FOREARM AND BICEPS CIRCUMFERENTIAL VARIATIONS IN SKIN TISSUE DIELECTRIC CONSTANT AND FIRMNESS

Tissue dielectric constant (TDC) and skin firmness assessed via indentation force (FORCE) help quantify lymphedema and track changes. We sought to determine potential differences in these parameters dependent on arm circumferential locations. Thus, TDC and FORCE were measured in 40 healthy women at medial, anterior and lateral locations on forearm and biceps. In five other women with unilateral lymphedema (68.6±7.6 years), TDC was measured at corresponding circumferential forearm positions. Measurements were done in triplicate using compact noninvasive devices. Results for healthy women (23.8±2.7 years) showed forearm medial TDC values (26.7±2.2) were less than anterior (28.0±2.4) or lateral (28.0±2.5) positions (p<0.001). Lymphedema patients had elevated values but similar medial-anterior-lateral patterns (33.7±8.0, 39.8±10.2 and 42.9±10.0). Biceps medial TDC values (24.1±2.2) were also less than either anterior (27.0±2.1) or lateral (28.2±3.3). Contrastingly, medial FORCE values at forearm and biceps were less than at anterior and lateral locations (p<0.001) and increased in the order of medial-anterior-lateral on forearm (p<0.001). The present findings provide reference values for both TDC and FORCE of commonly measured arm sites with specificity as to circumferential variations. This observed variation indicates the need for care in locating measurement positions for tracking patients with lymphedema.

Vertical Tropia Following Horizontal Transposition Surgery

Aim

The aim of this study was to determine the prevalence of vertical tropia following horizontal transposition of both vertical rectus muscles (HToVR) in patients with Duane syndrome or sixth nerve palsy.

Methods

This retrospective study included patients with Duane syndrome or sixth nerve palsy who had undergone HToVR muscles. Data collected included: age, gender, diagnosis, laterality, pre-operative angle of deviation, type of surgery and post-operative angle of deviation at one week, three months and six months. Information on the use of botulinum toxin (BT) ipsilateral medial rectus (MR), additional surgery was performed, and the presence of preoperative and postoperative binocular function and any vertical deviation was collected.

Results

There were 11 patients, eight patients with a diagnosis of Duane syndrome and three patients with a diagnosis of sixth nerve palsy. The mean age of the patients was 13 ± 14.79 years (range 5-55 years), four were female. The prevalence of post-operative vertical tropia was 54%. The mean vertical deviation for distance, was 7.6^ ± 2.94 (SD) (range 3^-9^). Stereoacuity was present preoperatively in 5 patients and 8 postoperatively. No patient developed diplopia or received further surgery for the vertical tropia. Of the six patients who had intraoperative BT at the time of the HToVR, four developed a vertical deviation.

Conclusion

The prevalence of vertical deviation following HToVR muscles was 54% in our series. None of the patients with an induced postoperative vertical deviation reported diplopia or required further surgery for it.

Introduction of an assessment toolkit associated with increased rate of DLB diagnosis

Background

Dementia with Lewy bodies (DLB) and dementia in Parkinson’s disease (PDD) are recognised to be under-recognised in clinical practice in the UK, with only one third to a half of expected cases diagnosed. We aimed to assess whether clinical diagnostic rates could be increased by the introduction of a structured assessment toolkit for clinicians.

Methods

We established baseline diagnostic rates for DLB and PDD in four memory clinics and three movement disorder/Parkinson’s disease (PD) clinics in two separate geographical regions in the UK. An assessment toolkit specifically developed to assist with the recognition and diagnosis of DLB and PDD was then introduced to the same clinical teams and diagnostic rates for DLB and PDD were reassessed.

For assessing DLB diagnosis, a total of 3820 case notes were reviewed before the introduction of the toolkit, and 2061 case notes reviewed after its introduction. For PDD diagnosis, a total of 1797 case notes were reviewed before the introduction of the toolkit and 3405 case notes after it. Mean values and proportions were analysed using Student’s t test for independent samples and χ² test, respectively.

Results

DLB was diagnosed in 4.6% of dementia cases prior to the introduction of the toolkit, and 6.2% of dementia cases afterwards, an absolute rise of 1.6%, equal to a 35% increase in the number of DLB cases diagnosed when using the toolkit (χ² = 4.2, P = 0.041).

The number of PD patients diagnosed with PDD was not found overall to be significantly different when using the toolkit: 9.6% of PD cases before and 8.2% of cases after its introduction (χ² = 1.8, P = 0.18), though the ages of PD patients assessed after the toolkit’s introduction were lower (73.9 years vs 80.0 years, t = 19.2, p < 0.001).

Conclusion

Introduction of the assessment toolkit was associated with a significant increase in the rate of DLB diagnosis, suggesting that a structured means of assessing symptoms and clinical features associated with DLB can assist clinicians in recognising cases. The assessment toolkit did not alter the overall rate of PDD diagnosis, suggesting that alternate means may be required to improve the rate of diagnosis of dementia in Parkinson’s disease.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome

BACKGROUND

Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome.

PATIENTS AND METHODS

Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method.

RESULTS

In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission.

CONCLUSION

Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

[Quality of care criteria in the treatment of penile cancer]

BACKGROUND

Penile cancer is a rare malignancy and the wide range of quality of care associated with it often results in inferior oncologic and functional treatment outcomes.

OBJECTIVES

Assessment of the current healthcare situation in clinical routine and identification of the relevant key features and reference values for quality of care.

MATERIALS AND METHODS

Search for relevant peer-reviewed articles and published congress abstracts in Medline, Embase and other databases as well as Google web search engine.

RESULTS

Key quality features of penile cancer management include organ-sparing surgery of the primary tumor, invasive inguinal lymph node staging and systemic treatment. Adherence to treatment guidelines is currently low. Centralization of care has already led to a considerable improvement in the quality of care in some areas and increasing conformity with the guidelines' recommendations.

CONCLUSION

Centralization of care and networks based on this can significantly improve patient outcomes. Thus, reference values for core parameters of quality cancer care can be generated and validated. Moreover, organ-sparing surgery, invasive lymph node staging and systemic therapy should be increasingly utilized. As a reference value, 90% adherence to the guidelines for these three features is recommended. However, before centralization of care can be introduced, aspects relevant to practical implementation must be addressed, such as the reimbursement of travel costs for those affected, infrastructure costs and instruments to measure quality of life and patient satisfaction after centralization.

Concordance between a neuroradiologist, a consultant radiologist and trained reporting radiographers interpreting MRI head examinations: An empirical study

INTRODUCTION

This study assessed agreement between MRI reporting radiographers and a consultant radiologist compared with an index neuroradiologist when reporting MRI head (brain/internal auditory meati [IAMs]) examinations. The effect on patient management of any discordant reports was also examined.

METHODS

Two trained MRI reporting radiographers (RRs), a consultant radiologist (CR) and an index neuroradiologist (INR) reported on a random sample of 210 MRI examinations. The radiographers reported during clinical practice and the radiologists in clinical practice conditions. Two independent consultant physicians (neuro-rehabilitation and neuropsychiatry) compared these reports with the index neuroradiologist report for agreement and the clinical importance of discrepant reports.

RESULTS

Overall observer agreement between the RRs and CR was comparable in relation to agreement with the INR: RR; 93/210 (44.3%); and the CR; 83/210 (39.4%) for all head MRI examinations (p = 0.32). For brain examinations the difference was similar: RR; 64/180 (35.6%); and CR; 54/190 (30.0%), p = 0.26. Agreement rates for the IAMs examinations were identical, 29/30 (97.7%). For all head MRI examinations (n = 210) there was a very small observed difference of <0.5% in mean agreement between the reporting radiographers and the consultant radiologist (p = 0.92) for examinations where a major disagreement would have been likely to have led to a change in patient management.

CONCLUSION

MRI reporting radiographers reported during clinical practice on MRI head examinations to a level of agreement comparable with a consultant radiologist.

IMPLICATIONS FOR PRACTICE

This is an area in which radiographers could provide additional reporting roles to the reporting service to increase capacity. Wider potential benefits include cost-effectiveness and role development/retention of radiographers.

Effective implementation and adaptation of structured robotic colorectal programme in a busy tertiary unit

BACKGROUND

Safety and feasibility of robotic colorectal surgery has been reported as increasing over the last decade. However safe implementation and adaptation of such a programme with comparable morbidities and acceptable oncological outcomes remains a challenge in a busy tertiary unit. We present our experience of implementation and adaptation of a structured robotic colorectal programme in a high-volume center in the United Kingdom.

METHODS

Two colorectal surgeons underwent a structured robotic colorectal training programme consisting of time on simulation console, dry and wet laboratory courses, case observation, and initial mentoring. Data were collected on consecutive robotic colorectal cancer resections over a period of 12 months and compared with colorectal cancer resections data of the same surgeons' record prior to the adaptation of the new technique. Patient demographics including age, gender, American Society of Anesthesiologist score (ASA), Clavien-Dindo grading, previous abdominal surgeries, and BMI were included. Short-term outcomes including conversion to open, length of stay, return to theatre, 30- and 90-days mortality, blood loss, and post-operative analgesia were recorded. Tumour site, TNM staging, diverting stoma, neo-adjuvant therapy, total mesorectal excision (TME) grading and positive resection margins (R1) were compared. p values less than or equal to 0.05 were considered statistically significant.

RESULTS

Ninety colorectal cancer resections were performed with curative intent from June 2018 to June 2020. Thirty robotic colorectal cancer resections (RCcR) were performed after adaption of programme and were compared with 60 non-robotic colorectal cancer resections (N-RCcR) prior to implementation of technique. There was no conversion in the RCcR group; however, in N-RCcR group, five had open resection from start and the rest had laparoscopic surgery. In laparoscopic group, there were six (10.9%) conversions to open (two adhesions, three multi-visceral involvements, one intra-operative bleed). Male-to-female ratio was 20:09 in RCcR group and 33:20 in N-RCcR groups. No significant differences in gender (p = 0.5), median age (p = 0.47), BMI (p = 0.64) and ASA scores (p = 0.72) were present in either groups. Patient characteristics between the two groups were comparable aside from an increased proportion of rectal and sigmoid cancers in RCcR group. Mean operating time, and returns to theaters were comparable in both groups. Complications were fewer in RCcR group as compared to N-RCcR (16.6% vs 25%). RCcR group patients have reduced length of stay (5 days vs 7 days) but this is not statistically significant. Estimated blood loss and conversion to open surgery was significantly lesser in the robotic group (p < 0.01). The oncological outcomes from surgery including TNM, resection margin status, lymph node yield and circumferential resection margin (for rectal cancers) were all comparable. There was no 30-day mortality in either group.

CONCLUSION

Implementation and integration of robotic colorectal surgery is safe and effective in a busy tertiary center through a structured training programme with comparable short-term survival and oncological outcomes during learning curve.

Rescue of cardiac function in obese type-2 diabetic mice by transfer of a human longevity gene

Background

Healthy longevity is the result of the interaction between favourable environment and unique genetic makeup. We showed that horizontal transfer of a longevity-associated gene variant (LAV-BPIFB4) improves endothelial function and accelerates the recovery from ischemia.

Purpose

To determine if the benefit of LAV-BPIFB4 gene therapy can be extended to diabetic cardiomyopathy.

Methods and results

We confirmed that human diabetic patients with heart failure (n=13) show a decreased cardiac expression of BPIFB4 compared with healthy subjects (n=10). Obese db/db mice received a systemic injection of adeno-associated viral vector (AAV9)-LAV-BPIFB4, AAV9-wild type (WT)-BPIFB4 (both 100 μL at 1×1012 GC/mL) or vehicle before the onset of cardiomyopathy, and were euthanised four weeks later for histological, metabolic and transcriptional analyses. Echocardiographic evaluation (n=8/group), performed at baseline and after gene therapy, showed that LAV-BPIFB4 treatment, despite not resolving hyperglycaemia, improved left ventricular function compared with the other groups. Histological analyses of the hearts (n=5 to 10/group) revealed that LAV-BPIFB4 reduced myocardial fibrosis and increased angiogenesis compared with vehicle and WT-hearts; moreover, LAV increased the expression of the alpha-isoform of the cardiac myosin heavy chain, which is associated with a superior cardiomyocyte contractility. Interestingly, LAV-BPIFB4 treatment induced an increase in cardiac SDF1 expression compared with WT and vehicle, despite the mechanism linking the two events is still unknown. The oral administration of the CXCR4 antagonist AMD-070, given at 2 mg/kg/day for four weeks, abolished several of the beneficial effects exerted by the LAV-BPIFB4 therapy in the obese diabetic mice, as assessed by echocardiography and histology (n=7/group).

At the molecular level, next-generation RNA sequencing (n=3 to 4 /group) showed 8 genes were differentially expressed by LAV-BPIFB4-hearts compared with vehicle-hearts. These genes are associated with mitochondrial and metabolic functions. Among them, changes in the UCP3, HMGCS2, CS, ATPB and TOMM20 expression were also validated at the protein level by western blotting. Lipidomics using ultrahigh-performance liquid chromatography-mass spectrometry (n=6 or 7/group) showed 63 metabolites differentially expressed by LAV-BPIFB4- compared with vehicle-hearts, with only 3 (two cardiolipins and one glycerophospholipid) returning close to the non-diabetic phenotype following LAV-BPIFB4 treatment.

Conclusions

This study newly shows the possibility of transferring the benefit of salutary polymorphic gene variants to protect the cardiovascular system from metabolic pressure. Rather than combating pathogenic mechanisms, the strategy activates alternative pathways overriding disease risk factors.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation project grant “Longevity-associated BPIFB4 gene therapy for treatment of ischemic disease”

Evaluation of antiretroviral therapy on metabolomics and atherogenic markers in HIV patients

Background

HIV-infected patients display an increased risk of cardiovascular events. HIV and antiretroviral therapy (ART) have both been suggested to increase the risk of cardiovascular events but their specific role remains unclear.

Purpose

The aim of this study was to analyse the metabolomic profile in a cohort of HIV-free, ART experienced and naïve HIV-infected patients and to identify the metabolite associated with atherosclerosis development and endothelial dysfunction. The impact of ART on inflammatory and autoimmune biomarkers known to underlie atherosclerosis burden was also investigated.

Methods

144 participants from a South African cohort were divided in three groups: HIV-free (n=50), HIV-infected/ART experienced (n=50) and HIV-infected/ART naïve (n=44). Targeted metabolomic analyses were performed using standard operating procedures. Atherosclerosis development was evaluated using coronary intima-media thickness (CITM) and endothelial dysfunction by flow-mediated dilation (FMD). Inflammatory biomarkers were measured with the Meso Scale Discovery® platform. The levels of autoantibodies against apolipoprotein A1 (anti-apoA1 IgG) and its specific C-terminal domain (anti-F3L1) levels were assessed by homemade ELISA assays.

Results

257 endogenous metabolites were identified in the 144 samples. Regarding the association of metabolites with the vascular markers, eight metabolites were found to be associated with FMD and eleven with CIMT. Among these metabolites, cytosine was negatively correlated with FMD (r=−0.22, p=0.009), while positively with CIMT (r=0.20, p=0.026). Interestingly, from the list of these 18 metabolites, ART-experienced patients displayed an increase in kynurenine (p=0.0007) and 3–2-hydroxyphenyl-propanoate (p=0.0009) levels and a decrease in itaconate (p=0.021) levels compared to ART-naïve patients. HIV-infected patients displayed a more proatherogenic profile compared to HIV-free subjects. Inflammatory markers (IFNg, IL-6, IL-10, TNFα, CRP all p&lt;0.05), circulating adhesion molecules (ICAM-1 and VCAM-1, p&lt;0.05), anti-apoA1 IgG and anti-F3L1 (p&lt;0.05) and CIMT (p=0.05) were increased while FMD (p=0.054) was decreased in HIV-infected patients compared to HIV-free participants. While ART treatment significantly reduced IFNg, IL-10, TNFα, VCAM-1, anti-apoA1 IgG and anti-F3L1, no significant differences were observed in other biomarkers between ART-experienced and naïve participants.

Conclusion

Metabolomic analysis identified metabolites that were differentially expressed in the 3 groups. 18 metabolites were significantly correlated with FMD or CITM, among which the levels of kynurenine, 3–2-hydroxyphenyl-propanoate and itaconate were modulated by ART. HIV patients displayed increased levels of inflammatory markers, circulating adhesion molecules and anti-apoA1 IgG which was downregulated by ART.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Fondation De Reuter; Fondation Schmidheiny; Fondation Prévot; SwissLife AG; Fondation pour la lutte pour le cancer et la recherche bio-médicale

A short term treatment with a Mek1/2 inhibitor promotes myocardial arteriogenesis and perfusion in vivo: focus on cardiac mural cells

Background

Arteriogenesis is crucial for heart recovery after ischaemia, but cellular and molecular mechanisms able to foster this phenomenon are still poorly characterised.

Purpose

To discover novel pro-arteriogenic approaches by exploiting cardiac mural cells endowed with arteriogenic capacity: pericytes (PCs) and vascular smooth muscle cells (VSMCs).

Methods and results

We derived human and murine CD31neg CD34pos cardiac PCs (cPCs) from myocardial samples of adult subjects and confirmed the pericyte phenotype and function in vitro. We discovered that the withdrawal of EGF and bFGF from the culture media induces the differentiation of cPCs into contractile VSMCs. Molecular investigations of pathways associated with the two factors showed that the Mek1/2-Erk1/2 signalling exerts an inhibitory transcriptional control on contractile VSMC genes. Screening of compounds able to interfere with this pathway revealed that PD0325901 – a potent Mek1/2 inhibitor (MeKi) tested in clinical trials for the treatment of cancer – activates the VSMC phenotype in cPCs. We observed a similar effect on coronary artery VSMCs. Next, we interrogated the effect of PD0325901 on cardiac arteriogenesis in vivo. Adult C57BL6/J mice were given the MeKi 10 mg/kg/day or vehicle (DMSO), orally for 14 days (n=11/group). At the endpoint, echocardiographic evaluation of left ventricle (LV) function and dimensions (n=6/group) showed no difference in comparison with the respective baseline in both groups. Effective inhibition of Mek1/2 in the heart of PD-treated mice was confirmed by the reduced immunostaining for the phosphorylated form of Erk1/2. The MeKi cardiotoxicity was ruled out by assessment of cardiomyocytes and vascular cells apoptosis (Tunel) and plasmatic levels of cTn-I. Histological analyses of the hearts (n=5/group) showed an increase in small arterioles (diameter &lt;20μm) density in the LV of PD-mice compared with the DMSO group (16.4 vs 11.7 art/mm2). No change was observed for the capillary density. The drug promoted the maturation of VSMCs within both small and large (&gt;20μm) arterioles, as shown by the higher ratio between the areas of the vascular wall occupied by the mature contractile marker SM myosin heavy chain and the synthetic/early contractile marker alpha-SM actin (αSMA). The PD treatment reduced the fraction of small arterioles covered with a CD34pos layer (53% vs 70% of total arterioles), along with a lower ratio between the areas occupied by adventitial CD34pos cells and αSMApos VSMCs, suggesting a contribution of cPCs to the arteriolar remodelling. Last, the drug improved the LV myocardial perfusion in the PD- vs the DMSO-group (6.8 vs 5.3 ml/min/g of LV tissue, n=6/group).

Conclusions

We show that a short treatment with a Mek1/2 inhibitor stimulates myocardial arteriogenesis and perfusion without either inducing cardiotoxicity or deteriorating heart function. This may be a novel, intriguing approach to promote therapeutic arteriogenesis.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Centre for Vascular Regeneration II

The impact of delayed diagnosis on the outcomes of oral cancer patients: a retrospective cohort study

The contemporary literature is discordant regarding the role of delayed diagnosis in the prognosis of patients with oral cancer. This study examined data on a previously reported cohort of 101 patients with oral squamous cell carcinoma diagnosed at a single institution between 2008 and 2010. The time interval between symptom onset and initial histological diagnosis (diagnostic delay) was recorded for each patient, as were demographic data and cancer features such as T stage, nodal status, and smoking status. The mean follow-up period was 4 years 10 months. The mean diagnostic delay was 4 months, mean overall survival was 5years 6 months, and mean disease-specific survival was 4 years 9 months. No significant correlation was found between diagnostic delay and overall survival, disease-specific survival, or recurrence rates. Patients with node-positive disease were more likely to be diagnosed earlier, whereas women and non-smokers were more likely to have a delayed diagnosis. Inherent tumour biology is likely an important prognostic factor separate to diagnostic delay. Public education efforts should focus on symptom recognition and encourage early presentation for investigation of oral lesions, particularly for females and non-smokers, so that more aggressive tumours can be treated sooner to give the best chance at survival.