Transbronchial lung cryobiopsy: Associated complications

INTRODUCTION

Transbronchial lung cryobiopsy (TBC) has emerged as a diagnostic alternative to surgical lung biopsy in interstitial lung disease (ILD). Despite its less invasive nature, some associated complications have been described.

OBJECTIVE

To evaluate complications of TBC and associated factors.

METHODS

Prospective evaluation of all patients with ILD submitted to TBC in our centre. Clinicodemographic variables and factors associated to TBC complications were analyzed. The effect of the variables on the complication risk was evaluated by a logistic regression model.

RESULTS

Ninety patients were included (mean age 60±13 years; 58.9% male). Twenty-two patients presented pneumothorax, 18 (81.8%) of which were treated with chest tube drainage [median air leak time: 1 day (IQR=2)]. Grade 2 and 3 bleeding was observed in 13 (14.4%) cases. Presence of visceral pleura in the sample accounted for almost more than 10 times the odds of pneumothorax (OR=9.59, 95% CI 2.95-31.17, p<0.001). Increased body mass index (BMI) was associated with bleeding (16% additional odds for each BMI unit increase (OR=1.16, 95% CI 1.01-1.34, p=0.049).

CONCLUSION

The most frequent complication of TBC was pneumothorax, although rapidly reversible. There was a positive association between pneumothorax and the presence of pleura in the biopsy samples as well as between bleeding and increased BMI. More studies about TBC complications are needed to improve the selection of the candidates for this procedure.

Dermoscopic and reflectance confocal microscopic presentation of Hailey-Hailey disease: A case series

BACKGROUND/PURPOSE

Hailey-Hailey disease is a rare inherited acantholytic skin disorder characterized by heterogeneous clinical presentation. Its differential diagnosis might be wide, including other genodermatoses, inflammatory, and infectious skin diseases. Although histopathology remains as diagnostic gold standard, noninvasive techniques such as dermoscopy and reflectance confocal microscopy may assist clinical examination. Herein, we aim to further characterize the dermoscopic and reflectance confocal microscopic presentation of Hailey-Hailey disease with histologic correlation.

METHODS

Eight patients with Hailey-Hailey disease were consecutively recruited. All patients were examined using dermoscopy and reflectance confocal microscopy.

RESULTS

In all cases, dermoscopy enabled the visualization of polymorphous vessels, including glomerular and linear-looped vessels, within a pink-whitish background. Reflectance confocal microscopy revealed wide suprabasilar partial acantholysis and clefting, crusts, dilated papillae with tortuous vessels, and inflammatory cells. Dyskeratosis, uplocated papillae, and adnexal sparing were also observed.

CONCLUSION

Although definite diagnosis was obtained by histopathology in all cases, dermoscopy and reflectance confocal microscopy allowed the identification of common features (even in cases with dissimilar clinical presentation) that may support an early diagnosis of Hailey-Hailey disease, and its differentiation from other more frequent skin disorders.

Incidental finding of a monostotic form of Paget Disease of the scapula in a lung cancer patient

Paget Disease of the bone is a metabolic disorder which leads to a profound alteration of the bone's architecture. It may be asymptomatic and, since its radiological features mimic those of bone metastases, may present a diagnostic dilemma during the evaluation of a cancer patient. We illustrate an uncommon monostotic form of the disease, affecting solely the scapula, diagnosed during the staging of a lung cancer patient.

PTEN and cetuximab resistance in head and neck squamous cell carcinoma (HNSCC)

6061

Background: Platinum-based chemotherapy in association to cetuximab is the standart first-line treatment for metastatic HNSCC. There is no established biomarker for cetuximab efficacy in HNSCC. We have previously shown that PTEN loss of expression is a bad prognostic factor for patients treated with platinum-based chemotherapy and cetuximab. The aim of the present study was evaluate the prognostic impact of PTEN loss of expression in patients treated with or without cetuximab and to evaluate its predictive value to cetuximab benefit. Methods: One hundred and nineteen patients with metastatic or locally recurrent HNSCC were included. Clinical data on treatment and outcomes was retroespectively colected from medical charts. Tissue micro-array was constructed to evaluate PTEN protein expression through immunohistochemistry. Citoplasmatic staining was evaluated using H-score. Tumors with H-score < 10 were considered to present PTEN loss of expression. Results: From the 119 patients 72 were treated with chemotherapy plus cetuximab while 47 were treated with chemotherapy alone. Median overall survival (mOS) was 9.2 months and median progression free survival (PFS) was 4.6 months. Patients treated with cetuximab compared to those who were not treated with cetuximab had a mOS of 11.4 vs 7.0 months (p = 0.770) and a median PFS of 6.2 vs 3.0 months (p = 0.249). Patients with PTEN loss of expression had a worse OS and PFS with mOS of 5.8 vs 10.5 months (p = 0.002) months and mPFS of 3.2 vs 5.2 (p = 0.015). On multivariate analysis including PTEN loss of expression and ECOG performance status both remained independently associated to survival with HR 2.25 (CI95% 1.28-3.97, p = 0.005) for PTEN loss of expression and a HR 1.63 (CI95% 1.07-2.50, p = 0.023) for ECOG. Negative prognostic impact of PTEN loss of expression was seen only in the cetuximab treated patients (mOS 7.3 vs 13.0 months; p = 0.002) but not in the chemotherapy only group (mOS 3.2 vs 7.5 months; p = 0.051). Interaction test for treatment group and PTEN loss of expression showed a p = 0.418. Conclusions: The present study confirms PTEN as a prognostic factor for metastatic HNSCC and suggests PTEN expression should be studied in larger cohorts to evaluate its predictive value to cetuximab response.

The gut microbiota, bile acids and their correlation in primary sclerosing cholangitis associated with inflammatory bowel disease

Background

Patients with primary sclerosing cholangitis associated with inflammatory bowel disease (PSC-IBD) have a very high risk of developing colorectal neoplasia. Alterations in the gut microbiota and/or gut bile acids could account for the increase in this risk. However, no studies have yet investigated the net result of cholestasis and a potentially altered bile acid pool interacting with a dysbiotic gut flora in the inflamed colon of PSC-IBD.

Aim

The aim of this study was to compare the gut microbiota and stool bile acid profiles, as well as and their correlation in patients with PSC-IBD and inflammatory bowel disease alone.

Methods

Thirty patients with extensive colitis (15 with concomitant primary sclerosing cholangitis) were prospectively recruited and fresh stool samples were collected. The microbiota composition in stool was profiled using bacterial 16S rRNA sequencing. Stool bile acids were assessed by high-performance liquid chromatography tandem mass spectrometry.

Results

The total stool bile acid pool was significantly reduced in PSC-IBD. Although no major differences were observed in the individual bile acid species in stool, their overall combination allowed a good separation between PSC-IBD and inflammatory bowel disease. Compared with inflammatory bowel disease alone, PSC-IBD patients demonstrated a different gut microbiota composition with enrichment in Ruminococcus and Fusobacterium genus compared with inflammatory bowel disease. At the operational taxonomic unit level major shifts were observed within the Firmicutes (73%) and Bacteroidetes phyla (17%). Specific microbiota-bile acid correlations were observed in PSC-IBD, where 12% of the operational taxonomic units strongly correlated with stool bile acids, compared with only 0.4% in non-PSC-IBD.

Conclusions

Patients with PSC-IBD had distinct microbiota and microbiota-stool bile acid correlations as compared with inflammatory bowel disease. Whether these changes are associated with, or may predispose to, an increased risk of colorectal neoplasia needs to be further clarified.

Ect Combined with Clomipramine and rTMS in an OCD Patient with Secondary Severe Depression

Introduction

Obsessive-compulsive disorder (OCD) has high rates of comorbidity with mood disorders, mainly major depressive disorder (MDD). Symptoms of depression are usually secondary to severe and disabling OCD. Electroconvulsive therapy (ECT) has been an effective and well tolerated therapeutic alternative in the management of refractory MDD. Other neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), have well known efficacy in MDD and also have shown positive results, in clinical trials, treating other psychiatric disorders such as OCD.

Objectives/aims

To determine the efficacy of combining rTMS, ECT and clomipramine in the treatment of severe OCD with comorbid severe MDD.

Methods

The authors report a case of a 54-year-old male patient diagnosed with severe OCD for 23 years. He has been submitted to several drug treatments and intensive cognitive-behavioural therapy (CBT) always with poor response. The patient was admitted in the beginning of 2016 in our inpatient unit. Besides continuing drug treatment (clomipramine IV) and CBT, he was submitted to 12 ECT sessions during one month (3 sessions per week) and to daily sessions of rTMS during the following month.

Outcome measures were obtained using Y-BOCS for OCD and HAM-D for depression.

Results

Our patient responded to ECT with mood improvement after session 4 to full euthymic state at the final session. He also responded well to rTMS with Y-BOCS score reduction.

Conclusion

Combined ECT and rTMS treatment with clomipramine IV and CBT was effective in our patient with a severe form of both disorders (OCD and MDD).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Improving the accuracy of synovial fluid analysis in the diagnosis of prosthetic joint infection with simple and inexpensive biomarkers

Aims

The aims of this study were to increase the diagnostic accuracy of the analysis of synovial fluid in the differentiation of prosthetic joint infection (PJI) by the addition of inexpensive biomarkers such as the levels of C-reactive protein (CRP), adenosine deaminase (ADA), alpha-2-macrogloblulin (α2M) and procalcitonin.

Patients and Methods

Between January 2013 and December 2015, synovial fluid and removed implants were requested from 143 revision total joint arthroplasties. A total of 55 patients met inclusion criteria of the receipt of sufficient synovial fluid, tissue samples and removed implants for analysis. The diagnosis of PJI followed the definition from a recent International Consensus Meeting to create two groups of patients; septic and aseptic. Using receiver operating characteristic curves we determined the cutoff values and diagnostic accuracy for each marker.

Results

There were 23 PJIs and 32 patients with aseptic loosening. The levels of total leucocyte count, proportion of polymorphonuclear leucocytes (PMNs), CRP, ADA and α2M in the synovial fluid were all significantly higher in those with a PJI than in those with aseptic loosening. The levels of procalcitonin were comparable in the two groups. Cutoff values for the optimal performance in the diagnosis of infection were: total leucocyte count > 1463 cells/μL (sensitivity (Sens) 100%, specificity (Spec) 71.9%, positive predictive value (PPV) 71.9%, negative predictive value (NPV) 100%); proportion of PMNs > 81% (Sens 78.3%, Spec 75.0%, PPV 69.2%, NPV 82.8%); CRP > 6.7mg/L (Sens 78.3%, Spec 93.8%, PPV 90.0%, NPV 85.7%); ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%) and α2M > 958 mg/L (Sens 47.8%, Spec 96.9%, PPV 91.7%, NPV 72.1%). The addition of a raised level of CRP or ADA to the total leukocyte count increased the specificity: total leukocyte count > 1463 cells/μL and CRP > 6.7mg/L (Sens 78.3%, Spec 100%, PPV 100%, NPV 86.5%) or with ADA > 61U/L (Sens 78.3%, Spec 96.9%, PPV 94.7%, NPV 86.1%).

Conclusion

The total leucocyte count in the synovial fluid offers great negative predictive value in the diagnosis of PJI and the addition of more specific markers such as CRP and ADA improves the positive predictive value. Thus the addition of simple and inexpensive markers to the measurement of the leucocyte count in the synovial fluid may reduce the number of equivocal results which demand more expensive investigation. Cite this article: Bone Joint J 2017;99-B:351–7.

Endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in non-small cell lung carcinoma

INTRODUCTION

Lung cancer staging has recently evolved to include endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for nodal assessment.

AIM

Evaluate the performance and safety of EBUS-TBNA as a key component of a staging algorithm for non-small cell lung carcinoma (NSCLC) and as a single investigation technique for diagnosis and staging of NSCLC.

METHODS

Patients undergoing EBUS-TBNA for NSCLC staging at our institution between April 1, 2010 and December 31, 2014 were consecutively included with prospective data collection. EBUS-TBNA was performed under general anesthesia through a rigid scope.

RESULTS

A total of 122 patients, 84.4% males, mean age 64.2 years. Histological type: 78 (63.9%) adenocarcinoma, 33 (27.0%) squamous cell carcinoma, 11 (8.9%) undifferentiated/other NSCLC. A total of 435 lymph node stations were punctured. Median number of nodes per patient was 4. EBUS-TBNA nodal staging: 63 (51.6%) N0; 8 (6.5%) N1; 34 (27.9%) N2, and 17 (13.9%) N3. EBUS-TBNA was the primary diagnostic procedure in 27 (22.1%) patients. EBUS-TBNA NSCLC staging had a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate of 83.3, 100, 100, 86.1, and 91.8%, respectively. No complications were attributable to the procedure.

CONCLUSION

A comprehensive lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective. Our EBUS-TBNA performance and safety in this particular setting was in line with previously published reports. Additionally, our study showed that, in selected patients, lung cancer diagnosis and staging are achievable with a single endoscopic technique.

[Predictive value of cerebellar growth and general movements assessments for neurodevelopment of very preterm infants at 18-24 months' corrected age]

INTRODUCTION

Fidgety movements assessments is very sensitive predicting long-term outcome or cerebral palsy of preterm, disrupted cerebellar growth has been reported in these patients.

AIM

To compare the predictive value of cerebellar ultrasound growth and fidgety movements assessments, for neurodevelopment outcome of very preterm at 18-24 month's corrected age (CA).

SUBJECTS AND METHODS

Prospective study of 88 infants cohort (<= 32 weeks' gestation), transverse cerebellar diameter was obtained by ultrasound via mastoid fontanel, in a weekly basis, until 40 weeks CA. Fidgety movements were assessed at 3 months CA. Neurodevelopment outcome at 18-24 month's CA was evaluated in 68 using Schedule of Growing Skills II Scale (SGS-II) and Amiel-Tison Neurologic Assessment (ATNA).

RESULTS

At term age, cerebellar growth was under 3rd percentile in 11 (10.3%). Fidgety movements were normal in 42 (61.8%) and abnormal or absent in 7 (10.3%). At 18-24 months CA, 54 (79.4%) were normal by the SGS-II and in 6 (8.8%) ATNA classified as cerebral palsy. Cerebellar diameter under 3rd percentile at term was associated with abnormal motor outcome and normal fidgety movements correlated with normal neurodevelopment.

CONCLUSION

Ultrasound cerebellar measurements and functional examinations (fidgety movements) have important complementary roles in predicting neurodevelopment of very preterm.

The role of prenatal exposures on body fat patterns at 7 years: Intrauterine programming or birthweight effects?

BACKGROUND AND AIMS

It remains unknown whether the effects of prenatal exposures on child's adiposity reflect entirely intrauterine programming. We aimed to assess the effects of maternal gestational weight gain, diabetes and smoking on the child's body fat patterns, disentangling the direct (through intrauterine programming) and indirect (through birthweight) effects.

METHODS AND RESULTS

We included 4747 singleton 7-year-old children from the Generation XXI birth cohort (Porto, Portugal). At birth, maternal and newborn's characteristics were obtained. Anthropometrics were measured at age 7 years and body fat patterns were identified by principal component analysis. Path analysis was used to quantify direct, indirect and total effects of gestational weight gain, diabetes and smoking on body fat patterns. Pattern 1 was characterized by strong factor loadings with body mass index, fat mass index and waist-to-height ratio (fat quantity) and pattern 2 with waist-to-hip ratio, waist-to-thigh ratio, and waist-to-weight ratio (fat distribution). The positive total effect of maternal gestational weight gain and diabetes on the child's fat quantity was mainly through a direct pathway, responsible for 91.7% and 83.7% of total effects, respectively (β = 0.022; 95% Confidence Interval (CI): 0.017, 0.027; β = 0.041; 95% CI: -0.011, 0.093). No effects on fat distribution were found. Maternal prenatal smoking had a positive direct effect on patterns 1 and 2, explaining 94.9% and 76.1% of total effects, respectively.

CONCLUSION

The effects of maternal gestational weight gain, diabetes and smoking on a child's fat quantity seem to be mainly through intrauterine programming. Maternal smoking also showed a positive direct effect on child's fat distribution.