Role of staging laparoscopy in the stratification of patients with perihilar cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is a rare cancer with a poor prognosis. Radical surgical resection is the only option for curative treatment. Optimal determination of resectability is required so that patients can be stratified into operative or chemotherapeutic treatment cohorts in an accurate and time-efficient manner. Staging laparoscopy is utilized to determine the presence of radiologically occult disease that would preclude further surgical treatment. The aim of this study was to analyse the utility of staging laparoscopy in a contemporary cohort of patients with perihilar cholangiocarcinoma.

METHODS

Patients diagnosed with potentially resectable perihilar cholangiocarcinoma between January 2010 and April 2015 were analysed retrospectively from a prospective database linked to UK Hospital Episode Statistics data. Patients with distal cholangiocarcinoma and gallbladder cancer were excluded from analysis.

RESULTS

A total of 431 patients with perihilar cholangiocarcinoma were referred for assessment of potential resection at a supraregional referral centre. Some 116 patients with potentially resectable disease subsequently underwent surgical assessment. The cohort demonstrated an all-cause yield of staging laparoscopy for unresectable disease of 27·2 per cent (31 of 114). The sensitivity for detection of peritoneal disease was 71 per cent (15 of 21; P < 0·001). The accuracy for all-cause non-resection for staging laparoscopy was 66 per cent (31 of 47) with a positive predictive value of progress to resection of 81 per cent (69 of 85). Neither the Bismuth-Corlette nor the Memorial Sloan Kettering Cancer Center preoperative scoring system was contingent with cause of unresectability at staging laparoscopy (P = 0·462 and P = 0·280 respectively).

CONCLUSION

In the present cohort, staging laparoscopy proved useful in determining the presence of radiologically occult metastatic disease in perihilar cholangiocarcinoma.

The wheat Phs-A1 pre-harvest sprouting resistance locus delays the rate of seed dormancy loss and maps 0.3 cM distal to the PM19 genes in UK germplasm

The precocious germination of cereal grains before harvest, also known as pre-harvest sprouting, is an important source of yield and quality loss in cereal production. Pre-harvest sprouting is a complex grain defect and is becoming an increasing challenge due to changing climate patterns. Resistance to sprouting is multi-genic, although a significant proportion of the sprouting variation in modern wheat cultivars is controlled by a few major quantitative trait loci, including Phs-A1 in chromosome arm 4AL. Despite its importance, little is known about the physiological basis and the gene(s) underlying this important locus. In this study, we characterized Phs-A1 and show that it confers resistance to sprouting damage by affecting the rate of dormancy loss during dry seed after-ripening. We show Phs-A1 to be effective even when seeds develop at low temperature (13 °C). Comparative analysis of syntenic Phs-A1 intervals in wheat and Brachypodium uncovered ten orthologous genes, including the Plasma Membrane 19 genes (PM19-A1 and PM19-A2) previously proposed as the main candidates for this locus. However, high-resolution fine-mapping in two bi-parental UK mapping populations delimited Phs-A1 to an interval 0.3 cM distal to the PM19 genes. This study suggests the possibility that more than one causal gene underlies this major pre-harvest sprouting locus. The information and resources reported in this study will help test this hypothesis across a wider set of germplasm and will be of importance for breeding more sprouting resilient wheat varieties.

Prospective study evaluating the relative sensitivity of 18F-NaF PET/CT for detecting skeletal metastases from renal cell carcinoma in comparison to multidetector CT and 99mTc-MDP bone scintigraphy, using an adaptive trial design

BACKGROUND

The detection of occult bone metastases is a key factor in determining the management of patients with renal cell carcinoma (RCC), especially when curative surgery is considered. This prospective study assessed the sensitivity of (18)F-labelled sodium fluoride in conjunction with positron emission tomography/computed tomography ((18)F-NaF PET/CT) for detecting RCC bone metastases, compared with conventional imaging by bone scintigraphy or CT.

PATIENTS AND METHODS

An adaptive two-stage trial design was utilized, which was stopped after the first stage due to statistical efficacy. Ten patients with stage IV RCC and bone metastases were imaged with (18)F-NaF PET/CT and (99m)Tc-labelled methylene diphosphonate ((99m)Tc-MDP) bone scintigraphy including pelvic single photon emission computed tomography (SPECT). Images were reported independently by experienced radiologists and nuclear medicine physicians using a 5-point scoring system.

RESULTS

Seventy-seven lesions were diagnosed as malignant: 100% were identified by (18)F-NaF PET/CT, 46% by CT and 29% by bone scintigraphy/SPECT. Standard-of-care imaging with CT and bone scintigraphy identified 65% of the metastases reported by (18)F-NaF PET/CT. On an individual patient basis, (18)F-NaF PET/CT detected more RCC metastases than (99m)Tc-MDP bone scintigraphy/SPECT or CT alone (P = 0.007). The metabolic volumes, mean and maximum standardized uptake values (SUV mean and SUV max) of the malignant lesions were significantly greater than those of the benign lesions (P < 0.001).

CONCLUSIONS

(18)F-NaF PET/CT is significantly more sensitive at detecting RCC skeletal metastases than conventional bone scintigraphy or CT. The detection of occult bone metastases could greatly alter patient management, particularly in the context when standard-of-care imaging is negative for skeletal metastases.

Mapping a Type 1 FHB resistance on chromosome 4AS of Triticum macha and deployment in combination with two Type 2 resistances

Markers closely flanking a Type 1 FHB resistance have been produced and the potential of combining this with Type 2 resistances to improve control of FHB has been demonstrated. Two categories of resistance to Fusarium head blight (FHB) in wheat are generally recognised: resistance to initial infection (Type 1) and resistance to spread within the head (Type 2). While numerous sources of Type 2 resistance have been reported, relatively fewer Type 1 resistances have been characterised. Previous study identified a Type 1 FHB resistance (QFhs.jic-4AS) on chromosome 4A in Triticum macha. Little is known about the effect of combining Type 1 and Type 2 resistances on overall FHB symptoms or accumulation of the mycotoxin deoxynivalenol (DON). QFhs.jic-4AS was combined independently with two Type 2 FHB resistances (Fhb1 and one associated with the 1BL/1RS translocation). While combining Type 1 and Type 2 resistances generally reduced visual symptom development, the effect on DON accumulation was marginal. A lack of polymorphic markers and a limited number of recombinants had originally prevented accurate mapping of the QFhs.jic-4AS resistance. Using an array of recently produced markers in combination with new populations, the position of QFhs.jic-4AS has been determined to allow this resistance to be followed in breeding programmes.

RNA-Seq bulked segregant analysis enables the identification of high-resolution genetic markers for breeding in hexaploid wheat

The identification of genetic markers linked to genes of agronomic importance is a major aim of crop research and breeding programmes. Here, we identify markers for Yr15, a major disease resistance gene for wheat yellow rust, using a segregating F2 population. After phenotyping, we implemented RNA sequencing (RNA-Seq) of bulked pools to identify single-nucleotide polymorphisms (SNP) associated with Yr15. Over 27 000 genes with SNPs were identified between the parents, and then classified based on the results from the sequenced bulks. We calculated the bulk frequency ratio (BFR) of SNPs between resistant and susceptible bulks, selecting those showing sixfold enrichment/depletion in the corresponding bulks (BFR > 6). Using additional filtering criteria, we reduced the number of genes with a putative SNP to 175. The 35 SNPs with the highest BFR values were converted into genome-specific KASP assays using an automated bioinformatics pipeline (PolyMarker) which circumvents the limitations associated with the polyploid wheat genome. Twenty-eight assays were polymorphic of which 22 (63%) mapped in the same linkage group as Yr15. Using these markers, we mapped Yr15 to a 0.77-cM interval. The three most closely linked SNPs were tested across varieties and breeding lines representing UK elite germplasm. Two flanking markers were diagnostic in over 99% of lines tested, thus providing a reliable haplotype for marker-assisted selection in these breeding programmes. Our results demonstrate that the proposed methodology can be applied in polyploid F2 populations to generate high-resolution genetic maps across target intervals.

Scuba diving injuries among Divers Alert Network members 2010-2011

BACKGROUND

Scuba diving injuries vary greatly in severity and prognosis. While decompression sickness (DCS) and arterial gas embolism can be tracked easily, other forms of diving injury remain unaccounted for.

PURPOSE

The purpose of this paper is to assess rates of overall self-reported scuba-diving-related injuries, self-reported DCS-like symptoms, and treated DCS and their association with diver certification level, diving experience and demographic factors.

METHODS

We analyzed self-reported data from a Divers Alert Network membership health survey conducted during the summer of 2011. Poisson regression models with scaled deviance were used to model the relative rates of reported injuries. Models were adjusted for sex, age, body mass index (BMI) and average annual dives, based on the bias-variance tradeoff.

RESULTS

The overall rate of diving-related injury was 3.02 per 100 dives, self-reported DCS symptoms was 1.55 per 1,000 dives and treated DCS was 5.72 per 100,000 dives. Diving-related injury and self-reported DCS symptom rates decreased for higher diver certification levels, increasing age, increasing number of average annual dives and for men; they increased for increasing BMI.

CONCLUSIONS

Diving injury rates may be higher than previously thought, indicating a greater burden on the diving community. Self-reported DCS-like symptoms are a small fraction of all dive-related injuries and those receiving treatment for DCS are an even smaller fraction. The small number of divers seeking treatment may suggest the mild nature and a tendency towards natural resolution for most injuries.

Recommendations for rescue of a submerged unresponsive compressed-gas diver

The Diving Committee of the Undersea and Hyperbaric Medical Society has reviewed available evidence in relation to the medical aspects of rescuing a submerged unresponsive compressed-gas diver. The rescue process has been subdivided into three phases, and relevant questions have been addressed as follows. Phase 1, preparation for ascent: If the regulator is out of the mouth, should it be replaced? If the diver is in the tonic or clonic phase of a seizure, should the ascent be delayed until the clonic phase has subsided? Are there any special considerations for rescuing rebreather divers? Phase 2, retrieval to the surface: What is a "safe" ascent rate? If the rescuer has a decompression obligation, should they take the victim to the surface? If the regulator is in the mouth and the victim is breathing, does this change the ascent procedures? If the regulator is in the mouth, the victim is breathing, and the victim has a decompression obligation, does this change the ascent procedures? Is it necessary to hold the victim's head in a particular position? Is it necessary to press on the victim's chest to ensure exhalation? Are there any special considerations for rescuing rebreather divers? Phase 3, procedure at the surface: Is it possible to make an assessment of breathing in the water? Can effective rescue breaths be delivered in the water? What is the likelihood of persistent circulation after respiratory arrest? Does the recent advocacy for "compression-only resuscitation" suggest that rescue breaths should not be administered to a non-breathing diver? What rules should guide the relative priority of in-water rescue breaths over accessing surface support where definitive CPR can be started? A "best practice" decision tree for submerged diver rescue has been proposed.

A Quasi-Nonlinear Analysis of the Anisotropic Behaviour of Human Gallbladder Wall

Estimation of biomechanical parameters of soft tissues from noninvasive measurements has clinical significance in patient-specific modeling and disease diagnosis. In this work, we present a quasi-nonlinear method that is used to estimate the elastic moduli of the human gallbladder wall. A forward approach based on a transversely isotropic membrane material model is used, and an inverse iteration is carried out to determine the elastic moduli in the circumferential and longitudinal directions between two successive ultrasound images of gallbladder. The results demonstrate that the human gallbladder behaves in an anisotropic manner, and constitutive models need to incorporate this. The estimated moduli are also nonlinear and patient dependent. Importantly, the peak stress predicted here differs from the earlier estimate from linear membrane theory. As the peak stress inside the gallbladder wall has been found to strongly correlate with acalculous gallbladder pain, reliable mechanical modeling for gallbladder tissue is crucial if this information is to be used in clinical diagnosis.

Normal and Anomalous Yield Stresses in a Tial Single Crystal and the Dominating Dislocation Mechanisms

Single crystal γ-TiAl with axial orientation [3 16 15] has been tested in compression between 4K and 1048K and the dislocation structures observed in TEM. The slip plane was found to be (111) over the entire temperature range tested. Three regimes exist in the variation of the yield stress with temperature, whereas the dislocation substructures are of two types, dominated by 30° 1/3[112] and 1/2 < 110] dislocations respectively. The anomalous yield stress is associated with 1/2 < 110] dislocations undergoing frequent cross-slip off the (111) plane.

Current diagnostic and therapeutic approaches for colorectal cancer liver metastasis

Colorectal cancer is the second leading cause of cancer death in the developed world, due to formation of distant metastases. The liver is a primary target organ of metastatic lesions, which substantially influence the morbidity of the disease. Prompt diagnosis of colorectal liver metastases leads to early treatment, which favours a better prognosis. Consequently, the diagnostic process has shifted from traditional clinical and biochemical procedures to technologically advanced imaging modalities, such as CT, MRI, FDG-PET and PET-CT. However, the only current curative therapeutic approach is the surgical resection of metastases, using the new methods of tissue excision and haemostasis. New therapeutic modalities like cryo- or radiofrequency ablation and portal vein embolisation as well as pharmaceutical innovations such as hepatic arterial infusion chemotherapy, isolated hepatic perfusion and contemporary chemotherapeutic regimens have emerged. While still under evaluation, they present promise for the future treatment of unresectable liver metastases.

Correlation of Mechanical Factors and Gallbladder Pain

Acalculous biliary pain occurs in patients with no gallstones, but is similar to that experienced by patients with gallstones. Surgical removal of the gallbladder (GB) in these patients is only successful in providing relief of symptoms to about half of those operated on, so a reliable pain-prediction model is needed. In this paper, a mechanical model is developed for the human biliary system during the emptying phase, based on a clinical test in which GB volume changes are measured in response to a standard stimulus and a recorded pain profile. The model can describe the bile emptying behaviour, the flow resistance in the biliary ducts, the peak total stress, including the passive and active stresses experienced by the GB during emptying. This model is used to explore the potential link between GB pain and mechanical factors. It is found that the peak total normal stress may be used as an effective pain indicator for GB pain. When this model is applied to clinical data of volume changes due to Cholecystokinin stimulation and pain from 37 patients, it shows a promising success rate of 88.2% in positive pain prediction.

CT finding of VGE in the portal veins and IVC in a diver with abdominal pain: a case report

The finding of abdominal venous gas emboli (VGE) on computerized tomography (CT) is reported for the first time in a recreational diver. The patient presented 2-3 hours after surfacing from two deep air dives and subsequently complained of visual blurring and abdominal pain. Gas bubbles in the inferior vena cava (IVC) and portal veins were found incidentally by computerized tomography (CT) during his work-up for abdominal pain. The patient was treated for decompression sickness (DCS) with a US Navy Treatment Table 6 and achieved complete resolution of symptoms. The routine use of CT for venous bubble detection in symptomatic divers is not endorsed, but may provide objective evidence of VGE when DCS is in the differential diagnosis and corroborative evidence would alter management.

Spontaneous cholesterol embolisation causing acute renal failure

We present a case of true spontaneous cholesterol embolisation causing acute renal failure. There was no history of vascular procedural interventions or thrombolytic therapy prior to her presentation, but the patient did have a history of difficult hypercholesterolemia and atherosclerosis. This case highlights the importance of remembering cholesterol embolisation as a potential cause of acute renal failure despite no apparent precipitant, especially with the presence of unexplained eosinophilia.