Properties of ^{187}Ta Revealed through Isomeric Decay

Mass-separated ^{187}Ta_{114} in a high-spin isomeric state has been produced for the first time by multinucleon transfer reactions, employing an argon gas-stopping cell and laser ionization. Internal γ rays revealed a T_{1/2}=7.3±0.9  s isomer at 1778±1  keV, which decays through a rotational band with perturbations associated with the approach to a prolate-oblate shape transition. Model calculations show less influence from triaxiality compared to heavier elements in the same mass region. The isomer-decay reduced E2 hindrance factor f_{ν}=27±1 supports the interpretation that axial symmetry is approximately conserved.

Navigating the Diagnostics of COVID-19

Introduction/Objective

The recent outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Hubei province, China in December 2019 and has spread worldwide at an alarming rate. With millions of individuals infected and over two hundred thousand deaths, the necessity to develop fast and efficient diagnostic methods is of high importance. Diagnostic modalities rely on a combination of epidemiology, clinical presentation, laboratory examination, and appropriate imaging to diagnose and distinguish SARS-CoV-2 from other pulmonary infections. The purpose of this paper is to report on currently available diagnostic screening methods for patients infected with SARS-CoV-2 to guide frontline healthcare workers involved with COVID-19 patient care.

Methods

An electronic literature search was performed for peer-reviewed articles published from January 1, 2020, until April 26, 2020. Articles were then reviewed and included based on the applicability to the topic.

Results

The preferred diagnostic approach is reverse transcription of the virus’ RNA followed by PCR amplification (RT-PCR). This method recognizes the gene-specific primers to target various viral protein genes, such as the envelope protein gene or the nucleocapsid protein gene, which enables this test to be both sensitive and specific toward SARS-CoV-2. However, this method has been proven to be time-consuming taking hours-to-days for the results. In order to improve the speed and efficiency of diagnostics, newer rapid diagnostic serological tests are being developed for testing SARS-CoV-2, each with its own unique advantages and disadvantages. They could potentially be used as triage tests to rapidly identify patients who are very likely to have COVID-19 in combination with other accurate diagnostic methods.

Conclusion

Therefore, a combination of diagnostic testing used in a timely manner may be beneficial for the rapid and accurate detection of SARS-CoV-2. This was evident in cases where despite initial negative RT-PCR tests for various patients, who later demonstrate chest CT scans with various degrees of consolidation and ground-glass opacity. Thus establishing the need for radiology diagnosis to be complementary to RT-PCR for COVID-19 patients. Hopefully, the continuous development and use of rapid diagnostic tests and the implementation of public health measures will help control the spread of the disease.

Prognosis of non-operative management of non-metastatic colorectal cancer in octa- and nonagenarians

INTRODUCTION

The aim of the study was to establish the natural history of elderly patients with non-metastatic colorectal cancer who underwent non-operative management in comparison with those who underwent operative management.

MATERIALS AND METHODS

A retrospective analysis of patients aged 80 years and above diagnosed with colorectal cancer between 2007 and 2015 in a tertiary care hospital in the Southwest of England was done. Patients were divided into non-operatively managed and operatively managed groups. Clinical demographics, Charlson Comorbidity Index, location of the tumour and overall survival between the two groups were compared.

RESULTS

A total of 407 patients were studied; 132 were treated non-operatively and 275 operatively. The non-operative group included fewer right-sided colon cancers (28.7% vs 54.9%), but significantly more rectal cancers were managed non-operatively (43.9 vs 23.6%, respectively). The two and five year overall survival was 38.9% and 11.3% respectively in the non-operative group, significantly lower than patients in the operative group where the two and five year survival was 78.9% and 59.6% respectively (p = .0001). The median Charlson Comorbidity Index was 7.99 for the non-operative group and 7.49 in the operative group (p = 0.109). Patients treated non-operatively were deemed unfit without objective frailty assessment and only 43/132(32.6%) had formal anaesthetic assessment before being deemed unfit for surgery.

CONCLUSION

The survival of octa- and nonagenarians with non-metastatic colorectal cancer managed conservatively is significantly less than counterparts managed operatively. Our present strategy of deciding and denying treatment of the elderly patient with colorectal cancer is arbitrary, highlighting the need for robust geriatric and frailty assessment.

The Role of Endobronchial Ultrasound in Early-Stage Non-Small Cell Lung Cancer

Aim The aim of this study is to assess the impact of EBUS on the concordance of clinical and pathological NSCLC staging in our center. Methods Data was collected retrospectively from the hospital database regarding patients who underwent surgical resection for early stage NSCLC between 2012 and 2017. Results A total of 251 patients were included. The mean age was 67 (±9), 55% (n=137) were male and 83% (n=209) were current/former smokers. In group A (n=154, 61%) clinical nodal stage (cN) was established from a combination of CT, PET CT and mediastinoscopy. Group B underwent additional EBUS (n=97, 39%). cN and pathological nodal staging (pN) were concordant in 78% (n=120) in group A versus 62% (n=60) in group B (p=0.009). Conclusion This study demonstrated higher rates of nodal discordance in patients who underwent EBUS which contrasts existing data that demonstrates improved concordance with EBUS. We describe these findings and potential explanations further in this study.

A Comparative Study Between 20% Mannitol and 3% Hypertonic Saline for Brain Oedema Reduction during Elective Brain Tumour Surgery

Cerebral oedema is an important manifestation of brain tumour. The significant reduction of cerebral oedema can show rapid improvement of the patients. Hypertonic saline solution and mannitol both are commonly used for this action. It is now time to choose the better one. This was a prospective randomized comparative study designed to evaluate the efficacy of 3% hypertonic saline (NaCl) in reduction of brain oedema during brain tumour surgery and compare it with that of 20% Mannitol. The study was conducted in the department of Anaesthesiology, Combined Military Hospital, Dhaka, Bangladesh from July 2016 to December 2016. A total number of 47 patients for brain tumour surgery were selected. After screening 40 patients were finalized. Then the patients were divided into 2 equal groups 20 patients in each. Patients of Group A received 3% hypertonic saline and Group B 20% mannitol. Uniform anaesthetic technique applied for all patients, fixed surgeon/group of surgeons carried out the surgery. Heart rate and noninvasive blood pressure were monitored and kept with in ±20% baseline values different means. ETCO2 were kept in between 28-32mm of Hg by adjusting ventilator setting. Reduction of brain oedema was monitored by subjective assessment of surgeons using a 3 point scale of brain relaxation. The data were recorded in preformed data sheet. The results were tested by chi-square test to see their level of significance i.e. p value <0.05 was considered as significant. At the opening of dura, the number of brain conditions classified as soft, adequate and tight were statistically non-significant between groups. After 0.5 hour and 1.0 hour 10% patient's brain was tight in Group A whereas it was 35% and 40% in Group B respectively. Reduction of brain oedema or brain relaxation was significantly better in Group A compared to Group B (p<0.05). Urine output was higher with mannitol than hypertonic saline (p<0.05). Duration of ICU and hospital stay in both Group A and Group B were statistically similar (p>0.05). Compared to mannitol, hypertonic saline caused an increase in serum sodium concentration over time (p<0.05). From the available data, use of 20% mannitol and 3% hypertonic saline for brain oedema reduction, it is suggested that hypertonic saline significantly reduces the risk of tight brain and produce the brain more soft than mannitol during brain tumour surgery.

Beyond the speed of SOUND

Much anticipation awaits the results of the SOUND trial, (Gentilini and Veronesi in Breast 21:678-681, 2012) which may prove the futility of performing sentinel node biopsy (SNB) in low-risk breast cancer patients. However, do we really not know the answer to the questions that the SOUND trial poses already? Consideration must be taken of the very much overlooked trials predating the sentinel node era, which risk stratified patients according to the absence of palpable lymphadenopathy and without dependence upon ultrasound imaging (clinically negative axilla). This automatically selects a low-risk group of patients for axillary disease (low axillary burden) and the relevance of these critical trials is discussed.

Computer-guided contouring of craniofacial fibrous dysplasia involving the zygoma using a patient-specific surgical depth guide

The aim of this study was to introduce a new computer-guided technique for contouring and shaving of craniofacial fibrous dysplasia involving the zygoma. Computer-guided contouring was performed for five patients with unilateral craniofacial fibrous dysplasia involving the zygoma, using a patient-specific surgical depth guide. This patient-specific guide with depth holes was virtually designed for each patient based on mirroring of the unaffected side. The guide was printed using rapid prototyping. In the surgical theatre, the guide was seated in place and implant drills were inserted through the guide holes, creating depth holes according to the preoperative planning. Bone removal was then continued using surgical burs and/or bone chisels, connecting the guiding depth holes. Satisfaction with facial aesthetics was evaluated by the patients using a Likert scale, and by the surgeons using the Whitaker rating scale. All patients were satisfied with the postoperative facial aesthetics. Four patients were rated category I on the Whitaker rating scale, and one patient as category II. In conclusion, this patient-specific surgical depth guide appears to offer a solution for the unpredictability of conventional bone removal in unilateral craniofacial fibrous dysplasia, especially in three-dimensional multiplanar areas such as the zygoma. Further investigations are required.

Multimodiale Therapie von Hirnmetastasen

Das Langzeitüberleben hat sich für Patienten mit metastasiertem Melanom durch die Etablierung der zielgerichteten Therapien sowie Immuntherapien mit 5-Jahres-Überlebensraten von ca. 50 % deutlich verbessert. Hirnmetastasen stellen jedoch weiterhin eine therapeutische Herausforderung dar. In der Vergangenheit lag das mediane Überleben für Patienten mit neu diagnostizierten Hirnmetastasen bei 2 – 6 Monaten 1. Retrospektive Analysen sprechen für einen Überlebensbenefit unter multimodaler Therapie mit einer 5-Jahres-Überlebensrate von über 20 % 1.

Wir berichten über einen 50-jährigen Patienten mit multiplen symptomatischen Hirnmetastasen bei Erstdiagnose. Nach Exstirpation einer symptomatischen Metastase wurde bei BRAF-V600E-Mutation eine Systemtherapie mit dem BRAF-Inhibitor Dabrafenib in Kombination mit dem MEK-Inhibitor Trametinib eingeleitet. Hierunter zeigte sich ein rascher deutlicher Regress der zerebralen und extrazerebralen Metastasen. Nach 8 Wochen wurde die Systemtherapie auf eine Immuntherapie mit Nivolumab plus Ipilimumab umgesetzt. Kurz nach Therapieeinleitung trat ein epileptischer Anfall auf und die Hirnmetastasen zeigten sich wieder progredient. Zwei symptomatische Hirnmetastasen wurden reseziert, eine Ganzhirnradiatio mit Hippocampusschonung wurde eingeleitet und die Immuntherapie fortgesetzt. Aktuell erfolgt eine zielgerichtete Therapie mit Encorafenib und Binimetinib. 17 Monate nach Erstdiagnose befindet sich der Patient in gutem Allgemeinzustand ohne neurologische Defizite. Dieser Fallbericht bestätigt den retrospektiv beobachteten Überlebensbenefit für Patienten mit Hirnmetastasen unter multimodaler Therapie.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI)

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Non-operative treatment of hepatic trauma: A changing paradigm. A Six year review of liver trauma patient in a single institute

OBJECTIVE

To review the managing strategies of adult patients with liver trauma in a tertiary care hospital during a six years period.

METHODS

The medical records of all patients admitted with a diagnosis of liver trauma from January 2012 to December 2017 in the Aga Khan University Hospital were retrospectively reviewed. The details of demographic, clinical, and outcome variables including morbidity and mortality rates were noted.

RESULTS

A total of 182 patients were admitted at AKUH with liver trauma between January 2012 and December 2017. Twenty-two patients were excluded according to our study criteria. Of 160 patients, 139 were male and 21 were female. One hundred twenty seven (79.4%) patients were less than 45 years of age. Most patients (89.4%) had no comorbids and 48 (44%) arrived at the hospital within 4 hours of injury. Majority, 101 (63.1%) of the patients had blunt trauma and 142 (89%) met with road accidents. A total of 109 (68.1%) patients were stable at arrival and 77 (48.1%) had abdominal signs present on examination. FAST ultrasound was done on 75 (46.9%) patients and CT scan abdomen on 145 (90.6 %) patients. Liver injuries were associated with other abdominal or systemic injuries in 139 (86.6%) patients. Low grade (Grade I & II) liver injuries were found in only 41 (25.6%) patients, with the remainder being high grade (Grade III- 41 patients, Grade IV-42 patients and Grade V-2 patients). Conservative treatment was offered to 68 (41.9%) patients, of which 57 (85.1%) remained stable and were eventually discharged. Of these, 2 expired and 3 required intervention. There were a total of 92 (57.2%) interventions done of which 60 patients were cured, 14 expired and 18 readmitted. Interventions included perihepatic packing (n=18), hepatorraphy (n=3), angioembolization (n=12) and hepatectomy (n=1). There were 16(10%) deaths in which liver haemorrhage and sepsis were the most common cause of mortality. Mean hospital stay in our study population was 8.9 days. Second admission was observed in 28 (17.5%) patients (n=28). Morbidity rate in our patients was 17.5% (n=28). The most common complication noted was that of a liver abscess, developing in 2 (1.3%) patients. Other significant problems were intra-abdominal collections (n=2) and biliary complications (n=3). Unstable haemodynamic status at arrival and prolonged stay in high dependency unit were noted to be independent risk factors for mortality.

CONCLUSIONS

Conservative treatment was found successful in most of our patients with an intervention rate of 57.5% and overall mortality rate of 10%. So, NOMLI can be safely offered to liver trauma patients, even in high grade injuries.

P806 Cavitation phenomenon in mechanical valves: not only microbubbles

Introduction

It is well described the presence of microbubbles (MBs) which are high-velocity, small, bright echoes presences that occur with the closing/opening of the mechanical double disk valve, more frequently in mitral position but less frequent growth of the cavitation bubbles are described.

We considered the echo studies of patients with growth of cavitation bubbles and we evaluate the possible impact of the hemodynamic parameters of their formation and then misdiagnosis with endocarditis.

Methods

We analyzed retrospectively the echocardiographic studies of 49 patients with growth of cavitation bubbles and we went back to all studies until the date of surgery if available, to see in how many of those echos, this phenomenon was present.

Patient"s blood pressure (BP) and heart rate (HR) measurement were available for each echo study. For the present analysis the last echo study with or without growth of cavitation bubbles were considered. The last echo study without growth of cavitation bubbles was considered as control group.

Results

Fourty nine patients (M26/F23) with mean age of 46.5 ± 13.6 years were identify as having growth of the cavitation bubbles and a total of 325 echo studies were reviewed. All patients had mitral valve replacement but 4, that had only aortic mechanical valve. 43% had mitral-aortic valve replacement and 5 had 3 or 4 valves replaced. The follow-up period was of 3697 ± 2481 days, 52%±31% of the echo studies reviewed had growth of the cavitation bubbles.

At the time of the study systolic BP was 124 ± 12.5 vs 121.1 ± 16.4 mmHg, p = 0.1 (echo study with versus without growth cavitation respectively), diastolic 72.7 ± 10.1 vs 69.4 ± 14.9 mmHg, p= 0.2; HR 81.3 ± 19.4 vs 73.7 ± 14.1 bpm, p = 0.05. No statistical differences in trans mitral gradients were found between the two groups (peak 11.8 ± 3.9 vs 11.7 ± 4.3 mmHg, p = 0.7; mean 4.6 ± 1.9 vs 4.2 ± 1 mmHg.6p = 0.1). 33 TEE were performed and in 50% of cases because of suspecion of endocarditis. Only 2 TEE were positive for endocarditis and one positive for pannus and high gradients across the valve in addition to cavitation.

Conclusion

Cavitation phenomenon in mechanical valves, in particular mitral bi-leaflet valve is well known but growth of cavitation bubbles is seldom described. We found that this fenomenon is frequently present although not constant, is related with increased HR and can be responsible of misdiagnosis with endocarditis.

Abstract P806 Figure.

The neutron electric dipole moment experiment at the Spallation Neutron Source

Novel experimental techniques are required to make the next big leap in neutron electric dipole moment experimental sensitivity, both in terms of statistics and systematic error control. The nEDM experiment at the Spallation Neutron Source (nEDM@SNS) will implement the scheme of Golub & Lamoreaux [Phys. Rep., 237, 1 (1994)]. The unique properties of combining polarized ultracold neutrons, polarized 3He, and superfluid 4He will be exploited to provide a sensitivity to ∼ 10−28 e · cm. Our cryogenic apparatus will deploy two small (3 L) measurement cells with a high density of ultracold neutrons produced and spin analyzed in situ. The electric field strength, precession time, magnetic shielding, and detected UCN number will all be enhanced compared to previous room temperature Ramsey measurements. Our 3He co-magnetometer offers unique control of systematic effects, in particular the Bloch-Siegert induced false EDM. Furthermore, there will be two distinct measurement modes: free precession and dressed spin. This will provide an important self-check of our results. Following five years of “critical component demonstration,” our collaboration transitioned to a “large scale integration” phase in 2018. An overview of our measurement techniques, experimental design, and brief updates are described in these proceedings.

P1217Zirconium-89 labelled probe for molecular imaging of inflammation in experimental atherosclerosis

Background

Early detection of inflamed atherosclerotic lesions by molecular imaging might improve risk assessment beyond that of vascular stenosis and plaque morphology imaging, and improve the clinical management of high-risk patients.

Purpose

To target the key features of unstable atherosclerotic lesions, we studied the feasibility of our radiotracer, based on modified human serum albumin (HSA), to identify inflamed atherosclerotic lesions by in vivo molecular imaging.

Methods

We applied a maleylated HSA (Mal-HSA) probe, recognised by scavenger receptors on macrophages, in an experimental in vivo imaging study of atherosclerosis. Mal-HSA was coupled with a positron-emittingmetal ion, Zirconium-89 (89Zr). The targeting potential of this probe was evaluated and compared with unspecific 89Zr-HSA and 18F-FDG in a mouse model of atherosclerosis (Apoe−/−, n=22) and compared with wild-type (WT) mice (C57BL/6, n=21) as controls. Radiotracer accumulation in the aortic arch was analysed in vivo by the fusion of positron emission tomography–magnetic resonance imaging (PET-MRI), radiotracer bio-distribution was measured ex vivo by gamma counter, and plaque uptake was evaluated by phosphor imaging (PI) autoradiography (ARG).

Results

PET-MRI, gamma counter measurements, and PI-ARG showed the accumulation of 89Zr-Mal-HSA in the atherosclerotic lesions of Apoe−/− mice. The maximum standardised uptake value (SUVmax) for 89Zr-Mal-HSA at 16 and 20 weeks were 26% and 20% higher (P<0.05) in Apoe−/− mice than control WT mice, whereas no difference in SUVmax was found for 18F-FDG in the same animals. 89Zr-Mal-HSA uptake in the aorta as evaluated by gamma counter 48 h post-injection was 32% higher (P<0.01) for Apoe−/− mice compared to WT mice, and the aorta-to-blood ratio was 10-fold higher (P<0.001) for 89Zr-Mal-HSA compared with unspecific 89Zr-HSA. HSA probes were mainly distributed to the liver, spleen, kidneys, bone and lymph nodes. The PI-ARG results corroborated the PET and gamma counter measurements, showing higher accumulation of 89Zr-Mal-HSA in the aortas of Apoe−/− mice compared to WT mice; 9.4±1.4 vs 0.8±0.3% (P<0.001).

Conclusions

The modified HSA-based radiotracer showed in vivo targeting of inflamed atherosclerotic lesions of mouse aorta, which could also be verified ex vivo. 89Zr-Mal-HSA seems to be a promising diagnostic tool for the identification of vascular inflammation. Further methodological studies are needed to verify its applicability for detecting rupture-prone plaques.

Acknowledgement/Funding

Swedish Research Council (22036); the Swedish HLF (20150423, 20170669); ALF (20150517, 447561, 726481); Söderberg Foundations, VINNOVA and KI

P6572Sinus arrest post-cardioversion

Introduction

Sinus arrest remains a recognized but likely underreported complication of cardioversion, with incidence ranging widely in the literature, from virtually 0% to 1.5%. After a case of elective cardioversion resulting in the need for ECMO support, we investigated possible risk factors that could help predict adverse outcomes after cardioversion.

Hypothesis

Cardioversion, while generally benign, is not without risks, and further study may help elucidate predictors of morbidity and mortality.

Methods

We retrospectively reviewed data of all patients who underwent cardioversion at three hospitals within the Lifespan health system, Rhode Island Hospital, Newport Hospital, and the Miriam Hospital, between 2000 and 2015. 23 patients who experienced sinus arrest after cardioversion, and characteristics of these patients were compared with those of 3:1 age-and-gender matched controls using binomial logistic regression analysis on Stata.

Results

Of 12,156 patients who underwent cardioversion, 23 patients (57% male, mean age 78±14), or 0.18%, experienced immediate post-cardioversion sinus arrest, defined as absence of sinus activity for greater than five seconds. Compared with 3:1 age-and-gender-matched controls who underwent cardioversion without incident, binomial logistic regression revealed that paroxysmal atrial fibrillation (OR 11.8; 95% CI 1.85–75.72; p=0.009), beta-blocker use (OR 58.0; 95% CI 2.4–1404.48; p=0.013), Amiodarone use (OR 19.9; 95% CI 2.0–198.32; p=0.011), and elevated ventricular rate (CV 0.028; 95% CI 0.0031–0.053; p=0.027) were statistically significant predictors of sinus arrest after cardioversion. Calcium-channel blocker use, Digoxin use, age, gender, PR interval, QRS duration, and corrected QT interval were not significant associations.

Conclusions

Sparse data exists regarding characteristics predisposing patients to adverse outcomes following cardioversion, and further risk stratification is warranted, given the potential for significant morbidity and mortality. Our findings raise questions that demand elucidation, such as whether beta-blockers or Amiodarone should be held prior to cardioversion.

Vasculitis allergica – ein nicht-IgE-vermitteltes Hypersensitivitätssyndrom

Die Diagnose „Vasculitis allergica“ suggeriert eine klassisch allergische IgE-vermittelte Genese. Dies ist jedoch nicht der Fall, vielmehr handelt es sich um einen hochkomplex ablaufenden Mechanismus, der häufig das eigentlich auslösende Antigen vor der Detektion bewahrt.

Die aktuelle Nomenklatur für dieses dermatologische Erkrankungsbild lautet kutane IgM oder IgG Immunkomplex-Vaskulitis, es handelt sich um eine leukozytoklastische Vaskulitis der postkapillären Venolen 3. Diese neue Einordnung legt die mit dem ursprünglichen Namen einhergehende Assoziation mit einer typisch IgE-vermittelten allergischen Erkrankung ab.

Vaskulitiden werden immunologisch betrachtet den Immunkomplex-Erkrankungen, der sogenannten Typ III Reaktion nach Coombs und Gell, zugeordnet 14, 15, 16. Sie werden als entsprechend dem dahinter liegenden immunologischen Prozess als „non-IgE-mediated allergic hypersensitivity Syndrom“ eingestuft 14, 15, 16. Viele Vaskulitiden machen sich klinisch zuerst an der Haut u. a. durch akut auftretende, rasch progrediente Ulzerationen bemerkbar, häufig assoziiert mit starker Schmerzhaftigkeit. Sie sind damit in der Ursachenabklärung eines Ulcus cruris bedeutsam, rangieren hier aber unter den seltenen Diagnosen.

Der lange bestehende Begriff einer „leukozytoklastischen Vaskulitis“ für diese Erkrankung steht entsprechend nicht länger für ein einzelnes Erkrankungsbild, sondern vielmehr für ein histologisches Muster einer Gruppe von Vaskulitiden, den sogenannten Immunkomplexvaskulitiden. 3 Hierbei handelt es sich von Gefäßkaliber überwiegend um „small vessel“ Vaskulitiden, diese können als „single organ vasculitis“ (SOV) mit alleiniger Manifestation an der Haut oder auch als kutanes Teilsymptom einer anderen „multi organ vasculitis“ (MOV) zum Beispiel im Rahmen eines systemischen Lupus erythematodes auftreten 1. Die kutane IgM oder IgG Immunkomplex-Vaskulitis zeigt den für Vaskulitiden klassisch plötzlich auftretenden, rasch progredienten Verlauf und ist klinisch durch eine typische Primäreffloreszenz, die palpable Purpura, mit hoher Inflammation charakterisiert. 2 Im Therapiekonzept steht an erster Stelle das auslösende Agens zu identifizieren und zu eliminieren 2, 42, 44. In der Regel zeigt dieser Typ von Vaskulitis eine überwiegend residuenfreie Abheilung mit niedrigem Rezidivrisiko unter der Voraussetzung, dass das auslösende Agens identifiziert und beseitigt ist 2, 41, 42, 44.

Segment IV hepatic artery in potential donors for living related liver transplantation: Evaluation with multi-detector CT

OBJECTIVE

To assess segment IV hepatic arterial anatomy and its variation on multi-detector computed tomography in potential liver donors.

METHODS

The retrospective study was conducted at Shifa International Hospital, Islamabad and comprised data of potential liver transplant donors related to the period between January 2012 and June 2017. Computed tomography scans were performed using multi-detector scanners. Images were transferred to work station for postprocessing and were analysed regarding the origination and variation of the arteries by two independent experienced radiologists.

RESULTS

Of the 455 patients whose records were evaluated, 299(65.7%) were males and 156(34.3%) were females. Six types of segment IV artery were defined based on their points of origin: left hepatic artery 285(62.6%), right hepatic artery 111(24.4 %), proper hepatic artery 9(1.8 %), common hepatic artery 29(6.4%), gastro duodenal artery 3(0.7 %), and dual 18(4.1 %).313 of total cases (68.8%) had normal anatomy with no variation. Those with aberrant/variant anatomy constituted 142(31.2%) of the total.

CONCLUSIONS

Multi-detector computed tomography angiography was found to be a fast, reliable and non-invasive technique that could evaluate normal as well as anatomical variants of segment IV arteries.

Circulating miRNAs as non-invasive biomarkers to predict aggressive prostate cancer after radical prostatectomy

BACKGROUND

Prostate cancer is an extremely heterogeneous disease. Despite being clinically similar, some tumours are more likely to recur after surgery compared to others. Distinguishing those that need adjuvant or salvage radiotherapy will improve patient outcomes. The goal of this study was to identify circulating microRNA that could independently predict prostate cancer patient risk stratification after radical prostatectomy.

METHODS

Seventy-eight prostate cancer patients were recruited at the Odette Cancer Centre in Sunnybrook Health Sciences Centre. All patients had previously undergone radical prostatectomy. Blood samples were collected simultaneously for PSA testing and miRNA analysis using NanoString nCounter technology. Of the 78 samples, 75 had acceptable miRNA quantity and quality. Patients were stratified into high- and low-risk categories based on Gleason score, pathological T stage, surgical margin status, and diagnostic PSA: patients with Gleason ≥ 8; pT3a and positive margin; pT3b and any margin; or diagnostic PSA > 20 µg/mL were classified as high-risk (n = 44) and all other patients were classified as low-risk (n = 31).

RESULTS

Using our patient dataset, we identified a four-miRNA signature (miR-17, miR-20a, miR-20b, miR-106a) that can distinguish high- and low-risk patients, in addition to their pathological tumour stage. High expression of these miRNAs is associated with shorter time to biochemical recurrence in the TCGA dataset. These miRNAs confer an aggressive phenotype upon overexpression in vitro.

CONCLUSIONS

This proof-of-principle report highlights the potential of circulating miRNAs to independently predict risk stratification of prostate cancer patients after radical prostatectomy.

Measurement of selected androgens using liquid chromatography-tandem mass spectrometry in reproductive-age women with Type 1 diabetes

STUDY QUESTION

What information does androgen profiling using liquid chromatography tandem mass spectrometry (LC-MS/MS) provide in reproductive-age women with Type 1 diabetes (T1D)?

SUMMARY ANSWER

In T1D women, androstenedione proved most useful of the measured androgens in differentiating subgroups based on clinical phenotypes of hyperandrogenism (HA) and polycystic ovary syndrome (PCOS).

WHAT IS KNOWN ALREADY

The prevalence of HA and PCOS are increased in women with T1D. These observations are based on measurement of serum androgens using immunoassays, to-date no studies using LC-MS/MS have been reported in reproductive-age women with T1D.

STUDY DESIGN, SIZE, DURATION

This was a cross-sectional study with recruitment of three groups of reproductive-age women: women with T1D (n = 87), non-diabetic women with (N = 97) and without PCOS (N = 101).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using LC-MS/MS, we aimed to characterize androgen profiles and PCOS status in women with T1D, and interpret findings in relation to cohorts of non-diabetic women with and without PCOS.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to non-diabetic women, dehydroepiandrosterone/dehydroepiandrosterone sulphate (DHEA/DHEAS) ratio was lower (P < 0.05) in women with T1D. Testosterone levels were greater in T1D women with clinical HA and anovulation compared to those without clinical HA and with regular cycles, while androstenedione levels were greater in T1D women with HA and anovulation compared to those with HA and regular cycles and also those without HA and with regular cycles (P < 0.05 for all). Compared to T1D women without PCOS, the 18% of T1D women who had PCOS were younger with lower BMI, an older age of menarche, and were more likely to have a positive family history of PCOS (P < 0.05 for all). Androgen levels did not differ between women with T1D and PCOS compared to BMI-matched non-diabetic women with PCOS, but androstenedione levels were greater in T1D women with PCOS compared to obese women with PCOS (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Relatively small subgroups of patients were studied, reducing the power to detect small differences. Free testosterone levels were not measured using equilibrium dialysis, and were not calculated - commonly used formulae have not been validated in T1D.

WIDER IMPLICATIONS OF THE FINDINGS

Androstenedione is a sensitive biochemical marker of clinical hyperandrogenism and PCOS in T1D. T1D women with PCOS are leaner than those without PCOS but are more likely to have a family history of PCOS. Women with T1D and PCOS have a similar biochemical phenotype to lean non-diabetic women with PCOS but differ from obese women with PCOS. The mechanisms underlying PCOS in T1D and its clinical significance require further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

The study was part-funded by the Meath Foundation. The authors have no competing interests.

Distraction subtalar arthrodesis for calcaneal malunion

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Patients and Methods

We prospectively studied 28 calcaneal malunion patients (the study group) who were managed by subtalar distraction arthrodesis using local calcaneal bone graft. The study group included 16 male and 12 female patients. The median age was 37.5 years (interquartile range (IQR) 29 to 43). The outcome of the study group was compared with a control group of ten patients previously managed by subtalar distraction arthrodesis using iliac bone graft. The control group included six male and four female patients. The median age was 41.5 years (IQR 36 to 44).

Results

The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly in the study and the control groups (p < 0.001). Fusion was achieved in 27 patients in the study group at a median time of 13 weeks (IQR 12 to 14), while all the patients in the control group achieved fusion at a mean time of 13.2 weeks (11 to 15). The mean talocalcaneal height and talar declination angle improved significantly in both the study and the control groups (p < 0.001). There was no significant difference between both groups concerning the preoperative or the postoperative clinical and radiological measurements. Donor site morbidity was reported in four out of ten patients in the control group.

Conclusion

Local calcaneal bone graft can successfully be used to achieve subtalar distraction arthrodesis with appropriate correction of alignment and calcaneal malunion. We recommend using local instead of iliac bone graft as it gave comparable results and avoids the possibility of donor site morbidity. Cite this article: Bone Joint J 2019;101-B:596–602.