Characterization of a temporoparietal junction subtype of Alzheimer's disease

Alzheimer's disease (AD) subtypes have been described according to genetics, neuropsychology, neuropathology, and neuroimaging. Thirty-one patients with clinically probable AD were selected based on perisylvian metabolic decrease on FDG-PET. They were compared to 25 patients with a typical pattern of decreased posterior metabolism. Tree-based machine learning was used on those 56 images to create a classifier that was subsequently applied to 207 Alzheimer's Disease Neuroimaging Initiative (ADNI) patients with AD. Machine learning was also used to discriminate between the two ADNI groups based on neuropsychological scores. Compared to AD patients with a typical precuneus metabolic decrease, the new subtype showed stronger hypometabolism in the temporoparietal junction. The classifier was able to distinguish the two groups in the ADNI population. Both groups could only be distinguished cognitively by Trail Making Test-A scores. This study further confirms that there is more than a typical metabolic pattern in probable AD with amnestic presentation.

[Gender-specific differences of the early postoperative and oncosurgical long-term outcome in rectal cancer-data obtained in a prospective multicenter observational study]

BACKGROUND

Gender-specific aspects have been increasingly considered in clinical medicine, also in oncological surgery.

AIM

To analyze gender-specific differences of early postoperative and oncological outcomes after rectal cancer resection based on data obtained in a prospective multicenter observational study.

PATIENTS AND METHODS

As part of the multicenter prospective observational study "Quality assurance in primary rectal cancer", data on tumor site, exogenic and endogenic risk factors, neoadjuvant treatment, surgical procedures, tumor stage, intraoperative and postoperative complications of patients with the histological diagnosis of rectal cancer were registered. Data from the years 2005-2006 and 2010-2011 were investigated with respect to gender-specific differences of postoperative morbidity, hospital mortality, local recurrency rate, disease-free and overall survival by univariable and multivariable analyses.

RESULTS

Overall, data from 10,657 patients were evaluated: 60.9% of the patients were male, who were significantly younger (p < 0.001). Men had a significantly higher rate of alcohol (p < 0.001) and nicotine abuse (p < 0.001) as well as a trend to a higher body mass index (BMI) compared with women. Although, there was no significant difference in the distribution of various tumor stages comparing men and women, neoadjuvant radiochemotherapy was used significantly more often in male patients (p < 0.001). In addition, male patients underwent an abdominoperineal rectum exstirpation more often, whereas creation of an enterostoma and Hartmann's procedure were more frequently used in women (p < 0.001 each). Multivariate analysis revealed that male patients developed a higher overall morbidity (odds ratio, OR: 1.5; p < 0.001) during both study periods and from 2010-2011 a higher hospital mortality (OR: 1.8; p < 0.001). After a median follow-up period of 36 months, gender did not have a significant impact on overall survival, disease-free survival or on the local tumor recurrency. The 5‑year overall survival was 60.5%, disease-free survival 63.8% and local recurrency rate was 5%.

CONCLUSION

Independent of other variables, gender differences were found with respect to early postoperative outcome but not to oncological long-term results after surgery of rectal cancer.

Type II retrocaval ureter causing hydronephrosis in a cat: case report

ABSTRACT Retrocaval ureter (RU) is an abnormal embryonic development of the caudal vena cava (CVC) that leads the ureter to be entrapped dorsal to the CVC. In most cases there is no clinical impact; however, it can cause hydronephrosis. We report a rare case of type II symptomatic retrocaval ureter in a feline treated with nephroureterectomy. A 4-year-old, intact male, mixed breed cat was submitted to abdominal ultrasound and severe right hydronephrosis was diagnosed, with no signs of obstruction. We performed an exploratory celiotomy, in which a displacement of the right ureter dorsal to the CVC was observed. The animal was treated with ureteronephrectomy and recovered well. No intraluminal cause was found, and a urethral catheter could be easily inserted across the ureter length. The real clinical relevance of the RU is unknown, since it is a common find in post-mortem examination without kidney impact and, when significant, is often associated to other causes of ureteral obstructions, such as calculi and strictures. Additionally, in humans, type II RU seldom develops obstruction and hydronephrosis. In our case, due to absence of other causes of obstruction, probably mechanical compression of the CVC against the psoas muscle caused the hydronephrosis.

[Surgical management of genital prolapse]

Although non invasive options exist, surgical management of genital prolapse is a gold standard. The main surgical approaches are abdominal -sacrocolpopexy- and vaginal -with or without mesh-. Sacrocolpopexy has proven to have better results than vaginal techniques, but is not appropriate for all women. Vaginal surgery remains a good option especially in older women who no longer have sexual activity. The surgical approach must adapt to patients' clinical characteristics. The choice has to be a shared decision after patients' loyal information.

Intravascular (post-hysterectomy) leiomyoma (IVL) as late tumor thrombus within the inferior vena cava (IVC)-A rare case primarily imposing as IVC thrombus originating from left renal vein after former left nephrectomy status

INTRODUCTION

Intravascular leiomyoma is a rare type of myoma. It was firstly described by Birch-Hirschfeld in 1896, however, its intracardiac subtype was firstly reported by Durck in 1907. Most patients are asymptomatic. The tumor invades mostly the tributaries of the inferior vena cava (IVC) with upward extension that may approach the intracardiac space.

AIM

By means of a scientific case report, a patient with the very rare diagnosis of an endocaval leiomyoma thrombus post-hysterectomy is described based on the clinical experiences obtained in the specific case management and selective references from the literature.

CASE PRESENTATION

A 48-years old female was diagnosed with intravascular tumor growth within the IVC with intracardiac extension using chest and abdominal CT scan, ECG and echocardiography which was approached by an interdisciplinary (vascular and cardiothoracic) surgical intervention (278 min) including heart-lung machine (99 min) with favorable postoperative result (R0 resection status with mid-term outcome, no recurrent tumor growth). Histopathological investigation diagnosed leiomyoma origin already from ovarian vein most likely in context to the former hysterectomy (3 years ago).

DISCUSSION AND CONCLUSION

Intravascular leiomyoma is a benign tumor with invasive tendency, which can be considered a diagnostic and therapeutic challenge. It should be thoroughly investigated to be planned for a radical surgical removal. By possible adherence to the intraabdominal or -thoracic organs, an interdisciplinary and eventually step-wise surgical approach (combining vascular, abdominal, thoracic and heart surgery as well as gynecology and urology), which can be demanding, is recommended to be seriously considered to i) reliably achieve R0 resection status and, thus, ii) provide best outcome, quality of life and prognosis.

A randomized controlled trial to test the efficacy of trans-tympanic injections of a sodium thiosulfate gel to prevent cisplatin-induced ototoxicity in patients with head and neck cancer

Background

Cisplatin-induced hearing loss is frequent and severe. Antioxidants such as sodium thiosulfate (STS) can neutralize the effects of cisplatin. The objective of the trial was to test the efficacy of trans-tympanic injections of a STS gel to prevent cisplatin-induced ototoxicity.

Methods

Eligible participants were newly diagnosed patients with stage III or IV squamous cell carcinoma of the mouth, oropharynx, hypopharynx, or larynx and scheduled to be treated by concurrent chemoradiation (CCR). Patients with asymmetric hearing were not eligible. The planed treatment included cisplatin 100 mg/m² at days 1, 22 and 43. A baseline pre-treatment complete audiometric evaluation (pure tone at frequencies ranging from 0.5 to 14 kHz, bone conduction at 0.5–4 kHz and DPOAEs) was performed. Adverse effects were noted according to CTCAE.

On the day before the beginning of CCR, eligible and consenting patients were randomized to receive a trans-tympanic injection of the gel either in the left ear or in the right ear. A final post-treatment complete audiometric evaluation was scheduled to be performed 1 month after the end of CCR by audiologists kept blind to the ear assignment.

For the main outcome, the permanent threshold shift (PTS) in decibel (dB) was calculated as the difference between the final and baseline measures at all pure tone frequencies at 0.5–14 kHz for each patient and for each ear. The main outcome was assessed blindly in a mixed linear model with the PTS as the dependent variable and intervention, frequency, their interaction and radiation dose to the cochlea as independent variables.

Results

Between January 2015 and April 2016, 13 patients were randomized. The trial was stopped in June 2016 for poor accrual. The average loss of hearing over all frequencies was 1.3 dB less for treated ears compared to control ears. Although not statistically (p = 0.61) nor clinically significant, the difference was in favor of the treated ears for all frequencies between 3 and 10 kHz.

Conclusions

Our trial suggests that STS deposited on the round window was safe for the middle and inner ears. More work is needed to improve the efficacy of trans-tympanic injections of cisplatin antidotes.

Trial registration

ClinicalTrials.gov, NTC02281006, Registered 3 November 2014.

Local electronic structure of the peptide bond probed by resonant inelastic soft X-ray scattering

Soft X-ray emission spectroscopy and RIXS are used to determine the local electronic structure of the peptide bond.

Optical rectification of a 100 W average power mode-locked thin-disk oscillator

We demonstrate terahertz (THz) generation at megahertz repetition rate by optical rectification in GaP crystals, using excitation average power levels exceeding 100 W. The laser source is a state-of-the-art diode-pumped Yb:YAG SESAM-mode-locked thin-disk laser, capable of generating 580 fs pulses at an average power up to 120 W and a repetition rate of 13.4 MHz directly from a one-box oscillator, without the need for any extra amplification stages. In this first demonstration, we measure a maximum THz average power of 78 μW at a central frequency of 0.8 THz. Our results show that optical rectification of state-of-the-art high average power ultrafast sources in nonlinear crystals is within reach and paves the way toward high average power, ultrafast laser pumped THz sources.

Prediction of the outcome of children who had a language delay at age 2 when they are aged 4: Still a challenge

PURPOSE

This study investigated the role that variables related to children and their environment play in the prediction of outcomes at 4 years of age for children with a language delay at 2 years.

METHOD

A longitudinal study was undertaken where 64 children (45 boys, 19 girls; mean age = 53.3 months; SD = 4.4) with language delay at age 2 years were re-evaluated at age 4 years. Three developmental trajectories were analysed.

RESULT

The early stages of grammar, as estimated by mean length of utterance at 3.5 years, are an important prognosis factor of subsequent language impairment (LI). Children who are exposed to several risk factors simultaneously are more likely to have a language delay (LD) or a LI, but the profile of LD children is more akin to that of the typically developing (TD) children. Children with LI tend to have profiles with a greater number of risk factors.

CONCLUSION

The results of this study encourage different intervention approaches depending on the child's language profile at 2 years, due to differing language prognosis. The results also point to the need to assess the child's environment. Future studies with large diverse population samples may give more precise information on potential risk factors and their cumulative effect.

[Hybrid prosthesis for vascular reconstruction of the internal carotid artery near the skull base after radical excision of a very rare malignant glomus caroticum paraganglioma]

BACKGROUND

Neck tumors are challenging regarding the diagnostic and therapeutic management particularly in cases of malignant growth near relevant vessels to achieve R0 resection status and the best prognosis.

AIM

The aim of this case report on a patient with a rare malignant tumor of the glomus caroticum (paraganglioma) is to present the successful outcome of a demanding interdisciplinary surgical approach (otorhinolaryngology and vascular surgery). Surgical re-intervention was necessary due to malignant tumor growth (detected in the histopathological investigation of the first specimen) including vascular resection using a hybrid graft for vascular reconstruction of the internal carotid artery near the skull base.

CASE REPORT

A 38-year-old male patient underwent magnetic resonance angiography and digital subtraction angiography to clarify the diagnosis of a tumor in the right neck. This was preoperatively embolized and subsequently resected including vascular reconstruction using a prosthetic interposition graft (7 cm; W.L. Gore, Putzbrunn, Germany) between the common and internal carotid arteries.

HISTOLOGY

malignant paraganglioma 40 mm in diameter with haemangiosis et lymphangiosis carcinomatosa demonstrating lymph node metastasis and prompting re-operation (neck dissection levels II, III, IV, V). This was followed by a novel vascular reconstruction using a GORE® hybrid vascular graft prosthetic stent (W.L. Gore) as interposition graft because of the short extracranial stump of the distal internal carotid artery near the skull base and to limit clamping time. Early postoperative outcome revealed no complications and after 24 months there were no signs or symptoms of recurrent tumor growth.

CONCLUSION

Extended resections, if necessary including vascular (arterial) segments, aim at achieving R0 classification as shown in this extremely rare and usually challenging malignant tumor. Hybrid vascular prostheses are suitable for time-saving vascular reconstruction (>50%) to provide sufficient blood supply.

The Impact of Limited Cancer Health Literacy on Patient Preference for Shared Care

Background: Patient are increasingly expected to engage in their own care. However, patients with limited health literacy often struggle with this. The expectation of patients' engagement in health care decisions by their healthcare providers likely increases the burden that cancer patients are already experiencing following a life-changing diagnosis. Involving patients with cancer in medical decision-making requires them to have an adequate understanding their disease and treatment options. Limited health literacy poses a barrier to patient engagement in their own care, contributing to health disparities and poorer cancer outcomes. Aim: Our primary objective was to determine levels of health literacy among patients with cancer and the extent of its association with patient preference for care. We also sought to identify sociodemographic and clinical characteristics associated with limited cancer health literacy. Methods: As part of a larger prospective cohort study, N = 345 adult cancer patients attending a large, university-affiliated outpatient oncology clinic were recruited using consecutive sampling. Face to face interviews were conducted using questionnaires. Instruments used included the 30-item Cancer Health Literacy Test (CHLT-30), and the Patient-Practitioner Orientation Scale (PPOS) to determine patient preference for shared care. The relationship between cancer health literacy and patient preference for shared care was examined using bivariate analysis, with logistic regression used to identify predictors. Results: Mean patient age was 60.0 ± 11.6 years. A greater female preponderance was observed (69.4%), with over half of patients indicating secondary school completion (51.6%). Up to 79.3% of patients reported a monthly household income of less than RM 4000 (approximately USD 1000), placing them in the bottom 40% of household incomes in Malaysia. A total of 59.1% of patients (n = 204) in this sample were found to have limited cancer health literacy, with an average score of 14.40 ± 4.04 out of a full score of 30. Patients with limited cancer literacy were 1.69 times (95% CI 1.42-2.03) less likely to prefer active participation in their care. Conclusion: Rates of limited cancer literacy in this sample (59.1%) appear to be at least three times higher than prevailing rates in high resource countries with established cancer control programs such as the United States (18%). One out of every two patients with cancer in this study were found to possess limited health literacy, making this a significant issue particularly given its association with lesser patient preference for shared care. This study marks an important first step toward increasing health literacy among patients with cancer and empowering patients to participate in their care, which may help mitigate the impact of disparities such as lower educational and socioeconomic levels traditionally associated with poorer cancer outcomes.

[Vascular surgical aspects in abdominal surgery : Results from a tertiary care center over a 10-year time period]

AIM

To investigate the perioperative management and outcome of patients undergoing abdominal surgery with additional vascular (comorbid) alterations for internal quality assurance of the clinical results.

METHODS

Over a defined study period all consecutive cases of the aforementioned profile were documented and retrospectively analyzed as part of an ongoing prospective monocentric observational study to reflect the daily surgical practice.

RESULTS

Over 10 years (from January 1999 to December 2008), a total of 113 cases were registered. Pancreas resection including vascular reconstruction showed the highest percentage (30.1%). Within the target patient groups, similar outcome data were found compared with international reports. An exception was in the case of mesenteric ischemia, where open surgery was more frequently used in comparison to the study situation (included together were patients treated by surgery and interventions). The majority of vascular alterations during the postoperative course and iatrogenic lesions occurred following pancreas resection. In the therapeutic profile there are two particularly important measures, namely open surgery on one hand and image-guided radiology as well as endoscopy on the other hand. The majority of patients with a rare visceral artery aneurysm (considerable potential for rupture or erosion) were more frequently treated with image-guided interventional radiology versus open surgery. This conforms to the current well-established sequential patient (individual), results, and, in particular, risk-adapted staged treatment approach.

CONCLUSION

Additional vascular surgical treatment of problematic situations during abdominal surgery or in emergency cases is not daily routine; however, it is a challenging field including a considerable potential for complications (morbidity) and definitely mortality. This requires an experienced surgeon with high expertise, if possible in a center for vascular medicine.

p-GaAs Nanowire Metal-Semiconductor Field-Effect Transistors with Near-Thermal Limit Gating

Difficulties in obtaining high-performance p-type transistors and gate insulator charge-trapping effects present two major challenges for III-V complementary metal-oxide semiconductor (CMOS) electronics. We report a p-GaAs nanowire metal-semiconductor field-effect transistor (MESFET) that eliminates the need for a gate insulator by exploiting the Schottky barrier at the metal-GaAs interface. Our device beats the best-performing p-GaSb nanowire metal-oxide-semiconductor field effect transistor (MOSFET), giving a typical subthreshold swing of 62 mV/dec, within 4% of the thermal limit, on-off ratio ∼10⁵, on-resistance ∼700 kΩ, contact resistance ∼30 kΩ, peak transconductance 1.2 μS/μm, and high-fidelity ac operation at frequencies up to 10 kHz. The device consists of a GaAs nanowire with an undoped core and heavily Be-doped shell. We carefully etch back the nanowire at the gate locations to obtain Schottky-barrier insulated gates while leaving the doped shell intact at the contacts to obtain low contact resistance. Our device opens a path to all-GaAs nanowire MESFET complementary circuits with simplified fabrication and improved performance.

[Impact of neoadjuvant chemotherapy on the peri-operative morbidity of radical cystectomy for muscle invasive bladder cancer]

INTRODUCTION

Platinum-based neoadjvant chemotherapy (NAC) before radical cystectomy (RC) is the gold standard in the treatment of muscle invasive bladder cancer (MIBC). We aimed to compare the peri-operative morbidity in patients treated by NAC then RC and patients having RC alone.

METHODS

Between 1st January 2008 and 31st December 2015, we retrospectively included consecutive patients undergoing RC for MIBC in 2centers. We collected clinical, pathological and peri-operative data (30day post operative complications according to the Clavien-Dindo score, delayed complications, pathological results). Patients treated by NAC (NAC-RC group) before RC were compared to patients performing RC alone. The NAC-RC group received 1 to 6cycle of high-dose MVAC, MVAC or gemcitabine-cisplatine chemotherapy. Logistic regression identified independant factors of peri-operative complications.

RESULTS

We included 199 patients: 48in the NAC-RC group and 151in the RC group. Complications rate was 73.9% in the NAC-RC group versus 73.8% in the RC group (P=1.0). In multivariate analyses, only the Charlson score was associated with an increased risk of peri-operative complications (P=0.05). PT0 tumour rate was significantly higher in the NAC-CR group (50% vs 7%, P<0.001).

CONCLUSION

NAC does not increase the peri-operative morbidity of the RC. Patients' pre operative comorbidities is the main risk factor for peri-operative complications.

[Modern interdisciplinary management of a uretero-iliac artery fistula (case report)]

INTRODUCTION

 Abnormal links between the arterial system and other luminal systems are a challenge to those in charge of their adequate diagnostic and therapeutic management.

OBJECTIVE

 Scientific case report on an individual who underwent successful treatment combining vascular-surgical and interventional radiology techniques for a rare right uretero-iliac artery fistula based on personal clinical experience, a selective literature research and a detailed discussion of current recommendations for diagnostic workup and subsequent treatment.

CASE CHARACTERISTICS

 A 79-year-old patient was admitted with haematuria : and bladder tamponade : in the presence of bilateral actinic ureteral strictures secondary to neoadjuvant radiochemotherapy followed by abdominoperineal rectum exstirpation due to suprasphincteric rectal cancer (ypT3ypN0M0). Laboratory tests revealed anaemia; transabdominal ultrasound demonstrated bilateral urinary retention. A complementary CT scan did not reveal any manifest bleeding resulting from intermittent haemorrhage.

SURGICAL PROCEDURE

 Initially, the bladder haematoma was removed and ureteral catheters were changed. Due to endoluminal bleeding in the right ureter, a combined procedure was initiated, involving a vascular-surgical approach (access to the right femoral artery, ultimate disobliteration and intimal refixation in the right superficial femoral artery due to dissection) and an interventional radiology approach (insertion of an Amplatzer [AMPLATZER™Vascular Plug II; St. Jude Medical, Saint Paul, Minnesota, USA] into the right internal iliac artery and iliac stenting by a cross-over manoeuvre from the left femoral access site) although no acute bleeding was detected in the CT scan (but acute haemorrhage from the right ureteric ostium was confirmed during cystoscopy).

CLINICAL COURSE

 The patient stabilised in due time in response to periinterventional treatment in the ICU. He was discharged on the 15th day after surgery without evidence of recurrent haemorrhage.

SUMMARY

 In the presented case, this promptly initiated (vascular-surgical and interventional radiology) hybrid operation was absolutely indicated, being the approach with the best prospects for recurrent arterial bleeding with clinical manifestation of haematuria and haemorrhage within the urinary bladder due to a uretero-iliac artery fistula.

CONCLUSION

 Today, a minimally invasive approach with stenting is the method of choice in the sequential, urgent management of a potentially life-threatening uretero-iliac fistula in the presence of arterial endoluminal bleeding and an imminent haemorrhagic shock.

Predictors of circulating INTERLEUKIN-6 levels in head and neck cancer patients

Background

Circulating interleukin-6 (IL-6) improves outcome prediction for second primary cancer (SPC) in head and neck cancer (HNC) patients. This study aimed to identify factors associated with IL-6 serum levels in HNC patients.

Methods

This study was conducted as part of a phase III chemoprevention trial. IL-6 was measured using chemiluminescent immunometric assay on pretreatment serum sample obtained from 527 stage I-II HNC patients. Patients’ lifestyle habits, sociodemographic, medical and tumor characteristics were evaluated before radiation therapy (RT). Factors independently associated with IL-6 levels before RT were identified using multiple linear regression.

Results

The median IL-6 serum level was 3.1 ng/L. In the multivariate analysis, eight factors were significantly associated (p <  0.05) with IL-6: age, gender, marital status, body mass index, tobacco consumption, comorbidities, Karnofsky Performance Status and HNC site. Smoking duration and lifetime pack-years were positively associated with IL-6 serum levels in a dose-response relationship (p-value for trend ≤0.03).

Conclusions

Circulating IL-6 is a strong predictor of the occurrence of SPC in HNC patients. We identified eight factors independently associated with serum IL-6 levels in 527 stage I-II HNC patients.

The dose-response relationship between lifetime smoking and IL-6 serum levels suggested a causal role of tobacco exposure on IL-6 production. Further studies are needed to establish whether the effect of tobacco exposure on SPC could be partly mediated by IL-6, a pro-inflammatory cytokine.

[Vomiting and collapse of a 28-year-old male long distance runner in middle European Summer]

BACKGROUND

Hyperthermia often ends fatally and must therefore be promptly recognized and adequately treated.

CASE

A 28-year-old man participated in a long-distance race (3 km) on a hot summer day (28 °C). The runner collapsed, had to vomit but continued the run and reached the finish. Neurologically, the patient presented with intermittent cerebral seizures. External cooling batteries were immediately applied and cold infusions were started. The patient was admitted to the intensive care unit of the university hospital (body temperature 40.2 °C). After a few hours, a manifest disseminated intravascular coagulopathy developed with multiple organ failure. It took 12 l of volume replacement, 8 units of fresh frozen plasma and 2 units of erythrocyte concentrates in the first 12 h to stabilize the patient. Although with the help of forced external cooling and application of cold infusions, the body temperature could be lowered to 38 °C by the next morning, the overall situation of the patient continued to deteriorate. Despite dialysis and massive substitution of coagulation factors, the patient could not be sufficiently stabilized and died of brain edema.

CONCLUSION

Not only the old or young children are subject to the potential danger of a fatal heat stroke but also young athletic persons after normal sports activities (3 km run). Cooling must be started immediately and the patient must be hospitalized as a vital emergency. If hemostasis fails due to the heat-related loss of hepatogenic protein synthesis, a viscious circle begins, which, as in the reported case, is irreversible despite maximum therapy and substitution.