Cancer-related lymphedema: clinical pearls for providers

Lymphedema is a chronic inflammatory condition that results from damage to the lymphatic system. Lymphedema is classified as either primary or secondary, the former being caused by a malformation of lymph vessels or nodes, and the latter resulting from trauma, chronic lymphatic system overload, or the sequelae of cancer treatments. In the present article, we focus on secondary cancer-related lymphedema (crl), a potential survivorship treatment-related effect. Treatments for breast, gynecologic, prostate, and head-and-neck cancers, and melanoma and other skin cancers are most frequently associated with crl. The incidence of crl varies widely based on cancer location and treatment modalities, with estimates ranging from 5% to 83% in various cancers. Given the lack of a universal definition and diagnostic criteria, the prevalence of crl is difficult to ascertain; current estimates suggest that more than 300,000 Canadians are affected by crl. Here, we present an overview of crl, divided into 5 subtopics: lymphedema risk factors; early identification and intervention; diagnosis and staging; management, with emphasis on the volume reduction and maintenance phases, plus patient support and education; and clinical pearls to help providers integrate knowledge about crl into their practice.

Safety and efficacy of hysteroscopic resection of uterine leiomyoma embedded at the base of a uterine septum

BACKGROUND

To determine the safety and efficacy of hysteroscopic resection of uterine leiomyoma embedded at the base of a uterine septum.

METHODS

This case series included 11 patients with infertility or recurrent pregnancy loss who were found to have a uterine septum (one septate and 10 sub-septate) and a uterine leiomyoma embedded at the base of the uterine septum. All patients underwent a hysteroscopic division of the uterine septum and hysteroscopic resection of the uterine leiomyoma. Safety was determined by any intra-operative complications, and any immediate or late postoperative complications. Efficacy was determined based on the findings on a postoperative trans-vaginal 3D ultrasound (TV 3D US) with a saline infusion sonohysterogram (SIH) and reproductive outcomes.

RESULTS

There were no reported intra-operative complications, or immediate or late postoperative complications. Eleven patients underwent TV 3D US with SIH; findings were normal in 8 (72.7%); 3 patients underwent a second operative hysteroscopy and subsequent TV 3D US with SIH were also normal. The analysis of reproductive outcomes was limited to patients who were < 40 years (9 patients). Seven patients conceived (77.8%), six delivered (66.7%) and one miscarried (14.3%).

CONCLUSIONS

Hysteroscopic myomectomy of a leiomyoma, which is embedded at the base of a uterine septum, can be safely performed at the same session of hysteroscopic division of the uterine anomaly. Improvement in reproductive outcomes is to be expected after such procedures.

Differential impact of life-long lower LDL-C levels on ischaemic stroke subtypes and coronary heart disease risk among 1 million individuals

Background

The relative impact of low density lipoprotein cholesterol (LDL-C) lowering on risk of ischaemic stroke [IS] and coronary heart disease [CHD] has been debated. The relevance of aetiologically distinct IS subtypes may contribute to this complex relationship, but the causal relationship and relative importance of LDL-C for risk of large artery, cardioembolic and small vessel stroke and CHD remains unclear.

Purpose

To disentangle the relative impact and quantify the causal effects of life-long differences in LDL-C on risk of cardioembolic, small vessel, and large artery stroke, and CHD.

Methods

We undertook a multi-ethnic Mendelian randomization (MR) study of 1,008,662 individuals including 66,218 IS cases (with TOAST subtyping available in 3 times more cases than previously available), and 103,536 CHD cases. IS results were based on a meta-analysis of summary and individual participant data from the MEGASTROKE Consortium and UK Biobank respectively, and CHD results on data from the CARDIoGRAMplusC4D Consortium and UK Biobank. We created a weighted genetic risk score based on 175 independent variants identified in previous genome-wide studies of LDL-C that included individuals of multiple ethnicities. This genetic instrument was used to estimate the causal effects of life-long differences in LDL-C for risk of IS, IS subtypes and CHD. In addition, the associations between functionally informed genomic regions representing LDL-lowering drug targets including HMGCR (for statins), NPC1L1 (for ezetimibe), and PCSK9 (for PCSK9-inhibitors) and the disease outcomes were examined.

Results

Life-long lower genetically determined LDL-C was associated with a 25% lower risk of CHD per standard deviation of the genetic score (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.73–0.77; p=2×10–91), but had a significantly weaker effect on IS (OR 0.92, 95% CI 0.88–0.95, p=8x10–6, p for heterogeneity=7.3x10–18). Underlying the relationship with IS was a strong association with large artery stroke (OR 0.75, 95% CI 0.68–0.83; p=2×10–8), comparable to that for CHD, but no significant effects on cardioembolic (OR 1.02, 95% CI 0.95–1.10; p=0.60) or small vessel strokes (OR 0.95, 95% CI 0.88–1.03; p=0.23). Results from multivariable MR analyses that accounted for potential pleiotropy with HDL-C and triglycerides showed no material difference. Additional analyses to examine sensitivity of these findings to the genetic risk score, ethnicity, and wider sources of pleiotropy were performed, and effects of genetic proxies for individual LDL-lowering drug targets assessed.

Conclusion

This study, the largest of its type to date, demonstrates that life-long lower genetically determined LDL-C levels have a materially weaker effect on IS than on CHD, and differences in the relative importance of life-long lower LDL-C for aetiologically distinct IS subtypes contribute to the differences observed.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Assiri M, Thind S, Bilal M, Irfan A, G. Al-Sehemi A. Biochemical studies on protein, phenolic contents and antioxidant activities of Sida cordifolia extracts

The study aimed to characterize the antioxidant properties regarding the Sida cordifolia with special reference to its detailed biochemical analysis. The study revealed that chlorophyll A (0.9 ± 0.3 mg/g), total chlorophyll content (3.0 ± 0.7 mg/g), total carotenoid content (0.3 ± 0.1 mg/g), total soluble proteins (7.5 ± 0.1 mg/g), and total phenolic contents (5.6 ± 1.3 mg/g) were found highest in flower tissue of S. cordifolia. However, peroxidase (POD) contents (118 ± 31 units/g), superoxide dismutase (SOD)  activity (64 ± 1.5 units/g) were maximum in the leaf tissues, while catalase (CAT)  contents (133 ± 25 units/g), ascorbate peroxidase (APX)  contents (145 ± 44 units/g) were also found more in the flowers of S. cordifolia rather than other parts. Our results conclude that leaves, stem, flower of S. cordifolia could be exploited in pharmacology due to presence of different antioxidants reflected in flower and leaf extract make them potent and profound therapeutic agents.                     KEY WORDS: Alkaloids, Flavonoids, Phenolics, Antioxidant, Sida cordifolia   Bull. Chem. Soc. Ethiop. 2020, 34(2), 427-434 DOI: https://dx.doi.org/10.4314/bcse.v34i2.18

Male Infertility: Evaluation and Treatment

Globally, 48.5 million couples are suffering from infertility. One of six couples in United Kingdom is categorized as infertile. In developing countries, infertility affects one of four couples. Male infertility constitutes about 40-50% of the incidence. A minimum of 30 million men worldwide are infertile. Mortality rate is higher in men with impaired semen quality than those who have normal semen quality. The initial evaluation of a male partner of an infertile couple should be done if there is a delay in the pregnancy in the female partner for one year or more from unprotected sexual intercourse. It can be done earlier if there is a predisposing factor for infertility. Identification of the underlying aetiology of infertility is the guide for treatment course which could be medical, surgical or through assisted reproductive technology. The aim of this review is to highligh the main courses of evaluation and treatment of male infertility.

Effect of Trihoney (A Mixture of Trigona, Mellifera and Tualang) on Male Reproductive Hormones and Insulin Resistance in Hypercholesterolaemic Rabbits

Introduction: Hypercholesterolaemia affects Sertoli and Leydig cells secretory functions, impairs steroidhormone biosynthesis, and disrupts the hypothalamic-pituitary-gonadal axis. The use of honey in previousstudies resulted in an improvement of male reproductive hormonal disturbances. This study aimed toinvestigate the protective effects of Trihoney on hypercholesterolemia-induced male reproductive hormonalchanges in male rabbits and compare its effects with atorvastatin. Materials and methods: Forty-eight maleNew Zealand white rabbits were assigned into 6 groups as follows; Control: commercial pellet; CH:commercial pellet with 0.6 g/kg/day Trihoney; HCD: 1% cholesterol diet; DH1: 1% cholesterol diet with 0.3g/kg/day Trihoney; DH2: 1% cholesterol diet with 0.6 g/kg/day Trihoney and DAt: 1% cholesterol diet with2mg/kg/day atorvastatin. After 12 weeks, the rabbits were sacrificed and blood samples were collected foranalysis of hormones and pro-inflammatory cytokines and calculation of HOMA-IR. The testes werehomogenized for intra-testicular testosterone measurement. Results: Serum testosterone reducedsignificantly in HCD (p<0.05) and DAt (p<0.05) groups. Likewise, intra-testicular testosterone reducedsignificantly in HCD (p<0.01) and DAt (p<0.01) groups. Serum FSH increased significantly in HCD (p<0.001)and DAt (p<0.01). Trihoney particularly at the dose of 0.6 g/kg/day improved serum and intra-testiculartestosterone (p<0.05) and FSH (p<0.05). Trihoney and atorvastatin improved serum pro-inflammatorycytokines. Trihoney and atorvastatin did not affect HOMA-IR. Conclusion: Trihoney attenuated thedetrimental effects of hypercholesterolaemia on male reproductive hormones which probably through alocal effect on testicular tissue and Trihoney anti-inflammatory effect independent of insulin resistance.Atorvastatin did not counteract the impact of hypercholesterolaemia on the reproductive hormones.

Population-based prevalence and associated risk factors of hypertension among adults in Benue State, Nigeria

Background

The increasing prevalence of hypertension in low- and middle-income countries is associated with increased morbidity and mortality.

Aim

To determine the prevalence of hypertension and associated risk factors in Benin state, Nigeria.

Materials and Methods

A population-based cross-sectional study was conducted among 1265 adults selected by multistage sampling technique. The World Health Organization (WHO) STEPwise approach was used to collect data. Data were analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 23.0 (IBM). We estimated prevalence and odds of hypertension at 5% level of significance.

Results

The prevalence of hypertension was 35.6%. The odds of hypertension was higher among age 30-39 (aOR: 2.0; 95% CI: 1.3-3.1) compared to age 18-29 years, males (aOR: 1.4; 95% CI: 1.1-2.0) compared to females, overweight (aOR: 2.3; 95%CI: 1.6-3.2), and obesity (aOR: 4.9; 95%CI: 3.2-7.7) compared to normal weight, and high cholesterol (aOR: 1.6; 95% CI: 1.1-2.3) compared to normal cholesterol.

Conclusion

The prevalence of hypertension was high among young adults in Benue State. The associated risk factors for hypertension were age, sex, overweight, obesity, and high total cholesterol.

Ottawa classification for symptomatic acetabular dysplasia assessment of interobserver and intraobserver reliability

Aims

The aim of the current study was to assess the reliability of the Ottawa classification for symptomatic acetabular dysplasia.

Methods

In all, 134 consecutive hips that underwent periacetabular osteotomy were categorized using a validated software (Hip2Norm) into four categories of normal, lateral/global, anterior, or posterior. A total of 74 cases were selected for reliability analysis, and these included 44 dysplastic and 30 normal hips. A group of six blinded fellowship-trained raters, provided with the classification system, looked at these radiographs at two separate timepoints to classify the hips using standard radiological measurements. Thereafter, a consensus meeting was held where a modified flow diagram was devised, before a third reading by four raters using a separate set of 74 radiographs took place.

Results

Intrarater results per surgeon between Time 1 and Time 2 showed substantial to almost perfect agreement among the raters (κappa = 0.416 to 0.873). With respect to inter-rater reliability, at Time 1 and Time 2 there was substantial agreement overall between all surgeons (Time 1 κappa = 0.619; Time 2 κappa = 0.623). Posterior and anterior rating categories had moderate and fair agreement at Time 1 (posterior κappa = 0.557; anterior κappa = 0.438) and Time 2 (posterior κappa = 0.506; anterior κappa = 0.250), respectively. At Time 3, overall reliability (κappa = 0.687) and posterior and anterior reliability (posterior κappa = 0.579; anterior κappa = 0.521) improved from Time 1 and Time 2.

Conclusion

The Ottawa classification system provides a reliable way to identify three categories of acetabular dysplasia that are well-aligned with surgical management. The term ‘borderline dysplasia’ should no longer be used.

Cite this article: Bone Joint Res. 2020;9(5):242–249.

128Non-invasive 3D mapping of earliest activation of premature ventricular complexes originating from intracardiac structures to guide catheter ablation

Funding Acknowledgements

Research funding from Catheter Precision, Inc.

Introduction

Catheter ablation for ventricular arrhythmias such as premature ventricular complexes and ventricular tachycardia is an established management approach.  Non-invasive mapping to localise the earliest activation (site of origin) on the myocardium may help guide ablation.  Established ECGi methods using the inverse solution to reconstruct epicardial electrograms are unable to accurately locate arrhythmias from the endocardium or from intracardiac structures.  VIVO™ (Catheter Precision) is a novel vectorcardiography based 3D mapping system that may be able to localise arrhythmias from any part of the ventricle.

Methods

We reviewed our initial experience utilising this mapping system to guide catheter ablation of ventricular ectopics from the inter-ventricular septum, coronary cusp or papillary muscle.  A patient-specific 3D heart and torso model was created using semi-automated segmentation of MRI or CT scan images.  A 3D topographic image of the patient’s torso was taken to accurately position surface ECG electrode locations onto the 3D heart-torso model.  An ECG of the PVC was imported from LabSystemPro (Bard) into VIVO™ for analysis prior to ablation.  The result was then compared with the site of earliest activation identified using invasive electro-anatomical (EA) mapping.

Results

VIVO™ was used in 12 cases where the PVC was localised to an intracardiac structure – six papillary muscle, four to the septum and two from the coronary cusp.  VIVO™ was able to accurately localise the earliest activation site when compared to the invasive map in 5/6 papillary muscle cases, 3/4 septal cases and 2/2 coronary cusp cases.  Ablation was acutely successful in all cases.  One additional patient had a PVC localised non-invasively to the postero-medial papillary muscle, however an invasive 3D electro-anatomical map or ablation was not performed.

In three cases we were able to merge the 3D geometry of the non-invasive map from VIVO™ into the Carto™ system to guide mapping and ablation in real time (see figure).

Conclusion

Our experience shows promising results for accurate non-invasive localisation of ventricular arrhythmias originating from intracardiac structures.  Non-invasive localisation is of particular value in cases where the arrhythmia is infrequent, difficult to induce or poorly tolerated haemodynamically.  The two cases where PVC localisation was inaccurate were performed using an older version of the software. With recent refinements, localisation is anticipated to be improved further.

We also present the first experience of combining the VIVO™ geometry with the real-time invasive EA map.  This has potential to significantly speed up mapping time and reduce the need for expensive multi-polar catheters by allowing the operator to see their target in real time 3D.  Further work is ongoing to validate the accuracy of VIVO™ prospectively and quantitatively.

Abstract Figure. VIVO map merged with Carto LV geometry

FRI0649-HPR HYDROXYCHLOROQUINE PRESCRIBING AND OPHTHALMOLOGY SCREENING WITHIN RHEUMATOLOGY DEPARTMENTS IN THE NORTH-WEST OF THE UNITED KINGDOM: A PROSPECTIVE REGIONAL AUDIT

Background:

Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of <1% up to five years and <2% up to ten years, but increases sharply to almost 20% after 20 years. Risk factors for retinopathy include doses >5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).

Objectives:

To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.

Methods:

Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.

Results:

473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.

20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR <60ml/min/m2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking <5mg/kg. In total, 36% of new starters were referred for a formal baseline Ophthalmology review.

In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for <5 years, and 33% of patients on HCQ for >5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.

Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.

Conclusion:

This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.

Acknowledgments:

Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.

Disclosure of Interests:

None declared

Infrared Spectroscopy and Density Functional Theory Investigations of the Reactivity of Titanium Atoms with Carbon Monoxide and Water Isolated in Solid Argon: Sequential Evolution from Triplet to Singlet State

Thermally evaporated titanium atoms reacted with carbon monoxide and water in solid argon at 12 K to produce the HTiOH-CO and HTiOH-(CO)₂ molecules, which were characterized using infrared spectroscopy on the basis of CO, Ti, and water concentration variations and of isotopic substitutions. The insertion product, HTiOH, resulting from the reaction of a titanium atom with a water molecule reacts with CO spontaneously to give the HTiOH-CO molecule, which in turn reacts with a second CO molecule to give HTiOH-(CO)₂ The density functional theory calculations were performed to elucidate the geometrical and electronic structures and support the spectral assignments. The topological analysis of the charge density within the experimentally observed molecules allowed us to rationalize the coordination sphere as well as the electron pairing on the titanium center.

Temperature-dependent transport properties of CVD-fabricated n-GaN nanorods/p-Si heterojunction devices

We report on the structural, electrical, and transport properties of high quality CVD-fabricated n-GaN nanorods (NRs)/p-Si heterojunction diodes.

169 Comparison of pregnancy outcomes in dairy heifers artificially inseminated with sexed semen deposited in the uterine horns versus the uterine body

The use of sexed semen (SS) for AI of cattle has resulted in lower pregnancy per timed AI (P/TAI) compared with conventional semen. This has been attributed to lower sperm dose and cell damage during the cell sorting-freezing process. Horn AI is a common practice in equines and canines to improve pregnancy rate when using low sperm doses. The objective was to compare P/TAI and pregnancy loss (PL) in dairy heifers inseminated with SS deposited in the uterine horn (UH) ipsilateral to the ovary containing the preovulatory follicle (POF) versus TAI in the uterine body (UB). This study was performed on two dairy farms in Georgia (A and B). On farm A, 74 Holstein heifers (12 months old) received a 5-day Cosynch + controlled internal drug release (CIDR) protocol including an intravaginal insert (Eazi-Breed CIDR, Zoetis Animal Health) containing 1.38g of progesterone for 5 days and a dose of gonadotrophin-releasing hormone (GnRH) intramuscularly (100µg, 2mL of Factrel, Zoetis Animal Health). At CIDR removal, heifers received a dose of prostaglandin F2α (PGF2α) intramuscularly (25mg, 5mL of Lutalyse, Zoetis Animal Health) and again 24h later; 72h after CIDR removal, heifers received 100µg of GnRH intramuscularly and TAI with frozen-thawed SS. On farm B, 237 Holstein×Jersey heifers (12 months old) received a modified 5-day Cosynch + CIDR. This protocol was similar to that on farm A but did not include GnRH at the time of CIDR insertion or a second dose of PGF2α 24h after CIDR removal. Immediately before TAI, heifers were examined using transrectal ultrasonography (TRUS) to determine on which ovary the POF was present. Each heifer was randomly assigned to TAI using SS in either the UH ipsilateral to the ovary containing the POF (n=150; farm A, n=32; farm B, n=118) or the UB regardless of where the POF was identified (n=161; farm A, n=42; farm B, n=119). Pregnancy was diagnosed 32 days after TAI using TRUS to determine P/TAI. Heifers diagnosed pregnant were re-examined using TRUS at 60 days of gestation to assess PL. Data were analysed using PROC LOGISTIC and the chi-square test of SAS (SAS Institute Inc.). Heifers that received SS in the UH had adequate P/TAI (50.6% (76/150); farm A: 50.0% (16/32); farm B: 50.8% (60/118)), which tended to be numerically greater (P=0.12) than that observed in heifers receiving SS in the UB (43.4% (70/161); farm A: 40.5% (17/42); farm B: 44.5% (53/119)). In addition, PL was not different between groups and was within normal ranges for dairy heifers (10.0 and 9.4% for UH and UB, respectively). In conclusion, TAI of dairy heifers with SS deposited in the UH ipsilateral to the ovary containing the POF resulted in adequate P/TAI, which was 7.2% greater than TAI in the UB. Horn AI with SS might become a valuable tool for optimising reproductive efficiency and genetic selection of dairy herds.

Effect of Heating on Compositional Characteristics and Oxidative Stability of Crude and Refined Rice Bran Oil

The compositional characteristics and oxidative stability of rice bran oil were determined by observing the formation of oxidative products and alteration in chemical composition of oils during microwave or oven heating. The values of oxidative indicators such as free acidity, peroxide, p-anisidine, total oxidation, thiobarbituric acid and color values, increased faster in refined oils compared to crude ones during heating. In gas chromatography analysis, the percentages of total saturated, monounsaturated and polyunsaturated fatty acids in the studied oils such as lab extracted crude rice bran oil, lab extracted and refined rice bran oil, crude rice bran oil from commercial mill and refined rice bran oil from commercial mill were: 23.07 to 23.56, 41.15 to 42.38 and 34.38 to 35.88, respectively. The heating caused the reduction of polyunsaturated fatty acids content with increasing saturated fatty acids content, and these changes were greater in refined rice bran oil indicating extensive lipid oxidation occurred in refined oil. The change in triacylglycerol species content as determined by High-performance liquid chromatography, was lower in crude oil; the higher stability of these species in crude oil could have contribution to reduce oxidation. During thermal treatment, the generation of hydroperoxides, their degradation and formation of secondary oxidative products evaluated by Fourier-transform infrared spectroscopy, were lower in crude oils. However, the rate of formation of oxidative products in lab prepared samples was lower compared to that in the samples collected from commercial mill. Under extreme thermal condition, the order of oxidative stability: lab extracted crude rice bran oil > crude rice bran oil from commercial mill>lab extracted and refined rice bran oil > refined rice bran oil from commercial mill. The present results will be useful to oil seed processing mills in refining of rice bran oil for economic feasibility and better marketability.