Znaczenie stosunku liczby neutrofili do limfocytów jako czynnika predykcyjnego dysfunkcji rozkurczowej lewej komory serca u chorych z przewlekłą chorobą nerek

Introduction. Left ventricular diastolic dysfunction (LVDD) occurs very often in patients with chronic kidney disease(CKD). The neutrophil to lymphocyte ratio (NLR) is a novel inflammatory marker, which has a predictive value in differentcardiovascular diseases. We have evaluated the association between NLR and LVDD among CKD patients.Material and methods. The study group consisted of 54 ambulatory patients with CKD at stages 3–5 with preservedleft ventricular (LV) systolic function. The CKD patients were divided into two groups, depending on the results of mitralearly diastolic velocity EmLV: the group with LV diastolic dysfunction LVDD(+), when EmLV < 8 cm/s, and the groupwith normal LV diastolic function LVDD(–), when EmLV ≥ 8 cm/s. NLR was calculated as the ratio of the neutrophil andlymphocyte counts.Results. Patients in LVDD(+) group had significantly higher values of NLR when compared to patients in LVDD(–) group(2.51 [1.12–9.82] vs. 1.75 [0.99–3.64], p = 0.007). NLR negatively correlated with EmLV (r = –0.311, p = 0.021), whilepositively with N-terminal B-type natriuretic propeptide (r = 0.292, p = 0.037). Among the examined parameters, NLRwas an independent predictive factor for LVDD with odds ratio 3.14 (95% confidence interval [CI] 1.05–9.42), p = 0.034.The area under the receiver operating characteristics curve for NLR was 0.714 (95% CI 0.575–0.828), p = 0.003, andusing a cut point of 1.77, the NLR predicted LVDD with a sensitivity of 92.3% and specificity of 53.6%.Conclusions. This study suggests that elevated neutrophil to lymphocyte ratio as an indicator of inflammation seems tobe a useful marker of LVDD in CKD patients.Wstęp. Dysfunkcja rozkurczowa lewej komory serca (LVDD) często rozwija się u osób z przewlekłą chorobą nerek (CKD). Stosunek liczby neutrofilów do liczby limfocytów (NLR) jest nowym markerem zapalnym, który uznaje się także za czynnik predykcyjny wielu chorób układu sercowo-naczyniowego. W opisanym badaniu oceniano związek między NLR a LVDD wśród chorych na CKD. Materiał i metody. Do badania włączono 54 chorych w 3.–5. stadium CKD z zachowaną frakcją wyrzutową lewej komory. Pacjentów podzielono na dwie grupy zależnie od wartości prędkości wczesnej fazy rozkurczowej pierścienia mitralnego (EmLV) — grupę z dysfunkcją rozkurczową lewej komory LVDD(+), kiedy EmLV wynosi poniżej 8 cm/s i grupę z prawidłową funkcją rozkurczową lewej komory LVDD(–), kiedy EmLV wynosi 8 cm/s lub więcej. Wyniki. Pacjęnci z grupy LVDD(+) charakteryzowali się istotnie wyższymi wartościami NLR niż chorzy z grupy LVDD(–), odpowiednio (2,51 [1,12–9,82] v. 1,75 [0,99–3,64]; p = 0,007). Stosunek liczby neutrofilów do liczby limfocytów korelował ujemnie z EmLV (r = –0,311; p = 0,021) oraz dodatnio ze stężeniem N-końcowego fragmentu propetydu natriuretycznego typu B (r = 0,292, p = 0,037). Spośród badanych parametrów NLR było niezależnym czynnikiem predykcyjnym LVDD z ilorazem szans 3,14 (95-proc. przedział ufności [CI] 1,05–9,42); p = 0,034. Pole powierzchni pod krzywą (ROC) dla NLR w rozpoznaniu LVDD wynosiło 0,714 (95% CI 0,575–0,828; p = 0,003), a wartość NLR 1,77 uzyskana w analizie ROC charakteryzowała się 92,3-procentową czułością i 53,6-procentową swoistością w rozpoznaniu LVDD. Wnioski. Wyniki badania sugerują, że podwyższony NLR jako parametr stanu zapalnego może być użytecznym markerem LVDD u chorych na CKD

Current Management of Brain Metastases: Overview and Teaching Cases

Over the past two decades, increased global incidence of malignancy, improved systemic disease treatment with prolonged survival, and increased central nervous system (CNS) surveillance in cancer patients have all contributed to a rise in cerebral metastatic disease. As many patients retain good neurologic function, the approach to their management has shifted markedly; a pre-terminal prognosis and palliative treatment have been replaced by individualized care plans to prolong functional survival. However, the rapid shifts in disease characteristics, treatment options and emerging evidence can be challenging to navigate, and a rational approach to brain metastases is needed. We discuss the changing epidemiology of brain metastases and consider approaches to prognostic classification. We review current treatment modalities and discuss the significant studies pertaining to each, with emphasis on Level 1 evidence when available and cooperative group trials, as well as studies on adverse effects. To integrate the information presented, we offer case scenarios that highlight pertinent decision-making factors. The shift in care goal for cerebral metastases from symptom palliation to prolongation of survival is not only feasible, but in many cases indicated. The appropriate application of various treatment modalities must be considered in the context of individual patients and their primary cancer

The approach to coronary bifurcation treatment and its outcomes in Poland: The single center experience

Background: Coronary bifurcation lesions pose therapeutic problems during percutaneous coronary interventions. The aim of this study was to analyze the strategy of coronary bifurcation treatment and associated angiographic as well as clinical outcomes in a large hospital in Northern Poland. Methods: Between January 2012 and January 2014 patients with stable coronary artery disease or non-ST-elevation acute coronary syndrome (NSTE-ACS) were treated with regular drug-eluting stents (rDES) or dedicated bifurcation stents (BiOSS Expert® or BiOSS LIM®). Clinical and angiographic controls were planned at 12 months. The primary endpoint was major adverse cardiovascular events (MACE) rate composed of cardiac death, myocardial infarction, and target lesion revascularization (TLR) at 12 months. Results: In total, 152 patients were enrolled in whom 158 stents were deployed (99 BiOSS stents and 59 rDES). Left anterior descending artery (50%) was the dominant target vessel followed by left circum¬flex (25%). There was no stent implantation failure. In 10 (6.3%) patients rDES was required within the side branch. At 12 months MACE rate was 11.2%, whereas TLR rate was 7.9%. In the logistic regression analysis final kissing balloon technique was the prognostic factor for better clinical outcome, whereas NSTE-ACS and true bifurcations were risk factors of a poor outcome. Conclusions: Percutaneous coronary bifurcation treatment is a safe and effective procedure, and pro¬visional T-stenting is the preferred technique. Both rDES as well as dedicated bifurcation stents enabled a simple and fast bifurcation treatment option with comparable MACE and TLR rates. (Cardiol J 2017; 24, 6: 589–596

Spinal tuberculoma in a patient with spinal myxopapillary ependymoma

Intramedullary spinal tuberculosis is a clinical curiosity. A 19-year-old female was diagnosed and treated for lumbosacral myxopapllary ependy moma (MPE). Three years later, she presented with back pain and hypoesthesia of the left upper limb. Besides revealing local recurrence, the MRI demonstrated a fresh lesion in the cervicomedullary area. The latter was operated and the histopathology revealed a tuberculoma

Impact of immobilisation and image guidance protocol on planning target volume margins for supine craniospinal irradiation

Background: The setup errors during supine-CSI (sCSI) using single or dual immobilisation (SM, DM) subsets from two institutions were reviewed to determine if DM consistently decreased the required planning target volumes (PTV) margins and to identify the optimal image guidance environments. Materials and methods: Ours and a sister institutional cohort, each with a subset of SM or DM sCSI and daily 3-dimensional online image verification sets, were reviewed for the cranial and spinal regions translational shifts. Using descriptive statistics, scatter plots and independent sample Mann-Whitney test we compared shifts in each direction for two subsets in each cohort deriving PTV margins (Van Herk: VH, Strooms: St recipes) for the cranial and spinal regions. Three image guidance (IG) protocols were simulated for two regions on the combined cohort with SM and DM subsets to identify the most optimal option with the smallest PTV margin. The IG protocols: 3F, 5F and 5FB where the systematic error correction was done using the average error from the first three, five and in the cranium alone (applied to both the cranium and spine, otherwise) for the first five set-ups, respectively. Results: 6968 image sets for 179 patients showed DM could consistently reduce the PTV margin (VH/St) for the cranium from 6/5 to 4/3.5 (31.8/30.8%) and 6/4 to 4/3.5 mm (30.5/16.8%) for primary and validation cohort, respectively. Similarly, for the spine it was 10/8.5 to 6/5.5 (38.6/38.4%) and 9/7.7 to 7/6 (21.6/21.4%), respectively. The “5F-IG” resulted in the smallest margins for both the cranial (3 mm) and spinal region (5 mm) for DM with estimated 95% CTV coverage probability. Conclusion: DM with 5F-IG would significantly reduce the required PTV margins for sCSI

Evaluation of Pathway to Diagnosis of Pediatric Brain Tumors in Tamil Nadu, India

PurposeDelayed diagnosis and poor awareness are significant barriers to the early intervention of pediatric brain tumors. This multicenter observational study aimed to evaluate the baseline routes and time to diagnosis for pediatric brain tumors in Tamil Nadu (TN), with the goal of promoting early diagnosis and timely referrals in the future.MethodsA standard proforma was used to retrospectively collect information on demographics, diagnosis, referral pathways, and symptoms of incident pediatric brain tumor cases between January 2018 and October 2020 across eight tertiary hospitals in TN. Dates of symptom onset, first presentation of health care, and diagnosis were used to calculate total diagnostic interval (TDI), patient interval (PI), and diagnostic interval (DI).ResultsA total of 144 cases (mean age, 6.64 years; range, 0-15.1 years) were included in the analysis. Among those, 94% (135/144) were from city/district areas, 40% (55/144) were self-referred, and 90% (129/144) had one to three health care professional visits before diagnosis. Median TDI, PI, and DI were 3.5 (IQR, 1-9.3), 0.6 (IQR, 0.1-4.6), and 0.6 (IQR, 0-3.3) weeks, respectively. Low-grade gliomas had the longest median TDI (6.6 weeks), followed by medulloblastomas (4.6 weeks) and high-grade gliomas (3.3 weeks). Average number of symptoms recorded was 1.7 at symptom onset and 1.9 at diagnosis.ConclusionAlthough there are some similarities with data from the United Kingdom, many low-grade and optic pathway tumors were unaccounted for in our study. DIs were relatively short, which suggests that infrastructure may not be a problem in this cohort. Increased training and establishment of proper cancer registries, combined with proper referral pathways, could enhance early diagnosis for these children

MicroRNAs in pulmonary arterial remodeling

Pulmonary arterial remodeling is a presently irreversible pathologic hallmark of pulmonary arterial hypertension (PAH). This complex disease involves pathogenic dysregulation of all cell types within the small pulmonary arteries contributing to vascular remodeling leading to intimal lesions, resulting in elevated pulmonary vascular resistance and right heart dysfunction. Mutations within the bone morphogenetic protein receptor 2 gene, leading to dysregulated proliferation of pulmonary artery smooth muscle cells, have been identified as being responsible for heritable PAH. Indeed, the disease is characterized by excessive cellular proliferation and resistance to apoptosis of smooth muscle and endothelial cells. Significant gene dysregulation at the transcriptional and signaling level has been identified. MicroRNAs are small non-coding RNA molecules that negatively regulate gene expression and have the ability to target numerous genes, therefore potentially controlling a host of gene regulatory and signaling pathways. The major role of miRNAs in pulmonary arterial remodeling is still relatively unknown although research data is emerging apace. Modulation of miRNAs represents a possible therapeutic target for altering the remodeling phenotype in the pulmonary vasculature. This review will focus on the role of miRNAs in regulating smooth muscle and endothelial cell phenotypes and their influence on pulmonary remodeling in the setting of PAH

Diagnosis and management of complications from the treatment of primary central nervous system tumors in adults.

Central nervous system (CNS) tumor patients commonly undergo multimodality treatment in the course of their disease. Adverse effects and complications from these interventions have not been systematically studied, but pose significant challenges in clinical practice and impact function and quality of life, especially in the management of long-term brain tumor survivors. Here the European Association of Neuro-Oncology (EANO) has developed recommendations to prevent, diagnose and manage adverse effects and complications in the adult primary brain CNS tumor (except lymphomas) patient population with a specific focus on surgery, radiotherapy and pharmacotherapy. Specifically, we also provide recommendations for dose adaptations, interruptions and re-exposure for pharmacotherapy that may serve as a reference for the management of standard of care in clinical trials. We also summarize which interventions are unnecessary, inactive or contraindicated. This consensus paper should serve as a reference for the conduct of standard therapy within and outside of clinical trials