Low-dose ACTH test for evaluation of hypothalamus-pituitary-adrenal axis preoperatively and 3-month follow-up in non-functioning pituitary adenomas

BACKGROUND

Peri-operative glucocorticoids are routinely administered to patients undergoing trans-sphenoidal surgery for non-functional pituitary adenomas (NFPA) irrespective of hypothalamus-pituitary-adrenal (HPA) axis status.

PURPOSE

Evaluation of HPA axis before and 12 weeks after endoscopic trans-sphenoidal adenomectomy (E-TSA) utilizing low-dose (1 μg) ACTH stimulation test (LDACTH) to determine the need for glucocorticoid administration in patients with NFPA. We also determined the factors that can predict occurrence of hypocortisolism at 12 weeks after surgery.

METHODS

Sixty-three consecutive patients with NFPA requiring surgical excision were enrolled in this study. Glucocorticoids were administered to patients with demonstrable hypocortisolism [preoperative peak cortisol < 16 μg/dL during LDACTH test, postoperative day 3 (POD-3) 0800 hrs Cortisol < 8 μg/dL or stimulated cortisol (LDACTH) < 16 μg/dL at 12 weeks].

RESULTS

Hypocortisolism was present in 43 patients (68.2%) pre-operatively and persisted in 33 patients (52.4%) on POD-3. Thirty-three patients (52.4%) had hypocortisolism at 12 weeks after surgery. Eleven patients (17.4%) did not require glucocorticoids during the entire study period and 30 patients (47.6%) did not require glucocorticoids after 3 months. None of the patients developed adrenal crisis during the study. Hypocortisolism on the third post-operative day was the single significant predictor of hypocortisolism at 12 weeks after the surgery. There was a significant correlation between POD-3 0800 hrs cortisol ≥ 8μg/dL and stimulated cortisol (LDACTH) ≥16μg/dL at 12 weeks (r = 0.62, p < 0.0001). POD-3 0800 hrs cortisol ≥ 8 μg/dL had 73% sensitivity and 79% specificity in predicting eucortisolism at 12 weeks.

CONCLUSIONS

HPA function is preserved in significant proportion of NFPA patients undergoing E-TSA. Perioperative glucocorticoids should be given only in patients with demonstrable preoperative hypocortisolism on 1 μg ACTH test. Postoperative day 3 0800 hrs cortisol is a reasonable predictor of HPA axis status at 12 weeks after surgery.

AB1151 COMPLIANCE/CONCORDANCE WITH MYCOPHENOLATE MOFETIL IN PATIENTS WITH CONNECTIVE TISSUE DISORDERS IN COVENTRY

Background:

Connective tissue disorders like Systemic lupus erythematosus (SLE) are multi-organ systemic conditions characterised by disordered immune function. Mycophenolate Mofetil (MMF) is commonly used for treatment of SLE1and other connective tissue disorders like Sjogren’s syndrome, myositis and Scleroderma. Compliance with drugs remains a significant issue in management of these conditions and varying reports from across the world2,3continue to show significant lack of concordance resulting in increased disease activity and damage.

Objectives:

The aim of this study was to investigate the compliance/concordance specifically with MMF treatment among patients attending clinics at University Hospitals Coventry and Warwickshire NHS Trust (UHCW)with SLE and other connective tissue disorders.

Methods:

Ethical approval was obtained through research and development department within the Trust. This is a retrospective study collating non-identifiable hospital pharmacy data in patients who requested the prescription for MMF drug between January 2015 and December2018. Since MMF was required to be prescribed from the hospital (i.e. General practitioners within the region were unable to prescribe it), we have records for all prescriptions for these patients. We extracted information on sample size, frequency of prescription requested and length of follow up. Clinical data were obtained from paper and electronic notes of the patients. Data were analysed using the data analysis tool pack for linear regression, on Microsoft Excel package version 16.29.1.

Results:

We recruited 144 patients into this study, (74%) of these are females. Age range for this group was 2-89 years, median age was 45 (±11.2) years with a mean (±SD) age of 35.6 (±11.2) years and a disease duration of 8.8 (±6.2) years. 73.1% were White British, the remaining included 8.3% Indian, 5.5% Pakistani, 2.7% Black British, 2% Caucasian, 2.1% Chinese, and 6.3% other. Overall, we had 54 patients with SLE and 90 Patients with other connective tissue disorders. Good compliance (81-100%) with MMF therapy was seen in 49 patients, (34%). Poor compliance (0-20%) was seen in 13 patients, (9%). We found a significant correlation between lack of compliance and risk of flares (r= 0.25,p< 0.002), displayed in Figure 1. We also found a significant difference in compliance patters depending on diagnosis and also on age. SLE patients were 34% less compliant with MMF in comparison to other connective tissue disorders. Demographics suggested the degree of compliance increased with age. Patients between 40-69 years of age were 65% more compliant in comparison to the age 20-39 years (p< 0.002).

Conclusion:

SLE and connective tissue disorder patients within Coventry continue to have issues relating to compliance/concordance with MMF treatment and this appears to be worse in patients with SLE and in the 20-39 years of age. These patients also appear to be getting flares hence, this remains a major problem in the management of these conditions.

References:

[1]Gordon C, Amissah-Arthur MB, Gayed M et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatol 2017; doi: 10.1093/rheumatology/kex286.

[2]Alsowaida N, Alrasheed M, Mayet A, Alsuwaida A and Omair M A. Medication adherence, depression and disease activity among patients with systemic lupus erythematosus. Lupus 2018,27(2), 327–332. doi:10.1177/0961203317725585.

[3]Chehab G, G M Sauer, J G Richter, R Brinks, R Willers, R Fischer-Betz, B Winkler-Rohlfing, and M Schneider. Medical Adherence in Patients with Systemic Lupus Erythematosus in Germany: Predictors and Reasons for Non-Adherence – a Cross-Sectional Analysis of the LuLa-Cohort.” Lupus (September 2018),1652–60. doi:10.1177/0961203318785245.

Disclosure of Interests:

None declared

OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

Background:

A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.

Objectives:

This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.

Methods:

Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.

Results:

One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.

Conclusion:

Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.

References:

[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036

Disclosure of Interests:

None declared

Search for an Invisibly Decaying Z^{'} Boson at Belle II in e^{+}e^{-}→μ^{+}μ^{-}(e^{±}μ^{∓}) Plus Missing Energy Final States

Theories beyond the standard model often predict the existence of an additional neutral boson, the Z^{'}. Using data collected by the Belle II experiment during 2018 at the SuperKEKB collider, we perform the first searches for the invisible decay of a Z^{'} in the process e^{+}e^{-}→μ^{+}μ^{-}Z^{'} and of a lepton-flavor-violating Z^{'} in e^{+}e^{-}→e^{±}μ^{∓}Z^{'}. We do not find any excess of events and set 90% credibility level upper limits on the cross sections of these processes. We translate the former, in the framework of an L_{μ}-L_{τ} theory, into upper limits on the Z^{'} coupling constant at the level of 5×10^{-2}-1 for M_{Z^{'}}≤6  GeV/c^{2}.

An assessment on crystallization phenomena of Si in Al/a-Si thin films via thermal annealing and ion irradiation

In the present study, crystallization of amorphous-Si (a-Si) in Al/a-Si bilayer thin films under thermal annealing and ion irradiation has been investigated for future solar energy materials applications. In particular, the effect of thickness ratio (e.g. in Al : a-Si, the ratio of the Al and a-Si layer thickness) and temperature during irradiation on crystallization of the Si films has been explored for the first time. Two sets of samples with thickness ratio 1 : 1 (set-A: 50 nm Al/50 nm a-Si) and thickness ratio 1 : 3 (set-B: 50 nm Al/150 nm a-Si) have been prepared on thermally oxidized Si-substrates. In one experiment, thermal annealing of the as-prepared sample (of both the sets) has been done at different temperatures of 100 °C, 200 °C, 300 °C, 400 °C, and 500 °C. Significant crystallization was found to initiate at 200 °C with the help of thermal annealing, which increased further by increasing the temperature. In another experiment, ion irradiation on both sets of samples has been carried out at 100 °C and 200 °C using 100 MeV Ni7+ ions with fluences of 1 × 1012 ions per cm2, 5 × 1012 ions per cm2, 1 × 1013 ions per cm2, and 5 × 1013 ions per cm2. Significant crystallization of Si was observed at a remarkably low temperature of 100 °C under ion irradiation. The samples irradiated at 100 °C show better crystallization than the samples irradiated at 200 °C. The maximum crystallization of a-Si has been observed at a fluence of 1 × 1012 ions per cm2, which was found to decrease with increasing ion fluence at both temperatures (i.e. 100 °C & 200 °C). The crystallization of a-Si is found to be better for set-B samples as compared to set-A samples at all the fluences and irradiation temperatures. The present work is aimed at developing the understanding of the crystallization process, which may have significant advantages for designing crystalline layers at lower temperature using appropriate masks for irradiation at the desired location. The detailed mechanisms behind all the above observations are discussed in this paper.

Crystallization of Ge in ion-irradiated amorphous-Ge/Au thin films

Herein, the structural, optical, and electrical properties of Au-induced crystallization in amorphous germanium (a-Ge) thin films are presented for future solar energy material applications.

Lymphatic Filariasis Presenting as a Swelling over the Upper Arm: A Case Report

Filariasis continues to be one of the endemic problems worldwide with 40% of the cases in India. We report a case of lymphatic filariasis in a 32-year old female who presented with a non-tender swelling over left upper arm. Blood sample showed no eosinophilia while the FNAC was diagnostic of W. bancrofti. Patient responded well with oral diethylcarbamazine. High index of suspicion of filariasis is indicated when dealing with a swelling of unknown cause especially in filariasis endemic areas.

Expansile manubriotomy for ventral cervicothoracic junction disease

Cervicothoracic junction can be approached anteriorly, anterolaterally, posterolaterally, and posteriorly. The anterior approaches in this region best address the ventral vertebral body disease but may cause significant morbidity. Twelve patients with their disease process located ventral to the spinal cord in the cervicothoracic junction underwent expansile manubriotomy and corpectomy. Eleven patients underwent fusion. One patient underwent an oblique corpectomy. All patients had their disease process from T1 to T3 vertebral levels. After dissection, the manubrium was cut open in the midline until the sternal notch. Further manubrial cut was extended laterally to just below the second rib. A self-retaining retractor was placed and opened. This gave an additional exposure of 10 cm from the midline towards the right side. It also opened the thoracic inlet. The superior mediastinum was dissected. Brachiocephalic vessels were looped down and a plane was made between the carotid artery laterally, and the trachea and esophagus medially. The prevertebral fascia was reached and opened to access the vertebral body. The procedure could be carried out successfully in all the patients. A patient with uncontrolled diabetes mellitus and end-stage renal disease with pyogenic epidural abscess succumbed to her illness after 3 weeks. Expansile manubriotomy is technically feasible, less invasive, and least morbid of all the anterior approaches for accessing the anteriorly located disease process above the T4 vertebral level.

New chemical and radiochemical routes to [18F]Rho6G-DEG-F, a delocalized lipophilic cation for myocardial perfusion imaging with PET

New chemical and radiochemical syntheses are described for the preparation of [¹⁸F]Rho6G-DEG-F, an ¹⁸F-labeled analogue of the fluoresecent dye rhodamine 6G, which has shown promise as myocardidal perfusion imaging agent. Tosylated precursors of [¹⁸F]Rho6G-DEG-F amenable to ¹⁸F-labeling were obtained either through a two-step synthesis from rhodamine 6G lactone (33% yield), or in one step from rhodamine 575 (64% yield), then purified by preparative C₁₈ chromatography. Manual synthesis of [¹⁸F]Rho6G-DEG-F was achieved in a single radiochemical step from either the tosylate salt or the tosylate/formate double salt in DMSO under standard nucleophillic aliphatic ¹⁸F-fluorination conditions (K[¹⁸F]F/K₂CO₃/Kryptofix 2.2.2.). Incorporation of the [¹⁸F]F^- was found to be satisfactory (≥34% by TLC), despite the protic character of the precursor molecules. [¹⁸F]Rho6G-DEG-F was manually synthesized in final decay-corrected radiochemical yields of 11-26% (tosylate salt) and 9-21% (tosylate/formate double salt). The protocol was transferred to an automated synthesis unit, where the product was obtained in 3-9% radiochemical yield (n=3) decay corrected to start-of-synthesis, >99% radiochemical purity, and a molar activity of 122-267 GBq/μmol (3.3-7.2 Ci/μmol).

PCR-SSCP analysis of MDGI gene and its association with milk production traits in river buffalo (Bubalus bubalis)

In this study, we investigated the genetic variation within 3'UTR of Mammary-Derived Growth Inhibitor (MDGI) gene of buffalo using PCR-SSCP and sequencing; and also analyzed association of polymorphism with the milk production traits. The study revealed two conformational patterns, 'A' and 'B' among 234 Mehsana buffaloes maintained with their records in the field and at farm. The frequency of SSCP variant 'A' was found to be invariably high in the buffalo population under study. Further, association analysis of SSCP variants with various milk production and milk quality traits indicated no significant effect on any of the traits investigated. Sequencing of SSCP variant 'A' showed homozygous G/G and A/A and 'B' had heterozygous G/C and A/G at positions +124 and +140 respectively, in the 3'UTR of buffalo MDGI. The preliminary results showed the substantial variations in the distribution of SSCP variants' frequencies within Mehsana buffaloes, however these variants had non-significant association with milk yield, fat yield and fat percentage in Mehsana buffaloes.

Combined trabeculotomy-trabeculectomy with antimetabolite and releasable suture: outcome with primary congenital glaucoma in a north Indian population

OBJECTIVE

To determine the surgical outcomes of combined trabeculotomy- trabeculectomy with mitomycin-C and releasable suture in children with primary congenital glaucoma (PCG) in a North Indian population.

DESIGN

Retrospective, interventional, consecutive, non-comparative case series.

MATERIALS AND METHODS

The medical records of 137 eyes of 77 patients who underwent combined trabeculotomy- trabeculectomy with 0.2 mg/ml mitomycin C (MMC) either bilaterally (49 patients) or unilaterally (28 patients) between January 2004 and March 2012 were reviewed retrospectively. The main outcome measures were postoperative intraocular pressures, corneal clarity and diameter, duration of follow-up, success rate and complications.

RESULTS

The mean preoperative intraocular pressure reduced from 34 ± 7 mm Hg (range 15- 54 mm Hg) to 17 ± 7 mm Hg (range 5 - 32 mm Hg) with a mean reduction of 44 % (P less than 0.001). The mean follow-up period was 24.4 ± 10.3 months (range 6 - 48 months). Complete success defined as intraocular pressure less than 21 mm Hg without any medication and clinically stable glaucoma at last follow-up was achieved in 113 eyes (83 %) while a 'qualified success' of intraocular pressure less than 21 mm Hg with one medication was achieved in ten eyes (7 %). The Kaplan-Meier survival analysis revealed success rates (at 'n' months) of 90 % (6), 85 % (12), 82 % (24), 80 % (36) and 77 % (48). There were no significant intraoperative or postoperative complications.

CONCLUSION

Primary combined trabeculotomy-trabeculectomy with mitomycin-C and releasable suture offers a viable surgical option in Northern Indian infants with primary congenital glaucoma. The use of 0.2 mg/ml mitomycin C for 2 minutes improves the overall success while the releasable suture decreases the risk of postoperative complications especially associated with the use of antimetabolites.

Retracted: Evaluation of the incidence of microcracks caused by Mtwo and ProTaper NEXT rotary file systems versus the Self Adjusting File: a scanning electron microscopic study

The following article from International Endodontic Journal, 'Evaluation of the incidence of microcracks caused by Mtwo and ProTaper NEXT rotary file systems versus the Self Adjusting File: a scanning electron microscopic study' by S. G. Saha, N. Vijaywargiya, S. Dubey, D. Saxena & S. Kala, published online on 24 November 2015 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor in Chief, Prof. Paul Dummer, and John Wiley & Sons Ltd. The retraction has been agreed due to the consideration that the SEM methodology used by the authors has the potential to cause cracks and is thus is not suitable for the evaluation of micro-cracks in roots.

The association between bone mineral density and higher body mass index in men

BACKGROUND

A number of studies have identified that higher body mass index is associated with higher bone mineral density. However, a small number of previous studies have indicated an association between higher body mass index (> 35 kg/m(2)) and lower bone mineral density. No previous study has investigated the association between higher body mass index and bone mineral density in a large male population.

METHODS

Data of men aged over 50 years of age who attended for a dual energy X-ray absorptiometry scan at a UK teaching hospital were collated. The population was divided according to body mass index increments of 5 kg/m(2). The mean bone mineral density of both the lumbar spine and femoral neck was ascertained for each body mass index category. Multiple linear regression analysis, adjusted for age, was used to investigate for an association between body mass index and bone mineral density.

RESULTS

Data of 1263 men were collated. Increasing body mass index was associated with increasing bone mineral density of both the lumbar spine and femoral neck up to 35 kg/m(2); further increase in body mass index was not associated with an increasing bone mineral density.

CONCLUSIONS

The beneficial effect upon bone mineral density of increasing body mass index exists up to 35 kg/m(2); a body mass index higher than 35 kg/m(2) is not associated with further increase in bone mineral density.