Carcinoid heart disease: the role of echocardiography in predicting post-surgical outcomes

Background

Carcinoid heart disease (CHD) often complicates neuroendocrine tumours (NET). The prognosis of CHD without intervention is poor; 3 year survival is estimated at 31%. Surgical valve replacement is the only treatment for CHD, but is associated with high 30-day mortality (10–15%).

Purpose

The aim is to identify pre-operative transthoracic echocardiogram (PTTE) findings that could determine which patients have a high likelihood of post-surgical mortality at 1 year.

Methods

This retrospective observational cohort study recruited 88 patients with a confirmed diagnosis of CHD between 2005–19 at University Hospital Birmingham; 49 (56%) of these were treated surgically. Indications for surgery: stable NET, symptomatic severe valvular dysfunction, progressive RV dilatation or RV dysfunction, no significant comorbidities. All patients underwent a standard PTTE. PTTE parameters assessed: right ventricular (RV) size, RV function (qualitative), TAPSE, RV fractional area change, RV S wave velocity, left ventricular (LV) size, LV ejection fraction and valve velocities. Surgery was performed by a single surgical team with bioprosthetic valve replacements.

Results

Patients were followed up for a median of 15 months (IQR: 6–59) after surgery, during which time there were 33 deaths, giving a median survival time of 30 months (IQR: 7–85). Increasingly severe RV dilatation was significantly associated with shorter survival (p=0.032). The estimated survival rate at three years was 67% in those with normal RV size, compared to 24% in the severe RV group (Figure 1). RV basal diameter was assessed used ROC curve analysis for the outcome of one year survival and returned an area under the curve of 0.66 (SE=0.10). Youden's index identified RV diameter >4.8cm to be the optimal cut-off for identifying high-risk patients. One year mortality rates were 26% (7/27) vs. 75% (9/12) in those with RV basal diameter of ≤4.8 vs. >4.8cm (p=0.006).

Conclusion

A pre-operative right ventricular basal diameter >4.8cm is associated with a near three-fold increase in post-operative mortality at one year. These findings highlight the importance of regular imaging in order to optimise the timing of surgery in patients with CHD.

Figure 1. Kaplan-Meier curve of post-op survival

Funding Acknowledgement

Type of funding source: None

Flow-Diversion Treatment for Unruptured Nonsaccular Intracranial Aneurysms of the Posterior and Distal Anterior Circulation: A Meta-Analysis

BACKGROUND

Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts.

PURPOSE

Our aim was to analyze the outcomes after flow diversion among nonsaccular unruptured lesions.

DATA SOURCES

A systematic search of 3 data bases (2005-2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

STUDY SELECTION

We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes.

DATA ANALYSIS

Aneurysm occlusion and complication rates were calculated (random effects meta-analysis).

DATA SYNTHESIS

We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%-92.4%; I² = 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%-22.4%; I² = 0%). Overall, 15% (37/213; 95% CI, 10%-20%; I² = 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%-12%; I² = 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%-92%; I² = 48% versus 33/36 = 89%; 95% CI, 80%-98%; I² = 0%; P = .31) and complication rates (35/162 = 17%; 95% CI, 10%-25%; I² = 24% versus 11/51 = 19%; 95% CI, 10%-31%; I² = 0%; P = .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3-15; P = .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%-9%; I² = 0%).

LIMITATIONS

Small and retrospective studies were available for this meta-analysis.

CONCLUSIONS

Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.

Immunological and Neurological Manifestations of COVID-19: An Intimate Relationship

Background: COVID-19 has superseded all medical scientific challenges in 2020. It presented with a range of respiratory involvement from the mild upper respiratory tract to severe pneumonia with ARDS. A percentage of these patients manifested variable neurological presentations expanding the challenges of patients’ assessment, care, and management. Objective: To discuss the neurological manifestations and the possible immunopathology of COVID-19. Methods: A literature search was performed in the PubMed database for the relevant articles published in English language between April 9th , 2020 and June 1, 2020. Few papers were extracted from Google Scholar and pre-print material as well. The keywords used to perform search included “COVID-19,” “SARS Cov2,” “neurological manifestations,” and “immunology and pathology of COVID-19”. However, animal studies were excluded in the neurological manifestations, and the final number of literature search outcome was 27 articles. Results: The immunopathology involves angiotensin-converting enzyme (ACE) receptor 2 and spike protein S1. COVID-19 has a tremendous affinity to the ACE2 receptor. The status of secondary hemophagocytic lymphohistiocytosis (sHLH) and the cytokine storm lead to different organ damage and the corresponding clinical manifestations. The documented neurological manifestations mainly include acute ischemic stroke, hemorrhagic stroke, temporal lobe, thalamic encephalitis, and one case of Guillain-Barre Syndrome, in addition to agitation, headache, and seizures. Conclusion: Although the intimate relationship between the neurons and the immune activation is the basic concept of COVID-19 immunopathology, the definite routes of entry to the neuronal cells are yet to be disclosed. Acute stroke, myositis, headache, and meningoencephalitis are the most common types of complications of COVID-19 so far.

SAT0130 TREAT-TO-TARGET STRATEGY OF >8.000 PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: DOES SMOKING AFFECT ACHIEVEMENT OF REMISSION ON METHOTREXATE AND TIME TO START OF FIRST BIOLOGIC? RESULTS FROM THE NATIONWIDE DANISH DANBIO REGISTRY

Background:

Smoking is a known risk factor for rheumatoid arthritis (RA). It is largely unknown whether smoking has any impact on disease activity and treatment outcomes (e.g. achieving remission on methotrexate and time to first biological disease modifying anti-rheumatic treatments (bDMARD)) in early RA with a modern treat-to-target strategy.

Objectives:

To explore if smoking was associated with treatment outcomes in newly diagnosed patients with RA starting first conventional synthetic (cs)DMARDs in routine care.

Methods:

Observational cohort study. Adult patients with RA starting first csDMARD during year 2010-2018 were identified in the Danish nationwide quality registry, DANBIO. Smoking status (current/never/previous) upon start of csDMARD (=baseline), disease activity, 1-year treatment outcomes and bDMARD treatment were retrieved from DANBIO. Data were censored Oct 2019.

Impact of smoking status was explored for the following outcomes: 1) median baseline disease activity baseline, 2) remission at 1-year (logistic regression analyses), 3) time to first bDMARD (Cox-regression analyses). Regression analyses were adjusted for gender and age.

Results:

Among 9515 patients, 8647 (91%) had available smoking status (Current 23%/never 50%/previous 27%) and were included. Baseline disease activity was independent of smoking status (Table 1). First line csDMARD was methotrexate in 91% of patients. Compared to never smokers, the current smokers were more often men, younger and sero-positive for IgM-RF and anti-CCP.

Table 1.

Patient characteristics and disease activity at baseline and 1 year stratified by smoking status. Numbers are medians (IQR) unless otherwise stated.

Smoking statusCurrentNeverPreviousBaselinePatient numbers, N200743082332Age, yrs58 (49-66)61 (48-71)62 (52-70)Female, %627163IgM-RF positive, %715465Anti-CCP positive, %715365DAS284.4 (3.4-5.3)4.4 (3.4-5.3)4.3 (3.3-5.3)CDAI18.7 (11.7-27.3)18.4 (10.9-27.4)18.5 (10.4-27.6)VAS patient global, mm60 (35-81)55 (30-77)55 (31-78)1 yearPatient number, N179338372053DAS282.6 (1.9-3.7)2.3 (1.7-3.4)2.5 (1.8-3.4)CDAI6.4 (2.8-12.5)4.9 (1.8-10.3)5.4 (2-10.8)DAS28-remission, %495753CDAI-remission, %273533VAS patient global, mm37 (14-67)29 (10-57)30 (11-58)

DAS28-response: DAS28(CRP)≤2.6; CDAI-remission: CDAI≤2.8

Never and previous smokers had higher odds of remission at 1 year’s follow-up compared to current smokers. In adjusted Cox regression analyses, baseline smoking was associated with shorter time to start of first bDMARD (Table 2).

Table 2.

Impact of baseline smoking status on treatment outcomes

ComparisonOdds Ratio (95% CI)pDAS28-remission 1 yr, yes vs. no*Never vs. current smoker1.43 (1.27;1.62)<0.001Previous vs. current1.14 (0.99;1.30)0.07CDAI remission 1 yr, yes vs. no*Never vs. current1.53 (1.34;1.75)<0.001Previous vs. current1.29 (1.11;1.50)<0.001ComparisonHazard Ratio (95% CI)pStart of bDMARD duringfollow-up**Never vs current smoker0.85 (0.76;0.96)0.006Previous vs. current1.05 (0.93;1.19)0.4

*Logistic regression analyses (adjusted for gender and age)

** Cox regression analyses (adjusted for gender and age)

Conclusion:

In this observational study of >8000 patients with RA starting a first csDMARD, current smoking was associated with lower odds of achieving remission on methotrexate and higher chance of having started bMDARD compared to never smokers. Seropositivity may be an intermediate variable. Further analyses are planned to study impact of comorbidities and other confounding factors.

Acknowledgments :

Thank you to all patients and departments who contribute to the DANBIO registry

Disclosure of Interests: :

Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Oliver Hendricks Grant/research support from: Pfizer, MSD, Ada Colic Consultant of: Advisory board Sanofi, Hanne Merete Lindegaard: None declared, Rabiah Ahmed: None declared, Anne Gitte Loft Grant/research support from: Novartis, Consultant of: AbbVie, MSD, Novartis, Pfizer and UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer and UCB, Gina Kollerup Speakers bureau: Eli Lilly, Marlene Andersen: None declared, Jolanta Grydehøj: None declared, Johnny Raun: None declared, Toke Thorgrimsen: None declared, Kasper Mortensen: None declared, Line Uhrenholt Speakers bureau: Abbvie, Eli Lilly and Novartis (not related to the submitted work), Dorte Jensen: None declared, Iben Ruge Grant/research support from: Novo Nordisk Foundation, Maren Kalisz: None declared, Kamilla Danebod: None declared, Niels Lomborg: None declared, Niels Steen Krogh: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis

Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage

BACKGROUND

Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy.

METHODS

Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role.

RESULTS

We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps.

CONCLUSIONS

Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

Predicting Factors of Angiographic Aneurysm Occlusion after Treatment with the Woven EndoBridge Device: A Single-Center Experience with Midterm Follow-Up

BACKGROUND AND PURPOSE

Flow disruption with the Woven EndoBridge is increasingly used for the treatment of intracranial aneurysms. We examined factors leading to aneurysm occlusion and Woven EndoBridge shape change during a midterm follow-up.

MATERIALS AND METHODS

Patients with a minimum 12-month angiographic follow-up were included. Through a univariate and multivariate analysis, independent predictors of adequate occlusion (Raymond-Roy 1/Raymond-Roy 2) and Woven EndoBridge shape change (decrease of the height of the device) were assessed.

RESULTS

Eighty-six patients/aneurysms were included. The aneurysm mean size was 5.5 mm (range, 3-11.5 mm). The most common locations were the MCA (43/86 = 50%), basilar tip (13/86 = 15.1%), and anterior communicating artery (12/86 = 14%). Twenty-one patients (21/86 = 24%) had acute SAH. Immediate and long-term Raymond-Roy 1/Raymond-Roy 2 occlusion rates were 49% (42/86) and 80% (68/86), respectively. Woven EndoBridge shape change was detected among 22% (19/86) of cases. At binary logistic regression, wide ostium (≥4 mm) (OR = 0.2; 95% CI, 0.01-1; P = .04) and regular aneurysm morphology (OR = 5.9; 95% CI, 1.4-24; P = .01) were independent factors of incomplete and adequate aneurysm occlusion, respectively. In addition, irregular morphology (OR = 5.4; 95%CI, 1.4-19; P = .01) and a wide ostium (OR = 9.8; 95% CI, 1.6-60; P = .03) significantly increased the probability of the Woven EndoBridge shape change. Decrease of the Woven EndoBridge height was more common among incompletely occluded aneurysms (6/12 = 50% versus 13/74 = 17.5%), but it was not an independent prognosticator of occlusion at the multivariate model.

CONCLUSIONS

The likelihood of good occlusion was 5 times lower in the presence of a wide ostium, whereas aneurysms with regular morphology were 6 times more likely to be occluded. Woven EndoBridge shape modification was strongly influenced by the aneurysm shape and ostium size, and it was not independently associated with the angiographic occlusion.

Treatment of Wide-Neck Intracranial Aneurysms with the Woven EndoBridge Device Associated with Stenting: A Single-Center Experience

BACKGROUND AND PURPOSE

The intrasaccular flow disruptor, the Woven EndoBridge device, is increasingly used for the treatment of wide-neck intracranial aneurysms. Due to unfavorable anatomy, additional stent placement is sometimes required to avoid Woven EndoBridge protrusion into bifurcation branches. We report our experience with the Woven EndoBridge associated with stent placement for the treatment of complex intracranial aneurysms.

MATERIALS AND METHODS

Patients with aneurysms treated with the Woven EndoBridge Single-Layer plus stent placement were evaluated retrospectively with prospectively maintained data. The technical feasibility, procedural complications, aneurysm occlusion, and clinical outcome were studied.

RESULTS

Seventeen patients and aneurysms treated with the Woven EndoBridge plus stent placement were included. The mean aneurysm size was 7 ± 3.1 mm. Aneurysm locations were the following: MCA (10 patients), anterior communicating artery (3 patients), basilar tip (3 patients), and posterior communicating artery (1 patient). Two lesions were ruptured and treated in the acute phase. The Woven EndoBridge and stent placement were successfully delivered in all cases. There were no permanent/major complications. Among the 2 patients with SAH, minor and completely reversible in-stent thrombosis occurred during treatment. An asymptomatic occlusion of the angular artery with a distal nonbifurcation aneurysm was discovered during the angiographic follow-up. Long-term (10.4 months) angiographic complete (Raymond-Roy I) and near-complete (Raymond-Roy II) occlusion was obtained in 11 (69%) and 2 (12.5%) aneurysms, respectively. The mean sizes of aneurysms showing Raymond-Roy I/Raymond-Roy II and Raymond-Roy III occlusion were 5.5 ± 2.1 mm and 10 ± 1 mm, respectively (P = .003). The mean fluoroscopy time was 35 ± 14 minutes.

CONCLUSIONS

Aneurysm embolization with the Woven EndoBridge device associated with stent placement appears technically feasible and effective for the treatment of lesions with unfavorable anatomy. In our study, this strategy was relatively safe with a low rate of relevant procedure-related adverse events.

Sentinel and Non-Sentinel Lymph Node Metastasis Prediction and Validation of the MSKCC Nomograms for Indian Breast Cancer Patients

Background: Sentinel lymph node (SLN) biopsy accurately stages the axilla, but is time consuming and resource intensive. Nomograms and scoring systems have been developed, based on clinical and pathologic data available before surgery, to attempt to predict the likelihood of lymph node metastasis before surgery. As the management of the axilla in patients with low nodal burden changes, it is also important to predict whether there will be further axillary disease in patients with a positive SLN. Aim: To explore the risk factors for SLN and non-SLN metastasis in Indian women with breast cancer, by analysis of clinical and pathologic data. To assess the validity and clinical utility of two MSKCC nomograms that predicts axillary lymph node status for Western patients. Methods: Clinical data, and pathologic data available from core biopsy, for a consecutive series of women having SLNB was analyzed, and was plotted on two MSKCC nomograms. Univariate analysis was done by χ2 and Fischer exact tests and multivariate analysis was done by logistic regression method. A receiver-operating characteristic (ROC) curve was drawn and predictive accuracy was assessed by calculating the area under the ROC curve (AUC). Results: 34% (89 out of 256) of our patients had SLN positivity. When correlated with SLN metastasis by univariate analysis, LVI (χ2 = 80, P ≤ 0.001), PNI (χ2 = 13.36, P ≤ 0.001), ER+ (χ2 = 6.85, P = 0.009), PR+ (χ2 = 7.1, P = 0.008) and age ( P = 0.03) were significant. However, multivariate analysis showed that age (OR=1.04, P = 0.007) and LVI (OR=0.07, P ≤ 0.001) were identified as independent predictors for SLN metastasis. The area under the ROC curve was 0.772 and it fairly correlated with MSKCC nomogram. Patients with MSKCC scores lower than 38% had a frequency of SLN metastasis of 7.7% (5/65) and this cut-off could be used as a guide for not doing frozen section analysis in this subgroup. Further axillary dissection showed 41% (38 out of 92) had non-sentinel nodes positive. When correlated with non-SLN metastasis by univariate analysis, LVI (χ2 = 8.8, P = 0.003), PNI (χ2 = 6.85, P = 0.009), and extracapsular extension (χ2 = 4.18, P = 0.04) were significant. Number of SLN negative ( P = 0.01), SLN ratio (number of SLN positive/total number of SLN removed) ( P = 0.01) and size of SLN metastasis ( P = 0.002) were significant. However, multivariate analysis showed that only size of SLN metastasis (OR=0.845, P = 0.02) was identified as independent predictor for non-SLN metastasis. The area under the ROC curve was 0.66 and it poorly correlated with MSKCC nomogram. Conclusion: The MSKCC nomogram can provide a fairly accurate prediction of the probability of SLN metastasis, but is not for non-SLN metastasis. An institutional nomogram for non-SLN metastasis, including additional factors such as size of SLN metastasis, may improve prediction.

Critical points in the pathway of antibiotic prescribing in a children's hospital: the Antibiotic Mapping of Prescribing (ABMAP) study

BACKGROUND

The World Health Organization has identified antimicrobial resistance (AMR) as one of the most significant global risks facing modern medicine. Interventions to improve antibiotic prescribing have so far had limited impact.

AIM

To understand the barriers to effective antibiotic prescribing.

METHODS

Mixed methodologies were used to investigate prescribing behaviours to identify the critical points in the antibiotic prescribing pathway for hospital inpatients. We assessed knowledge, experience or empowerment of prescribers, organizational factors, and use of the laboratory. Phase 1 was an online survey to map barriers and facilitators to antibiotic prescribing (56 participants). Phase 2 consisted of focus groups and interviews to gain more understanding of prescribing behaviours (10 participants). Phase 3 was an online survey to obtain opinions on possible solutions (22 participants).

FINDINGS

Barriers to prescribing were: laboratory factors 71.6%, resource issues 40%, time constraints 17.5%, pressure from others 52%. Ninety-three percent of prescribers were concerned about AMR. In three scenarios only 9% were confident not to prescribe antibiotics for a patient without bacterial infection; 53% would prescribe unnecessarily broad-spectrum antibiotics for pneumonia. Only 5% would de-escalate antibiotics in a microbiologically confirmed bacteraemia. Despite concerns about AMR, prescribers did not perceive that continuing antibiotics for individual patients might promote resistance. Prescribers were unwilling to change antibiotics out of hours and reported that they preferred professional support for antibiotic prescribing.

CONCLUSION

There was a marked disparity between prescribers, self-reporting of prescribing behaviour and responses to clinical scenarios. It was not clear whether training alone would change behaviours. Prescribers desired a directive mechanism to support antibiotic prescribing and stewardship.

Child understandings of the causation of childhood burn injuries: Child activity, parental domestic demands, and impoverished settings

BACKGROUND

Burns are a global public health problem. In South Africa, the rate of paediatric burn deaths is 5 times higher than other upper middle-income countries, with concentrations in impoverished settings. Globally, the majority of research focuses on expert and caregiver descriptions of burn occurrence, causation, and prevention, with limited consideration of children's perspectives. This study investigated children's understanding of the causation and prevention of childhood burns.

METHODS

Data were collected from eighteen 10- to 11-year-old children living in selected impoverished, fire-affected neighbourhoods in Cape Town, through 3 isiXhosa focus groups. All focus groups were transcribed, coded, and analysed for emerging themes through thematic analysis.

RESULTS

Themes regarding burn causation and risks centred around 4 themes: (a) developmental limits in context; (b) domestic chores, child capacity, and inability to say "no"; (c) inadequate supervision and compromised caregiving; and (d) unsafe structures. Child accounts of prevention pertained to (e) burn injury prevention activities in comprised environments and emphasized child agency, and upgrading the physical environment.

CONCLUSION

The children in this study ascribed burn injuries as the consequence of their developmental limits in the context of poverty, constraints on parental supervision, and unsafe environments. The children recommended safety education and upgrading their physical environments as part of burns injury prevention. The child accounts offer useful insights to inform safety interventions in impoverished settings.

Polymorphism of the brain-derived neurotrophic factor and dynamics of the seizure threshold of electroconvulsive therapy

During a course of electroconvulsive therapy (ECT), the level of currency necessary to induce an epileptic seizure in a patient may either remain relatively stable or-more often-may require repeated upward adjustment over time due to a constantly increasing seizure threshold. We aimed to determine whether a common polymorphism of the brain-derived neurotrophic factor (BDNF), which constitutes an important and ubiquitously expressed neurotrophine in the brain, affects the stimulation threshold of ECTs required to induce an epileptic seizure over time. Twenty-seven adult patients who underwent at least 12 consecutive ECT sessions were analyzed for the stimulation intensities required during the course of the stimulation as well as their BDNF gene status. We could not find a relation between the Val/Met polymorphism of the BDNF and the development of the seizure threshold during the course of the ECT sessions. Mechanisms and predispositions other than the BDNF polymorphism investigated in this study are responsible for the change in seizure thresholds over the course of ECT.

Nationwide prevalence of Rickettsia felis infections in patients with febrile illness in Bangladesh

From July 2015 to December 2016, the presence of rickettsial pathogens was investigated for 414 patients with unknown fever in eight places in all the divisions of Bangladesh. Rickettsia felis was identified in blood samples from all the regions (overall detection rate, 19.6%), suggesting nationwide prevalence of R. felis infections.

Pulmonary Functions, Oxidative Stress and DNA Damage in Workers of a Copper Processing Industry

Background:

Occupational exposure to excessive level of copper results in many adverse health effects.

Objective:

To measure pulmonary function, oxidative stress, and extent of DNA damage in workers of a copper processing industry.

Methods:

30 men working in a copper processing industry and 30 men matched for age and socioeconomic status (comparison group) were included in this study. Pulmonary function test parameters were measured for all participants. Serum malondialdehyde (MDA), ferric reducing ability of plasma (FRAP), glutathione (GSH) content in RBCs and 8-OHdG were assayed by ELISA. Extent of DNA damage in leucocytes was assayed by comet assay.

Results:

Pulmonary function parameters, FVC, FEV₁, PEFR, and MVV measured in workers were significantly (p<0.05) lower than those observed in the comparison group. Compared to the comparison group, MDA was significantly (p=0.002) increased in studied workers; TAOC (p=0.017), and GSH (p=0.020) were significantly lower in workers than the comparison group. There was significant DNA damage in leucocytes in workers compared to the comparison group (difference in olive tail moment p<0.001). PEFR, FEF_25-75%, and MEF_50% were negatively correlated with MDA.

Conclusion:

The observed DNA damage would be due to increased oxidative stress resulting from excessive exposure to copper.

AutoIHC-scoring: a machine learning framework for automated Allred scoring of molecular expression in ER- and PR-stained breast cancer tissue

In prognostic evaluation of breast cancer Immunohistochemical (IHC) markers namely, oestrogen receptor (ER) and progesterone receptor (PR) are widely used. The expert pathologist investigates qualitatively the stained tissue slide under microscope to provide the Allred score; which is clinically used for therapeutic decision making. Such qualitative judgment is time-consuming, tedious and more often suffers from interobserver variability. As a result, it leads to imprecise IHC score for ER and PR. To overcome this, there is an urgent need of developing a reliable and efficient IHC quantifier for high throughput decision making. In view of this, our study aims at developing an automated IHC profiler for quantitative assessment of ER and PR molecular expression from stained tissue images. We propose here to use CMYK colour space for positively and negatively stained cell extraction for proportion score. Also colour features are used for quantitative assessment of intensity scoring among the positively stained cells. Five different machine learning models namely artificial neural network, Naïve Bayes, K-nearest neighbours, decision tree and random forest are considered for learning the colour features using average red, green and blue pixel values of positively stained cell patches. Fifty cases of ER- and PR-stained tissues have been evaluated for validation with the expert pathologist's score. All five models perform adequately where random forest shows the best correlation with the expert's score (Pearson's correlation coefficient = 0.9192). In the proposed approach the average variation of diaminobenzidine (DAB) to nuclear area from the expert's score is found to be 7.58%, as compared to 27.83% for state-of-the-art ImmunoRatio software.

Structural brain changes are associated with response of negative symptoms to prefrontal repetitive transcranial magnetic stimulation in patients with schizophrenia

Impaired neural plasticity may be a core pathophysiological process underlying the symptomatology of schizophrenia. Plasticity-enhancing interventions, including repetitive transcranial magnetic stimulation (rTMS), may improve difficult-to-treat symptoms; however, efficacy in large clinical trials appears limited. The high variability of rTMS-related treatment response may be related to a comparably large variation in the ability to generate plastic neural changes. The aim of the present study was to determine whether negative symptom improvement in schizophrenia patients receiving rTMS to the left dorsolateral prefrontal cortex (DLPFC) was related to rTMS-related brain volume changes. A total of 73 schizophrenia patients with predominant negative symptoms were randomized to an active (n=34) or sham (n=39) 10-Hz rTMS intervention applied 5 days per week for 3 weeks to the left DLPFC. Local brain volume changes measured by deformation-based morphometry were correlated with changes in negative symptom severity using a repeated-measures analysis of covariance design. Volume gains in the left hippocampal, parahippocampal and precuneal cortices predicted negative symptom improvement in the active rTMS group (all r⩽-0.441, all P⩽0.009), but not the sham rTMS group (all r⩽0.211, all P⩾0.198). Further analyses comparing negative symptom responders (⩾20% improvement) and non-responders supported the primary analysis, again only in the active rTMS group (F_{(9, 207)}=2.72, P=0.005, partial η ²=0.106). Heterogeneity in clinical response of negative symptoms in schizophrenia to prefrontal high-frequency rTMS may be related to variability in capacity for structural plasticity, particularly in the left hippocampal region and the precuneus.

Care pathways for patients with bipolar disorders at Psychiatry Clinic Affektiva, Gothenburg: Identifying and solving issues for a more efficient and safe care

Introduction

The Psychiatry Clinic Affektiva has developed a care pathway for patients with bipolar disorder (BD). It consists of one outpatient clinic and two inpatient wards. Clinical observations suggest that patients with BD benefit from treatment in a dedicated unit with tailored care programs and that better outcomes are achieved in terms of reduced average length of stay and safer transitions to outpatient care for this group.

Aims

The aim is to improve the care of bipolar patients by increasing bed-availability and overall continuity in the care pathway and monitoring core aspects in the management of outpatients in order to reduce admissions and to facilitate standardized treatment and collaboration between in- and outpatients unit.

Method

We developed a structure to monitor and measure specific outcomes such as readmission within 28 days, relapse within 12 months and the use of lithium in this group. We also developed a standardized care protocol in order to improve the safety and the equality.

Results

At this stage our preliminary results from our efforts are promising but further monitoring is needed to confirm our hypothesis. More data will be collected during 2017.

Conclusions

Affektiva Psychiatry Clinic has developed a model for continuously monitoring several essential aspects in the care of patients with BD and providing a specific care program.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

MRF-ANN: a machine learning approach for automated ER scoring of breast cancer immunohistochemical images

Molecular pathology, especially immunohistochemistry, plays an important role in evaluating hormone receptor status along with diagnosis of breast cancer. Time-consumption and inter-/intraobserver variability are major hindrances for evaluating the receptor score. In view of this, the paper proposes an automated Allred Scoring methodology for estrogen receptor (ER). White balancing is used to normalize the colour image taking into consideration colour variation during staining in different labs. Markov random field model with expectation-maximization optimization is employed to segment the ER cells. The proposed segmentation methodology is found to have F-measure 0.95. Artificial neural network is subsequently used to obtain intensity-based score for ER cells, from pixel colour intensity features. Simultaneously, proportion score - percentage of ER positive cells is computed via cell counting. The final ER score is computed by adding intensity and proportion scores - a standard Allred scoring system followed by pathologists. The classification accuracy for classification of cells by classifier in terms of F-measure is 0.9626. The problem of subjective interobserver ability is addressed by quantifying ER score from two expert pathologist and proposed methodology. The intraclass correlation achieved is greater than 0.90. The study has potential advantage of assisting pathologist in decision making over manual procedure and could evolve as a part of automated decision support system with other receptor scoring/analysis procedure.

Outcomes Following a Moderately Hypofractionated Adjuvant Radiation (START B Type) Schedule for Breast Cancer in an Unscreened Non-Caucasian Population

AIMS

Breast cancer is the most common cancer in women. Western data have confirmed hypofractionated radiation therapy to be safe and effective in the adjuvant radiation therapy of breast cancers. We report the disease-related outcomes in a non-Caucasian, unscreened population treated with hypofractionated radiation.

MATERIALS AND METHODS

Unselected case notes of patients presenting to a tertiary cancer centre between June 2011 and December 2013 were reviewed from the electronic hospital case records. Patients with a diagnosis of non-metastatic invasive non-sarcomatous breast cancer were identified. Demographic information, oestrogen receptor (ER), progesterone receptor (PR), HER2 status, pathological tumour, nodal stage at diagnosis and outcomes of treatment, including systemic therapies, surgery and hypofractionated radiation, were documented. Local recurrence rates, disease-free survival (DFS) and overall survival were calculated.

RESULTS

Overall 925 patents were identified, median age 53.0 years (interquartile range 45-61), 330 of whom had neoadjuvant chemotherapy. The median follow-up time was 22.6 months and 23.5 months for overall and neoadjuvant chemotherapy groups, respectively. ER, PR and HER2 status was available in 788 patients, 77.2% of whom were ER/PR positive, 14.7% had triple negative disease, while 9.5% were HER2 rich. Overall, 34.2% (113 patients) underwent breast conservation surgery; 744 (80.4%) patients were treated with systemic chemotherapy and 878 (94.9%) patients received adjuvant radiation therapy, of whom 407 (44.0%) received supraclavicular-fossa radiotherapy. Overall survival, DFS and locoregional recurrence-free survival (LRRFS) for the overall group were 93%, 86.9% and 97.1%, respectively. LRRFS in the breast conservation surgery versus mastectomy groups were 99% versus 95.5% (P=0.003), with more node-positive patients in the mastectomy group. Stage N0/1 had better LRRFS compared with N2/2 (99.1% versus 95.7%); 94.3% versus 82.3%; P=0.005, 0.000. Grade 3 (53.8%) tumours had worse overall survival compared with grade 1 or grade 2 disease (89.6% versus 100% and 96.4%; P<0.001) although the LRRFS was not significantly different between the groups (98.9% versus 97.8%; P=0.37). There was no difference in LRRFS based on molecular subtypes.

CONCLUSION

Local recurrence rates following hypofractionated radiation in our population were comparable with those reported by the START trialists and were found to be safe in the medium term for patients irrespective of breast conservation surgery/mastectomy or radiotherapy to the supraclavicular field. Molecular group frequencies were comparable with Western populations but did not affect LRRFS.

Prevention of antibiotic-associated metabolic syndrome in mice by intestinal alkaline phosphatase

AIMS

To examine whether co-administration of intestinal alkaline phosphatase (IAP) with antibiotics early in life may have a preventive role against metabolic syndrome (MetS) in mice.

METHODS

A total of 50 mice were allocated to four treatment groups after weaning. Mice were treated with azithromycin (AZT) ± IAP, or with no AZT ± IAP, for three intermittent 7-day cycles. After the last treatment course, the mice were administered a regular chow diet for 5 weeks and subsequently a high-fat diet for 5 weeks. Body weight, food intake, water intake, serum lipids, glucose levels and liver lipids were compared. 16S rRNA gene pyrosequencing was used to determine the differences in microbiome composition.

RESULTS

Exposure to AZT early in life rendered mice susceptible to MetS in adulthood. Co-administration of IAP with AZT completely prevented this susceptibility by decreasing total body weight, serum lipids, glucose levels and liver lipids to the levels of control mice. These effects of IAP probably occur as a result of changes in the composition of specific bacterial taxa at the genus and species levels (e.g. members of Anaeroplasma and Parabacteroides).

CONCLUSIONS

Co-administration of IAP with AZT early in life prevents mice from susceptibility to the later development of MetS. This effect is associated with alterations in the composition of the gut microbiota. IAP may represent a novel treatment against MetS in humans.

A population-based study of tuberculosis case fatality in Canada: do Aboriginal peoples fare less well?

SETTING

The Province of Alberta, Canada.

OBJECTIVES

To explore trends in tuberculosis (TB) case fatality, compare TB case-fatality rates by population group and determine prognostic factors associated with TB-related death in Alberta from 1996 to 2012.

DESIGN

Retrospective cohort analysis.

RESULTS

During the study years, all-cause TB case fatality fell from 10.7% to 6.3%; the fall was attributable to a change in population structure, as there were more foreign-born and fewer older cases with time. A stable 2% of TB cases died without treatment. Compared to other population groups, Canadian-born Aboriginal case patients were more likely to die without treatment and to die younger. Of TB deaths that were TB-related, 68.9% occurred before or during the initial phase of treatment; of these, TB was a contributory cause of death in 77.5%, i.e., another medical condition was the primary cause of death. In multivariate analysis, age >64 years, aboriginality and miliary/disseminated or central nervous system disease were independent predictors for TB-related death.

CONCLUSION

Preventive therapy for those with latent tuberculous infection and a high-risk medical condition, early diagnosis of disease, and special support of older, Aboriginal or comorbid cases, once diagnosed, are necessary to further minimise TB case fatality in Alberta, Canada.