Effects of perioperative magnesium on postoperative analgesia following thoracic surgery: a meta-analysis of randomised controlled trials.

To evaluate the analgesic effects of intravenous magnesium in patients undergoing thoracic surgery. Randomised clinical trials (RCTs) were systematically identified from MEDLINE, EMBASE, Google Scholar and the Cochrane Library from inception to May 1st, 2023. The primary outcome was the effect of intravenous magnesium on the severity of postoperative pain at 24 hours following surgery, while the secondary outcomes included association between intravenous magnesium and pain severity at other time points, morphine consumption, and haemodynamic changes. Meta-analysis of seven RCTs published between 2007 and 2019, involving 549 adults, showed no correlation between magnesium and pain scores at 1-4 (standardized mean difference [SMD]=-0.06; p=0.58), 8-12 (SMD=-0.09; p=0.58), 24 (SMD=-0.16; p=0.42), and 48 (SMD=-0.27; p=0.09) hours post-surgery. Perioperative magnesium resulted in lower equivalent morphine consumption at 24 hours post-surgery (mean difference [MD]=-25.22 mg; p=0.04) and no effect at 48 hours (MD=-4.46 mg; p=0.19). Magnesium decreased heart rate (MD = -5.31 beats/min; p=0.0002) after tracheal intubation or after surgery, but had no effect on postoperative blood pressure (MD=-6.25 mmHg; p=0.11). There was a significantly higher concentration of magnesium in the magnesium group compared with that in the placebo group (MD = 0.91 mg/dL; p<0.00001). This meta-analysis provides evidence supporting perioperative magnesium as an analgesic adjuvant at 24 hours following thoracic surgery, but no opioid-sparing effect at 48 hours post-surgery. The severity of postoperative pain did not significantly differ between any of the postoperative time points, irrespective of magnesium. Further research on perioperative magnesium in various surgical settings is needed.

A 12-Year Comparison of Alzheimer's Dementia Patients With Their Informants in Taiwan.

BACKGROUND: To update the characteristics of patients with Alzheimer's disease (AD) and their informants in Taiwan and compare them from 12 years ago. METHODS: 1218 patients with AD and their informants were recruited from six hospitals in Taiwan. The uniform data set version 3.0 (UDS3, form A1-A3) were administered. RESULTS: Compared with the first registration from 2010-2012 (n = 691), the mean clinical dementia rating sum of boxes score was significantly lower, more patients living independently, and more informants not living together with the patients. A total of 11.2%, 4.1%, 12.8%, and 0.5% of the patients had a reported history of cognitive impairment in their mothers, fathers, siblings, and children, respectively. CONCLUSION: Compared with the data from 2010, patients have been diagnosed at a milder disease stage, and their informants used telephone contact more frequently instead of living with the patients. Family histories of cognitive impairment in patients with AD remain frequent.

Is Circulating Vitamin D Status Associated with the Risk of Venous Thromboembolism? A Meta-Analysis of Observational Studies.

BACKGROUND: Although vitamin D is antithrombotic, associations between serum vitamin D status and the risk of venous thromboembolism (VTE) remain inconsistent. METHODS: We searched the EMBASE, MEDLINE, Cochrane Library, and Google Scholar databases from inception to June 2022 to identify observational studies examining associations between vitamin D status and VTE risk in adults. The primary outcome presented as odds ratio (OR) or hazard ratio (HR) was the association of vitamin D levels with the risk of VTE. Secondary outcomes included the impacts of vitamin D status (i.e., deficiency or insufficiency), study design, and the presence of neurological diseases on the associations. RESULTS: Pooled evidence from a meta-analysis of sixteen observational studies, including 47648 individuals published from 2013 to 2021, revealed a negative relationship between vitamin D levels and the risk of VTE either based on OR (1.74, 95% confidence interval (CI): 1.37 to 2.20, p < 0.00001; I2 = 31%, 14 studies, 16074 individuals) or HR (1.25, 95% CI: 1.07 to 1.46, p = 0.006; I2 = 0%, 3 studies, 37,564 individuals). This association remained significant in subgroup analyses of the study design and in the presence of neurological diseases. Compared to individuals with normal vitamin D status, an increased risk of VTE was noted in those with vitamin D deficiency (OR = 2.03, 95% CI: 1.33 to 3.11) but not with vitamin D insufficiency. CONCLUSIONS: This meta-analysis demonstrated a negative association between serum vitamin D status and the risk of VTE. Further studies are required to investigate the potential beneficial effect of vitamin D supplementation on the long-term risk of VTE.

Epilepsia Partialis Continua as the First Presenting Symptom in Probable Sporadic Creutzfeldt-Jacob Disease: A Case Report and Literature Review.

We present the case of a middle-aged man suffering from epilepsia partialis continua 3 weeks before the start of cognition decline, visual disturbance, and pyramidal dysfunction. The epilepsia partialis continua was difficult to control, and the underlying cause was uncertain even after thorough surveys for infection, inflammation, autoimmunity, and neoplasm. However, progressive signal intensity changes were noted over the involved cortical gyri, bilateral caudate, and putamen on serial magnetic resonance diffusion-weighted images, which were compatible with sporadic Creutzfeldt-Jacob disease. Therefore, we tested for 14-3-3 protein in the cerebrospinal fluid, and the results were positive. Multifocal myoclonus jerks, severe mental decline, akinetic mutism, and typical periodic sharp wave complexes on electroencephalogram developed late in his disease course. He died under the hospice care, and his total disease duration was approximately 5 months. This case highlights that epilepsia partialis continua can be the first presenting symptoms of sporadic Creutzfeldt-Jacob disease, and that magnetic resonance imaging abnormalities can be helpful to identify the disease.

Risk of hemophagocytic lymphohistiocytosis in adults with fevers of unknown origin: the clinical utility of a new scoring system on early detection.

The diagnosis of hemophagocytic lymphohistiocytosis (HLH) is delayed by most physicians. This study aimed to identify early parameters and suitable scoring systems for the risk of HLH. Clinical and laboratory data collected ≤3 days after admission were defined as early parameters and used to calculate the number of HLH-2004 criteria met and bone marrow (BM) score. Between January 2006 and February 2016, 233 immunocompetent adults with naïve fever of unknown origin who underwent a BM study were enrolled to mimic patients at risk of HLH and randomly assigned into the developmental or validation cohort. Hemophagocytic lymphohistiocytosis was finally diagnosed in 47 patients, with non-Hodgkin lymphoma as the major etiology (51.1%). Upon admission, four-fifths of patients who developed subsequent HLH fulfilled ≤3 of 8 HLH-2004 criteria, and 6 early parameters were independent predictors of HLH: anemia (hemoglobin < 10 g/dL), thrombocytopenia (platelet count < 100 × 103 /µL), leukoerythroblastosis, hyperbilirubinemia (total bilirubin > 2 × upper normal limit), hyperferritinemia (ferritin > 1000 ng/mL), and splenomegaly. Compared with the HLH criteria met upon admission, the BM score was an independent predictor (odds ratio = 1.621; 95% confidence interval, 1.355-1.940) with excellent discrimination (area under the receiver operating characteristic curve = 0.920; 95% confidence interval, 0.883-0.958). The sensitivity and specificity for a BM score cutoff of 10 points were 95% and 75%, respectively. When approaching immunocompetent adults with a continuously high fever, the BM score at initial admission assists with early identification of patients at risk of HLH.

Rituximab induction therapy, survival benefits, and the increasing selection of radiotherapy as the postinduction treatment in patients with primary mediastinal large B-cell lymphoma.

BACKGROUND: Primary mediastinal large B-cell lymphoma (PMBCL) is a rare malignancy that has been reported in young individuals, especially young women. Patients with PMBCL commonly receive rituximab induction. This single-institution study was designed to analyze the clinical benefits of rituximab induction and its impact on postinduction treatments (PITs), especially radiotherapy. METHODS: The benefits of rituximab induction were evaluated by complete response (CR), early treatment failure, relapse, and overall survival (OS) rates. The impact of the induction therapy on the adoption of PIT was evaluated by the proportion of patients who had received at the last follow up any PIT modality [i.e., radiotherapy or hematopoietic stem cell transplantation (HSCT)], radiotherapy alone, HSCT alone, or both modalities. RESULTS: Between 1999 and 2012, 48 PMBCL patients (29 men, 60%) were identified; they had a median age of 31 years. Twenty-eight patients received rituximab induction; of these, 23 (82%) patients also underwent fludeoxyglucose-positron emission tomography (FDG-PET) evaluation. Rituximab induction was significantly associated with higher rates of CR and OS, and lower rates of early treatment failure and relapse. Regarding PIT, patients with rituximab induction were more likely to receive radiotherapy alone [with rituximab induction (25%) vs. without rituximab induction (5%)], and patients with FDG-PET evaluation were similarly more likely to receive radiotherapy alone [with FDG-PET evaluation (28.6%) vs. without FDG-PET evaluation (0%)]. In multivariate analysis, age older than 60 years [hazard ratio (HR), 16.697; 95% confidence interval (CI), 1.106-252.022; p = 0.042] and rituximab induction (HR, 0.089; 95% CI, 0.012-0.653; p = 0.017) were significantly associated with OS. CONCLUSION: Rituximab improved the CR and OS rates of patients with PMBCL, but these improvements may be attributable to the increased use of radiotherapy (which may have also resulted from FDG-PET evaluation).

A "bone marrow score" for predicting hematological disease in immunocompetent patients with fevers of unknown origin.

Delayed diagnosis of hematological malignancies in immunocompetent patients with fever of unknown origin (FUO) remains an exhausting challenge for non-hematologist physicians. This retrospective cohort study aimed to establish a scoring system, "bone marrow (BM) score", to identify FUO patients who require early bone marrow biopsy (BMB) to diagnose hematological disease. Two cohorts, comprising 85 (training) and 20 (validation) eligible immunocompetent patients, with FUOs diagnosed between January 1, 2006 and July 31, 2013, underwent BMBs and were enrolled in the study. Demographic, laboratory, imaging, diagnostic, and outcome data were collected and retrospectively analyzed. Factors associated with hematological etiologies diagnosed using BMBs in the training cohort were identified and scored according to the relative hazards. These were further validated using the validation cohort. For the training cohort, 29 of 85 (34.1%) patients had hematological etiologies diagnosed using BMB. Seven factors significantly predicted the diagnostic yield of hematological diseases in the BM and were scored, with the 6 points for leucoerythroblastic changes in peripheral blood smears, 5.5 for elevated ferritin level (>1000 ng/mL), 4 for splenomegaly, 2 for thrombocytopenia, 1.5 for each of elevated lactate dehydrogenase levels and anemia, and 1 for neutropenia. When the cut-off value of the scoring system was set to 6, its sensitivity and specificity to diagnose hematological diseases in the BM of immunocompetent FUO patients were 93% and 58%, respectively. For the validation cohort, 7 of 20 (35%) patients had hematological disease, and all had BM scores higher than the cut-off, with the sensitivity and specificity at 100% and 77%, respectively. As immunocompetent FUO patients with hematological disease have poor prognoses, the "BM score" is valuable for non-hematologist physicians to identify immunocompetent FUO patients requiring early BMB.

Pre-existing diabetes mellitus in patients with multiple myeloma.

OBJECTIVES: Type 2 diabetes mellitus is present in approximately 10% of patients at diagnosis of multiple myeloma (MM) and is associated with increased risks of adverse events caused by novel antimyeloma agents. However, the impact of type 2 diabetes on the survival of patients with MM has not been studied. METHODS: We enrolled newly diagnosed patients with MM in Taipei Veterans General Hospital between 1999 and 2007 and identified those with pre-existing diabetes. The impact of pre-existing diabetes on patients with MM was evaluated by comparing clinical features, treatments and adverse reactions related to glycaemic control and overall survival (OS) of patients with and without pre-existing diabetes. RESULTS: Of 310 patients with MM, 73% were men and 40 (12.9%) had pre-existing diabetes. Compared with their non-diabetic counterparts, MM patients with pre-existing diabetes had a significantly higher proportion of renal impairment [(RI), serum creatinine ≥ 2.0 mg/dL] and International Staging System stage III at diagnosis, and a significantly lower proportion of bisphosphonate use and a lower rate of RI reversal (P = 0.087). During the course of the disease, hyperglycaemia and hypoglycaemia of any grade were noted in 23 (67.6%) and 6 (17.6%) of these patients, respectively. Antidiabetic therapy was changed in 10 (29.4%) of 34 evaluable patients. MM patients with pre-existing diabetes had a significantly higher all-cause mortality risk (hazard ratio, 1.509; 95% confidence interval, 1.023-2.225, P = 0.037) compared with their non-diabetic counterparts. CONCLUSIONS: Our study demonstrated the impact of pre-existing diabetes on clinical features and OS in patients with MM.

International Staging System predicts prognosis of Chinese patients with multiple myeloma across different calendar periods with application of novel agents.

The applicability of the International Staging System (ISS) for Chinese patients with multiple myeloma (MM) has not been demonstrated, especially with respect to treatments with novel agents. Newly diagnosed MM patients at Taipei Veterans General Hospital were enrolled between 1996 and 2007. Data regarding clinical features, laboratory tests, and outcome at last follow-up were collected. A total of 389 MM patients (71% male) were enrolled, with median age of 71 years. At diagnosis, 72.7% had Durie-Salmon (DS) stage III disease, 56.2% had ISS stage III disease, and 34% had serum creatinine ≧2.0 mg/dL. Compared with patients diagnosed in the first calendar period 1996-2001, the patients of the second calendar period 2002-2007 were older and more of these patients had received novel agents, especially thalidomide. The median overall survival period was 20.5 months, with a significant increase of patients in the second calendar period (15.3 and 28.2 months, respectively; P = 0.002), especially for those with ISS stages I and II. In the Cox proportion model, elevated serum ß(2) microglobulin at diagnosis (≧3.5 mg/L), old age (≧65 years), and impaired renal function were found to be independently associated with poor survival. Over the entire period, the ISS was found to be effective in providing an accurate prognosis with respect to different ages and calendar periods. This is the first study to show the applicability of ISS for Chinese patients with MM, especially for those who had received thalidomide.

Chronic kidney disease stage 5 as the prognostic complement of International Staging System for multiple myeloma.

BACKGROUND: Reversal of renal impairment (RI) in patients with multiple myeloma (MM) has been evaluated using the estimated glomerular filtration rate (eGFR(MDRD) ) formula developed by the Modification of Diet in Renal Disease study group. However, the prognostic impact of eGFR(MDRD) at diagnosis of MM is not well studied, particularly its use in conjunction with the International Staging System (ISS). METHODS: Newly diagnosed patients with MM were enrolled between 1996 and 2007. Data on clinical features, laboratory tests, and overall survival were compared in terms of corresponding eGFR(MDRD). RESULTS: A total of 387 patients with MM (median age, 71 yr) were enrolled. At diagnosis, 56% had ISS stage III disease; the median values of serum creatinine (SCr) and eGFR(MDRD) were 1.4 mg/dL and 38.2 mL/min/1.73 m(2) , respectively. Thirty-four percent of patients had SCr of ≥ 2.0 mg/dL, and 81.2% had chronic kidney disease stages 3-5 (CKD 3-5). Higher CKD stages were significantly more common in men, older patients (≥ 65 yr), and those with Durie-Salmon and ISS stage III, light-chain diseases, anemia, thrombocytopenia, hypercalcemia, elevated serum ß(2) microglobulin, or lactate dehydrogenase. In the Cox regression model, CKD 4-5 or CKD 5 alone was independently associated with poor survival. A diagnosis of CKD 5 was shown to be useful in identifying the subgroup of ISS-III patients at high risk - those with a median overall survival of 7.2 months. CONCLUSIONS: Our study demonstrates the prognostic impact of eGFR(MDRD) in patients with MM and CKD 5 as the ISS-independent surrogate predictor of poorest prognosis.

Pneumothorax after bevacizumab-containing chemotherapy: a case report.

Bevacizumab added to 5-fluorouracil-based chemotherapy can improve outcomes in patients with metastatic colorectal cancer. Bevacizumab had several notable adverse effects including bowel perforation but pneumothorax had never been reported in the available English literature. We reported a 45-year-old male with lung metastases from colorectal cancer who had spontaneous pneumothorax after the second cycle of bevacizumab-containing chemotherapy. His pneumothorax resolved after tube thoracostomy with a small caliber catheter. The mechanism of pneumothorax developed after bevacizumab therapy was not clear as bowel perforation but tumor necrosis with ruptured parietal pleura might be the cause. In patients who had chest discomfort after bevacizumab-containing therapy, pneumothorax should never be overlooked as one of the differential diagnoses.