Chemotherapy extravasation injuries beyond the immediate stage: A series of 15 cases treated according to a preset surgical algorithm based on time of presentation.

Chemotherapy extravasation can cause severe harm. There is a lack of evidence-based standardization on the surgical management of such injuries beyond the immediate stage. In an algorithm connecting presentation time post-injury with surgical treatment could help standardize future treatment. This study prospectively validated a preset standardized surgical algorithm based on presentation time in a consecutive series between October 2017 and October 2020. Chemotherapeutic agent, site and extent of injury, type of surgery and outcome at a minimum of 6 months' follow-up were collected. Seven thousand six hundred twelve individuals received chemotherapy during that period; 15 patients suffered extravasation injuries, 2 of whom were referred from outside our hospital. This algorithm distinguished: A) beyond the immediate stage and up to 2 days, treated with saline subcutaneous washout (SCWO) and vacuum-assisted closure (VAC) dressing; B) 2 to 5 days, open surgical decompression and VAC dressing; C) 5 to 10 days, non-operative management with surveillance; and D) more than 10 days, radical necrotic excision with or without VAC dressing and tissue reconstruction. In 2 patients in Group A and 3 patients in Group B, all vesicant symptoms resolved. Five of the 6 patients in Group C (3 vesicant, 3 non-vesicant) did not progress into necrosis or infection, and 1 case of vesicant extravasation progressed to a localized ulcer beyond this period and, as surgery was refused, led to a chronic ulcer with stiffness; 2 cases of non-vesicant extravasation developed a recall phenomenon but resolved after the third cycle. Of the 4 patients in Group D, all vesicant, 2 were treated with no complications, 1 had complex regional pain syndrome (CRPS) due to late presentation, and 1, referred with necrotizing fasciitis, underwent above-elbow amputation but died due to septic shock. This study demonstrated a uniform surgical approach in a series of 15 cases; larger studies are still needed to validate the efficacy of this protocol in reducing morbidity. LEVEL OF EVIDENCE: IV.

Relapse of porphyria cutanea tarda after treatment with phlebotomy or 4-aminoquinoline antimalarials: a meta-analysis.

BACKGROUND: Porphyria cutanea tarda (PCT) is the most common human porphyria. It is caused by hepatic deficiency of uroporphyrinogen decarboxylase activity, which is acquired in the presence of multiple susceptibility factors. PCT presents clinically with cutaneous blistering photosensitivity and is readily treatable with either repeated phlebotomy or 4-aminoquinoline antimalarials. OBJECTIVES: To perform a systematic review and meta-analysis to compare the effectiveness of these quite different treatment approaches, especially on relapse rates (RRs) after achieving remission. METHODS: Published studies that included follow-up for at least 1 year after treatment of PCT were included. The primary study outcome was PCT relapse. Pooled data are reported as the RRs per person-year of follow-up with 95% confidence intervals (CIs). RESULTS: Of 375 articles identified as pertaining to PCT treatment, 12 were eligible for analysis. Of these, five used high-dose 4-aminoquinoline regimens (two combined with phlebotomy and three without phlebotomy), five used low-dose 4-aminoquinoline regimens and three used phlebotomy. RRs during the year after treatment were similar for the high- and low-dose 4-aminoquinoline groups (35-36%) and lower in the phlebotomy group (20%). The pooled RRs with their 95% CIs were 8·6 (3·9-13·3) per 100 person-years in the high-dose 4-aminoquinoline group, 17·1 (8·9-25·3) per 100 person-years in the low-dose 4-aminoquinoline group and 5·1 (0·5-10·6) per 100 person-years in the phlebotomy group. Subgroup and sensitivity analyses showed similar results. CONCLUSIONS: Clinical or biochemical RRs ranged from 5 to 17 per 100 person-years after remission of PCT. Relapses were somewhat more frequent after remission with 4-aminoquinoline regimens than after remission following phlebotomy. Prospective studies are needed to define better how often relapses occur with these treatments after documenting both clinical and biochemical remission of PCT.

Seasonal variation of indoor radon concentration in a desert climate.

Radon is one of the sources that negatively affect dwellings air quality and is ranked as a main cause of lung cancer after cigarette smoking. The indoor radon concentrations usually affected by the conditions of the environment surrounding the dwellings. Seasonal variations can have a significant impact on the indoor radon concentrations. In this article, we studied the seasonal variations of indoor radon concentration in a desert climate, particularly in gulf countries that usually leave the windows and doors closed all over the time. Four hundred dosimeters containing CR-39 detectors were planted for three months to measure the variation in radon concentration between winter and summer seasons. Our measurements showed that a building with a basement revealed a significant variation between radon concentration in winter (44.3 ± 3.1Bqm-3) and in summer (26.1 ± 1.7Bqm-3). Buildings without basements showed that the indoor radon concentration in winter (16.1 ± 1.7Bqm-3) is very much close to that in summer (16.7 ± 1.8Bqm-3). Our results indicated that seasonal variations can significantly affect indoor radon concentration for buildings established with basements. However; in the study region, the average indoor radon concentration as well as the annual effective dose rate are found to be below the action level recommended by ICRP.

Prevalence and in-hospital mortality trends of infections among patients with cirrhosis: a nationwide study of hospitalised patients in the United States.

BACKGROUND: Data on bacterial infections in hospitalised patients in the US with cirrhosis are derived largely from single centre data. Countrywide data in this population are lacking. AIM: To assess prevalence of infections among hospitalised patients in the US and examine their impact on in-hospital mortality and health care resources utilisation. METHODS: Nationwide Inpatient Sample (1998-2007) was queried for hospitalisations with cirrhosis and examined for infections including spontaneous bacterial peritonitis (SBP), urinary tract infection (UTI), skin and soft tissue infections, pneumonia and Clostridium difficile infections (CDI). In-hospital mortality, length of stay (LOS) and total charges were analysed. RESULTS: Of 742,391 admissions with cirrhosis, 168,654 (23%) had discharge diagnosis of any infection. Between 1998 and 2007, there was a trend towards increasing prevalence of infections (21-25%). Higher rates of infection were associated with ascites (22-25%) and renal insufficiency (RI) (38-43%). Infection with RI increased from 13% in 1998 to 27% in 2007. UTI was the most common infection (9-12%) followed by subcutaneous tissue infections (5-6%) and SBP (2-3%, around 12% in patients with ascites). Infection rate was similar among teaching and nonteaching hospitals with CDI and SBP being more common in teaching hospitals. In-hospital mortality was about 5%, over fivefold higher in infected cirrhotics, and associated with higher LOS and charges. Sepsis (38-42%), pneumonia (23-30%), SBP (16-23%) and CDI (11-16%) contributed most to in-hospital mortality. CONCLUSIONS: The prevalence of infections among hospitalised patients with cirrhosis in the US is increasing and is associated with in-hospital mortality, renal insufficiency and costs.

Meta-analysis: the impact of oral anti-viral agents on the incidence of hepatocellular carcinoma in chronic hepatitis B.

BACKGROUND: Five oral nucleos(t)ide analogues are available to treat chronic hepatitis B (CHB). With the availability of newer agents, their efficacy on incidence of hepatocellular carcinoma (HCC) is not well described. AIM: To determine the efficacy of oral anti-viral agents in reducing HCC risk in relationship with other known factors. METHODS: Published studies of at least 20 CHB patients treated with an oral anti-viral agent and followed for >2 years were analysed for incidence of HCC per 100 person years follow-up. RESULTS: Pooled homogeneous data from six studies showed lamivudine (LAM) treatment (n = 3306) to reduce HCC risk by 51% compared with no treatment (n = 3585) (3.3 vs. 9.7 per 100 person years, P < 0.0001). Pooled data from 49 studies (23 with LAM; 16 with adefovir; and 10 with entecavir, tenofovir or telbivudine) of 10 025 treated patients showed HCC incidence of 1.3 per 100 person years, independent of the agent used. Patient age >50 years and hepatitis B virus-DNA detectability at HCC diagnosis increased risk of HCC by twofold with a 10-fold higher risk among patients with cirrhosis compared with chronic hepatitis. Meta-regression showed patient age, study location (Eastern vs. Western) and type of study (randomised or not) contributed to heterogeneity. CONCLUSIONS: Lamivudine treatment significantly reduces the incidence of HCC compared with no treatment. However, HCC still develops at a rate of 1.3 per 100 patient years in CHB patients receiving an oral anti-viral agent. This finding highlights the need for continued HCC surveillance, particularly in CHB patients with inadequate viral suppression, older age and cirrhosis.