Effects of Volume Overload and Current Techniques for the Assessment of Fluid Status in Patients with Renal Disease.

Volume overload is an important, may be the foremost, independent prognostic factor determining the outcome of hemodialysis patients. Therefore, it is crucial to measure fluid status of these patients and avoid volume overload. This review aims to evaluate volume overload, its effects on patients with renal diseases and current methodologies measuring volume status in the body. These techniques will be first classified as clinical evaluation and non-clinical and/or instrumental techniques, which includes biomarkers, ultrasonography, relative blood volume monitoring, bioimpedance, echocardiography, pulmonary artery catheterization, esophageal and/or suprasternal Doppler, and blood viscosity. Advantages and limitations of these different techniques will be reviewed extensively by comparing each other. At last, insights gained from this review can highlight the future prospects in this active area of research.

Dosimetric comparison of stereotactic MR-guided radiation therapy (SMART) and HDR brachytherapy boost in cervical cancer.

PURPOSE: The standard of care in locally advanced cervical cancer (LACC) is concomitant chemoradiotherapy followed by high-dose-rate brachytherapy (HDR-BT). Although previous studies compared HDR-BT with stereotactic body radiotherapy (SBRT), there is scarce data regarding the dosimetric outcomes of stereotactic MR-guided adaptive radiation therapy (SMART) boost in lieu of HDR-BT. METHODS AND MATERIALS: In this single-institutional in-silico comparative study, LACC patients who were definitively treated with external beam radiotherapy followed by HDR-BT were selected. Target volumes and organs at risk (OARs) were delineated in MRI and HDR-planning CT. An HDR-BT and a SMART boost plan were generated with a prescribed dose of 28 Gy in four fractions for all patients. The HDR-BT and SMART boost plans were compared in regard to target coverage as well OARs doses. RESULTS: Mean EQD2 D90 to HR-CTV and IR-CTV for HDR-BT plans were 89.7 and 70.5 Gy, respectively. For SMART, the mean EQD2 D90 to HR-PTV, HR-CTV, and IR-CTV were 82.9, 95.4, and 70.2 Gy, respectively. The mean D2cc EQD2 of bladder, rectum, and sigmoid colon for HDR-BT plans were 86.4, 70.7, and 65.7 Gy, respectively. The mean D2cc EQD2 of bladder, rectum, and sigmoid colon for SMART plans were 81.4, 70.8, and 73.6 Gy, respectively. All dose constraints in terms of target coverage and OARs constraints were met for both HDR-BT and SMART plans. CONCLUSIONS: This dosimetric study demonstrates that SMART can be applied in cases where HDR-BT is not available or ineligible with acceptable target coverage and OAR sparing. However, prospective clinical studies are needed to validate these results.

Magnetic Resonance Imaging-Guided Stereotactic Body Radiation Therapy for Medically Inoperable Endometrial Cancer.

Endometrial carcinoma is the most frequently diagnosed gynecological cancer among women aged 50 and older in developed countries. In patients who are not amenable to surgery, radiotherapy results in improved survival with acceptable adverse effect profiles. Definitive stereotactic body radiotherapy (SBRT) as a monotherapy remains an unaddressed concept in the literature. Here, we present the case of an 86-year-old woman who was diagnosed with early-stage endometrial carcinoma and was medically inoperable due to cardiac comorbidities. She was treated with magnetic resonance imaging-guided online adaptive radiotherapy-based SBRT. She tolerated the treatment well, with mild increased vaginal discharge. Complete metabolic and radiological responses were obtained. She continues to be disease free in the first year of treatment with no long-term side effects. Our protocol presents promising results with a safe toxicity profile for inoperable early-stage endometrial cancer. Future studies are warranted in light of the current knowledge.

Subjective cognitive assessments and N-back are not correlated, and they are differentially affected by anxiety and depression.

Cognitive function (CF) is a core feature related to all psychiatric disorders. However, self-report scales of CF (SRSC) may not always correlate with CF's objective measures and may have different mediators. Tools to select for evaluating CF in diverse psychiatric populations and their determinants need to be studied. In this study, we aimed to assess the association of SRSC (Perceived Deficit Questionnaire-Depression (PDQ-D), and World Health Organization's Adult Attention Deficit Hyperactivity Disorder Self-Report Scale (ASRS) and its inattentiveness subscale) with Letter-N-back as an objective measure of CF, and to analyze their association with psychopathology. Two hundred nine (131 nonclinical, and 78 clinical with a psychiatric diagnosis of ICD10 F31-39 [mood disorders excluding Bipolar I] or F40-F49 [neurotic, stress-related or psychosomatic disorder] categories) participants were evaluated with PDQ-D, ASRS, Beck Depression Inventory (BDI), and Beck's Anxiety Inventory (BAI), and N-back. Both groups' data were included in the analysis. PDQ-D showed a small correlation with N-back scores, whereas ASRS showed no correlation. PDQ-D and ASRS showed a large correlation. Age and BAI scores significantly predicted both PDQ-D and ASRS, whereas the cognitive subscale of BDI predicted PDQ-D, but not ASRS. Only BAI scores predicted N-back results. The mediation model revealed that 2-back scores of N-back task directly affects PDQ-D scores, independent of BDI scores. However, the cognitive subscale of BDI moderated 2-back and PDQ-D association. On the contrary, BAI scores significantly mediated the association of 2-back scores with PDQ-D. The direct effect of 2-back scores in PDQ-D was insignificant in the mediation of BAI scores. Our study validates the discordance between SRSC and an objective measurement of CF. Anxiety may affect both self-report and objective measurement of CF, whereas depressive thought content may lead to higher cognitive dysfunction reports in nondemented participants.

Magnetic Resonance Image-Guided Hypofractionated Ablative Radiation Therapy for Hepatocellular Carcinoma With Tumor Thrombus Extending to the Right Atrium.

Hepatocellular carcinoma (HCC) presenting with tumor thrombus (TT) and inferior vena cava (IVC)/right atrium (RA) infringement point to an advanced-stage disease that is deemed inoperable. Stereotactic body radiotherapy is an emerging treatment option for this group of patients with promising outcomes in recent studies that are comparable to conventional treatment methods, namely, transarterial chemoembolization and transarterial radioembolization. Here, we report a case of HCC with RA extension through the IVC. The patient was referred to our clinic for treatment options, and he was found suitable for magnetic resonance imaging-guided radiotherapy (MRgRT). We treated the patient with MRgRT in five fractions to a total dose of 40 Gray. The tumor was tracked during the treatment sessions, and adaptive treatment planning was performed before each fraction. The patient tolerated the treatment well with no acute grade 3-4 toxicities. The last follow-up showed that the patient had a complete biochemical response and is now a candidate for an orthotopic liver transplant. To our knowledge, this report is the first to document the MRgRT treatment of an HCC with TT and RA extension. MRgRT is safe and feasible for this patient group and can be an effective bridging therapy for liver transplants.

Magnetic Resonance Imaging-Guided Online Adaptive Lattice Stereotactic Body Radiotherapy in Voluminous Liver Metastasis: Two Case Reports.

Lattice Radiotherapy (LRT) is a technique in which heterogeneous doses are delivered to the target so large tumors can have optimal doses of radiation without compromising healthy tissue sparing. To date, case reports and case series documented its application for bulky tumors mainly in the pelvic region. LRT not only provides dosimetric advantages but also promotes tumor control by triggering some radiobiological and immunological pathways. We report two cases of giant liver metastases for whom other treatment options were not suitable. We treated both patients with Magnetic Resonance Image-Guided Radiotherapy (MRgRT) with online adaptive LRT (OALRT) technique. Adaptive plans were generated before each fraction. Tumors were observed to have regressed interfractionally so the location and number of spheres were adapted to tumor size and daily anatomy of the surrounding organs at risk (OAR). Both patients had good treatment compliance without any Grade 3+ side effects. They are both under follow-up and report improvement. By reporting the first application of OALRT by using MRgRT in liver metastases, we show that MRgRT is a promising modality for LRT technique with better target and OAR visualization as well as online adaptive planning before each fraction according to the daily anatomy of the patient.

Magnetic Resonance Imaging-Guided Radiation Therapy for Early-Stage Gastric Mucosa-Associated Lymphoid Tissue Lymphoma.

Lymphoid neoplasia derived from mucosa-associated lymphoid tissue (MALT; also abbreviated as MALToma) is most commonly seen in the stomach. Radiotherapy (RT) is indicated in early-stage disease as a standard of care. With the advent of RT techniques, large field irradiation was replaced by involved site and involved field approaches. Magnetic resonance imaging-guided online adaptive RT (MRgRT) has the advantage of better soft tissue visualization, adaptive planning before each fraction, and online tumor tracking during treatment; hence, it could be a safe and effective choice for gastric MALToma patients. Herein, we investigated the interfractional changes in target and the impact of MRgRT on daily dosimetry in a gastric MALToma case. A patient diagnosed with MALToma who failed to respond to antibacterial treatment was referred to our clinic for RT. He was found to be suitable for MRgRT. We treated the patient with MRgRT in 20 fractions to a total dose of 30 Gy. Reoptimized adaptive plans were generated before each fraction since the coverages of the original plan were inadequate in each fraction. The patient showed good compliance and tolerated the treatment well. To our knowledge, this is the first documented case of a gastric MALToma treated with MRgRT. MRgRT is safe and feasible for this patient group with improved target coverage using small planning target volume margins. Without online adaptive planning, the target coverages would be inadequate and we would risk surrounding tissues to get higher doses.

Classification of reflux patterns in patients with great saphenous vein insufficiency and correlation with clinical severity.

PURPOSE: This study aims to establish a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency and to evaluate the relationship between this classification, the demographics, and severity of clinical findings. METHODS: This is a retrospective study from prospectively collected data of 503 patients who had the complaint of varicose vein. All patients had complete physical examination and their medical history was recorded. Lower limbs of all patients were examined with Doppler ultrasonography. A total of 787 limbs with great saphenous vein insufficiency were included in the analysis. The reflux patterns of great saphenous vein insufficiency were classified into 4 types as: type 1, great saphenous vein reflux without involvement of malleolar region and saphenofemoral junction (SFJ); type 2, reflux involving malleolar region with competent SFJ; type 3, reflux involving SFJ with competent malleolar region; and type 4, reflux involving both the SFJ and the malleolar region. We evaluated the association between the classification of great saphenous vein insufficiency and age, sex, body mass index (BMI), disease duration, clinical, etiological, anatomical and pathophysiological elements (CEAP) classification and venous clinical severity score (VCSS). RESULTS: The mean age of the patients was 45.3±11.7 years, with a male-to-female ratio of 2:3. The most common reflux pattern in patients with great saphenous vein insufficiency was type 3 (48.9%), while 14.8% of patients had type 1, 10.4% had type 2, and 25.7% had type 4. Patients with type I reflux pattern were younger in age (p = 0.002), had lower BMI (p = 0.002), fewer number of children (p = 0.008), as well as milder clinical severity score (p = 0.002) compared to other reflux types. Duration of disease symptoms was not significantly correlated with the reflux patterns, but VCSS increased with the involvement of malleolar region as in type 2 compared to type 1 (2.82±1.67 vs. 2.74±2.31), and further increased with the involvement of SFJ as in type 3 (4.13±2.92 vs. 2.82±1.67). Patients with diffuse reflux pattern (type 4) had the most severe clinical presentation (4.59±2.9). CONCLUSION: We developed a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency based on the involvement of malleolar region and/or SFJ. We showed an association between weight, BMI, VCSS, CEAP classification and the extent of insufficiency.

Recurrent Solitary Fibrous Tumor in Intradural Extramedullary Space: Case Report and Review of the Literature.

Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare neoplasm arising from spindle cells and most commonly arising from pleura. Spinal SFT/HPC is a rare entity; hence, it is not on the top of the differential diagnosis list when a clinician faces a spinal lesion. In the review of the literature, there exist less than 50 case reports of intradural extramedullary SFT/HPC. Here, we present a 54-year-old female patient who underwent subtotal surgical excision of an intradural extramedullary spinal mass pathologically reported to be SFT/HPC and had symptomatic recurrence in the 3rd year of follow-up. Surgical intervention was unachievable and the patient was given 45 Gy to the surgical cavity followed by a 5.4 Gy boost to visible tumor with external radiotherapy. Patient reported significant relief of her symptoms. We aim to contribute to the formation of a treatment algorithm for this rare entity.

Noninvasive optical coherence tomography imaging correlates with anatomic and physiologic end-organ changes in healthy normotensives with systemic blood pressure variability.

OBJECTIVE: Blood pressure variability (BPV) is considered as a novel risk factor for cardiovascular disease including left ventricular hypertrophy, vascular stiffness, and renal dysfunction. In this study, we aimed to determine the relationship between ambulatory BPV with subclinical organ damage and vascular stiffness parameters in normotensive healthy subjects. METHODS: A total of 100 healthy subjects over 18 years of age were included in this cross-sectional study. We divided the participants into two groups according to the median value of the SD of mean 24-h blood pressure (BP) (Group 1: SD of mean 24-h BP <10.15 and Group 2: SD of mean 24-h BP >10.15). BPs of these subjects were recorded over a 24-h period using ambulatory BP monitoring. Mobil-O-Graph device was used to estimate the augmentation index (AIx), pulse wave velocity (PWV), and ambulatory BP measurement. The choroidal thickness was measured by using optical coherence tomography device. RESULTS: The mean age of the patients was 25.4 ± 5.0 years. Choroidal thickness was correlated with PWV, AIx, protein excretion, and SD of systolic and diastolic BP (P < 0.05). Additionally, participants with higher BP variability have lower choroidal thickness and higher AIx. CONCLUSION: We showed that even in normotensive subjects, BPV correlates with choroid thickness. Thus, BPV can be an early prognostic parameter for pathologic vascular changes.

Effect of Uric Acid-Lowering Agents on Cardiovascular Outcome in Patients With Heart Failure: A Systematic Review and Meta-Analysis of Clinical Studies.

Several trials have been completed in patients with heart failure (HF) treated with uric acid (UA)-lowering agents with inconsistent results. We aimed to investigate whether lowering UA would have an effect on mortality and cardiovascular (CV) events in patients with HF in a systematic review and meta-analysis. The primary outcome measures were all-cause mortality, CV mortality, CV events, and CV hospitalization in patients with HF. We included 11 studies in our final analysis. Overall, allopurinol treatment was associated with a significant increase in the risk for all-cause mortality (hazard ratio [HR]: 1.24, 95% confidence interval [CI]: 1.04-1.49, P = .02). The trial heterogeneity is high (heterogeneity χ2 = 37.3, I2 = 73%, P < .001). With regard to CV mortality, allopurinol treatment was associated with a 42% increased risk of CV mortality (HR: 1.42, 95% CI: 1.11-1.81, P = .005). There was a trend toward increased CV hospitalization in the same group (HR: 1.21, 95% CI: 0.95-1.53, P = .12). Uric acid-lowering treatments increase all-cause and CV mortality but did not increase CV hospitalization significantly in this study.

The effect of chronic kidney disease on lipid metabolism.

The major cause of death among chronic kidney disease patients is cardiovascular diseases. Cardiovascular and kidney disease are interrelated and increase the severity of each other. Dyslipidemia is one the major causes of cardiovascular disease among chronic kidney disease patients along with diabetes and hypertension. The relationship between dyslipidemia and chronic kidney disease is reciprocal. Dyslipidemia is known to be a risk factor for chronic kidney disease and chronic kidney disease causes major alterations on lipoprotein profile, defined as the "dyslipidemic profile" of chronic kidney disease patients. Increased triglyceride, very low density lipoprotein and oxidized low density lipoprotein as well as decreased high density lipoprotein and changes in the composition of lipoproteins contribute to the "dyslipidemic profile." Treatment strategies targeting the "dyslipidemic profile" of chronic kidney disease could contribute to prevent cardiovascular diseases. Current therapy is based on the patient kidney function and consist mainly of statins. This review focuses on the effects of chronic kidney disease on the lipoprotein profile and how this may impact novel therapeutic approaches to cardiovascular risk.

Antidiuretic Hormone and Serum Osmolarity Physiology and Related Outcomes: What Is Old, What Is New, and What Is Unknown?

CONTEXT: Although the physiology of sodium, water, and arginine vasopressin (AVP), also known as antidiuretic hormone, has long been known, accumulating data suggest that this system operates as a more complex network than previously thought. EVIDENCE ACQUISITION: English-language basic science and clinical studies of AVP and osmolarity on the development of kidney and cardiovascular disease and overall outcomes. EVIDENCE SYNTHESIS: Apart from osmoreceptors and hypovolemia, AVP secretion is modified by novel factors such as tongue acid-sensing taste receptor cells and brain median preoptic nucleus neurons. Moreover, pharyngeal, esophageal, and/or gastric sensors and gut microbiota modulate AVP secretion. Evidence is accumulating that increased osmolarity, AVP, copeptin, and dehydration are all associated with worse outcomes in chronic disease states such as chronic kidney disease (CKD), diabetes, and heart failure. On the basis of these pathophysiological relationships, an AVP receptor 2 blocker is now licensed for CKD related to polycystic kidney disease. CONCLUSION: From a therapeutic perspective, fluid intake may be associated with increased AVP secretion if it is driven by loss of urine concentration capacity or with suppressed AVP if it is driven by voluntary fluid intake. In the current review, we summarize the literature on the relationship between elevated osmolarity, AVP, copeptin, and dehydration with renal and cardiovascular outcomes and underlying classical and novel pathophysiologic pathways. We also review recent unexpected and contrasting findings regarding AVP physiology in an attempt to explain and understand some of these relationships.

Unilateral leg edema: Is it always vascular?

Unilateral lower extremity edema below the knee commonly results from deep venous thrombosis, venous insufficiency, or lymphedema. The patient history, a physical examination, and lower extremity venous duplex ultrasound often reveal the underlying etiology, which is frequently of vascular origin. Presently described is the case of a 23-year-old patient who underwent a diagnostic workup for unilateral leg swelling and was found to have a relatively uncommon cause of edema: lipedema. Lipedema is a disease characterized by subcutaneous adipose tissue deposition, and although diagnosed very rarely in general cardiology outpatient clinics, it has been demonstrated to be a cause of lower extremity edema in approximately one-fifth of cases in specialized clinics.