Proton Therapy Mediates Dose Reductions to Brain Structures Associated With Cognition in Children With Medulloblastoma.

PURPOSE: Emerging evidence suggests proton radiation therapy may offer cognitive sparing advantages over photon radiation therapy, yet dosimetry has not been compared previously. The purpose of this study was to examine dosimetric correlates of cognitive outcomes in children with medulloblastoma treated with proton versus photon radiation therapy. METHODS AND MATERIALS: In this retrospective, bi-institutional study, dosimetric and cognitive data from 75 patients (39 photon and 36 proton) were analyzed. Doses to brain structures were compared between treatment modalities. Linear mixed-effects models were used to create models of global IQ and cognitive domain scores. RESULTS: The mean dose and dose to 40% of the brain (D40) were 2.7 and 4.1 Gy less among proton-treated patients compared with photon-treated patients (P = .03 and .007, respectively). Mean doses to the left and right hippocampi were 11.2 Gy lower among proton-treated patients (P < .001 for both). Mean doses to the left and right temporal lobes were 6.9 and 7.1 Gy lower with proton treatment, respectively (P < .001 for both). Models of cognition found statistically significant associations between higher mean brain dose and reduced verbal comprehension, increased right temporal lobe D40 with reduced perceptual reasoning, and greater left temporal mean dose with reduced working memory. Higher brain D40 was associated with reduced processing speed and global IQ scores. CONCLUSIONS: Proton therapy reduces doses to normal brain structures compared with photon treatment. This leads to reduced cognitive decline after radiation therapy across multiple intellectual endpoints. Proton therapy should be offered to children receiving radiation for medulloblastoma.

Comparison of the diagnoses, the outpatient clinics they visited, and the number of visits of patients with and without a diagnosis of fibromyalgia syndrome: Do patients with fibromyalgia syndrome come to the hospital more often?

OBJECTIVES: Fibromyalgia syndrome (FMS) has a wide spectrum of symptoms that includes all body parts. So FMS is a great imitator. This brings to mind the possibility that fibromyalgia patients visit outpatient clinics in many departments more than non-fibromyalgia patients. However, there is not enough data on this subject. This study aims to compare the number of outpatient visits of patients with FMS with those without a diagnosis of FMS and to examine their diagnoses. METHODS: The diagnoses of 140 patients (70 with fibromyalgia and 70 controls), and departments of the outpatient clinics they visited were analyzed retrospectively. In the control group, patients who visited the same outpatient clinic with the complaint of knee pain, but who did not have FMS and who had never been diagnosed with FMS before, were recruited as age- and gender-matched. RESULTS: The total number of outpatient clinic visits, as well as the number of visits to physical medicine and rehabilitation, obstetrics and gynecology, general surgery, internal medicine, and psychiatry departments, were significantly higher in fibromyalgia group patients compared to the control group. In addition, the number of diagnoses in the 5th chapter (mental, behavioral, and neurodevelopmental disorders, F01-F99) of International Classification of Diseases-10 was significantly higher in the fibromyalgia group. CONCLUSION: It should be kept in mind that patients with FMS visit more hospitals and outpatient clinics than other patients. Physicians and patients should be informed about this issue to reduce unnecessary health costs.

Rare complication of ganglion impar blockade with the transsacrococcygeal approach: A case of rectal perforation.

Although it has been reported that caution should be exercised in terms of rectal perforation, as the ganglion impar is located just behind the rectum in the presacral space, the authors could not find any case or images of rectal perforation occurring during ganglion impar blockade in the literature. In this report, the case of a 38-year-old female with rectal perforation that developed during ganglion impar blockade, performed by the transsacrococcygeal approach under fluoroscopy guidance, is presented. Wrong needle selection and the structurally short presacral space of the patient may have influenced the development of rectal perforation in the patient. This study presents the first case and images of rectal perforation in the literature that developed during the application of ganglion impar blockade using the transsacrococcygeal technique. In ganglion impar block applications, technically appropriate needles should be used, and care should be taken in terms of rectal perforation.

Genetic susceptibility to cognitive decline following craniospinal irradiation for pediatric central nervous system tumors.

BACKGROUND: Survivors of pediatric central nervous system (CNS) tumors treated with craniospinal irradiation (CSI) exhibit long-term cognitive difficulties. Goals of this study were to evaluate longitudinal effects of candidate and novel genetic variants on cognitive decline following CSI. METHODS: Intelligence quotient (IQ), working memory (WM), and processing speed (PS) were longitudinally collected from patients treated with CSI (n = 241). Genotype-by-time interactions were evaluated using mixed-effects linear regression to identify common variants (minor allele frequency > 1%) associated with cognitive performance change. Novel variants associated with cognitive decline (P < 5 × 10-5) in individuals of European ancestry (n = 163) were considered replicated if they demonstrated consistent genotype-by-time interactions (P < .05) in individuals of non-European ancestries (n = 78) and achieved genome-wide statistical significance (P < 5 × 10-8) in a meta-analysis across ancestry groups. RESULTS: Participants were mostly males (65%) diagnosed with embryonal tumors (98%) at a median age of 8.3 years. Overall, 1150 neurocognitive evaluations were obtained (median = 5, range: 2-10 per participant). One of the five loci previously associated with cognitive outcomes in pediatric CNS tumors survivors demonstrated significant time-dependent IQ declines (PPARA rs6008197, P = .004). Two variants associated with IQ in the general population were associated with declines in IQ after Bonferroni correction (rs9348721, P = 1.7 × 10-5; rs31771, P = 7.8 × 10-4). In genome-wide analyses, we identified novel loci associated with accelerated declines in IQ (rs116595313, meta-P = 9.4 × 10-9), WM (rs17774009, meta-P = 4.2 × 10-9), and PS (rs77467524, meta-P = 1.5 × 10-8; rs17630683, meta-P = 2.0 × 10-8; rs73249323, meta-P = 3.1 × 10-8). CONCLUSIONS: Inherited genetic variants involved in baseline cognitive functioning and novel susceptibility loci jointly influence the degree of treatment-associated cognitive decline in pediatric CNS tumor survivors.

Follow-up of at least 3 years after ganglion impar block for control of chronic coccygodynia.

INTRODUCTION: Although it is well known that ganglion impar block (GIB) reduces pain in the short term in patients with chronic coccygodynia, there are insufficient data on long-term treatment outcomes. The aim of this study was to examine the long-term outcomes of patients who underwent GIB for chronic coccygodynia and possible factors that might affect these outcomes. METHODS: The pre-treatment, 1st-hour, and 3rd-week numeric rating scale (NRS) scores of patients who underwent GIB 36-119 (min-max) months ago (between November 2011 and October 2018) due to coccygodynia were obtained from the medical records. Final NRS scores and presence of factors that may affect success such as accompanying low back pain (LBP) were questioned via telephone interviews. Treatment success was defined as a 50% or more reduction in final NRS scores compared with pre-treatment NRS scores. RESULTS: Telephone interviews were made with 70 patients. Treatment success was achieved in 55.7% of the patients. The patients were divided into two groups as those who achieved treatment success (group A) and those who could not (group B) and were compared. The NRS scores at the 3rd week and the number of patients with LBP in the group B were significantly higher than the group A. No serious complications developed in any patients. CONCLUSION: In patients with chronic coccygodynia, GIB is an effective and safe treatment option for pain reduction in the long term. Accompanying LBP and high pain scores in the 3rd week after injection should be considered as parameters that negatively affect long-term treatment success.

Do the presence, size, and shape of plantar calcaneal spurs have any significance in terms of pain and treatment outcomes in patients with plantar fasciitis?

BACKGROUND: : The purpose of this study was to determine the effect of the presence, size, or type of calcaneal spurs on pain or the outcomes of extracorporeal shock wave therapy (ESWT) therapy in patients with plantar fasciitis. METHODS: Seventy-four patients with unilateral plantar fasciitis who had no pain in the contralateral foot, either currently or in the past, were included in the study. The length, base width, type, and presence of plantar calcaneal spurs in both heels of the patients were determined using radiography. A total of five sessions of ESWT (3 bar, 2000 shocks/session, 12 Hz frequency) with an interval of 3 days were performed on the painful sides of the patients. Symptom duration and numerical rating scale (NRS) scores were recorded pretreatment and 1 week and 12 weeks after treatment. RESULTS: : Spurs were detected in 85.1% of painful feet and 71.6% of painless feet, this difference was statistically significant (p = 0.046). There was no significant correlation between the type of the spurs and whether the foot was painful. Patients with spur sizes of >5 mm or with horizontal and hooked spurs had a higher NRS decrease than patients with spur sizes of ≤5 mm or with a vertical spur. Symptom duration, spur length, and base width were found to be correlated with pretreatment NRS scores. DISCUSSION: The presence and size of calcaneal spurs are associated with pain. However, it should be kept in mind that a high rate of spurs can also be found in painless feet, so spur is not the only factor that causes pain. Patients with a spur size of ≤5 mm or a vertical spur have less pain relief with ESWT.

Cognitive Sparing in Proton versus Photon Radiotherapy for Pediatric Brain Tumor Is Associated with White Matter Integrity: An Exploratory Study.

Radiotherapy for pediatric brain tumors is associated with reduced white matter structural integrity and neurocognitive decline. Superior cognitive outcomes have been reported following proton radiotherapy (PRT) compared to photon radiotherapy (XRT), presumably due to improved sparing of normal brain tissue. This exploratory study examined the relationship between white matter change and late cognitive effects in pediatric brain tumor survivors treated with XRT versus PRT. Pediatric brain tumor survivors treated with XRT (n = 10) or PRT (n = 12) underwent neuropsychological testing and diffusion weighted imaging >7 years post-radiotherapy. A healthy comparison group (n = 23) was also recruited. Participants completed age-appropriate measures of intellectual functioning, visual-motor integration, and motor coordination. Tractography was conducted using automated fiber quantification (AFQ). Fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) were extracted from 12 tracts of interest. Overall, both white matter integrity (FA) and neuropsychological performance were lower in XRT patients while PRT patients were similar to healthy control participants with respect to both FA and cognitive functioning. These findings support improved long-term outcomes in PRT versus XRT. This exploratory study is the first to directly support for white matter integrity as a mechanism of cognitive sparing in PRT.

Does osteoporosis cause pain even without a fracture? An observational study.

INTRODUCTION/BACKGROUND: Osteoporotic fractures are usually painful. However, data on whether osteoporosis without fracture causes pain are insufficient. This study aims to determine whether osteoporosis without fracture is the cause of pain. METHODOLOGY: Patients aged over 18 years who visited the Physical Medicine and Rehabilitation outpatient clinic of a tertiary university hospital for dual-energy X-ray absorptiometry scan and were suitable for dual-energy X-ray absorptiometry scan without a history of fracture were included in the study. Patients with a history of fractures or those with fracture/fracture sequelae on X-rays were excluded. The cervical, lumbar, and thoracic spine and general body pains of the patients were questioned and dual-energy X-ray absorptiometry results were recorded. RESULTS: The study was conducted with 139 patients. Lumbar bone mineral density and T score values of the patients were found to be negatively correlated with the numerical rating scale levels of the cervical, thoracic, lumbar spine, and general body pain. Hip total bone mineral density and T score values were also negatively correlated with numerical rating scale scores of the lumbar and thoracic spine and general body pain. When the patients were divided into two groups as those with and without osteoporosis, it was found that the cervical, lumbar, thoracic spine, and general body pain numerical rating scale levels of the patients with osteoporosis were significantly higher than the group without osteoporosis. CONCLUSION: The results of this study showed that osteoporosis might be associated with pain even though there is no fracture.

Incidence and Disease Course of COVID-19 Infection Among Unvaccinated Patients Who Received Local Corticosteroid Injections.

OBJECTIVE: There are concerns that local corticosteroid injections may increase the risk of COVID-19 infection because of the immunosuppressive effect of corticosteroids. This study aimed to examine the relationship between local corticosteroid injections and the risk of COVID-19 infection. DESIGN: The date and type of procedure as well as the dose and type of corticosteroids used in patients who underwent local corticosteroid injections within 1 yr after the first COVID-19 case in the country were examined retrospectively and recorded. Patients who did not receive corticosteroids were included in the control group. Coronavirus disease 2019 infection histories of all patients were recorded. RESULTS: There was no significant difference between the patients who received local corticosteroids and the control group in terms of the incidence of COVID-19 infections, and the number of patients who needed hospitalization or intensive care treatment. In addition, it was found that the administration of two injections, the type of procedure performed, and the dose and type of steroids were not associated with the incidence or severity of COVID-19 infections. CONCLUSIONS: It has been shown that local corticosteroid injections are not associated with the incidence of COVID-19 infections and the number of patients who need hospitalization or intensive care treatment due to COVID-19.

Is Low-Dose Dextrose Prolotherapy as Effective as High-Dose Dextrose Prolotherapy in the Treatment of Lateral Epicondylitis? A Double-Blind, Ultrasound Guided, Randomized Controlled Study.

OBJECTIVES: To investigate the effects of prolotherapy (PrT) on pain, functionality, clinical improvement and to compare the 5% low and 15% high dose dextrose PrT in chronic lateral epicondylitis. DESIGN: A double-blind, parallel groups, randomized controlled study. SETTINGS: Outpatient Clinic. PARTICIPANTS: Sixty patients (N=60), aged 44.30±10.31 years old, with chronic lateral epicondylitis were allocated randomly into 3 groups. INTERVENTIONS: To Group 1 5% dextrose PrT, to Group 2 15% dextrose PrT, to Group 3 0.9% saline injections were done at 3 times (weeks 0, 3, 6), to the entheses of forearm extensors and annular ligament. MAIN OUTCOME MEASURES: The primary outcomes were handgrip strength, visual analog scale-rest (VAS-R), visual analog scale-activity (VAS-A), pressure-pain threshold, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH). The secondary outcomes were clinical improvement (Disease Global Assessment Questionnaire), side effects, and complications. Primary outcomes were collected at baseline week 0, week 3, and 12. Secondary outcomes were collected at weeks 3 and 12. RESULTS: In Group 2, VAS-A and VAS-R (at week 3), handgrip strength and pressure-pain threshold (at week 12) were significantly different than other groups (P<.05). In Groups 1 and 2, there was a difference in primary outcomes at week 12 than baseline (P<.05). In Group 3, there was no difference in VAS-R, VAS-A, and handgrip strength at weeks 3 and 12 than baseline (P>.05). CONCLUSION: In chronic lateral epicondylitis, 5% and 15% dextrose PrT is more effective in pain, handgrip strength, functionality, and clinical improvement than %0.9 saline. There was no difference in functionality, clinical improvement, side effects, and complications between the PrT groups. 15% dextrose PrT was more effective in handgrip strength and pressure-pain threshold at week 12 and pain at week 3. We recommend 15% dextrose PrT based on this study.

Patient-reported neurocognitive function in adult survivors of childhood and adolescent osteosarcoma and Ewing sarcoma.

PURPOSE: Little is known regarding long-term neurocognitive outcomes in osteosarcoma and Ewing sarcoma (EWS) survivors despite potential risk factors. We evaluated associations among treatment exposures, chronic health conditions, and patient-reported neurocognitive outcomes in adult survivors of childhood osteosarcoma and EWS. METHODS: Five-year survivors of osteosarcoma (N = 604; median age 37.0 years) and EWS (N = 356; median age 35.0 years) diagnosed at < 21 years from 1970 to 1999, and 697 siblings completed the Childhood Cancer Survivor Study Neurocognitive Questionnaire and reported chronic health conditions, education, and employment. Prevalence of reported neurocognitive difficulties were compared between diagnostic groups and siblings. Modified Poisson regression identified factors associated with neurocognitive difficulties. RESULTS: Osteosarcoma and EWS survivors, vs. siblings, reported higher prevalences of difficulties with task efficiency (15.4% [P = 0.03] and 14.0% [P = 0.04] vs. 9.6%, respectively) and emotional regulation (18.0% [P < 0.0001] and 15.2% [P = 0.03] vs. 11.3%, respectively), adjusted for age, sex, and ethnicity/race. Osteosarcoma survivors reported greater memory difficulties vs. siblings (23.5% vs. 16.4% [P = 0.01]). Comorbid impairment (i.e., ≥ 2 neurocognitive domains) was more prevalent in osteosarcoma (20.0% [P < 0.001]) and EWS survivors (16.3% [P = 0.02]) vs. siblings (10.9%). Neurological conditions were associated with worse task efficiency (RR = 2.17; 95% CI = 1.21-3.88) and emotional regulation (RR = 1.88; 95% CI = 1.01-3.52), and respiratory conditions were associated with worse organization (RR = 2.60; 95% CI = 1.05-6.39) for EWS. Hearing impairment was associated with emotional regulation difficulties for osteosarcoma (RR = 1.98; 95% CI = 1.22-3.20). Patient report of cognitive difficulties was associated with employment but not educational attainment. CONCLUSIONS: Survivors of childhood osteosarcoma and EWS are at increased risk for reporting neurocognitive difficulties, which are associated with employment status and appear related to chronic health conditions that develop over time. IMPLICATIONS FOR CANCER SURVIVORS: Early screening, prevention, and treatment of chronic health conditions may improve/prevent long-term neurocognitive outcomes.

Pediatric rhabdomyosarcoma incidence and survival in the United States: An assessment of 5656 cases, 2001-2017.

BACKGROUND: While rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents, past epidemiology studies of this malignancy used data that covered <30% of the US population. Therefore, we evaluated RMS incidence using data from U.S. Cancer Statistics (USCS) and survival trends using the National Program of Cancer Registries (NPCR), which covers 100% and 94% of the U.S. population, respectively. METHODS: Incidence and survival were assessed for pediatric patients diagnosed with RMS during 2003-2017 and 2001-2016, respectively. Both demographic and clinical variables were evaluated. Age-adjusted incidence rates, average annual percent change (AAPC), and 5-year relative survival (RS) were calculated, all with corresponding 95% confidence intervals (CIs). Cox regression models were used to evaluate the impact of demographic and clinical variables on survival. RESULTS: We identified 5656 primary RMS cases in USCS during 2003-2017. The age-adjusted incidence rate was 4.58 per 1 million (95% CI: 4.46-4.70) with an AAPC of 0.3% (95% CI: -0.7 to 1.2%). In NPCR, 5-year RS for all cases was 68.0% (95% CI: 66.6-69.3%). In multivariable analyses, non-Hispanic (NH) Black cases had worse survival compared with NH White cases (hazard ratio [HR] = 1.16, 95% CI: 1.01-1.33). CONCLUSION: The incidence and survival rates were stable in the largest and most comprehensive population-based analysis for pediatric RMS cases in the U.S. Additionally, we observed a survival disparity among NH Black cases. Findings from this study could inform interventions to address disparities, risk stratification strategies, and clinical trial design.

Comparison of the effectiveness of conventional physical therapy and extracorporeal shock wave therapy on pain, disability, functional status, and depression in patients with chronic low back pain.

Objectives: The aim of this study was to compare the effectiveness of conventional physical therapy (transcutaneous electrical nerve stimulation, hot pack, and therapeutic ultrasound) and extracorporeal shock wave therapy (ESWT) on pain, disability, functional status, and depression in patients with chronic low back pain (LBP). Patients and methods: Ninety-one patients with chronic LBP were included in the study and randomized to groups that received ESWT or conventional physiotherapy; of these, 70 completed the study (37 males, 33 females; mean age: 46.4±13.3 years; range, 18 to 65 years). Outcome measures included the Visual Analog Scale, the pressure pain algometer, Oswestry Disability Index (ODI), Health Assessment Questionnaire (HAQ), fingertip-to-floor distance, and the Beck Depression Inventory. The assessments were made before treatment and at the first and 12th weeks after treatment. Results: Extracorporeal shock wave therapy was more effective than conventional physical therapy in terms of Visual Analog Scale scores, the pressure algometer, ODI, HAQ, and fingertip-to-floor distance at the first and 12th week. Conclusion: Extracorporeal shock wave therapy is superior to conventional physical therapy in terms of improving pain, spinal mobility, and functional status in patients with chronic LBP.

A Prospective Evaluation of Fatigue in Pediatric Brain Tumor Patients Treated With Radiation Therapy.

Background: Fatigue is a well-established consequence of cranial radiotherapy in survivors of pediatric brain tumor, but less is known about acute fatigue during radiotherapy treatment. This study aimed to longitudinally evaluate fatigue in newly diagnosed pediatric patients with brain tumors during treatment. Methods: Primary caregivers of pediatric patients with brain tumors completed the proxy-reported Parent Fatigue Scale assessments prior to radiotherapy and weekly during radiotherapy treatment. The association between clinical factors and fatigue at each assessment was evaluated with multiple linear regressions. A comparison of fatigue between radiation modalities was also analyzed. Results: A total of 33 caregivers completed pre-radiation fatigue assessments, with 29 reporting fatigue during radiotherapy. Patients were aged 3 to 16 years (M = 8.32) at diagnosis and diagnosed with medulloblastoma (n = 23), primitive neuroectodermal tumor (n = 2), ependymoma (n = 1), germ cell tumor (n = 1), pineoblastoma (n = 1), atypical teratoid rhabdoid (n = 1), and other unspecific tumors (n = 3). Moderate-to-severe fatigue was reported for the majority of patients (31/33; 94%) during treatment. Craniospinal irradiation dose was the only significant predictor of fatigue (p < .05), but this association was restricted to the first week of therapy and was attenuated by therapy completion. Discussion: Although fatigue is often considered a long-term consequence of cranial radiotherapy, this pilot study demonstrates that moderate-to-severe fatigue is pervasive prior to radiotherapy and persists throughout treatment in pediatric patients with brain tumors, regardless of radiation modality or clinical factors. Additional research is warranted to establish a link between acute and long-term fatigue and develop interventions to mitigate this adverse outcome.

Epicardial adipose tissue thickness and growth differentiation factor 15 in axial spondyloarthritis: A cross-sectional study.

OBJECTIVES: To investigate growth differentiation factor-15 (GDF-15) levels and the thickness of epicardial adipose tissue (EAT) in patients with axial spondyloarthritis (axSpA) and to evaluate their relationship with functional status, disease activity, disease duration, and the type of medical treatment received by the patients. METHODS: This cross-sectional study was carried out at Kirsehir Ahievran University School of Medicine between February and June 2020. Twenty-nine healthy controls and 44 patients with axSpA were included in the study. Gender, age, erythrocyte sedimentation rate, GDF-15, body mass index, complete blood count, ejection fraction, the EAT thickness, and C-reactive protein of all participants were recorded. Ankylosing Spondylitis Quality of Life Index, Bath Ankylosing Spondylitis Functional Index, the disease duration, Bath Ankylosing Spondylitis Metrology Index, and Bath Ankylosing Spondylitis Disease Activity Index scores of patients with axSpA were noted. RESULTS: Epicardial adipose tissue thickness values (0.35±0.09 cm) in the AxSpA group were higher compared to the control group (0.26±0.06 cm) (p<0.01). Growth differentiation factor-15 levels of the control group and axSpA group were similar. The treatment received by the patients did not have a significant relationship with EAT thickness and GDF-15. Bath Ankylosing Spondylitis Functional Index scores, disease duration, and age were significantly positively correlated with GDF-15 levels. CONCLUSION: In this study, EAT thickness values were found to be significantly higher in the axSpA group. In addition, GDF-15 was positively correlated with age, Bath Ankylosing Spondylitis Functional Index score, and disease duration.

Masseter Muscle Thickness And Elasticity in Bruxism After Exercise Treatment: A Comparison Trial.

OBJECTIVE: The purpose of this study was to evaluate the effects of Rocabado's 6 × 6 exercises on masseter muscle thickness, muscle elasticity, and pain scores in patients with bruxism. METHODS: A total of 58 participants with bruxism were divided into 2 groups as the exercise group (EG) and control group (CG). A self-care program was applied for the participants in the CG. For those in the EG, in addition to the self-care program, an exercise treatment was performed for 6 days per week for a total of 8 weeks. Using ultrasonography, bilateral masseter muscle thickness and elasticity were assessed before and after treatment. Pain was measured using a visual analog scale. Changes over time within the groups and group-time interactions for continuous variables were assessed using mixed 2-way repeated measures analysis of variance. RESULTS: The improvement in muscle elasticity (P = .015; P = .004) and pain values (P = .049; P = .040) were greater in the EG compared with the CG. There was no significant difference between the 2 groups for masseter muscle thickness (P > .05). CONCLUSION: This study suggests that Rocabado's 6 × 6 exercises are effective in the treatment of muscle elasticity and pain values in participants with bruxism.

Hydroxychloroquine treatment alters retinal layers and choroid without apparent toxicity in optical coherence tomography.

Background To investigate whether single retinal layer, choroidal and peripapillary retinal fiber layer thicknesses were affected in patients under hydroxychloroquine treatment without retinal toxicity Methods Forty-nine patients under hydroxychloroquine treatment (HCQ group) and 39 healthy volunteers, a total of 88 individuals, were included in the study. Patients with HCQ treatment were further divided into two groups as less than 5 years of HCQ use (group 1, 29 patients) and 5 years or more of HCQ use (group 2, 20 patients). All participants underwent full ophthalmologic examination and optical coherence tomography (OCT) imaging as OCT is a recommended tool for screening toxicity by the American Association of Ophthalmology. The automatic segmentation of retinal layers included retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), outer plexiform layer (OPL), outer nuclear layer (ONL), retina pigment epithelium (RPE), inner retinal layers (IRL), outer retinal layers (ORL) and total retina thickness (TRT). Choroidal thickness (ChT), choroidal vascularity index and peripapillary RNFL were also measured. Results Both inferior and nasal parafoveal RNFL, temporal parafoveal GCL, and IPL layer thicknesses were decreased, while temporal parafoveal RPE layer thicknesses were increased in hydroxychloroquine users. Subfoveal ChTs were significantly reduced in both groups 1 and 2 compared to the control group(p = 0.042 and p = 0.009, respectively) and temporal ChT thicknesses were statistically decreased in group 2 compared to the control group(p = 0.018), but not for nasal ChT. Conclusions Hydroxychloroquine use may cause parafoveal retinal layer thickness alterations and also subfoveal and parafoveal ChT alterations even without evident retinal toxicity in OCT.

Is Detection of Relapse by Surveillance Imaging Associated With Longer Survival in Patients With Rhabdomyosarcoma?

BACKGROUND: We investigated whether surveillance imaging had an impact on post-relapse survival in patients with rhabdomyosarcoma (RMS). We hypothesized that relapse detected by imaging (group IM) would be associated with longer survival compared with relapse detected with a clinical sign or symptom (group SS). MATERIALS AND METHODS: We performed an observational multi-institutional study in 127 patients with relapsed RMS comparing overall survival (OS) after relapse using Kaplan-Meier and Cox proportional hazards analyses. RESULTS: Relapse was detected in 60 (47%) group IM and 67 (53%) SS patients. Median follow-up in survivors was 4 years (range 1.0 to 16.7 y). Four-year OS rates were similar between group IM (28%, 95% confidence interval [CI]: 14%-40%) and SS (21%, 95% CI: 11%-31%) ( P =0.14). In multivariable analyses accounting for institution, age at diagnosis, time to relapse, risk group at diagnosis, and primary site, not receiving chemotherapy (hazard ratio [HR]: 6.8, 95% CI: 2.8-16.6), radiation (HR: 3, 95% CI: 1.7-5.3), or surgery (HR: 2.8, 95% CI: 1.6-4.8) after relapse were independently associated with poor OS. CONCLUSION: These results on whether surveillance imaging provides survival benefit in patients with relapsed RMS are inconclusive. Larger studies are needed to justify current surveillance recommendations. Chemotherapy, radiotherapy and surgery to treat recurrence prolong OS.