-
Journal of Clinical Medicine Research Dec 2023The use of thromboelastography (TEG) has demonstrated decreased blood product utilization in patients with specific etiologies of major gastrointestinal bleeding (GIB),...
A Retrospective Study Comparing the Effect of Conventional Coagulation Parameters Vs. Thromboelastography-Guided Blood Product Utilization in Patients With Major Gastrointestinal Bleeding.
BACKGROUND
The use of thromboelastography (TEG) has demonstrated decreased blood product utilization in patients with specific etiologies of major gastrointestinal bleeding (GIB), such as variceal and non-variceal bleeding in cirrhosis patients; however, in a non-cirrhosis patient with GIB, there is far less evidence in the literature. Our retrospective study compares the effect of TEG-guided blood product utilization in patients with major GIB with all etiologies, including cirrhosis, admitted to medical intensive care unit (MICU).
METHODS
A retrospective chart review was conducted on patients admitted to the MICU of a tertiary academic medical center diagnosed with GIB using ICD-9/10 codes from 2014 to 2018. A total of 1,889 patients were identified, and validation criteria such as "GI or hepatology consult note", type and screen, pantoprazole, or octreotide drip" were used, which resulted in 997 patients, out of which 369 had a diagnosis of cirrhosis. Propensity score matching was done for baseline variables (age, sex, and race), ICU length of stay, hospital length of stay, ventilator days, and vasopressor use. As a result, 88 patients were included in the final analysis, with 44 in TEG and 44 in non-TEG group. A sub-group analysis was done in 46 patients with cirrhosis, 23 in TEG group and 23 in non-TEG group after propensity score matching.
RESULTS
There was significantly higher total blood volume (4,207 mL vs. 2,568 mL, P = 0.04) in the TEG group as compared to the non-TEG group, including total volume of cryoprecipitate (80 mL vs. 55 mL, P = 0.03) and total volume of platelet (543 mL vs. 327 mL, P = 0.03). In the cirrhosis sub-group, there was no significant difference in the amount of blood products transfused between the two groups.
CONCLUSION
This study revealed that TEG is not superior to conventional coagulation parameters in limiting the volume of blood product transfusion in major GIB patients in ICU settings.
PubMed: 38189039
DOI: 10.14740/jocmr5022 -
Frontiers in Endocrinology 2023To develop and internally validate a novel predictive model for mutations in pheochromocytomas and retroperitoneal paragangliomas (PPGLs).
AIM
To develop and internally validate a novel predictive model for mutations in pheochromocytomas and retroperitoneal paragangliomas (PPGLs).
METHODS
Clinical data of patients with PPGLs who presented to Peking Union Medical College Hospital from 2013 to 2022 and underwent genetic testing were retrospectively collected. Variables were screened by backward stepwise and clinical significance and were used to construct multivariable logistic models in 50 newly generated datasets after the multiple imputation. Bootstrapping was used for internal validation. A corresponding nomogram was generated based on the model. Sensitivity analyses were also performed.
RESULTS
A total of 556 patients with PPGLs were included, of which 99 had a germline mutation. The prediction model revealed that younger age of onset [Odds ratio (OR): 0.93, 95% CI: 0.91-0.95], synchronous metastasis (OR: 6.43, 95% CI: 2.62-15.80), multiple lesion (OR: 0.22, 95% CI: 0.09-0.54), retroperitoneal origin (OR: 5.72, 95% CI: 3.13-10.47), negative 131I-meta-iodobenzylguanidine (MIBG) (OR: 0.34, 95% CI: 0.15-0.73), positive octreotide scintigraphy (OR: 3.24, 95% CI: 1.25-8.43), elevated 24h urinary dopamine (DA) (OR: 1.72, 95% CI: 0.93-3.17), NE secretory type (OR: 2.83, 95% CI: 1.22- 6.59), normal secretory function (OR: 3.04, 95% CI: 1.04-8.85) and larger tumor size (OR: 1.09, 95% CI: 0.99-1.20) were predictors of mutations in PPGLs, and showed good and stable predictive performance with a mean area under the ROC curve (AUC) of 0.865 and coefficient of variation of 2.2%.
CONCLUSIONS
This study provided a novel and useful tool for predicting mutations by integrating easily obtained clinical data. It may help clinicians select suitable genetic testing methods and make appropriate clinical decisions for these high-risk patients.
Topics: Humans; Pheochromocytoma; Iodine Radioisotopes; Retrospective Studies; Succinate Dehydrogenase; Paraganglioma; Mutation; Adrenal Gland Neoplasms
PubMed: 38179299
DOI: 10.3389/fendo.2023.1285631 -
Theranostics 2024The kidneys are commonly considered as the potential dose-limiting organ for peptide receptor radionuclide therapy (PRRT), making the risk of nephrotoxicity a primary...
The kidneys are commonly considered as the potential dose-limiting organ for peptide receptor radionuclide therapy (PRRT), making the risk of nephrotoxicity a primary concern. This retrospective analysis with prospective documentation and long-term follow-up aims to assess the risk of nephrotoxicity after PRRT in a large cohort of patients with neuroendocrine neoplasms (NENs) treated at our institution over the past 18 years. A total of 1361 NEN patients treated with 1-10 cycles of Lu-DOTA-TOC/-NOC/-TATE, Y-DOTA-TOC/-NOC/-TATE, DUO-PRRT (sequential administration of Y- and Lu-), or TANDEM-PRRT (combination of Y- and Lu- on the same day concomitantly) were included in this analysis. All parameters were prospectively documented in a structured database comprising over 250 items per patient and retrospectively analyzed. Kidney function, including serum creatinine, blood urea nitrogen, cGFR, and electrolytes, was evaluated before each PRRT cycle and during follow-up. Restaging was regularly performed at 6-month intervals until death. Treatment-related adverse events were graded according to the Common Terminology Criteria for Adverse Events (CTCAE v.5.0). Between 2000 and 2018, a total of 5409 cycles of PRRT were administered to 1361 NEN patients. Follow-up after complete treatment was available for 1281 patients receiving 4709 cycles of PRRT, with a median follow-up time of 69.2 months (interquartile range, 32.8-110.5 months) and a maximum follow-up time of 175 months. Baseline creatinine levels were normal in 1039/1281 (81.1%) subjects, while grade 1 (G1) renal insufficiency was present in 221/1281 (17.3%) prior to PRRT. G2 was present in 19/1281 (1.5%), and G3 in 2/1281 (0.2%). After treatment, the proportion of G3/G4 grade patients only increased from 0.2% to 0.7%. Mean creatinine levels increased from a baseline of 0.90 ± 0.30 to 1.01 ± 0.57 mg/L (80.0 ± 26.7 to 89.4 ± 50.8 μmol/L) after treatment. In our main analysis cohort of 1244 patients (4576 cycles), 200 patients experienced an increase in CTCAE creatinine grade. Age, number of treatment cycles, type of radionuclides, and length of follow-up time were the main factors affecting CTCAE creatinine grading after treatment. When comparing the subgroups treated with different radionuclides, the risk of nephrotoxicity after Y treatment alone and the Y/Lu combination group was higher than after Lu treatment alone. In the Y treatment subgroup, the two significant risk factors for an increased CTCAE creatinine grade were identified to be age (≥60) and a long follow-up time. : This retrospective analysis with prospective documentation in a large cohort of 1281 NEN patients receiving 4709 cycles of PRRT co-administered with renal protection, treated through the individualized approach at a single institution over 18 years, did not reveal any evidence of long-term PRRT-related renal toxicity. The results of our study suggest that with the use of proper renal protection, nephrotoxicity due to PRRT is more likely a myth than a reality.
Topics: Humans; Retrospective Studies; Creatinine; Prospective Studies; Neuroendocrine Tumors; Octreotide; Renal Insufficiency; Organometallic Compounds; Radioisotopes
PubMed: 38169589
DOI: 10.7150/thno.92487 -
Theranostics 2024Peptide receptor radionuclide therapy (PRRT) for the treatment of neuroendocrine tumors (NETs) has been explored for more than two decades, but there are only limited...
Peptide receptor radionuclide therapy (PRRT) for the treatment of neuroendocrine tumors (NETs) has been explored for more than two decades, but there are only limited data on the treatment of NETs of unknown primary site (CUP-NETs). This study aimed to analyze the long-term outcome, efficacy, and safety of PRRT in patients with CUP-NETs. Patients with pathologically confirmed metastatic CUP-NET who received lutetium-177 (Lu) and/or yttrium-90 (Y) labeled somatostatin analogs between March 2001 and March 2019 were retrospectively reviewed; those patients were referred as cCUP-NETs (clinical CUP-NETs). Eighty-one patients had unknown primary tumors even after [Ga]Ga-SSTR and [F]FDG PET/CT and were classified as pCUP-NETs (PET CUP-NETs). Treatment response was assessed according to RECIST 1.1 and PERCIST. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier analysis, and adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. A total of 575 PRRT cycles were administered to 156 patients (76 men and 80 women) evaluable for analysis: these patients were monitored for a median period of 92.3 mo (range, 4.0-169.1 mo). The disease control rate was 41.4% (43.4%) by RECIST and 40.2% (40.8%) by PERCIST in cCUP-NENs (pCUP-NETs). The objective response rate (ORR) with PRRT was 29.4% and 32.2% in cCUP-NENs and pCUP-NETs, respectively. The median PFS and OS for the entire cohort were 17.4 mo (95% confidence interval [95% CI], 11.4-23.4) and 67.4 mo (95% CI, 47.2-87.2) for all patients, respectively. The median OS for G3 tumors was significantly lower (15 mo) than for patients with G1 NET (85.5 mo), G2 (71.7 mo), and for patients with unknown grade (63.3 mo) NETs (P = 0.186, HR: 10.6, 95% CI: 3.87, 28.97, P = 0.09). PRRT was well tolerated by all patients. During treatment and long-term follow-up, CTCAE grade 3 and grade 4 thrombocytopenia and leukocytopenia were observed in only 3 patients (1.9%); there was no evidence of renal or hepatic toxicity. In a large cohort of patients with advanced CUP-NETs treated with PRRT in a real-world scenario and followed up to 14 years after the commencement, PRRT has demonstrated favorable and clinically significant efficacy and survival with minimal and acceptable side effects. Our results indicate that PRRT is a well-tolerated and effective treatment option for patients with metastatic CUP-NETs expressing somatostatin receptors.
Topics: Male; Humans; Female; Positron Emission Tomography Computed Tomography; Neoplasms, Unknown Primary; Retrospective Studies; Neuroendocrine Tumors; Radioisotopes; Receptors, Somatostatin; Octreotide; Organometallic Compounds
PubMed: 38164147
DOI: 10.7150/thno.88619 -
Theranostics 2024Radionuclide therapies are an important tool for the management of patients with neuroendocrine neoplasms (NENs). Especially [I]MIBG and [Lu]Lu-DOTA-TATE are routinely... (Review)
Review
Radionuclide therapies are an important tool for the management of patients with neuroendocrine neoplasms (NENs). Especially [I]MIBG and [Lu]Lu-DOTA-TATE are routinely used for the treatment of a subset of NENs, including pheochromocytomas, paragangliomas and gastroenteropancreatic tumors. Some patients suffering from other forms of NENs, such as medullary thyroid carcinoma or neuroblastoma, were shown to respond to radionuclide therapy; however, no general recommendations exist. Although [I]MIBG and [Lu]Lu-DOTA-TATE can delay disease progression and improve quality of life, complete remissions are achieved rarely. Hence, better individually tailored combination regimes are required. This review summarizes currently applied radionuclide therapies in the context of NENs and informs about recent advances in the development of theranostic agents that might enable targeting subgroups of NENs that previously did not respond to [I]MIBG or [Lu]Lu-DOTA-TATE. Moreover, molecular pathways involved in NEN tumorigenesis and progression that mediate features of radioresistance and are particularly related to the stemness of cancer cells are discussed. Pharmacological inhibition of such pathways might result in radiosensitization or general complementary antitumor effects in patients with certain genetic, transcriptomic, or metabolic characteristics. Finally, we provide an overview of approved targeted agents that might be beneficial in combination with radionuclide therapies in the context of a personalized molecular profiling approach.
Topics: Humans; Neuroendocrine Tumors; 3-Iodobenzylguanidine; Quality of Life; Octreotide; Carcinoma, Neuroendocrine; Radioisotopes
PubMed: 38164150
DOI: 10.7150/thno.87345 -
Gastroenterology Apr 2024Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND & AIMS
Gastrointestinal angiodysplasias are vascular anomalies that may result in transfusion-dependent anemia despite endoscopic therapy. An individual patient data meta-analysis of cohort studies suggests that octreotide decreases rebleeding rates, but component studies possessed a high risk of bias. We investigated the efficacy of octreotide in reducing the transfusion requirements of patients with angiodysplasia-related anemia in a clinical trial setting.
METHODS
The study was designed as a multicenter, open-label, randomized controlled trial. Patients with angiodysplasia bleeding were required to have had at least 4 red blood cell (RBC) units or parental iron infusions, or both, in the year preceding randomization. Patients were allocated (1:1) to 40-mg octreotide long-acting release intramuscular every 28 days or standard of care, including endoscopic therapy. The treatment duration was 1 year. The primary outcome was the mean difference in the number of transfusion units (RBC + parental iron) between the octreotide and standard of care groups. Patients who received at least 1 octreotide injection or followed standard of care for at least 1 month were included in the intention-to-treat analyses. Analyses of covariance were used to adjust for baseline transfusion requirements and incomplete follow-up.
RESULTS
We enrolled 62 patients (mean age, 72 years; 32 men) from 17 Dutch hospitals in the octreotide (n = 31) and standard of care (n = 31) groups. Patients required a mean number of 20.3 (standard deviation, 15.6) transfusion units and 2.4 (standard deviation, 2.0) endoscopic procedures in the year before enrollment. The total number of transfusions was lower with octreotide (11.0; 95% confidence interval [CI], 5.5-16.5) compared with standard of care (21.2; 95% CI, 15.7-26.7). Octreotide reduced the mean number of transfusion units by 10.2 (95% CI, 2.4-18.1; P = .012). Octreotide reduced the annual volume of endoscopic procedures by 0.9 (95% CI, 0.3-1.5).
CONCLUSIONS
Octreotide effectively reduces transfusion requirements and the need for endoscopic therapy in patients with angiodysplasia-related anemia.
CLINICALTRIALS
gov, NCT02384122.
Topics: Aged; Humans; Male; Anemia; Angiodysplasia; Colonic Diseases; Gastrointestinal Hemorrhage; Iron; Multicenter Studies as Topic; Octreotide; Randomized Controlled Trials as Topic; Standard of Care; Female
PubMed: 38158089
DOI: 10.1053/j.gastro.2023.12.020 -
Pancreatology : Official Journal of the... Feb 2024/Objectives: Persistent organ failure (OF) in severe acute pancreatitis (SAP) is caused by activation of cytokine cascades, resulting in inflammatory injury....
BACKGROUND
/Objectives: Persistent organ failure (OF) in severe acute pancreatitis (SAP) is caused by activation of cytokine cascades, resulting in inflammatory injury. Anti-inflammation may be helpful in OF remission in early SAP. To assess the efficacy of anti-inflammatory regimens for OF prevention and remission in patients with predicted SAP and display clinical doctors' acceptance of these strategies, we conducted this retrospective study in the real world.
METHODS
Clinical data of patients with predicted SAP from 2010 to 2017 were retrospectively reviewed. Cases were divided into conventional support (C), C+ somatostatin/octreotide (C + S/O), and C + S/O + Cyclooxygenase-2-inhibitors (C + S/O + COX-2-I). The occurrence of SAP, OF, changes of proportion for three strategies, length of hospital stay, meperidine injection, and cytokine levels were compared. The constituent ratios of the three schemes over eight years were evaluated.
RESULTS
A total of 580 cases (C = 124, C + S/O = 290, C + S/O + COX-2-I = 166) were included. The occurrences of SAP in the C + S/O (28.3 %) and C + S/O + COX-2-I (18.1 %) groups were significantly lower than that in C group (60.5 %, P < 0.001), mainly by reducing persistent respiratory failure (P < 0.001) and renal failure (P = 0.002). C + S/O and C + S/O + COX-2-I regimens significantly decreased new onset OF and enhanced OF amelioration within 48 h when compared with C treatment (P < 0.001) in patients with OF score <2 and ≥ 2 on admission, respectively. C + S/O and C + S/O + COX-2-I as compared with C group significantly decrease OF occurrences in a multivariate logistic regression analysis (P < 0.05).
CONCLUSIONS
Somatostatin or its analogs and cyclooxygenase-2 inhibitors are promising for OF prevention and remission in patients with predicted SAP. The acceptance of combined strategies in the real world has increased, and the occurrence of SAP has decreased annually.
Topics: Humans; Pancreatitis; Octreotide; Cyclooxygenase 2 Inhibitors; Retrospective Studies; Acute Disease; Cyclooxygenase 2; Somatostatin; Cytokines
PubMed: 38155082
DOI: 10.1016/j.pan.2023.12.006 -
Cureus Nov 2023Insulinoma, a neuroendocrine tumor originating from pancreatic islets, presents unique challenges in diagnosis and management. We present a case of a 73-year-old female...
Insulinoma, a neuroendocrine tumor originating from pancreatic islets, presents unique challenges in diagnosis and management. We present a case of a 73-year-old female with recurrent hypoglycemia leading to syncope, who underwent emergency pancreatectomy for a secreting insulinoma with multiple comorbidities. This case report aims to shed light on the complexities of insulinoma management and the importance of tailored perioperative strategies. The patient, presenting with severe hypoglycemia, was admitted for optimization. Preoperative assessment labeled her as ASA IVE and indicated a high risk of perioperative morbidity. General anesthesia, invasive monitoring, and epidural anesthesia were planned. Intraoperative glucose control was crucial, achieved with continuous blood glucose monitoring, octreotide administration, and insulin titration. The patient was extubated post-surgery, and pain was managed with epidural infusion. She was discharged on the 4th postoperative day with follow-up care. Insulinoma diagnosis relies on clinical, biochemical, and imaging tests, with 72-hour fasting as the gold standard. Localizing the tumor within the pancreas is essential for surgical success, often requiring invasive techniques. Surgical resection remains the definitive treatment, while medical management may be necessary in select cases. Anesthetic management should prioritize agents that minimize the cerebral metabolic rate for oxygen. Careful intraoperative glucose control and vigilant postoperative monitoring are essential. This case report highlights the intricate management of insulinoma, emphasizing tailored perioperative strategies that balance glucose regulation, anesthesia techniques, and postoperative care. However, the limited existing literature underscores the need for further research to refine anesthesia protocols, glucose control methods, and postoperative care, ultimately improving outcomes for patients with insulinoma.
PubMed: 38149158
DOI: 10.7759/cureus.49425 -
Cureus Nov 2023N-butyl-2-cyanoacrylate (NB2CYA) is frequently used in the treatment of variceal hemorrhage with a success rate in hemostatic control of 87%-100%. Although rare,...
N-butyl-2-cyanoacrylate (NB2CYA) is frequently used in the treatment of variceal hemorrhage with a success rate in hemostatic control of 87%-100%. Although rare, complications include esophageal perforation, infection, or arterial and venous embolization. We present the case of a 67-year-old male with chronic ethanolic liver disease hospitalized due to melena and hematemesis. He had anemia requiring transfusion support, octreotide, and pantoprazole infusion. Upper digestive endoscopy was performed showing gastric varices with a hemorrhagic rupture point treated with cyanoacrylate. The patient developed respiratory failure over the next 48 hours with chest computed tomography (CT) angiography showing several dense, scattered linear images, with arterial vascular trajectories suggestive of cyanoacrylate embolization. It was decided to provide ventilatory support with invasive mechanical ventilation, initiate systemic corticosteroid therapy, and transfer the patient to the intensive care unit (ICU). The patient was ventilated for 11 days with initial favorable evolution, but after two episodes of decompensation of his chronic liver disease (CLD) (hepatic encephalopathy and hepatorenal syndrome) and a new nosocomial pneumonia, he ended up dying. The present case illustrates a rare but potentially fatal complication associated with cyanoacrylate, highlighting the importance of a high suspicion index in cases of respiratory failure and dyspnea after this therapy.
PubMed: 38143678
DOI: 10.7759/cureus.49329 -
International Journal of Surgery Case... Jan 2024Cystic lesions in the liver are commonly encountered space-occupying lesions having various etiologies such as simple cysts, malignancies, hydatid cysts, and pancreatic...
INTRODUCTION
Cystic lesions in the liver are commonly encountered space-occupying lesions having various etiologies such as simple cysts, malignancies, hydatid cysts, and pancreatic pseudocysts.
CASE PRESENTATION
An eight-year-old girl initially presented with acute abdominal pain, fever, and a cystic lesion in the upper abdomen. Surgical intervention was performed based on an initial diagnosis of an inflammatory cyst. Later, she developed pleural effusion. Further investigations, unveiled a cystic mass arising from the head of the pancreas, and a pancreatico-pleural fistula. Retrospective analysis revealed a history of trauma that started her illness course. Conservative management involving intercostal tube drainage and octreotide infusion resulted in a favorable outcome.
DISCUSSION
Pancreatic pseudocyst is typically results from pancreatitis or trauma but in rare cases, they can have extended to unusual locations such as the liver. This case highlights the varied presentations and complex interplay of symptoms associated with intrahepatic pseudocysts. The initial oversight of trauma in the patient's history underscore the importance of thorough history-taking for an accurate diagnosis. The complexity of this case emphasize the necessity of a multidisciplinary approach in managing such atypical presentations.
CONCLUSION
Intrahepatic pseudocysts, especially those resulting from post-traumatic pancreatic pseudocyst, are uncommon and are not typically included in the differential diagnosis of liver lesions. This case highlights the significance of identifying unusual presentation and thoroughly investigating the patient's medical history to make an accurate diagnosis. A multidisciplinary approach is essential for effective patient management in these complex cases.
PubMed: 38100928
DOI: 10.1016/j.ijscr.2023.109125