[A challenge for colorectal surgeons: pathogenesis, progression and management of the secondary tumors of the ovary]

A common clinical problem encountered by colorectal surgeons is the secondary tumors of the ovary (STO), particularly in young female patients. Most STO are from the digestive tract, and the known possible metastatic mechanisms include lymphatic, hematogenous, and intraperitoneal spreading. The molecular and histopathological characteristics of STO from different sites are diverse. It is particularly important to correctly identify the origin and feature of STO, which should be clarified by combining medical history, histopathology, immunohistochemistry, molecular biology, imaging and other means. The prognosis of patients with STO is poor in general. Comprehensive therapies based on surgical resection can benefit some patients. There is no specific treatment for STO at present, but not giving up easily on these patients is the right choice that every surgeon should understand.

Alarmin-activated B cells accelerate atherosclerosis after myocardial infarction via plasma cell-immunoglobulin dependent mechanisms

Introduction

Myocardial infarction (MI) accelerates atherosclerosis and for years greatly increases the risk of recurrent cardiovascular events, such as stroke and MI. B cell-derived autoantibodies produced in response to MI also persist for years.

Purpose

We investigated the role of B cells in adaptive immune responses to MI.

Methods

We used an apolipoprotein-E-deficient (ApoE−/−) mouse model of MI-accelerated atherosclerosis to assess the importance of B cells using loss and gain of function approaches. In loss of function experiment, after inducing an MI we depleted B cells using an anti-CD20 antibody. Gain of function experiments involve transfers of purified MI-B cells from different donor mice, isolated one week after MI, into atherosclerotic ApoE−/− mice.

Results

Depletion of B cells in MI mice prevented immunoglobulin G accumulation in plaques and MI-induced acceleration of atherosclerosis. Adoptive transfer of wildtype MI-B cells into atherosclerotic ApoE−/− mice greatly increased IgG accumulation in plaque and accelerated atherosclerosis in recipient mice. Cytokines that promote humoral immunity were also greatly increased in B cells activated by MI. These cells formed germinal centres within the spleen where they differentiated into antibody-producing plasma cells. Transfer of MI-B cells deficient in Blimp-1, the transcriptional repressor that drives their terminal differentiation to antibody-producing plasma cells failed to accelerate atherosclerosis in recipient mice. Alarmins released from infarcted heart were responsible for activation of B cells via toll-like receptors; transfer of MI-B cells deficient in MyD88, the canonical adaptor protein for inflammatory signaling downstream of toll-like receptors, prevented acceleration of atherosclerosis in recipient mice.

Conclusion

Our data implicate early B cell activation and autoantibodies as a central cause for accelerated atherosclerosis post MI and identifies novel therapeutic strategies towards preventing recurrent cardiovascular events such as MI and stroke.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council of Australia

[Blepharospasm, dry eye and extractable nuclear antigen antibodies (French translation of the article)]

PURPOSE

The goal of this study is to determine a link between benign essential blepharospasm and Sjogren's syndrome by analyzing the presence of extractable nuclear antigens in this population.

METHODS

Seventy-two patients with benign essential blepharospasm (BEB) were included in this study. We eliminated patients with hemifacial spasm or blepharospasm secondary to corneal pathology. We collected the values of the Schirmer I test and the results of the anti-SSA and anti-SSB antibodies.

RESULTS

Our study included 72 patients (144 eyes) whose 62 women (86.1%). Mean age was 74.3 years±10.73. Average Schirmer I test was 3.14mm±4.00mm. Five women (8% of this female population) had positive anti-SSA and SSB antibodies. Their mean age was 65.66 years±13.24 whereas the negative antibody patients had an average age of 75.42±9.27. There was no significant difference between their Schimer I test and the Schirmer I of negative antibody population.

CONCLUSION

This study illustrates the possible association between the presence of Sjögren's syndrome and the occurrence of a BEB justifying the search for anti-SSA and anti SSB in blepharospasm patients.

Blepharospasm, dry eye and extractable nuclear antigen antibodies

PURPOSE

To study whether there is an association between benign essential blepharospasm and Sjögren's syndrome by analyzing the presence of antibodies to extractable nuclear antigens in this population.

METHODS

Seventy-two patients with benign essential blepharospasm (BEB) were included in this study. We excluded patients with hemifacial spasm or blepharospasm secondary to known corneal pathology. We recorded results of Schirmer I testing as well as levels of anti-SSA/Ro and anti-SSB/La antibodies.

RESULTS

Our study included 72 patients (144 eyes), of which 62 (86.1%) were women. The mean age was 74.3±10.73 years. The mean Schirmer I test result was 3.14±4.00mm. Five women (8% of this female population) were found to have positive anti-SSA/Ro and anti-SSB/La antibodies. Their mean age was 65.66±13.24 years, while the mean age of the antibody-negative patients was 75.42±9.27 years. There was no statistically significant difference between the Schirmer I tests of the antibody positive and negative patients.

CONCLUSION

This study demonstrates a possible association between Sjögren's syndrome and benign essential blepharospasm, justifying anti-SSA/Ro and anti-SSB/La testing in these patients.

Efficacy of a Latex Agglutination Test for Rapid Identification of Staphylococcus aureus: Collaborative Study

Fifteen laboratories completed a collaborative study comparing the efficacy of a latex agglutination kit (Aureus Test) with that of AOAC Official Method 987.09 (coagulase test for identification of Staphylococcus aureus). Each laboratory analyzed 240 strains of bacteria, including 160 isolates of S. aureus and 80 isolates of other bacteria. Upon receipt of cultures, collaborators subcultured each isolate on both tryptic soy agar (TSA) and Baird-Parker agar medium (BPA) to determine whether the growth medium has any effect on either method. For cultures grown on TSA, the latex test had sensitivity and specificity rates of 99.2 and 97.1 %, respectively, whereas the coagulase test had respective rates of 98.4 and 92.5%. For cultures able to grow on BPA, the latex test had sensitivity and specificity rates of 99.2 and 96.6%, respectively, while the coagulase test had respective rates of 98.3 and 91.3%. By using the McNemar pairwise comparison test of the 2 methods, the falsepositive and false-negative rates of the latex test were significantly lower (p < 0.01) than those of the coagulase test for strains grown either on TSA or BPA. The latex agglutination test for identification of S. aureus isolated from foods has been adopted by AOAC INTERNATIONAL.

[Correlation between BRAP expression and prognosis of patients with laryngeal squamous cell carcinoma]

Objective:To investigate the expression of BRCA1 associated protein（BRAP） and its correlations with clinicopathological features and prognosis of patients with laryngeal squamous cell carcinoma（LSCC）. Method:The protein expression of BRAP in LSCC tissues and normal laryngeal tissues were assessed by immunohistochemistry and Western blot, and their correlations with clinicopathological features and prognosis were statistically analyzed. Result:The expression of BRAP in LSCC was significantly higher than that in normal laryngeal tissues（P<0.05）. BRAP expression was significantly correlated with the TNM stage and lymph node metastasis（P<0.05）. Kaplan-Meier survival analysis showed that LSCC patients with high BRAP expression had worse overall survival than those with low BRAP expression（P<0.01）. Multivariate Cox proportional-hazards analysis showed that the high expression of BRAP protein was an important poor prognostic indicator of the patients. Conclusion:BRAP is related with the development of LSCC, and it may be used as an important prognostic biomarker for LSCC patients.

Changes on Dynamic Cerebral Autoregulation Are Associated with Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Early identification of vasospasm prior to symptom onset would allow prevention of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH). Dynamic cerebral autoregulation (DCA) is a noninvasive means of assessing cerebral blood flow regulation by determining independence of low-frequency temporal oscillations of systemic blood pressure (BP) and cerebral blood flow velocities (CBFV).

METHODS

Eight SAH patients underwent prospectively a median of 7 DCA assessments consisting of continuous measurements of BCFV and BP. Transfer function analysis was applied to calculate average phase shift (PS) in low (0.07-0.2 Hz) frequency range for each hemisphere as continuous measure of DCA. Lower PS indicated poorer regulatory response. DCI was defined as a 2-point decrease in Glasgow Coma Score and/or infarction on CT.

RESULTS

Three subjects developed symptomatic vasospasm with median time-to-DCI of 9 days. DCI was significantly associated with lower PS over the entire recording period (Wald = 4.28; p = 0.039). Additionally, there was a significant change in PS over different recording periods after adjusting for DCI (Wald = 15.66; p = 0.001); particularly, a significantly lower mean PS day 3-5 after bleed (14.22 vs 27.51; p = 0.05).

CONCLUSIONS

DCA might be useful for early detection of symptomatic vasospasm. A larger cohort study of SAH patients is currently underway.

P3432Coronary artery calcium score is of limited sensitivity in detecting subclinical atherosclerosis in young individuals with family history of coronary artery disease

Introduction

Family history of premature coronary artery disease (CAD) is known to predispose individuals to adverse CAD events, often at a younger age. Current risk stratification strategy is suboptimal, as up to 50% of individuals were considered “low-risk” prior to their first presentation of myocardial infarction. Coronary artery calcium score (CACS) is a marker of atherosclerosis and provides incremental value in risk stratification. However, the utility of CACS may be limited in younger patients as they often have non-calcified atherosclerotic plaques. In this study, we evaluate the sensitivity of CACS in detecting subclinical atherosclerosis in different age groups.

Method

From 310 referrals to a specialized unit in the management of early atherosclerosis, 222 individuals with a family history of premature CAD (defined as CAD events in first-degree family members, male<55 and female<65) and aged between 35 and 55 were enrolled for assessment of their CAD risks. Individuals with possible, probably or definite familial hypercholesterolemia were excluded. In addition to clinical and risk factor evaluation, cardiac CT and CACS were performed in select individuals, at the discretion of the treating physician.

Results

Of the 141 (59% male, mean age 45.9±6.0 year) individuals that completed clinical evaluation, 65 (73% male, mean age 47.4±6.9 years) have subclinical atherosclerosis (defined by the presence of atherosclerotic plaques in any of the coronary artery segments in cardiac CT). Of them, 52 have CACS>0, giving an overall sensitivity of 80%. The breakdown by age group is shown in table 1. The sensitivity of CACS in detecting subclinical atherosclerosis is quite modest in younger individuals (60% in individuals <45 year-old) but improves with patient age (>85% in >45 years).

Table 1. Sensitivity of CACS in different age groups Age group True Positive Fast Negative Sensitivity N (CAC+ CTCA+) (CAC+ CTCA−) (%) <40 6 4 60 10 41–45 7 4 55 11 46–50 19 3 86 22 51–55 20 1 95 21

Conclusion

In younger individuals (<45 years) with family history of premature CAD, CACS is of limited sensitivity in detecting subclinical atherosclerosis, and should not be used to rule out CAD. Further studies are warranted.

P3412Risk factors, biomarkers and framingham risk estimate fail to identify presence of subclinical atherosclerosis in young individual with family history of premature coronary artery disease

Introduction

Patients with family history of premature coronary artery disease (CAD) are at increased risk of CAD events at a younger age. Risk factor based approaches and clinical evaluation are most commonly used to assess these individuals. However, it has been recently shown that up to 50% of individual presenting with their first myocardial infarction (MI) were considered to be “low risk” prior to that event. MI is often a result of plaque rupture preceded by progression of subclinical atherosclerosis. Detection of subclinical atherosclerosis may therefore help target prevention of plaque progression. We assessed the value of clinical risk factor, biomarkers and Framingham Risk Score (FRS) in predicting subclinical atherosclerosis in individuals with a family history of premature CAD.

Methods

From 310 referrals, 222 individuals between the ages of 35 and 55 with a family history of premature CAD (CAD events in first-degree family members (male <55, female <65)) were enrolled for evaluation of risk of CAD. Those with familial hypercholesteremia (possible, probable or definite) were excluded. Patients underwent clinical and risk factor evaluations as well as Cardiac CT or Calcium Score (CS) to assess presence of subclinical / clinical atherosclerosis at the discretion of the treating physician.

Results

In this pilot, 141 individuals (59% male, mean age 45.9±6.0 years) completed evaluation, and 65 (46%) had evidence of subclinical atherosclerosis on CT coronary angiography or CT calcium score with a mean segment involvement score (SIS) of 2.8 and mean CS of 152, putting them above the 80th percentile for their age and sex. Aside from male sex, age, and smoking history, other traditional risk factors and biomarkers including diabetes mellitus, hypertension, total cholesterol, LDL-C, HDL-C and Cholesterol/HDL-C were not significantly different between those with or without subclinical atherosclerosis (Table 1).

Table 1

Conclusion

In young individuals with a family history of premature CAD, risk factors, biomarkers, and FRS failed to identify individuals with premature, subclinical atherosclerosis in this pilot study. Detection of subclinical atherosclerosis and early implementation of treatment with the aim of stabilizing plaques and stopping progression might prove vital in reducing events in these individuals. Further studies are warranted.

Do repeat ultrasounds affect orchiectomy rate in patients with testicular torsion treated at a pediatric institution?

INTRODUCTION

Testicular torsion is a urological emergency; as the testicular salvage rate decreases with time, prompt intervention is required to restore the blood flow. Interhospital transfers and ultrasound examinations, while clinically essential to proper treatment and diagnosis, may adversely affect outcomes by delaying surgical intervention. Patients transferred to another institution for treatment of testicular torsion may experience a further time delay by undergoing two ultrasound examinations: one at the initial admitting institution and one at the receiving institution. To the knowledge of the authors, no study has yet explored the time delays and outcomes associated with these repeat ultrasounds.

OBJECTIVE

The objective was to investigate the impact of repeat ultrasound imaging on time to treatment and patient outcomes in patients with testicular torsion.

STUDY DESIGN

A retrospective chart review of 133 patients, aged 0-20 years, treated at the authors' institution for testicular torsion was conducted. Neonate patients and patients who did not receive ultrasound were excluded. Demographic and clinical variables were collected from the electronic medical record. Pearson Chi-squared and t-tests were used for univariate comparisons, and multivariate logistic regression analysis was performed to measure the relationships between variables.

RESULTS

Forty-nine percent of patients were primary patients, and 51% were transfer patients. Fifty-two percent of transfer patients received repeat ultrasounds. In comparison to salvaged patients, those who underwent orchiectomy experienced a greater delay between presentation at the institution and surgical intervention (229 min vs 177 min, p = 0.048). The transfer status does not appear to be related to the outcome, i.e. orchiectomy versus salvage. Patients who underwent orchiectomy were more likely than salvaged patients to have received repeat ultrasounds (p = 0.008). Repeat ultrasound patients had three times the likelihood of orchiectomy of single ultrasound patients. In a subset analysis of transfer patients, repeat ultrasound patients were more likely than single ultrasound patients to receive an orchiectomy (p = 0.03).

DISCUSSION

In agreement with previous studies, patients who underwent orchiectomy were found to experience greater treatment delays and trend toward transfer. Specifically, repeat ultrasound and time between presentation and intervention appear to influence patient outcomes. The effect of repeat ultrasound on outcomes appears to be independent of the transfer status. The study was limited by its retrospective nature and small sample size.

CONCLUSION

The analysis suggests that efforts to prevent repeat ultrasounds and minimize the time between presentation and intervention would improve patient outcomes. It is proposed that standardized clinical decision-making procedures, such as the TWIST scoring system, be incorporated into hospital protocols.

Randomized equivalence trial of the King Vision aBlade videolaryngoscope with the Miller direct laryngoscope for routine tracheal intubation in children <2 yr of age

Background.

We conducted a randomized equivalence trial to compare direct laryngoscopy using a Miller blade (DL) with the King Vision videolaryngoscope (KVL) for routine tracheal intubation. We hypothesized that tracheal intubation times with DL would be equivalent to the KVL in children <2 yr of age.

Methods.

Two hundred children were randomly assigned to tracheal intubation using DL or KVL. The primary outcome was the median difference in the total time for successful tracheal intubation. Secondary outcomes assessed were tracheal intubation attempts, time to best glottic view, time for tracheal tube entry, percentage of glottic opening score, airway manoeuvres needed, and complications.

Results.

The median difference between the groups was 5.7 s, with an upper 95% confidence interval of 7.5 s, which was less than our defined equivalence time difference of 10 s. There were no differences in the number of tracheal intubation attempts and the time to best glottic view [DL median 5.3 (4.1-7.6) s vs KVL 5.0 (4.0-6.3) s; P =0.19]. The percentage of glottic opening score was better when using the KVL [median 100 (100-100) vs DL median 100 (90-100); P <0.0001]. Use of DL was associated with greater need for airway manoeuvres during tracheal intubation (33 vs 7%; P <0.001). Complications did not differ between devices.

Conclusions.

In children <2 yr of age, the KVL was associated with equivalent times for routine tracheal intubation when compared with the Miller blade.

Clinical trial registration

NCT02590237.