Is water-soluble contrast enema examination for integrity of rectal anastomosis necessary prior to ileostomy reversal?

Background and Aim

Routine use of water-soluble contrast enema (WSCE) to assess anastomotic integrity is debated. This study aimed to evaluate the role of WSCE to assess anastomotic integrity following anterior resections (AR) with defunctioning stoma prior to reversal and identify factors to limit its selective use.

Methods

This retrospective study evaluated all WSCE performed over a 7-year period at a high-volume colorectal unit. Risk factors for radiological abnormality/leak, including malignancy, chemoradiotherapy, and immediate postoperative complications, were recorded. A gastrointestinal specialist radiologist and surgeon validated all WSCEs reported as abnormal.

Results

Of the 486 WSCE studies identified, 92 were excluded (repeat studies (n = 51), pediatric cases [n = 2], no AR [n = 39]). A total of 394 WSCE studies were evaluated (260 cancer; 134 noncancer patients); 14% (37/260) of cancer patients and 8% (10/134) of noncancer patients had abnormal studies (P = 0.072). Of the 37 abnormal studies in cancer patients, 73% (27/37) radiological leaks were found, and 41% (n = 11/27) of these patients had postoperative complications. Of the 10 abnormal studies in noncancer patients, 20% (2/10) radiological leaks were found, but none of these patients had postoperative complications. Overall leak rates were 7% (29/394), and rates were significantly higher in cancer patients than noncancer patients (10 vs 2%, P = 0.005).

Conclusion

Routine use of WSCE may not be necessary prior to reversal. WSCE should be selectively used in event of postoperative leak or complications. Noncancer resections are less likely demonstrate a leak.

Bone accrual in oligo-amenorrheic athletes, eumenorrheic athletes and non-athletes

BACKGROUND

Mechanical loading improves bone mineral density (BMD) and strength while decreasing fracture risk. Cross-sectional studies show that exercise advantage is lost in oligo-amenorrheic athletes (OA). Longitudinal studies examining the opposing effects of exercise and hypogonadism on bone are lacking in adolescents/young adults.

OBJECTIVE

Evaluate differences in bone accrual over 12 months in OA, eumenorrheic athletes (EA) and non-athletes (NA). We hypothesized that bone accrual would be lower in OA than EA and NA, with differences most pronounced at non-weight bearing trabecular sites.

METHODS

27 OA, 29 EA, and 22 NA, 14-25 years old, completed 12-months of the prospective study. Athletes were weight-bearing endurance athletes. Subjects were assessed for areal BMD and bone mineral content (BMC) using DXA at the femoral neck, total hip, lumbar spine and whole body (WB). Failure load (a strength estimate) at the distal radius and tibia was assessed using microfinite element analysis of data obtained via high resolution peripheral quantitative computed tomography (HRpQCT). The primary analysis was a comparison of changes in areal BMD, BMC, and failure load across groups over 12-months at the respective sites.

RESULTS

Groups did not differ for baseline age, height or BMI. Percent body fat was lower in both OA and EA compared to NA. OA attained menarche later than EA and NA. Over the follow-up period, OA gained 1.9 ± 2.7 kg of weight compared to 0.5 ± 2.4 kg and 0.8 ± 2.3 kg in EA and NA respectively (p = 0.09); 39% of OA resumed menses. Changes in BMD, BMD Z-scores, and tibial failure load over 12-months did not differ among groups. At follow up, EA had higher femoral neck, hip and WB BMD Z-scores than NA, and higher hip BMD Z-scores than OA (p < 0.05) after adjusting for covariates. At follow-up, radial failure load was lower in OA vs. NA, and tibial failure load lower in OA and NA vs. EA (p ≤ 0.04 for all). Change in weight and fat mass were associated with changes in BMD measures at multiple sites.

CONCLUSION

Despite weight gain and menses recovery in many OA during follow-up, residual deficits persist without catch-up raising concerns for suboptimal peak bone mass acquisition.

Abstract P6-18-30: Phase Ib/II study of capecitabine 7/7 schedule with neratinib in patients with HER2-positive metastatic breast cancer (MBC)

Background: Neratinib (N) is a potent irreversible inhibitor of HER1, HER2, and HER4 and has been shown to have antitumor activity in patients (pts) with human epidermal growth factor receptor 2 (HER2) - positive breast cancer. A previous study of combination of neratinib with capecitabine (X) was associated with &gt; G 3 diarrhea in &gt; 20% of patients. Currently, the NALA study is evaluating this combination of N with X at standard schedule against control. X at 7 day on and 7 day off schedule (7/7) has been shown to be well-tolerated with less ≥G3 toxicities. We are conducting a phase Ib/II study of N with X (7/7) in pts with pretreated HER2+ MBC (NCT03377387). Methods: Eligible pts had HER2+ MBC, normal left ventricular ejection fraction (LVEF ≥ 50%); pts can have any and up to 4 prior chemotherapy-based treatments in phase Ib and II portions, respectively. Primary endpoints are to define maximum tolerated dose and efficacy in phase I and phase II portions, respectively. Secondary endpoints include safety and tolerability; exploratory endpoint is to quantify cell-free DNA to correlate with response for phase II portion. There were 4 cohorts for phase Ib with dose level 1 with starting dose of X at 1500 mg BID at 7/7 schedule with N at 240 mg daily. Results: As of July 1, 2018 8 pts have been enrolled in 2 cohorts. The median age is 63y (range: 57-79), and median ECOG is 0 (range: 0-1). 4 patients were treated at dose level 1 and 2 of 4 patients experienced dose-limiting toxicity with G3 diarrhea during cycle 1. Other significant toxicities included G3 hand foot syndrome (n=1), G3 fatigue (n=1) and G3 nausea (n=1). Three pts have now been treated at dose level -1 (X at 1000 mg twice daily 7/7 and N at 240 mg daily) and no ≥ G3 toxicities has been noted. Once MTD is reached, the phase II portion will occur to assess the efficacy and to further establish the safety and tolerability of capecitabine and neratinib at the MTD. Conclusions: The phase Ib/II study combining neratinib and capecitabine 7/7 is ongoing and updated result will be presented.

Citation Format: Wang R, Singh J, Sterlin V, Goldstein M, Lake D, Wong S, Baselga J, Norton L, Dang C. Phase Ib/II study of capecitabine 7/7 schedule with neratinib in patients with HER2-positive metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-30.

Bone Parameters in Anorexia Nervosa and Athletic Amenorrhea: Comparison of Two Hypothalamic Amenorrhea States

OBJECTIVE

We have reported low bone mineral density (BMD), impaired bone structure, and increased fracture risk in participants with anorexia nervosa (AN) and normal-weight oligoamenorrheic athletes (OAs). However, data directly comparing compartment-specific bone parameters in participants with AN, OAs, and controls are lacking.

DESIGN

A total of 468 female participants 14 to 21.9 years old were included: 269 with AN, 104 OAs, and 95 normal-weight eumenorrheic controls. Dual-energy x-ray absorptiometry was used to assess areal BMD (aBMD) of the whole body less head (WBLH), spine, and hip. High-resolution peripheral quantitative computed tomography was used to assess volumetric BMD (vBMD), bone geometry, and structure at the non-weight-bearing distal radius and weight-bearing distal tibia.

RESULTS

Participants with AN had lower WBLH and hip aBMD z scores than OAs and controls (P < 0.0001). Participants with AN and OAs had lower spine aBMD z scores than controls (P < 0.01). At the radius, total and cortical vBMD, percentage cortical area, and thickness were lower in the AN and OA groups than in controls (P ≤ 0.04); trabecular vBMD was lower in participants with AN than controls. At the tibia, participants with AN had lower measures for most parameters compared with OAs and controls (P < 0.05); OAs had lower cortical vBMD than controls (P = 0.002). Participants with AN and OAs had higher fracture rates than controls. Stress fracture prevalence was highest in OAs (P < 0.0001); nonstress fracture prevalence was highest in participants with AN (P < 0.05).

CONCLUSION

AN is deleterious to bone at all sites and both bone compartments. A high stress fracture rate in OAs, who have comparable WBLH and hip aBMD measures to controls, indicates that BMD in these women may need to be even higher to avoid fractures.

Axial Length, Refractive Error, and Keratometry in Patients with Branch Retinal Vein Occlusion

Purpose

To evaluate ocular parameters that may predispose to the development of branch retinal vein occlusion (BRVO).

METHODS

This prospective study included patients with unilateral BRVO evaluated in the authors' clinic. The mean period from the acute phase was 2.29 ±1.57 years (range 1–6 years). All patients underwent a complete ophthalmologic examination including subjective refraction, axial length measurements, and keratometry readings. The fellow eye served as a control in each patient. The variables of interest were compared between the affected eye and the fellow eye using the parametric t-test and the nonparametric Wilcoxon test.

Results

Twenty-four consecutive patients (14 women, 10 men, mean age 62.4 years) were included in the study. The mean axial length in the affected eye was significantly shorter compared to the mean fellow eye length. No difference was found between the two eyes in mean subjective refraction or mean keratometry readings.

CONCLUSIONS

The authors found that eyes with BRVO have a shorter axial length compared to the fellow eye in the same patient.

Evaluating the peptide structure prediction capabilities of a purely ab-initio method

DEEPSAM is a relatively new global optimization algorithm aimed to predict the structure of bio-molecules from sequence, without any additional preliminary assumption. It is an evolutionary algorithm whose mutation operators are built by hybridizing the diffusion equation method, molecular dynamics simulated annealing, and a quasi-Newton local minimization method. The goal of this study was to evaluate the structure prediction capabilities of DEEPSAM by running it upon NMR structures of linear peptides (10-20 residues). The results indicate that DEEPSAM successfully predicted the conformations of these peptides, using modest computing resources.

The impact of CT head scans on ED management and length of stay in bizarre behavior patients

METHODS

A 5-year retrospective chart review was conducted at 3 EDs. Inclusion criteria were patients ≥18years old triaged as "mental health - bizarre behavior" (deviation from normal cognitive behaviour with no obvious cause) with a CT head scan ordered in the ED. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by an Emergency Physician for inter-rater reliability.

RESULTS

266 cases met study criteria. Population demographics: 49% percent female, average age 51years old, 28% homeless, 58% arrived by police or ambulance. CT head results: 1 (0.4%) case with possible acute findings, 105 (39%) with incidental findings (i.e. cerebral atrophy) that did not impact clinical management. Average time to physician assessment was 1:48 (hour:min) (sd 1:11), time to CT completion was 5:05 (sd 7:28) and an average delay of 3:17 awaiting results. Subgroup analysis revealed a net increase in ED length of stay (ED LOS) of 5:02 from obtaining neuroimaging. 85% of patients were referred to a consultant, 92% were to psychiatry.

CONCLUSIONS

CT head results prolonged ED LOS, delayed patient disposition and did not change the patient's clinical management. A prospective trial for ordering CT head scans in these patients is warranted.

Comparative study of magnetic resonance defaecography and evacuation proctography in the evaluation of obstructed defaecation

AIM

Obstructed defaecation syndrome is a common condition of multifactorial aetiology and requires specialized evaluation. Accurate and reproducible pelvic floor imaging is imperative for multidisciplinary decision-making. Evacuation proctography (EP) and magnetic resonance defaecography (MRD) are the main imaging modalities used to assess dynamic pelvic floor function. The aim of this prospective study was to compare the findings and acceptability of MRD and EP in the same cohort of patients.

METHOD

This was a prospective comparative study of MRD vs EP in 55 patients with obstructed defaecation syndrome in a single National Health Service Foundation Trust.

RESULTS

Fifty-five patients were recruited and underwent both EP and MRD. Detection rates for rectocoele were similar (82% vs 73%, P = 0.227), but EP revealed a significantly higher number of trapping rectocoeles compared to MRD (75% vs 31%, P < 0.001). EP detected more rectal intussusceptions than MRD (56% vs 35%, P = 0.023). MRD appeared to underestimate the size of the identified rectocoele, although it detected a significant number of anatomical abnormalities in the middle and anterior pelvic compartment not seen on EP (1.8% enterocoele, 9% peritoneocoele and 20% cystocoele). Patients achieved higher rates of expulsion of rectal contrast during EP compared to MRD, but this difference was not significant (76% vs 64% in MRD, P = 0.092). Of the two studies, patients preferred MRD.

CONCLUSIONS

MRD provides a global assessment of pelvic floor function and anatomical abnormality. MRD is better tolerated by patients but it is not as sensitive as EP in detecting trapping rectocoeles and intussusceptions.

Pricing the urban cooling benefits of solar panel deployment in Sydney, Australia

Cities import energy, which in combination with their typically high solar absorption and low moisture availability generates the urban heat island effect (UHI). The UHI, combined with human-induced warming, makes our densely populated cities particularly vulnerable to climate change. We examine the utility of solar photovoltaic (PV) system deployment on urban rooftops to reduce the UHI, and we price one potential value of this impact. The installation of PV systems over Sydney, Australia reduces summer maximum temperatures by up to 1 °C because the need to import energy is offset by local generation. This offset has a direct environmental benefit, cooling local maximum temperatures, but also a direct economic value in the energy generated. The indirect benefit associated with the temperature changes is between net AUD$230,000 and $3,380,000 depending on the intensity of PV systems deployment. Therefore, even very large PV installations will not offset global warming, but could generate enough energy to negate the need to import energy, and thereby reduce air temperatures. The energy produced, and the benefits of cooling beyond local PV installation sites, would reduce the vulnerability of urban populations and infrastructure to temperature extremes.

IgG4-related Disease Presenting as a Pancreatic Mass and Bilateral Lacrimal Gland Swelling

IgG4-related disease is characterized by multi-system inflammation and possible elevation in serum immunoglobulin-G4 level. Treatment regimens include glucocorticoids, disease-modifying anti-rheumatic agents and recently, rituximab infusions have been reported to be effective in treatment-refractory disease. We present a case of a 64-year-old male presenting with acute abdominal pain and scleral icterus. An abdominal ultrasound demonstrated extensive biliary ductal dilatation. A computed tomography (CT) scan and a magnetic resonance cholangiopancreatography (MRCP) revealed a 4.8 cm pancreatic head mass. He underwent an exploratory laparotomy, and a pathologic examination of the mass revealed a dense lymphoplasmacytic infiltrate. The patient’s IgG subclass 2 level was elevated. A review of the patient’s medical records revealed that, in 1992, he presented with bilateral periorbital discomfort not severe enough to require intervention. In 2006, he presented with bilateral periorbital swelling and discomfort. A magnetic resonance imaging (MRI) scan showed gross enlargement of the lacrimal glands, and a biopsy revealed a dense lymphoplasmacytic infiltrate. He was treated with corticosteroids, cyclosporine and methotrexate. The regimen was repeated in 2009 for recurrent symptoms. Hence, on our encounter, a diagnosis of IgG4-related disease was made and he was treated with rituximab that resulted in complete remission.

Aflibercept as a Second Line Therapy for Neovascular Age Related Macular Degeneration in Israel (ASLI) study

PurposeThe purpose of this study is to evaluate an early switch to aflibecept in eyes with neovascular age-related macular degeneration (nvAMD) showing partial or lack of response for initial therapy with bevacizumab.MethodsThe Aflibercept as a Second Line Therapy for Neovascular Age Related Macular Degeneration in Israel (ASLI) was a prospective, multicenter, single-arm clinical trial. Eyes with nvAMD having incomplete response to 3-9 prior bevacizumab injections were recruited. Three monthly intravitreal aflibercept (2 mg) injections were administered, followed by two bi-monthly injections and a final examination at week 28. An optional injection was allowed at week 20.ResultsForty-seven eyes of 46 patients (mean±SD age 76±8 years) were recruited. The mean number of prior bevacizumab injections was 5.5±2.9. The mean visual acuity improved from 60.3±10 ETDRS letters at baseline to 63.1±15 letters at week 28 (P=0.02, paired t-test). The central subfield thickness (CST) reduced from 409±127 micron at baseline to 330±110 microns at week 4 (P=0.0002; paired t-test), and 277±70 microns at week 28 (P=0.00002; paired t-test). Twenty-two eyes had three to five prior bevacizumab injections (mean 5.1±0.7), and 25 eyes had six to nine prior injections (7.32±1.2). Both groups had reduced CST from baseline to week 28 (P=0.0004 and P=0.0007; paired t-test, respectively). Thirty-five (75%) eyes required the optional additional aflibercept injection at week 20.ConclusionsThe ASLI study demonstrated improved BCVA and reduced CST following an early switch to aflibercept therapy in eyes with prior incomplete response to initial therapy with three to nine bevacizumab injections.

The FIELDS Instrument Suite for Solar Probe Plus: Measuring the Coronal Plasma and Magnetic Field, Plasma Waves and Turbulence, and Radio Signatures of Solar Transients

NASA's Solar Probe Plus (SPP) mission will make the first in situ measurements of the solar corona and the birthplace of the solar wind. The FIELDS instrument suite on SPP will make direct measurements of electric and magnetic fields, the properties of in situ plasma waves, electron density and temperature profiles, and interplanetary radio emissions, amongst other things. Here, we describe the scientific objectives targeted by the SPP/FIELDS instrument, the instrument design itself, and the instrument concept of operations and planned data products.

History matching of a complex epidemiological model of human immunodeficiency virus transmission by using variance emulation

Complex stochastic models are commonplace in epidemiology, but their utility depends on their calibration to empirical data. History matching is a (pre)calibration method that has been applied successfully to complex deterministic models. In this work, we adapt history matching to stochastic models, by emulating the variance in the model outputs, and therefore accounting for its dependence on the model's input values. The method proposed is applied to a real complex epidemiological model of human immunodeficiency virus in Uganda with 22 inputs and 18 outputs, and is found to increase the efficiency of history matching, requiring 70% of the time and 43% fewer simulator evaluations compared with a previous variant of the method. The insight gained into the structure of the human immunodeficiency virus model, and the constraints placed on it, are then discussed.

Longitudinal Study of the Effects of an Adjustable Ergonomic Keyboard on Upper Body Musculoskeletal Symptoms

A longitudinal study assessed the differential impact of standard and adjustable ergonomic keyboards on musculoskeletal symptoms among 71 computer users over a six month period. A total of 73 subjects participated: 34 subjects used a standard, flat keyboard and 37 used an adjustable, ergonomic keyboard. Subjects completed weekly surveys of perceived keyboard comfort, and body discomfort, along with other items. The ergonomic keyboard was rated favorably and for users there were significantly improvements neck, shoulder and arm comfort.