Management of chronic osteomyelitis following gunshot injuries: a systematic review of literature

Background: chronic osteomyelitis of long bones are common in daily clinical practice, however, the treatment of these diseases has still been a challenge and difficult for orthopedic surgeons. Gunshot injuries lead to damage to bone and soft tissues that can complicate with bacterial invasion and cause bone infection. Many ways can overcome of bone infection, surgical debridement; bone fixation and antibiotic are used in management of chronic osteomyelitis. The objective of this systematic review was to review available studies reporting in management of chronic osteomyelitis following gunshot injuries and compare the methods used into the treatment

Methods: a comprehensive literature search was performed from the electronic databases Medline, PubMed, Google scholar, and Cochrane collaboration between 1995 and 2016. References were analyzed from included studies, inclusion criteria included [1] English literatures, [2] Humans clinical trials, [3] Orthopedic Journals only, [3] Definitive treatment strategy for management chronic osteomyelitis. In total, 5 articles were included in the systematic review

Results: a total of 278 patients from 5 studies were included in this systematic review. The mean age of the patients is all studies were 33.84 year; the ratio male to female is 6:1. The most of patients were classified as Gaustilio type lllB and CiernyMader type lllB. The result of all different studies shows a good outcome in 260 patients but 7 patients had poor outcome who were still had bone infection and one patient end by amputation. Radiographic X-ray did postoperative follow up every two weeks. The mean follow up duration was 40 months and all patients responsible for keep the fixator clean

Conclusion: our systematic review showed that the patients with chronic osteomyelitis were treated by surgical debridement and bone fixation had a good result. But, this research lost the randomized trials methods, risk factors of patients, compare control groups and good statistical analysis. Without any direct comparison of treatment modalities, it is difficult to determine which individual treatment option is the most efficacious

Poor survival outcome of docetaxel every three weeks plus prednisone for treatment of patients with hormone-refractory metastatic prostate cancer

Since previous studies have indicated there are improvements in overall survival, the aim of this phase II clinical study was to evaluate docetaxel every three weeks plus prednisone as first-line chemotherapy for treatment of hormone-refractory metastatic prostate cancer [HRMPC]. Thirty-five metastatic HRPC patients were treated with docetaxel 70 mg/m2 every 3 weeks plus oral prednisolone 5 mg twice daily at the clinical oncology departments of Tanta, Mansoura and Menofia University Hospitals during the period from June 2006 to December 2008. The primary endpoint was assessment of the overall tumor response rate. Secondary endpoints were assessment of PSA response rate, overall survival rate, and the time to disease progression. The median number of cycles administered was 6 cycles. Partial response was observed in 15 patients [42.9%] with evaluable measurable disease. Median survival from protocol entry was 15 months. Median time-to-time disease progression was 10 months. Prostate-specific antigen [PSA] declined >/= 50% in 9 patients [25.7%]. The most common grade _ toxicity associated with studied protocol was neutropenia [85.7%]. When given with prednisone, treatment with docetaxel every three weeks does not improve survival, soothe benefit of docetaxel-based therapy is not clear this high risk and poor prognostic group of patients

Oral capecitabine in combination with gemcitabine in management of advanced pancreatic carcinoma

Preclinical studies indicate positive biochemical and synergistic effects between capecitabine, an oral fluorouracil, and gemcitabine, the standard treatment for advanced pancreatic cancer [APC]. The goals of this study were to investigate the efficacy and safety of such combination for patients with APC. Twenty-two eligible patients with APC were treated with oral capecitabine and gemcitabine [CapGem regimen]. Capecitabine was given in a dose of 750 mg/m2 BID daily from day 1 to day 14 followed by one-week rest. Gemcitabine was given on day 1 and day 8 in a dose of 1000 mg/m2/dose given as i.v. infusion in 250 ml normal saline for 30 minutes of each 3-week cycle. Tumor lesions were assessed for objective response by physical examination and abdominal CT every two cycles of chemotherapy. Adverse events were monitored continuously during treatment and for one month after the last dose of the study. Estimation of survival was done every two months alter completion of chemotherapy cycles. The results revealed that among the 22 studied patients, two patients achieved complete clinical response [9.1%] and five patients [22.7%] achieved partial response with overall objective response rate 31.8% [95% CI, 0.21 to 0.39]. The median response duration of all responders was 31 weeks [95% CI, 18 to 39 weeks]. CA-19-9 was dropped >50% in eight patients and dropped >90% in five patients. The median time to disease progression in all 22 patients was 32 weeks [95% CI, 21 to 40 weeks]. The median survival for the whole studied group was 36 weeks [95% CI, 27 to 48 weeks]. Treatment was generally well tolerated in the outpatient settings. In conclusion, capecitabine in combination with gemcitabine was well tolerated regimen with apparent efficacy in patients with APC. Therefore, the supra-additive antitumor effect of such combination regimen of CapGem plus the advantage of oral administration of capecitabine merits this protocol promising

Role of gemcitabine, oxaliplatin and prednisolone combination as first-line chemotherapy in non-Hodgkin's Lymphoma

Non-Hodgkin's lymphomas [NHL] are commonly treated with cyclophosphamide, doxorubicin, vincristine and prednisolone [CHOP]. The objective of the current study was to evaluate the efficacy and safety of gemcitabine, oxaliplatin and corticosteroids [GEMOX-P] as first-line treatment for patients with intermediate-high grade non-Hodgkin's lymphoma [NHL]. Thirty-three patients with intermediate/high grade NHL were randomized into two groups. First group received standard [CHOP] with prednisolone tablets 40 mg/m2/day for five days. The second group received gemcitabine 1000 mg/m2 D1, 8, then oxaliplatin 80 mg/m2 D1 and prednisolone tablets 40 mg/m2/day for five days with recycling every 21 days. The primary end point was response rate. The secondary end points were disease-free survival and overall survival. From the results of this study, it was concluded that the regimen of [GEMOX-P] had beneficial effects over [CHOP] regimen, that included higher complete response rate in high-risk cases and lower cardiac and hepatic toxicity, but there was no difference after 18 months in disease free or overall survival between both treatment arms. Selection of cases that may benefit from chemotherapy treatment either [CHOP] or [GEMOX-P] is needed balance between anticipated toxicities, treatment outcome and cost benefit aspect

Can mobilized unprocessed whole blood replace leukapheresis product for autologous peripheral blood stem cell transplantation in patients with lymphoma? implementation of pre-apheresis CD34 analysis

High dose chemotherapy [HDC] with peripheral blood stem cell transplantation [PBSCT] is increasingly used therapeutic option for patients with hematological malignancies. This requires leukaphresis and cryopreservation of at least 1-2 x 10 [6]/kg CD34+ cells. As the leukapheresis procedures is expensive, time-consuming, and involve several technical and psychological problems for the patients. The aim of this study was to develop a simplified, safe, and cost effective peripheral blood stem protocol for collection of at least 1-2 x 10 [6]/kg CD34+ stem cells with liquid preservation at 4°C which may be suitable for patients refusing leukapheresis or in areas lacking cryopreservation facilities. Patients and Twelve patients with relapsed lymphomas underwent stem cell mobilization with rhG-CSF subcutaneous 10 ug/kg/day for 5 days. At the day of stem cell harvest white blood cells [WBCs], mononuclear cells [MNCs] and CD34+ cell count were estimated from peripheral blood. According to absolute count of CD34+ cells in the peripheral blood, CD34+ cells in 1000 ml blood and/patient kg were calculated. Patients with CD34+ cells < 1 x 10 [6]/kg, leukapheresis was performed, while extraction of 1000 ml mobilized whole blood by 2 phlebotomies was performed for patients with calculated CD34+ cells > 1 x 10 [6]/kg. Six patients were candidate for whole blood collection by phlebotomy with liquid preservation while leukapheresis and cryopreservation were necessary to reach the target stem cell dose for another 6 patients. Hematological recovery after high dose chemotherapy was compared between both groups. Pre-apheresis MNCs, and CD34+ cells count were higher in six patients candidate for leukapheresis than patients candidate for unprocessed mobilized whole blood collection [27.7 +/- 3.4 x 10 [9]/L, and 26.6 +/- 6.9 x 10 [6]/L] versus [39.5 +/- 5.7 x 10[9]/L, 89.8 +/- 21.9 x 10 [6]/L] respectively and this difference was statistically significant [p < 0.01 and 0.001] respectively. The apheresis product and collected mobilized unprocessed whole blood both exceed the minimum target cell dose for auto transplantation. The patients with leukapheresis received product contained more MNCs and CD34+ cells [2.9 +/- 0.3 x 10 [8]/kg and 2.15 +/- 0.5 x 10 [6]/kg] higher than patients received collected mobilized whole blood [2.6 +/- 0.4 x 10 [8]/kg and 1.28 +/- 0.3 x 10 [6]/kg] respectively and this difference was statistically significant for CD34 [p < 0.01]. There was non significant difference between patients who received apheresis products for neutrophil and platelets recovery [p > 0.07 and 0.057], where the days to reach ANC >/= 0.5 x10 [9]/L was 10.3 +/- 1.5 [8-12] days and for platelet >/= 20 x10 [9]/L was 11.3 +/- 3.01 [7-15] while patients received whole blood the ANC was 12.3 +/- 1.9 [9-16] and for platelets was 16.0 +/- 4.3 [8- 20] days but this was statistically non significant. In some patients with CD34+ cell count more than 65/uL measured in peripheral blood at the day of stem cell collection and if the total CD34+ cell/kg count in one liter blood exceed target stem cell dose of 1 x 10 [6]/kg, mobilized unprocessed whole blood collected by phlebotomy with liquid preservation can replace leukaphresis product for stem cell autotransplantation. The mobilized unprocessed whole blood with liquid preservation was able to reconstitute bone marrow after HDC like cryopreserved mobilized PBSC with lower cost and effort

efficacy and tolerability of rituximab plus CHOP immuno-chemotherapy in comparison with CHOP chemotherapy alone in management of aggressive diffuse CD20 positive large-B-cell lymphoma

Background: Diffuse large B-cell Lymphoma [DLBCL] is the most common form of aggressive non-Hodgkinis lymphoma [NHL] accounting for 30% of all NHL cases. CHOP chemotherapy containing cyclphosphamide, doxorubicin, vincristine and prednisolone, is the conventional standard treatment for those patients but still curative in less than 50% of patients. Rituximab is a chimeric targeting antibody that binds specifically to CD20 antigen, expressed on 85% of cells of the B-cell lineage; leading to specific elimination of B-cells through multiple mechanisms

Purpose: The addition of rituximab to CHOP [CHOP-R] in management of patients with DLBCL could improve the response rate, event-free survival and overall survival. We conducted this trial is to compare the efficacy and tolerability of CHOP plus rituximab [CHOP-R] with CHOP alone in patients with CD20+ DLBCL

Patients and Methods: Thirty six patients with untreated CD20 positive DLBCL were randomly assigned to receive either eight courses of CHOP chemotherapy alone [cyclophosphamide: 750 mg/m2 IV DI, Vincristine: 1.4 mg/m2 IV DI [Maximum: 2 mg], Doxorubicin: 50mg/m2 IV DI and prednisolone: 100 mg/day PO Dl-D5] every three weeks [19 patients] or eight cycles of CHOP in addition to rituximab: 375 mg /m2 IV on day 1 of each cycles [17 patients]

Results: Thirty sex patients [median age. 62 year] were included and with a median follow-up of 18 months, CHOP-R was significantly superior to CHOP alone in terms of complete response rate [76.4% versus 57.9%]. Event-free survivial [59% versus 42%] and overall survival [76% versus 63% respectively. Sub- analysis have revealed that: the benefit of CHOP-R was seen in patients with both high-and low-risk International prognostic index [IPI] status. Also of great importance was the excellent tolerability profile with no clinically significant increase in the adverse events was seen with rituximab plus CHOP compared to CHOP alone

Conclusions: Rituximab plus CHOP represents a good acievementthe first advance in therapy of patients with CD20+ DLBCL. The magnitude of the effect on improvement of complete response rate, event-free survival and overall survival, was so great that statistically significant benefits were apparent after 18 months follow-up. Rituximab was well- tolerable md did not add any significant toxicity to CHOP chemotherapy

therapeutic outcome of multimodality approach in management of locally advanced, stage III and IVa invasive thymoma

Background: surgery is the treatment of choice for malignant thymoma whenever a complete resection can be accomplished. For locally advanced [LA] and unresectable stage III and IVa thymoma, the therapeutic outcome has been poor

Purpose: to assess tumor response, respectability, event-free survival and, overall survival of multimodality approach in therapy of LA stage III and IVa malignant invasive thymoma

Patients and Methods: fourteen patients [7 males and 7 females] with histologically confirmed invasive thymoma were treated. The median age was 48 years [range: 24-64 years]. Six patients [42.9%] were in clinical stage III disease and, 8 patients [57.1%] had stage IVa disease. The most common histological type was lymphoepithelial [57.1%]. The treatment protocol consisted of 3 courses of induction cisplatin-based chemotherapy [PAC with corticostreoids: cisplatin: 50 mg/m[2] IV DI, doxorubicin: 50 mg/m[2] IV DI, cyclophosphamide: 50 mg/m2 IV DI and, prednisolone: 60 mg/m[2] PO D1-5], then surgery followed by postoperative radiotherapy and completion consolidation chemotherapy; another 3 courses of PAC plus corticosteroids

Results: fourteen patients were enrolled and assessed for response. After induction chemotherapy, complete response encountered in four patients [28.6%], partial response in 7 patients [50%], stable disease in 1 patient [7.1%] and progressive disease in 2 patients [14.3%]. Ten patients [71.4%] performed surgical resection: total resection in 8 patients [57.1%] and, subtotal in 2 patients [14.3%]. 1 refused surgery, 1 patient died with stable disease [7.1%], and 2 patients [lied with progressive disease [14.3%]. At the end of the study and after a median follow-up of 18 months. 11 patients were alive [78.6 %] and 9 patients are event-free [64.3%]. The 3-year calculated actuarial overall and event-free survival of studied patients was 71.3% and 57.1% respectively

Conclusion: Combined treatment approach in management of LA and unresectable invasive thymema is encouraging and demonstrated high objective overall response rates with increased respectability rate and, improvement of overall survival. Preoperative induction chemotherapy followed by surgical resection, postoperative radiotherapy and consolidation chemotherapy may become the standard treatment of LA and unresectable invasive thymoma

Intravesical sequential chemo - immunotherapy in superficial transitional cell bladder cancer

Thirty-five patients of [Ta/Tl] bladder tumors that initially treated with transurethral resection were randomized into three groups. Group A included patients received intravesical 2 g of gemcitabine in 100 ml saline once weekly for six consecutive weeks. Group B received 150 mg of BCG diluted in 50 ml saline once weekly for six consecutive weeks. Group C received sequential combination of weekly intravesical 2 g of gemcitabine in 100 ml saline for six consecutive weeks, then six weekly intravesical 75 mg of BCG diluted in 50 ml saline. After median follow up of 17 months, recurrence of progression was assessed as terminal events of the study. High risk cases that may have either multiple bladder lesions or more than grade I or associated with CIS were present in 72.7% and 66.7% in arm A, B and C, respectively. The most common local side effects were dysuria, hematuria, frequency and cystitis either bacterial or chemical. Systemic toxicities included neutropenia, thrombocytopenia, fever and malaise. Patients treated with intravesical chemo-immunotherapy had higher incidence of systemic toxicities. 36.4%, 66.7% and 75% were disease-free cases; however recurrence was present in 45.5%, 25% and 16.7% of cases in groups A, B and C, respectively