Trend analysis and regional tumor incidence in Germany for testicular cancer between 2003 and 2014

BACKGROUND

Testicular germ cell tumor (TGCT) is one the most common solid tumors in men between the age of 15 and 35 with an overall incidence rate of 1-1.5 %. Epidemiologic studies have demonstrated different incidence patterns in western civilized countries with overall rising incidence trends.

OBJECTIVE

To analyze differences in regional tumor incidence rates for TGCT and perform a trend analysis for TGCT between 2003 and 2014 in Germany.

MATERIAL AND METHODS

TGCT cases in Germany which were diagnosed between 2003 and 2014 were provided by the Robert-Koch-Institute, Berlin. For statistical analysis, cluster and spatial scan tests according to Kulldorff were used for cases with seminoma and non-seminoma. Results are presented in administrative districts and graphically illustrated. We performed a trend-analysis in order to evaluate age-adjusted incidence trends in Germany. Tests were two-sided with a level of significance of α=0.05.

RESULTS

In total we included 35,066 patients. Overall, 22,634 cases had newly diagnosed seminoma and 12,432 were diagnosed as non-seminoma. Maximum incidence of seminoma and non-seminoma was observed for age-group 38-40 years and 26-28 years, respectively. No second peak for the incidences of seminoma and non-seminoma with respect to age were observed. Cluster analysis revealed areas with high and low incidence rates as well as slightly different spatial distribution in Germany between seminoma and nonseminoma. Furthermore, there was no significant increase in age-adjusted incidence rates over the reviewed time period in both cohorts.

DISCUSSION

In this study differences in reginal tumor incidence rates for seminoma and non-seminoma are reported with both tumor entities revealing distinct clusters. Furthermore, tumor incidence trends for seminoma and nonseminoma between 2003 and 2014 were stable which might indicate the beginning of a plateau phase for TGCT incidence rates in Germany.

CONCLUSION

In this analysis we were able to identify regions with significantly higher tumor incidence rates for both seminoma and non-seminoma which were specific for these two subtypes. Furthermore, trend analysis revealed a steady incidence rate for testicular cancer in Germany.

Coherent transport through a Majorana island in an Aharonov-Bohm interferometer

Majorana zero modes are leading candidates for topological quantum computation due to non-local qubit encoding and non-abelian exchange statistics. Spatially separated Majorana modes are expected to allow phase-coherent single-electron transport through a topological superconducting island via a mechanism referred to as teleportation. Here we experimentally investigate such a system by patterning an elongated epitaxial InAs-Al island embedded in an Aharonov-Bohm interferometer. With increasing parallel magnetic field, a discrete sub-gap state in the island is lowered to zero energy yielding persistent 1e-periodic Coulomb blockade conductance peaks (e is the elementary charge). In this condition, conductance through the interferometer is observed to oscillate in a perpendicular magnetic field with a flux period of h/e (h is Planck’s constant), indicating coherent transport of single electrons through the islands, a signature of electron teleportation via Majorana modes.

Theories predict teleportation of phase-coherent single electrons through a topological superconducting island. Here, the authors report persistent Coulomb blockade conductance peaks due to coherent transport of single electrons through patterned InAs-Al islands embedded in an Aharonov-Bohm interferometer.

Relating Andreev Bound States and Supercurrents in Hybrid Josephson Junctions

We demonstrate concomitant measurement of phase-dependent critical current and Andreev bound state spectrum in a highly transmissive InAs Josephson junction embedded in a dc superconducting quantum interference device (SQUID). Tunneling spectroscopy reveals Andreev bound states with near unity transmission probability. A nonsinusoidal current-phase relation is derived from the Andreev spectrum, showing excellent agreement with the one extracted from the SQUID critical current. Both measurements are reconciled within a short junction model where multiple Andreev bound states, with various transmission probabilities, contribute to the entire supercurrent flowing in the junction.

Early clinical outcomes of a rapid colorectal cancer diagnosis pathway using faecal immunochemical testing in Nottingham

AIM

We introduced primary care access to faecal immunochemical testing (FIT) as a stratification tool for symptomatic patients considered to be at risk of colorectal cancer (CRC) prior to urgent referral. We aimed to evaluate clinical and pathway outcomes during the first 6 months of this novel approach.

METHOD

FIT was recommended for all patients who consulted their general practitioner with lower gastrointestinal symptoms other than rectal bleeding and rectal mass. We undertook a retrospective audit of the results of FIT, related clinical outcomes and resource utilization on prospectively logged cases between November 2017 and May 2018.

RESULTS

Of the 1862 FIT kits dispatched by post 91.4% were returned, with a median return time of 7 days (range 2-110 days); however, 1.3% of returned kits could not be analysed. FIT results ≥ 150.0 μg haemoglobin (Hb)/g faeces identified patients with a significantly higher risk of CRC (30.9% vs 1.4%, chi-square 167.1, P < 0.0001). FIT results ≥ 10.0 μg Hb/g faeces identified patients with significantly higher risk of significant noncancer bowel pathology (24.1% vs 4.9%, chi-square 73.6, P < 0.0001) and FIT results < 4.0 μg Hb/g faeces identified a group more likely to have non-CRC pathology (5.1% vs 2.4%, chi-square 3.9, P < 0.05). The CRC detection rate in 531 patients investigated after a FIT result of < 4.0 μg Hb/g faeces was 0.2%. In 899 investigated patients, a FIT result with a threshold of 4.0 μg Hb/g faeces had sensitivity 97.2% (85.5-99.9% CI), specificity 61.4% (58.1-64.7% CI), negative predictive value 99.8% (98.7-100.0% CI) and positive predictive value 9.5% (8.7-10.4% CI).

CONCLUSION

A symptomatic pathway incorporating FIT is feasible and appears more clinically effective than pathways based on age and symptoms alone.

[Intertriginous psoriasis]

Intertriginous psoriasis is a variant of psoriasis that is associated with inflammatory lesions in skin folds. Patients often feel ashamed, are subjected to stigmatization, social isolation, or experience mental health issues. There is no general consensus on the definition of intertriginous psoriasis. Depending on the definition used, the prevalence varies substantially. Due to the particular location of skin lesions, therapeutic management is very challenging. Mild symptoms can be treated with topical corticosteroids or topical immunomodulators. There are encouraging data demonstrating the efficacy of ixekizumab, possibly charting the way for it to become a systemic treatment option.

25 A Pilot Implementation of Providing Enhanced Support to Care Homes within A Primary Care Network

Introduction

People living with severe frailty in care homes are vulnerable to frequent non-elective hospital attendances. However provision of enhanced healthcare support to care home residents can reduce this risk and increase quality of life for residents.1 The framework for enhanced health in care homes (EHCH) summarises best practice in this area and provides guidance for implementing services.2

Methods

This study was a pilot implementation of the EHCH framework based on a Primary Care and Specialist Frailty Multidisciplinary Team (MDT) and delivered on a Primary Care Network (PCN) footprint. The MDT targeted five care homes in a PCN area with historically high levels of non-elective attendances. The model of care was based on the principle of anticipatory care planning, training and support for care home staff to understand and implement plans.

Results

Over the pilot period of 9 months, non-elective attendances from the 5 homes reduced by 27% compared to the previous year, which was a significant reduction (p&lt;0.042). There was variation between the homes in the reduction in non-elective attendances with the greatest impact seen in the homes that had the highest level of attendance at training and engagement in the care planning process. Feedback received from the care home staff indicated that they felt more confident to refer to the care plans and had alternative options to calling 999. A quality audit of the care plans completed as part of the pilot revealed a number of additional training needs for clinicians completing the plans to ensure consistency of recoding. This training was delivered following the pilot period.

Conclusions

The pilot demonstrated that the EHCH framework could be successfully implemented on a PCN footprint. Analysis shows this implementation coincided with a reduction in non-elective attendances from the targeted homes. Further analysis is required to compare the impact in different homes and to understand contributing factors. The pilot implementation provides helpful information to inform PCN development.

References

1. Lloyd T, Wolters A and Steveton A (2014) The impact of providing enhanced support for care home residents in Rushcliffe: Health Foundation consideration of findings from the Improvement Analytics Unit. The Health Foundation.

2. NHS England (2016) The framework for enhanced health in care homes.

Design and development of Ionization Profile Monitor for the Cryogenic sections of the ESS Linac

Saclay CEA/IRFU is working for the delivery of five Non-Invasive Profile Monitors in the frame of the in-kind contribution agreement signed with the European Spallation Source. Neutrons will be produced by spallation reactions of 2 GeV proton beam impinging on a Tungsten target. To accelerate protons a powerful linear accelerator of 5MW is under construction. Diagnostic devices are mandatory tools for the tuning and protection of the machine. The non-invasive profile monitors provide a measurement of the beam profile in transverse directions to the beam propagation. This project raises several physical and technical challenges including low signal detection of ions or electrons, profile distortions induced by the beam Space Charge effect and non-uniformities of electric field. Simulation and model of the critical aspects of the detector have been performed in order to prove the performance and the feasibility of the detector. A series of prototypes has been built with different readout types, and tested in real conditions at the 3MeV proton accelerator IPHI. All of them show some advantages and drawbacks revealed by the tests in real beam conditions. In this paper we present the results of the tests for the various configuration readout systems to agree with the model and simulation of the detector. In concluding remarks, we will discuss the performance of the prototypes and point out the camerabased one to be the more suitable for the final design.

Diverging Awareness of Postoperative Delirium and Cognitive Dysfunction in German Health Care Providers

Purpose

Postoperative cognitive dysfunction (POCD) appears in up to 30% of patients suffering from postoperative delirium (POD). Both are associated with higher mortality and postoperative complications, prolonged hospital stays, and increased costs. Multi-modal models with pre-admission risk reduction counselling, perioperative monitoring, and training of multidisciplinary patient care providers have been shown to decrease the prevalence of both. The aim of our study is to understand how far those measures are known and implemented in routine care and to detect potential gaps in the current practice regarding risk communication and information flow between involved caregivers for patients at risk for POD/POCD.

Patients and Methods

As part of a multicenter study, seven semi-structured focus group (FG) discussions with nurses and physicians from tertiary care hospitals (surgery, anesthesiology, and orthopedics, n=31) and general practitioners (GPs) in private practice (n=7) were performed. Transcribed discussions were analyzed using qualitative content analysis.

Results

POD is present above all in the daily work of nurses, whereas physicians do not perceive it as a relevant problem. Physicians report that no regular risk assessment or risk communication was performed prior to elective surgery. Information about POD often gets lost during hand-offs and is not regularly reported in discharge letters. Thus, persisting cognitive dysfunction is often missed. The importance of standardized documentation and continuous education concerning risks, screening, and treatment was emphasized. The often-suggested pre-OP medication adjustment was seen as less important; in contrast, avoiding withdrawal was regarded as far more important.

Conclusion

Altogether, it seems that standards and available best practice concepts are rarely implemented. In contrast to physicians, nurses are highly aware of delirium and ask for standardized procedures and more responsibility. Therefore, raising awareness regarding risks, screening tools, and effective preventive measures for POD/POCD seems an urgent goal. Nurses should have a central role in coordination and care of POD to prevent the risk for POCD.

Heat Mitigation Strategies for Finishing Beef Cattle During the Summer in the Southeastern United States Reduces Heat Load and Improves Weight Gain, but does not Influence Meat Quality

ObjectivesThe objective of this research was to determine the effect of heat mitigation strategies on meat quality when finishing cattle under heat stress conditions.Materials and MethodsForty-five Angus crossbred steers (446 ± 23 kg) were blocked by weight and randomly assigned to 1 of 3 finishing environments: shaded with fan (CWF), shaded without fan (CNF), or outside no shade (OUT). For 92 d steers were individually fed a corn-based total mixed ration and were weighed every 3 wk. Environmental monitors (Kestrel Instruments) were used to quantify heat load index (HLI) and accumulated heat load units (AHLU). When the first treatment group averaged 613 kg all steers were harvested. Carcass quality and yield data were collected 24 h postmortem. Strip loins were removed from the right side of each carcass at 24 h postmortem, vacuum packaged, and aged (2 ± 1°C) for 5 d. Strip loins were then fabricated into 2.54-cm steaks anterior to posterior. The first steak was designated for proximate analysis, followed by two steaks for slice shear force (14 and 21 d aging), two steaks for other analyses, and the remaining 7 steaks were randomly assigned to shelf life (SL) for 6 d following 28 d of wet aging. Steaks were vacuum packaged and held (2 ± 1°C) for their respective days of aging. After 28 d, shelf life steaks were opened, placed in Styrofoam trays with PVC overwrap, and placed in retail display cases (1 ± 2°C). Steaks were frozen (–20°C) once they reached their assigned day of wet aging or simulated shelf life. Objective color L* (lightness), a* (redness), b* (yellowness), and isobestic wavelengths were recorded daily (± 2 h). Hue, chroma, DE, and deoxymyoglobin (%Dmb), oxymyoglobin (%Omb), and metmyoglobin (%Mmb) were calculated. Data were analyzed using a mixed model (JMP v.13; SAS) and means were separated using LSmeans at a = 0.05.ResultsEnvironmental monitors showed that CWF and CNF had lower HLI and AHLU (P < 0.01) than OUT. Final weights were greater for CWF than OUT (P = 0.02) while CNF was similar (P ≥ 0.17) to both. Similar results were observed for hot carcass weights where CWF > OUT (P = 0.03), and CNF was similar to both (P ≥ 0.23). Treatment differences were not observed for USDA yield grade (P = 0.38), dressing percent (P = 0.93), kidney pelvic heart fat (P = 0.89), ribeye area (P = 0.47), backfat thickness (P = 0.49), marbling score (P = 0.71), overall maturity (P = 0.92), or subjective lean color (P = 0.16). No differences in fat color scores were observed between CNF and OUT (P = 0.95) while CWF were whiter (P ≤ 0.04) than both. Protein analysis showed CWF had more protein than OUT (P = 0.01) while CNF was similar to both (P ≥ 0.90). No differences were observed for lipid content (P = 0.99), ash (P = 0.39), or moisture (P = 0.92). Treatment nor day of aging effected slice shear force (P = 0.45 and P = 0.53, respectively). While treatment differences were not observed for a*, b*, hue, chroma and DE (P = 0.51, P = 0.65, P = 0.18 P = 0.57, and P = 0.57, respectively). Treatment values for L* were lighter for CNF than CWF (P = 0.04), while OUT was similar to both (P ≥ 0.14). There were no differences for %Dmb, %Omb, and %Mmb (P = 0.24, P = 0.32, and P = 0.39, respectively) among the treatments.ConclusionResults indicate that heat stress mitigation is a viable method to improve weight, however, does not impact the quality of the meat.

P6388Effects of Interleukin-1 blockade with anakinra in patients with ST-segment elevation acute myocardial infarction on recurrent ischemic events: results from the VCUART3 study

Background

ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of recurrent ischemic events. Prior studies of IL-1 blockade have shown conflicting results regarding the risk of future events.

Methods

We enrolled patients with STEMI within 12 hours of presentation at 3 sites in the United States of America. After revascularization, patients were randomly assigned to receive anakinra 100 mg twice daily, anakinra 100 mg once daily (standard dose) alternated with placebo once daily every 12 hours, or placebo every 12 hours for 14 days in 1:1:1 ratio. Prespecified exploratory endpoints for recurrent ischemic events, adjudicated by an independent committee, evaluated the composite risk of subsequent acute myocardial infarction (AMI, World Health Organization classification Type 1), unstable angina, or urgent revascularization. Data are expressed as median and interquartile range or number and percentage. Cox regression analysis was used to generate unadjusted hazard ratios and confidence intervals. (ClinicalTrials.gov number, NCT01950299)

Results

Of 311 patients screened, 99 subjects (81% males, 58% Caucasians, 55 [49–62] years of age) were randomly assigned to anakinra twice daily (N=31), anakinra once daily (N=33) or placebo (N=35). The cohort included patients with hypertension (57%), tobacco use (55%), diabetes mellitus (30%), and prior diagnosis of coronary artery disease (21%) without statistically significant imbalances in the demographic characteristics between groups (all P>0.05). Discharge medications for the index STEMI admission, in addition to the study medication, included aspirin (100%), statins (100%), P2Y12 inhibitors (100%), beta-blockers (90%), and angiotensin converting enzyme inhibitor/angiotensin receptor blocker (84%), without statistically significant imbalances between the 3 groups. Over the 1-year follow-up, recurrent ischemic events occurred in 5/35 (14.3%) patients treated with placebo and 6/64 (9.1%) patients treated with anakinra (hazard ratio = 0.68 [0.20–2.24], P=0.53). No differences were observed between high- and low-dose anakinra treatment groups.

Conclusions

A two week treatment with IL-1 receptor antagonist, anakinra, did not significantly decrease or increase recurrent ischemic events over the course of a 1-year follow-up in patients with STEMI.

Acknowledgement/Funding

Funded by NHLBI 1R34HL121402; Drug supply by Swedish Orphan Biovitrum

Parapharyngeal abscess and vocal cord palsy caused by minor salivary gland sialadenitis: an atypical presentation treated using an endoscopic surgical approach

Parapharyngeal infections carry a significant risk of extensive suppuration and airway compromise. We report the case of a patient presenting with a right paranasopharyngeal abscess, featuring atypical symptoms that made diagnosis particularly challenging. Complications included evidence of right vocal cord paralysis, likely secondary to involvement of the vagus nerve. Notably, this paralysis occurred in isolation, without involvement of cranial nerves IX or XI, which would be expected from jugular foramen encroachment. Imaging demonstrated the presence of a collection extending towards the skull base, which was drained using a transnasal endoscopic approach, avoiding the use of external incisions. Tissue biopsies from the abscess wall suggest that the underlying aetiology was minor salivary gland sialadenitis, which has not been previously reported in the literature.

Comparison of high-flow oxygen therapy with standard oxygen therapy for prevention of postoperative pulmonary complications after major head and neck surgery involving insertion of a tracheostomy: a feasibility study

Major operations on the head and neck that involve microvascular reconstruction and a tracheostomy are prolonged procedures with considerable postoperative risk. Postoperative pulmonary complications are common because of mechanical ventilation, immobility, and inadequate humidification. High-flow heated oxygen therapy (HFOT) may overcome some of these issues, but we know of no published studies to support its use. The aim of this single-site randomised controlled trial therefore was to explore its feasibility and safety in these patients. Twenty patients were randomised to have HFOT (10 patients) or standard oxygen therapy (10 patients). HFOT was used from cessation of mechanical ventilation until decannulation of the tracheostomy. The primary outcome was feasibility. The secondary outcome measures explored the incidence of postoperative pulmonary complications, achievement of milestones of weaning from the tracheostomy, and hospital length of stay. A total of 21 patients were consecutively recruited and all provided informed consent. One who did not require a tracheostomy was later excluded. All patients initially had the intervention as planned, and one was electively changed to the control group because of discomfort caused by the high-flow oxygen. There were no adverse events or safety concerns in either group. Secondary outcomes showed a reduction in the incidence of pulmonary complications in the HFOT group. The use of HFOT is safe and feasible in patients who have microvascular reconstruction of the head and neck and a tracheostomy.

[Standard surgery for small renal masses (<4 cm)]

BACKGROUND

Several new treatment strategies have emerged in the treatment of small renal masses (<4 cm in diameter). Active surveillance and ablative techniques have been introduced but it remains unclear which patients will benefit the most from these new treatment options. A surgical approach remains standard of care. In recent decades, radical nephrectomy has been replaced by nephron-sparing surgery for the management of small renal masses.

RESULTS

In addition to the open partial nephrectomy, which is considered the standard approach, the number of surgeries performed using minimally invasive techniques is increasing. Recent data show that there might be some benefits such as less blood loss. The disadvantages shown by laparoscopic partial nephrectomy such as prolonged warm ischemia, longer operation times, and postoperative renal impairment might be negligible for the robotic approach. Therefore, current guidelines allow these approaches in addition to open partial nephrectomy if sufficient surgical expertise is given.