Idiopathic pulmonary fibrosis and lung cancer: future directions and challenges.

Idiopathic pulmonary fibrosis (IPF) is a progressive disease of pulmonary scarring. New treatments slow disease progression and allow pulmonary fibrosis patients to live longer. Persistent pulmonary fibrosis increases a patient's risk of developing lung cancer. Lung cancer in patients with IPF differs from cancers that develop in the non-fibrotic lung. Peripherally located adenocarcinoma is the most frequent cell type in smokers who develop lung cancer, while squamous cell carcinoma is the most frequent in pulmonary fibrosis. Increased fibroblast foci in IPF are associated with more aggressive cancer behaviour and shorter doubling times. Treatment of lung cancer in fibrosis is challenging because of the risk of inducing an exacerbation of fibrosis. In order to improve patient outcomes, modifications of current lung cancer screening guidelines in patients with pulmonary fibrosis will be necessary to avoid delays in treatment. 2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) computed tomography (CT) imaging can help identify cancer earlier and more reliably than CT alone. Increased use of wedge resections, proton therapy and immunotherapy may increase survival by decreasing the risk of exacerbation, but further research will be necessary.

Bleeding Risk Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer in Men on Baseline Anticoagulant or Antiplatelet Therapy.

PURPOSE: Patients on anticoagulant/antiplatelet medications are at a high risk of bleeding following external beam radiation therapy for localized prostate cancer. SBRT may reduce the bleeding risk by decreasing the volume of bladder/rectum receiving high doses. This retrospective study sought to evaluate the rates of hematuria and hematochezia following SBRT in these patients. METHODS: Localized prostate cancer patients treated with SBRT from 2007 to 2017 on at least one anticoagulant/antiplatelet at baseline were included. The minimum follow-up was 3 years with a median follow-up of 72 months. Patients who had a rectal spacer placed prior to SBRT were excluded. Radiotherapy was delivered in 5 fractions to a dose of 35 Gy or 36.25 Gy utilizing the CyberKnife system. Hematuria and hematochezia were prospectively assessed before and after treatment using the Expanded Prostate Cancer Index Composite (EPIC-26). Toxicities were scored using the CTCAE v4. Cystoscopy and colonoscopy findings were retrospectively reviewed. RESULTS: Forty-four men with a median age of 72 years with a history of taking at least one anticoagulant and/or antiplatelet medication received SBRT. Warfarin (46%), clopidogrel (34%) and rivaroxaban (9%) were the most common medications. Overall, 18.2% experienced hematuria with a median time of 10.5 months post-SBRT. Altogether, 38.6% experienced hematochezia with a median time of 6 months post-SBRT. ≥ Grade 2 hematuria and hematochezia occurred in 4.6% and 2.5%, respectively. One patient required bladder neck fulguration and one patient underwent rectal cauterization for multiple non-confluent telangiectasia. There were no grade 4 or 5 toxicities. Cystoscopy revealed bladder cancer (40%) and benign prostatic bleeding (40%) as the most common hematuria etiology. Colonoscopy demonstrated hemorrhoids (54.5%) and radiation proctitis (9.1%) as the main causes of hematochezia. There was no significant change from the mean baseline EPIC-26 hematuria and hematochezia scores at any point during follow up. CONCLUSION: In patients with baseline anticoagulant usage, moderate dose prostate SBRT was well tolerated without rectal spacing. High grade bleeding toxicities were uncommon and resolved with time. Baseline anticoagulation usage should not be considered a contraindication to prostate SBRT.

Impact of Age on Patient-Reported Outcomes Following Stereotactic Body Radiation Therapy for Prostate Cancer.

Purpose Stereotactic body radiation therapy (SBRT) delivers large radiation doses to the prostate while minimizing exposure to adjacent normal tissues. Large fraction sizes may increase the risks of functional decrements. Elderly men may be at an increased risk of these toxicities due to poor baseline function and hence limited reserve. This study describes patient-reported outcomes following SBRT for clinically localized prostate cancer in the elderly. Methods Between 2007 and 2017, 179 hormone-naive elderly patients (≥ 70 years old) and 210 patients under 70 years old with clinically localized prostate cancer were treated with 35-36.25 Gy SBRT in five fractions utilizing the CyberKnife Radiosurgical System (Accuray Inc.). Quality of life (QOL) was assessed using the Expanded Prostate Index Composite-Short Form (EPIC-26) questionnaire at baseline and at 1, 3, 6, 12, 18, 24, 30, and 36 months following the completion of treatment. EPIC scores range from 0 to 100, with lower values representing worsening symptoms. Results EPIC scores in the elderly cohort mirrored those in the younger cohort. EPIC urinary obstructive/irritative scores declined at one month post-SBRT (mean change from baseline ≥70: -7.9; <70: -11.1) before returning to baseline at three months post-SBRT (mean change from baseline ≥70: -0.4; <70: -1.4). The EPIC urinary incontinence scores declined slowly over the three years following treatment without recovery (mean change from baseline ≥70: -6.6; <70: -4.8). EPIC Bowel scores transiently declined at one month post-SBRT (mean change from baseline ≥70: -8.5; <70: -9.1) and then experienced a second more protracted decline over the next three years without recovery (mean change from baseline ≥70: -4.5; <70: -1.8). Hormonal EPIC scores were not impacted by radiation treatment or age. Older men had lower baseline and post-treatment EPIC sexual summary scores at all time points. However, there was no clinically significant difference in the EPIC sexual bother score between younger and older men at baseline and following treatment. Conclusions In the first three years following treatment, the impact of SBRT treatment on patient-reported outcomes was minimal. Our findings suggest that SBRT for clinically localized prostate cancer should not be deferred in older men solely due to concerns of increased morbidity. Further studies should be conducted to evaluate the impact of age on outcomes or morbidity following SBRT.

Rare Occurrence of Prosthetic Knee Septic Arthritis Due to Streptococcus viridans in the Background of a Dental Procedure.

The American Academy of Oral Medicine, American Dental Association (ADA), in conjunction with the American Academy of Orthopedic Surgeons (AAOS) and the British Society for Antimicrobial Chemotherapy, advises against the universal use of antimicrobial prophylaxis prior to dental procedures for the prevention of prosthetic joint infection (PJI). Here, we discuss the case of a patient with PJI in the background of periodontal scaling, which was done a week prior to presentation to the hospital. The PJI occurred with Streptococcus (S.) viridans, a rare organism for PJI but a common oral commensal. As the number of prosthetic joint surgeries are increasing and more data become available, prophylactic antibiotics might be considered to prevent PJI, especially in high-risk patients.

Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations.

Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase. Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment. Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF.

[Effect of Leishmania mexicana, RANTES and TNF alpha on splenic dendritic cells of newborn and adult BALB/c mice: phenotypic characteristics and migratory properties]. / Efecto de la Leishmania mexicana, RANTES y TNF alfa en el fenotipo y propiedades migratorias in vitro de células dendríticas esplénicas de ratones BALB/c neonatos y adultos.

Dendritic cells (DCs) are essential in the development and regulation of the immune response (IR). The inherent potential of DCs to induce a specific immune response in the neonatal period is controversial. It has been suggested that the specific IR in neonates depends on the quantitative relation of DC/T lymphocytes, as well as on the neonatal or adult age at which the interaction antigen/DC/T lymphocytes occurs. This suggests that this contact has an influence on the phenotypic and/or biological properties of DCs, which modifies its behavior. Therefore, the effects of Leishmania mexicana (L. mexicana) and of TNFalpha and RANTES cytokines on immunophenotypical characteristics were evaluated on spleen DCs, from neonate and adult BALB/c mice, by using flow cytometry and in vitro migratory properties with a Boyden Chamber. In basal conditions, neonate and adult DCs express the same molecules (CD40, CD86, MHCII and CD54). When the DCs interact with the antigen L. mexicana, the expression of these molecules are similar in adults and in neonates, with the exception of CD40 whose intensity of expression was raised (P < 0.05) in both groups. The rate of migration of the DCs in a culture medium conditioned of L. mexicana, RANTES and TNFalpha was higher in adults than in newborn mice. These observations suggest that neonatal and adult mice DCs have similar phenotypic characteristics. Under the effect of the same stimulus they respond differently; suggesting that other factors are involved in the higher susceptibility that newborns have to infections.

Efecto de la Leishmania mexicana, RANTES y TNF alfa en el fenotipo y propiedades migratorias in vitro de células dendríticas esplénicas de ratones BALB/c neonatos y adultos / Dendritic cells of BALB/c mice: phenotypic characteristics and migratory properties

Las células dendríticas (CDs) son esenciales en el desarrollo y regulación la respuesta inmunitaria (RI). Existen controversias en cuanto al potencial de inducción de la RI por las CDs en el período neonatal. Se ha propuesto que la RI específica de un neonato depende de la relación cuantitativa CD/linfocito T, y del momento, etapa neonatal o adulta, del encuentro con el antígeno, lo que parece influir sobre las propiedades fenotípicas y biológicas de las CDs, modificando su comportamiento. Por tal motivo, nos planteamos evaluar el efecto de un antígeno, Leishmania mexicana (L. mexicana) y de las citoquinas TNFa y RANTES sobre las características fenotípicas y propiedades migratorias, in vitro, de las CDs esplénicas provenientes de ratones BALB/c neonatos y adultos, usando citometría de flujo y la cámara de Boyden. Las CDs de ratones neonatos y adultos, en condiciones basales, expresan de manera similar, las moléculas CD40, CD86, CMHII y CD54. Este mismo fenómeno se observó al incubar dichas células con el Ag (L. mexicana) a excepción de la molécula CD40 cuya intensidad de expresión se elevó significativamente (P<0,05) en ambos grupos de estudio. El índice de migración de las CDs en presencia de medio de cultivo condicionado de L. mexicana, RANTES y TNFa fue mayor en adultos que en neonatos. Estos resultados muestran que las CDs neonatales son fenotípicamente similares a las adultas. Ante los mismos estímulos se comportan de manera diferente, sugiriendo la existencia de otros factores, que pudieran explicar la mayor susceptibilidad a infecciones en la etapa neonatal.

Dendritic cells (DCs) are essential in the development and regulation of the immune response (IR). The inherent potential of DCs to induce a specific immune response in the neonatal period is controversial. It has been suggested that the specific IR in neonates depends on the quantitative relation of DC/T lymphocytes, as well as on the neonatal or adult age at which the interaction antigen/DC/T lymphocytes occurs. This suggests that this contact has an influence on the phenotypic and/or biological properties of DCs, which modifies its behavior. Therefore, the effects of Leishmania mexicana (L. mexicana) and of TNFa and RANTES cytokines on immunophenotypical characteristics were evaluated on spleen DCs, from neonate and adult BALB/c mice, by using flow cytometry and in vitro migratory properties with a Boyden Chamber. In basal conditions, neonate and adult DCs express the same molecules (CD40, CD86, MHCII and CD54). When the DCs interact with the antigen L. mexicana, the expression of these molecules are similar in adults and in neonates, with the exception of CD40 whose intensity of expression was raised (P<0,05) in both groups. The rate of migration of the DCs in a culture medium conditioned of L. mexicana, RANTES and TNFa was higher in adults than in newborn mice. These observations suggest that neonatal and adult mice DCs have similar phenotypic characteristics. Under the effect of the same stimulus they respond differently; suggesting that other factors are involved in the higher susceptibility that newborns have to infections.