Integration of Intraosseous Approach Method in Georgia.

OBJECTIVE: In pediatric emergencies, as in case of shock, the use of intraosseous (IO) route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome. Nevertheless, the IO approach is not used at all and/or is limited because of lack of demand and lack of training on the issue of medical staff. The aim of the study was to test applicable and/or demand of IO in clinics providing pediatric critical care services and assess the opportunities to integrate IO access use in emergency care in Georgia. METHODS: A quasi-experimental study was conducted, following a training of medical staff to perform IO access procedure. Our study involved 140 children admitted to emergency department, 114 of whom underwent venous access and 26 underwent IO access. Several parameters were monitored and reported. Outcomes were compared between the 2 procedures. RESULTS: Use of an IO catheter has significantly altered the clinical outcome of the patient's condition; 35% of the total number of patients needed to continue their treatment in the intensive care unit, whereas 65% of the patient's continued treatment in the various general wards (compared with 99% and 1%, respectively, in intravenous access patients). None of IO patients were transferred to other clinics because of the deterioration of their clinical condition. Complications in the form of local infection were not observed in any of the patients using the IO approach (which is interesting in terms of infection control). CONCLUSION: With proper training and in certain indications, the internationally approved method can be safely used in pediatric emergency management in Georgian and similar country health system contexts. Several urgent conditions with high rates of requiring hospitalization could benefit from the IO approach.

Interleukin-33, endothelin-1, and inflammatory parameters in chronic spontaneous urticaria.

Background: Endothelin-1 (ET-1) and interleukin-33 (IL-33) can modulate the activation of mast cells and basophils in the pathophysiology of allergic diseases, interplaying with other mediators of "low-grade inflammation." Objective: To compare ET-1, IL-33, the neutrophil-lymphocyte ratio (NLR), eosinophil-lymphocyte ratio (ELR), platelet-lymphocyte ratio (PLR), eosinophil-basophil ratio (EBR), systemic immune inflammation index (SII), and system inflammation response index (SIRI) in patients with chronic spontaneous urticaria (CSU) and are antihistamine sensitive (AHS), antihistamine resistant (AHR), omalizumab sensitive (OmS), and omalizumab resistant (OmR). Methods: A prospective observational study enrolled 68 consecutive patients with CSU diagnosed and managed according to the dermatology section of the European Academy of Allergology and Clinical Immunology (EAACI), the European Union funded network of excellence, the Global Allergy and Asthma European Network (GA2LEN), the European Dermatology Forum (EDF), and the World Allergy Organization guidelines. Patients with a urticaria control test score of >12 are considered treatment sensitive, and ≤ 12 are considered resistant. The control group consisted of 20 sex-matched subjects without urticarial diseases. Total immunoglobulin E (IgE), antinuclear antibodies (ANA), thyroid stimulating hormone, antithyroid peroxidase, mean platelet volume (MPV), NLR, ELR, PLR, EBR, SII, SIRI, ET-1, and IL-33 were measured at the study entry and compared between the study groups. Results: Thirty AHS group, 38 AHR group, and 20 control group patients were included. The AHS, AHR, and control groups did not differ in demographic parameters, but the CSU groups were characterized by higher indicators of inflammation. In comparison with the AHS group, the AHR group was characterized by higher levels of IL-33 (p = 0.007), ET-1 (p = 0.032), C-reactive protein (p = 0.016), MPV (p = 0.002), and higher rates of positive ANA (p = 0.019). Of the 38 patients from the AHR group, 30 (79%) were included in the OmS group and 8 (21%) were included in the OmR group. The OmR group was characterized by higher levels of C-reactive protein (p = 0.022), EBR (p < 0.001), higher rates of ANA (p = 0.004), and lower levels of ET-1 (p = 0.025) than the OmS group. Conclusion: Our study did not confirm NRL, PRL, SII, and SIRI, PLR as the biomarkers of treatment response to antihistamines and/or omalizumab in CSU. Higher blood levels of IL-33 and ET-1 characterize AHR CSU.

Relationship of Complete Blood Count Derived Biomarkers With Methotrexate Resistance.

Background Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic inflammation and joint damage. Among the therapeutic agents, methotrexate remains a cornerstone of initial treatment. Complete blood count (CBC)-derived biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and systemic immune response index (SIRI) have been extensively studied in various diseases. Still, their specific role in RA patients undergoing methotrexate treatment has not been investigated. Objective This study aimed to investigate the relationship of CBC-derived biomarkers with methotrexate resistance in newly diagnosed rheumatoid arthritis patients. Methods We performed a comprehensive analysis of 54 RA patients, divided into methotrexate-resistant (MTXR) and methotrexate-sensitive (MTXS) groups. Analysis of variance (ANOVA) was used to assess differences in hematological biomarkers between groups. Standard t-tests were used to compare specific biomarkers between the MTXR and MTXS groups. The chi-squared test was used to compare categorical variables between groups. Pearson's correlation test was also used to examine correlations between these biomarkers and Disease Activity Score 28 (DAS28) in both groups. Receiver operating characteristic (ROC) curve analysis was performed for each biomarker to determine predictive ability. Results A statistically increased PLR ratio was observed in the MTXR group compared to the MTXS group. Significant correlations between DAS28 and NLR, PLR, SII, and SIRI were observed in the MTXR group. In contrast, these correlations were absent in the MTXS group. In addition to PLR, DAS28 and ESR were significantly higher in the MTXR group than in the MTXS group. None of these biomarkers showed prognostic value for methotrexate treatment outcomes. Conclusion PLR could be used as a biomarker for resistance to methotrexate treatment in a specific RA patient population. Increased PLR and ESR, together with higher DAS28, might be associated with a more pronounced inflammatory state in MTXR patients.

A case of improved quality of life in a patient with inoperable pancreatic cancer after repeated RFA.

Radiofrequency ablation (RFA) has widespread popularity due to its immune-modulation effects in many cancers. Optimal settings to apply RFA in pancreatic cancer, in which the advanced stage of the tumor at the diagnosis makes various therapeutic approaches fail, are still demanding. We report the case of a patient with unresectable pancreatic cancer in which 3 repetitive RFA has been applied over a period of 3 months. Results revealed an improvement in the patient's clinical condition associated with the reduced incidence of CD4+CD45RO+ T lymphocytes and declined TGF-ß level in serum. The good quality of life and disease-free survival were maintained for the next months. Booster application of RFA procedure might be a promising option to improve the quality of life in pancreatic cancer patients.

Cured giant hepatocellular carcinoma after transarterial embolization complicated with liver abscess formation.

Many patients with hepatocellular carcinoma cannot be treated surgically because of the advanced stage of the tumor and/or coexisting cirrhosis. Transcatheter arterial embolization (TAE) represents an alternative therapeutic approach for some of these patients. However, it is not a curative measure, and an additional therapy is required to eradicate the residual disease. In this communication, we report a case of 55-year-old man with giant hepatocellular carcinoma located in the right lobe of the liver that was successfully treated with TAE. TAE completely devascularized the tumor in one session. Despite of postembolization antibiotic therapy, complete tumor necrosis led to abscess formation. After 57 days of abscess drainage, necrotic tumor tissue was completely evacuated from the drained cavity; no viable tumor tissue was identified by computed tomography/magnetic resonance imaging scan on a 5 year follow-up. TAE procedure can be suggested as a modulator of antitumor immune response, by exposing tumor antigens after necrosis leading to inflammation. In addition to necrosis caused by TAE, an antimicrobial acute inflammatory reaction in the treated area led to the complete destruction of the giant tumor.

Immunomodulatory Changes Following Isolated RF Ablation in Colorectal Liver Metastases: A Case Report.

Background: Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer-related deaths in developed countries. The liver is the most prevalent site of metastasis from CRC. Currently, the gold-standard treatment for colorectal liver metastases (CLMs) is surgical resection. However, depending on the pattern of the disease, a significant number of patients may require different approaches alone or in combination with surgery, including thermal ablation (radiofrequency (RFA) or microwave (MWA) ablation) or transarterial liver-directed therapies, although the latter is not yet part of the standard treatment for CRC liver metastases. Methods and Results: We present the case of a 63-yearold man with bilobar CLM who was treated with transarterial embolization (TAE) and RFA followed by chemotherapy. A post-RFA study of immune parameters revealed the downregulation of CD39 expression in the circulating CD4+ T cell population and a reduction of the serum levels of cytokines IL-10, TGF-ß, IFN-gamma and IL-17, which positively correlated with the diminished serum level of gamma-glutamyl transferase (GGT) and the subdued inflammatory markers: the neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR). Later, the patient underwent chemotherapy. Liver failure developed within two years and nine months following tumour ablation, leading to the death of the patient. Conclusions: However, the denial of adjuvant chemotherapy by the patient gave us the opportunity to assess the immunomodulatory changes following RFA in the absence of any other therapeutic modalities.

Study to evaluate the immunomodulatory effects of radiofrequency ablation compared to surgical resection for liver cancer.

Introduction: Hepatic cancer is a highly lethal tumour with increasing worldwide incidence. These tumours are characterized by the proliferation of malignant cells, generalised immunosuppression and chronic inflammation marked with an increase in inflammatory markers as a neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR) and overexpression of CD4+CD39+ on T lymphocytes. The studies have outlined immunomodulatory changes in liver cancer patients as the plausible explanation for the better survival. The aim of this pilot study was understand the possible immunomodulatory effect of radiofrequency (RF) energy and liver resection (non-radiofrequency based devices; non-RF device) in relation to NLR, PLR and expression of CD4+CD39+ T lymphocytes and compare the magnitude of these changes. Material and Methods: In the present study, 17 patients with hepatic cancer were prospectively divided into treatment groups radiofrequency ablation (RFA group) and Liver resection using non-RF devices (LR group). A blood sample was collected from each patient, one month before and after the procedure and compared with the blood samples of age-matched healthy volunteers for group wise comparison. The Mann-Whitney U test, Mc Nemar test and Wilcoxon rank test were used for statistical comparisons as appropriate. Results: A decrease in NLR was reported after RFA from 4.7±3.3 to 3.8±1.8 (P=0.283), in contrary to an increase from 3.5±2.8 to 4.5±3.2 (P=0.183) in LR group. Likewise, a decrease was discerned in PLR following RFA from 140.5±79.5 to 137±69.2 respectively (P=0.386) and increase in the LR group from 116±42.2 to 120.8±29 respectively (P=0.391). A significant decrease in CD4+CD39+ lymphocytes from 55.8±13.8 to 24.6±21.1 (P=0.03) was observed in RFA group whilst a significant increase was reported in LR group from 47.6±8.8 to 55.7±33.2 (P=0.38). Conclusion: Studies have shown that decrease in the NLR, PLR and expression of CD4+CD39+ on T lymphocytes as the marker of better survival in hepatic cancer patients and our findings have confirmed that these changes can be induced following application of RF energy. Moreover, this could be the explanation of better survival observed in different studies using RFA or other RF-based devices in comparison to non-RF based liver resection techniques. However, further larger studies are needed to confirm these findings.

Long-term survival in a patient with low-level inflammatory markers and liver metastasis, converted resectable by TACE.

Case report presents the successful treatment of unresectable liver metastasis in a patient with colon cancer. A 44-year-old male underwent right hemicolectomy followed by capecitabine for a moderately differentiated adenocarcinoma of the colon. 2 years later, a liver metastatic lesion was detected and had increased in size despite chemotherapy with capecitabine plus oxaliplatin (XELOX). Curative liver resection was conducted after conversion of unresectable tumor to resectable by transarterial chemoembolization followed by chemotherapy - irinotecan with fluorouracil and folinic acid (FOLFIRI). No recurrence was observed during 22-month follow-up after hepatectomy.

Tumor Regression in HCC Patient with Portal Vein Tumor Thrombosis after Intraportal Radiofrequency Thermal Ablation.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Portal vein tumor thrombosis (PVTT) is a frequent entity in HCC, which strictly limits the gold standard treatment options such as surgical resection and transarterial chemoembolization. Therefore, the prognosis of patients with PVTT is extremely poor and an emergence of seeking an alternative option for intervention is inevitable. We present a case of a 60-year-old male patient with HCC induced PVTT who was subjected to the intraportal RFA and stenting-VesOpen procedure. No additional medical intervention was performed. The repeated CT performed 5 months after the VesOpen procedure revealed significant decrease of the tumor size, patent right, and main portal vein and a recanalization of the left portal vein, which was not processed. At this time point, liver functional tests, appetite, and general condition of the patient were improved evidently. This report designates the RFA as an instrumental option of therapeutic intervention for HCC patients with PVTT.