44-Expression (90%) als Proben klonaler Plasmazellen von Patienten mit medullärem/fokal-ossärem MM (33%) oder pEMP/SOP (27%) (p<0,001). Eine moderate/starke CD44-Expression zeigte sich zudem signifikant häufiger bei Proben klonaler Plasmazellen von paraskelettalen pEMP, SOP oder MM-EM (82%) im Vergleich zu klonalen Plasmazellen aus nicht paraskelettalen Manifestationen von MM-EM/pEMP (44%) oder medullärem/fokal-ossärem MM (33%) (p=0,02). Bezüglich der CD31 und der CXCR4-Expression zeigte sich in den untersuchten Gruppen kein signifikanter Unterschied. CD81 konnte in keiner der untersuchten Proben nachgewiesen werden. Eine 1q21-Amplifikation trat in ähnlicher Häufigkeit beim MM-EM (33%), pEMP/SOP (57%) und medullärem/fokal-ossärem MM (44%) auf. Zudem wurde eine 1q21-Amplifikation signifikant häufiger in nicht paraskelettalen MM-EM/pEMP-Proben (64%) im Vergleich zu Proben aus SOP, paraskelettalem MM-EM und pEMP (9%) oder medullärem/fokal-ossärem MM (44%) dargestellt (p=0,02). Hingegen wurden die Aberrationen del(17p13), t(4;14) und t(14;16) in keiner der pEMP/SOP Proben nachgewiesen. Schlussfolgerungen: Wir beobachteten ein unterschiedliches Lokalisationsmuster der Extramedullärmanifestationen bei Patienten mit pEMP/SOP gegenüber Patienten mit MM-EM. Patienten mit pEMP/SOP zeigten ein signifikant längeres Gesamtüberleben im Vergleich zu Patienten mit MM mit und ohne Extramedullärmanifestationen. Die vorliegende Untersuchung zeigt zudem signifikante Unterschiede in der Antigenexpression und im Muster zytogenetischer Aberrationen zwischen medullärem/fokal-ossärem MM, MM-EM sowie pEMP/SOP. Diese Beobachtungen sprechen für unterschiedliche Mechanismen der Tumorpathogenese verschiedener medullärer und extramedullärer Plasmazelldyskrasien.Extramedullary myeloma (MM-EM) is a rare but clinically relevant manifestation of multiple myeloma (MM) that appears to differ from classical medullary/focal-osseous MM in terms of clinical course and biological characteristics. MM-EM can be distinguished from solitary plasmacytoma, which occurs as primary extramedullary plasmacytoma (pEMP) or solitary osseous plasmacytoma (SOP). The cytogenetic and immunohistochemical differentiation between MM, MM-EM and pEMP/SOP remains poorly understood despite major differences in clinical course, therapy and prognosis. Methods: We analyzed 87 patients with medullary/focal-osseous MM (n=18), MM-EM (n=49), and pEMP/SOP (n=20) by immunohistochemistry (expression of CXCR4, CD31, CD44 and CD81). In addition, we analyzed cytogenetic profiles using fluorescence in situ hybridization (FISH) in combination with cytoplasmic immunoglobulin staining ("clg-FISH") to detect the cytogenetic aberrations del(17p), del(13q), C-MYC-amplification, t(4;14), t(11;14), t(14;16) and 1q21-amplification. Results: While the majority of pEMP/SOP involved the head/neck region (60%), MM-EM most frequently (40%) showed disseminated extramedullary manifestations. Median overall survival (OS) was significantly longer in patients with pEMP/SOP (not reached) than in patients with MM with or without extramedullary manifestations at diagnosis (72 versus 60 months, p=0.01). Clonal plasma cell (PC) samples from MM-EM revealed more frequently a moderate/strong CD44 expression intensity (90%), compared to those from medullary/focal-osseous MM (33%) or pEMP/SOP (27%) (p<0.001). Beside this, moderate/strong CD44 expression was more frequently identified by clonal PC samples from paraskeletal pEMP, SOP or MM-EM (82%) compared to non-paraskeletal manifestations from MM-EM, pEMP (44%) or medullary/focal-osseous MM (33%) (p=0.02). No significant differences were identified in CD31 and CXCR4 expression intensities between the patient groups. CD81 expression was not detected in any sample. 1q21-amplification occurred in a similar frequency of clonal PC samples from MM-EM (33%), pEMP/SOP (57%) and medullary/focal-osseous MM (44%). In addition, 1q21-amplification was detected significantly more frequently in clonal PC samples from non-paraskeletal MM-EM or pEMP (64%) compared to SOP, paraskeletal MM-EM and pEMP (9%) or medullary/focal-osseous MM (44%) (p=0.02). In contrast, del(17p13), t(4;14) and t(14;16) were not present in any of the pEMP/SOP clonal PC samples. Conclusion: We observed different patterns of localization of extramedullary manifestations in patients with pEMP/SOP versus patients with MM-EM. Patients with pEMP/SOP showed significantly longer OS compared to patients with MM with or without extramedullary manifestations. The present study identifies relevant differences in antigen expression intensities and profiles of cytogenetic aberrations between medullary/focal-osseous MM, MM-EM and pEMP/SOP. These observations indicate different mechanisms of tumor pathogenesis in medullary and extramedullary PC dyscrasias

Limnoecological relationships between water level fluctuations and Ostracoda (Crustacea) species composition in Lake Sunnet (Bolu, Turkey)

The ecological characteristics of ostracods in Lake Sunnet were monitored monthly between May 2005 and September 2007; 9 living and 5 subfossil ostracod taxa were recorded. Among the species, Ilyocypris getica was reported in Turkey for the first time; while Stenocypria fischeri was found for the second time in the country in 55 years. The most abundant species, Limnocythere inopinata, was collected in dry and wet months, while I. bradyi was the only species found in only the wet months. The 9 species clustered into 3 groups based on their ecological preference. Species composition and occurrences were closely related to the lake water level fluctuation, from 7 to 13 m within a year. These fluctuations played a significant role in changes in the physicochemical characteristics of the lake, along with ostracod species composition (P < 0.01). A strong negative correlation (P < 0.05) between precipitation and both ambient temperature and SO4 was also interpreted as the outcome of such fluctuations. The number of species corresponded with salinity changes. Most of the ostracod species appearing in Lake Sunnet were tolerant to the large water level fluctuation. These results correspond with the idea of 'pseudorichness,' when species composition is dominated by cosmopolitans over noncosmopolitans, an indication of low water quality in a lake. Changes in the lake have been accelerated by anthropogenic activities such as water diversions for chicken farms and agricultural fields during dry climatic conditions. The occurrence of these activities appears to have produced seasonal differences in the lake's water quality and species composition

Decreased serum vitamin B-12 and vitamin D levels affect sleep quality in children with familial Mediterranean fever

WOS: 000419778900010PubMed ID: 29143127Familial Mediterranean fever is an autoinflammatory disorder characterized by recurrent fever and serositis. We aimed to describe serum vitamin B-12 and vitamin D levels and their correlation with self-reported sleep quality of pediatric FMF patients. Sixty-three children with FMF were enrolled to the study. Information on sleep quality was obtained using self-administration of Pittsburg Sleep Quality Index (PSQI). The patients were divided into subgroups depending on vitamin D serum concentrations: >= 20 and = 200, < 200 pg/ml. B-12 levels were not correlated with PSQI scores, whereas significant correlation was found between vitamin D and total PSQI scores and daytime sleepiness. Total PSQI score, sleep disorders and daytime sleepiness sub-scores were statistically high in patients with serum D vitamin levels below 20 ng/ml. Sleep efficiency was found lower in patients with serum B-12 levels below 200 pg/ml. B-12 may have a positive role on effective sleep. More importantly, we suggest that vitamin D is protective against sleep disorders and poor sleep, it may also improve daytime activities