Outcomes of repeat two-stage exchange hip arthroplasty for prosthetic joint infection

Aims

The increasing infection burden after total hip arthroplasty (THA) has seen a rise in the use of two-stage exchange arthroplasty and the use of increasingly powerful antibiotics at the time of this procedure. As a result, there has been an increase in the number of failed two-stage revisions during the past decade. The aim of this study was to clarify the outcome of repeat two-stage revision THA following a failed two-stage exchange due to recurrent prosthetic joint infection (PJI).

Patients and Methods

We identified 42 patients who underwent a two-stage revision THA having already undergone at least one previous two stage procedure for infection, between 2000 and 2015. There were 23 women and 19 men. Their mean age was 69.3 years (48 to 81). The outcome was analyzed at a minimum follow-up of two years.

Results

A satisfactory control of infection and successful outcome was seen in 26 patients (57%). There therefore remained persistent symptoms that either required further surgery or chronic antibiotic suppression in 16 patients (38%). One-third of patients had died by the time of two years’ follow-up.

Conclusion

The rate of failure and complication rate of repeat two-stage exchange THA for PJI is high and new methods of treatment including host optimization, immunomodulation, longer periods between stages, and new and more powerful forms of antimicrobial treatment should be investigated. Cite this article: Bone Joint J 2019;101-B(6 Supple B):110–115.

Routine ultrasound at 32 vs 36 weeks' gestation: prediction of small-for-gestational-age neonates

OBJECTIVE

To evaluate and compare the performance of routine ultrasonographic estimated fetal weight (EFW) and fetal abdominal circumference (AC) at 31 + 0 to 33 + 6 and 35 + 0 to 36 + 6 weeks' gestation in the prediction of a small-for-gestational-age (SGA) neonate.

METHODS

This was a prospective study of 21 989 singleton pregnancies undergoing routine ultrasound examination at 31 + 0 to 33 + 6 weeks' gestation and 45 847 undergoing routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. In each case, the estimated fetal weight (EFW) from measurements of fetal head circumference, AC and femur length was calculated using the Hadlock formula and expressed as a percentile according to The Fetal Medicine Foundation fetal and neonatal population weight charts. The same charts were used for defining a SGA neonate with birth weight < 10^th and < 3^rd percentiles. For each gestational-age window, the screen-positive and detection rates, at different EFW percentile cut-offs between the 10^th and 50^th percentiles, were calculated for prediction of delivery of a SGA neonate with birth weight < 10^th and < 3^rd percentiles within 2 weeks and at any stage after assessment. The areas under the receiver-operating characteristics curves (AUC) in screening for a SGA neonate by EFW and AC at 31 + 0 to 33 + 6 and at 35 + 0 to 36 + 6 weeks' gestation were compared.

RESULTS

First, the AUCs in screening by EFW for a SGA neonate with birth weight < 10^th and < 3^rd percentiles delivered within 2 weeks and at any stage after screening at 35 + 0 to 36 + 6 weeks' gestation were significantly higher than those at 31 + 0 to 33 + 6 weeks (P < 0.001). Second, at both 35 + 0 to 36 + 6 and 31 + 0 to 33 + 6 weeks' gestation, the predictive performance for a SGA neonate with birth weight < 10^th and < 3^rd percentiles born at any stage after screening was significantly higher using EFW Z-score than AC Z-score. Similarly, at 35 + 0 to 36 + 6 weeks, but not at 31 + 0 to 33 + 6 weeks, the predictive performance for a SGA neonate with birth weight < 10^th and < 3^rd percentiles born within 2 weeks after screening was significantly higher using EFW Z-score than AC Z-score. Third, screening by EFW < 10^th percentile at 35 + 0 to 36 + 6 weeks' gestation predicted 70% and 84% of neonates with birth weight < 10^th and < 3^rd percentiles, respectively, born within 2 weeks after assessment, and the respective values for a neonate born at any stage after assessment were 46% and 65%. Fourth, prediction of > 85% of SGA neonates with birth weight < 10^th percentile born at any stage after screening at 35 + 0 to 36 + 6 weeks' gestation requires use of EFW < 40^th percentile. Screening at this percentile cut-off predicted 95% and 99% of neonates with birth weight < 10^th and < 3^rd percentiles, respectively, born within 2 weeks after assessment, and the respective values for a neonate born at any stage after assessment were 87% and 94%.

CONCLUSIONS

The predictive performance for a SGA neonate of routine ultrasonographic examination during the third trimester is higher if, first, the scan is carried out at 35 + 0 to 36 + 6 weeks' gestation than at 31 + 0 to 33 + 6 weeks, second, the method of screening is EFW than fetal AC, third, the outcome measure is birth weight < 3^rd than < 10^th percentile, and, fourth, if delivery occurs within 2 weeks than at any stage after assessment. Prediction of a SGA neonate by EFW < 10^th percentile is modest and prediction of > 85% of cases at 35 + 0 to 36 + 6 weeks' gestation necessitates use of EFW < 40^th percentile. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Abstract OT2-07-04: A phase 1b study of poziotinib in combination with T-DM1 in women with advanced or metastatic HER2-positive breast cancer

Background:Poziotinib represents a new class of irreversible quinazoline inhibitors of ErbB receptor tyrosine kinases that inhibit the proliferation of tumor cells in culture and in vivo by inhibiting HER-1 (EGFR), HER-2, HER-4. ErbB signaling plays important roles in the progression of HER2+ breast cancer. Poziotinib has promising clinical activity in breast cancer, and other solid tumors including lung, gastric, and colorectal cancers.

Study SPI-POZ-101, is being conducted to evaluate the safety and efficacy of the combination of daily poziotinib and T-DM1, HER2 antibody-drug-conjugate every three weeks in patients with HER2+ advanced or metastatic breast cancer.

Trial Objectives and Design: The primary objectives of the study are to determine the maximum tolerated dose (MTD) or maximum administered dose (MAD) of daily poziotinib plus T-DM1 (every 3 weeks) in women with advanced or metastatic HER2 positive breast cancer; and to evaluate the Objective Response Rate (ORR) in these patients.

The secondary objectives include disease control rate (DCR), progression-free-survival (PFS), safety and pharmacokinetics at the MTD/MAD dose level of poziotinib plus T-DM1.

In Part 1, the dose of poziotinib plus standard dose of T-DM1 (3.6 mg/kg IV) on Day 1 of each cycle will be determined using a “3+3” design with up to 3 escalating dose levels, 8, 10 and 12 mg with no DLT or to de-escalate to 6 mg with DLT observed in Cycle 1. Patients in current dose cohort, if not discontinued, will continue treatment until discontinuation of therapy.

In Part 2 of the study, approximately 10 patients will be treated at the MTD/MAD to confirm dose for safety of the combination and to evaluate preliminary efficacy.

Eligibility Criteria: The study will enroll female patients between 18 and 90 years with confirmed HER2 overexpression or gene-amplified tumor via immunohistochemistry [IHC] with IHC 3+ or IHC 2+ with confirmatory fluorescence in situ hybridization [FISH]+ or [ISH]+ and must have had at least 2 lines of anti-HER2 directed therapies either in the metastatic or early-stage disease setting. Patients must have adequate hematologic, hepatic, cardiac and renal functions and have at least one measurable lesion per RECIST 1.1 criteria. Exclusion criteria includes unstable CNS metastases or seizure disorder; anticancer chemotherapy, TKIs, biologics, immunotherapy, radiotherapy, or investigational treatment within 15 days; ≥ Grade 2 adverse events; known hypersensitivity to receptor tyrosine kinase inhibitors or any of the components of poziotinib tablets or T-DM1 IV solution.

Statistical Methods: Part 1 of the study will enroll 3 to 6 patients at each dose using 3+3 design. Part 2 will enroll 10 patients at the MTD/MAD. The efficacy analysis will be conducted using the Evaluable Population based on RECIST 1.1. The Clopper-Pearson 95% confidence interval will be estimated using exact method based on binomial distribution.

Target Accrual:Part 1: 6-18 patients Part 2: 10 patients

ClinicalTrials.gov Identifier: NCT03429101

Contact Information: Spectrum Pharmaceuticals. SPI-POZ-101@sppirx.com

Poziotinib is currently under clinical investigation and has not been approved for use in breast cancer.

Citation Format: Bhat G, Potter D, Bharadwaj J, Khan N, Shabazz L, Tache J, Yang Z. A phase 1b study of poziotinib in combination with T-DM1 in women with advanced or metastatic HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-07-04.

Effects of cross-fostering and developmental exposure to mixtures of environmental contaminants on hepatic gene expression in prepubertal 21 days old and adult male Sprague-Dawley rats

The notion that adverse health effects produced by exposure to environmental contaminants (EC) may be modulated by the presence of non-chemical stressors is gaining attention. Previously, our lab demonstrated that cross-fostering (adoption of a litter at birth) acted as a non-chemical stressor that amplified the influence of developmental exposure to EC on the glucocorticoid stress-response in adult rats. Using liver from the same rats, the aim of the current study was to investigate whether cross-fostering might also modulate EC-induced alterations in hepatic gene expression profiles. During pregnancy and nursing, Sprague-Dawley dams were fed cookies laced with corn oil (control, C) or a chemical mixture (M) composed of polychlorinated biphenyls (PCB), organochlorine pesticides (OCP), and methylmercury (MeHg), at 1 mg/kg/day. This mixture simulated the contaminant profile reported in maternal human blood. At birth, some control and M treated litters were cross-fostered to form two additional groups with different biological/nursing mothers (CC and MM). The hepatic transcriptome was analyzed by DNA microarray in male offspring at postnatal days 21 and 78-86. Mixture exposure altered the expression of detoxification and energy metabolism genes in both age groups, but with different sets of genes affected at day 21 and 78-86. Cross-fostering modulated the effects of M on gene expression pattern (MM vs M), as well as expression of energy metabolism genes between control groups (CC vs C). In conclusion, while describing short and long-term effects of developmental exposure to EC on hepatic transcriptomes, these cross-fostering results further support the consideration of non-chemical stressors in EC risk assessments.

Hepatic Hydatid Cyst: A Case Report

Hepatic hydatid disease is a goonotic disease caused by Echinococcus granulosus and it is endemic in different parts of the world. This infection is an important public health problem. Although it is distributed throughout the world but common in the livestock grazing regions of the world such as in Central Europe, Africa, South America, Central Asia and China. Here we present the case "30 years old female" with the complaints of right upper abdominal pain for 3 months, nausea & occasional vomiting for 1 month and was admitted under general surgery ward at Mymensingh Medical College Hospital, Mymensingh, Bangladesh on 12th March 2018. Considering history, physical examination, serological investigations, imaging studies and exploratory laparotomy the diagnosis is hepatic hydatid cyst. Echinococcus granulosus produces cysts in almost every organs of the body most commonly in the liver. Man is the incidental intermediate host where definitive host is carnivores such as dogs. Hydatid cyst always starts as a fluid filled, cyst like structure (stage I), which may proceed to a stage II lesion if daughter cysts and/or matrix develop. In some instances, the stage II lesion becomes hypermature and due to starvation, dies to become a mummified, inert, calcified, stage III lesion. Ultrsound is the preferred firstline imaging but CECT give more precise information regarding the morphology of the cyst. Magnetic Resonance Imaging is particularly useful because of its multiplaner capabilities and more detail anatomical resolution.

Magnetic Resonance Imaging of Cerebral Palsy in the Assessment of Time of Brain Insult

The aim of this cross-sectional study was to find out the role of Magnetic resonance imaging (MRI) in the assessment of time of brain insult in cerebral palsy (CP). The study was conducted in the Department of Radiology & Imaging, Mymensingh Medical College Hospital, Mymensingh and a total number of 35 patients with were enrolled from January 2015 to December 2016. Maximum patients (57.2%) were under five years followed by 34.3% were of 5 to <8 years and 8.7% were of 8 to <12 years of age and mean age was 4.7 years. Majority of the patients were male 28(80%) and female were 7(20%). Among the patients 23(65.7%) came from poor, whereas 11(31.4%) came from middle class and only one (2.9%) from rich socioeconomic group. According to gestational age of the patients, 26(74.3%) were term (≥37weeks) at delivery and rest (25.7%) were preterm (<37 weeks). Delayed cry after birth were present in 32 (80%) patients. Regarding types of cerebral palsy spastic diplegia, spastic quadriplegia, hemiplegia and extrapyramidal were found 3(8.6%), 25(71.4%), 4(11.4%) and 3(8.6%) respectively. Abnormal MRI was reported in 94.2% patients and gave clues to time of insult in 79.9% (excluding the 14.3% miscellaneous findings). The findings were mal-developments (5.7%), periventricular white matter lesions (25.7%), cortical or deep grey matter lesions (48.6%), miscellaneous (14.3%) and normal (5.7%). Brain mal-developments were more seen in term than in preterm born children (5% vs. 0%). Periventricular white matter lesions were seen significantly more in preterm than in term born children (77.8% vs. 3.9%). Cortical or deep grey matter lesions occurred significantly more in term than in preterm born children (60% vs. 20%). Based on the study it can be concluded that Magnetic Resonance Imaging (MRI) can help in the assessment of time of insult to the developing brain in cerebral palsy (CP).

Visualization and Classification of Deeply Seated Collateral Networks in Moyamoya Angiopathy with 7T MRI

BACKGROUND AND PURPOSE

Collateral networks in Moyamoya angiopathy have a complex angioarchitecture difficult to comprehend on conventional examinations. This study aimed to evaluate morphologic patterns and the delineation of deeply seated collateral networks using ultra-high-field MRA in comparison with conventional DSA.

MATERIALS AND METHODS

Fifteen white patients with Moyamoya angiopathy were investigated in this prospective trial. Sequences acquired at 7T were TOF-MRA with 0.22 × 0.22 × 0.41 mm³ resolution and MPRAGE with 0.7 × 0.7 × 0.7 mm³ resolution. Four raters evaluated the presence of deeply seated collateral networks and image quality in a consensus reading of DSA, TOF-MRA, and MPRAGE using a 5-point scale in axial source images and maximum intensity projections. Delineation of deeply seated collateral networks by different imaging modalities was compared by means of the McNemar test, whereas image quality was compared using the Wilcoxon signed-rank test.

RESULTS

The relevant deeply seated collateral networks were classified into 2 categories and 6 pathways. A total of 100 collateral networks were detected on DSA; 106, on TOF-MRA; and 73, on MPRAGE. Delineation of deeply seated collateral networks was comparable between TOF-MRA and DSA (P = .25); however, both were better than MPRAGE (P < .001).

CONCLUSIONS

This study demonstrates excellent delineation of 6 distinct deeply seated collateral network pathways in Moyamoya angiopathy in white adults using 7T TOF-MRA, comparable to DSA.

Translocation of a gut pathobiont drives autoimmunity in mice and humans

Despite multiple associations between the microbiota and immune diseases, their role in autoimmunity is poorly understood. We found that translocation of a gut pathobiont, Enterococcus gallinarum, to the liver and other systemic tissues triggers autoimmune responses in a genetic background predisposing to autoimmunity. Antibiotic treatment prevented mortality in this model, suppressed growth of E. gallinarum in tissues, and eliminated pathogenic autoantibodies and T cells. Hepatocyte-E. gallinarum cocultures induced autoimmune-promoting factors. Pathobiont translocation in monocolonized and autoimmune-prone mice induced autoantibodies and caused mortality, which could be prevented by an intramuscular vaccine targeting the pathobiont. E. gallinarum-specific DNA was recovered from liver biopsies of autoimmune patients, and cocultures with human hepatocytes replicated the murine findings; hence, similar processes apparently occur in susceptible humans. These discoveries show that a gut pathobiont can translocate and promote autoimmunity in genetically predisposed hosts.

Segmental resection is a safe oncological alternative to total proctocolectomy in elderly patients with ulcerative colitis and malignancy

AIM

The standard approach for the surgical management of colorectal cancer (CRC) in the setting of ulcerative colitis (UC) involves total proctocolectomy (TPC). However, some patients also undergo a partial resection (PR). This may be an attractive option in older patients with a high risk for surgery. The aim of this study was to compare the risk of metachronous cancer after PR or TPC for CRC in the setting of UC.

METHOD

This was a retrospective cohort study conducted through the Nationwide Veterans Affairs Healthcare System (VA). Patients who had UC and underwent a PR or TPC for CRC were followed from the time of their surgery to their most recent clinical follow-up. The primary outcome was development of metachronous cancer in the PR group. Secondary outcomes included surgical and medical outcomes.

RESULTS

Fifty-nine patients were included: 24 (40.7%) underwent PR and 35 (59.3%) underwent TPC. The median age at cancer diagnosis was 73.0 and 61.7 years in PR and TPC groups, respectively (P < 0.0005). Amongst patients undergoing PR, 15 (60%) had no active UC at the time of surgery, whereas in patients undergoing TPC, at the time of surgery eight (23.5%) had no active UC (P = 0.005). No patient who underwent a partial colectomy developed a metachronous cancer in the retained colonic segment during the follow-up period (median 7 years).

CONCLUSION

Our study suggests that PR for CRC in the setting of UC may be a viable option in a selected cohort of patients, especially among the elderly.

Feasibility of Brain Atrophy Measurement in Clinical Routine without Prior Standardization of the MRI Protocol: Results from MS-MRIUS, a Longitudinal Observational, Multicenter Real-World Outcome Study in Patients with Relapsing-Remitting MS

BACKGROUND AND PURPOSE

Feasibility of brain atrophy measurement in patients with MS in clinical routine, without prior standardization of the MRI protocol, is unknown. Our aim was to investigate the feasibility of brain atrophy measurement in patients with MS in clinical routine.

MATERIALS AND METHODS

Multiple Sclerosis and Clinical Outcome and MR Imaging in the United States (MS-MRIUS) is a multicenter (33 sites), retrospective study that included patients with relapsing-remitting MS who began treatment with fingolimod. Brain MR imaging examinations previously acquired at the baseline and follow-up periods on 1.5T or 3T scanners with no prior standardization were used, to resemble a real-world situation. Brain atrophy outcomes included the percentage brain volume change measured by structural image evaluation with normalization of atrophy on 2D-T1-weighted imaging and 3D-T1WI and the percentage lateral ventricle volume change, measured by VIENA on 2D-T1WI and 3D-T1WI and NeuroSTREAM on T2-fluid-attenuated inversion recovery examinations.

RESULTS

A total of 590 patients, followed for 16 months, were included. There were 585 (99.2%) T2-FLAIR, 425 (72%) 2D-T1WI, and 166 (28.2%) 3D-T1WI longitudinal pairs of examinations available. Excluding MR imaging examinations with scanner changes, the analyses were available on 388 (65.8%) patients on T2-FLAIR for the percentage lateral ventricle volume change, 259 and 257 (43.9% and 43.6%, respectively) on 2D-T1WI for the percentage brain volume change and the percentage lateral ventricle volume change, and 110 (18.6%) on 3D-T1WI for the percentage brain volume change and percentage lateral ventricle volume change. The median annualized percentage brain volume change was -0.31% on 2D-T1WI and -0.38% on 3D-T1WI. The median annualized percentage lateral ventricle volume change was 0.95% on 2D-T1WI, 1.47% on 3D-T1WI, and 0.90% on T2-FLAIR.

CONCLUSIONS

Brain atrophy was more readily assessed by estimating the percentage lateral ventricle volume change on T2-FLAIR compared with the percentage brain volume change or percentage lateral ventricle volume change using 2D- or 3D-T1WI in this observational retrospective study. Although measurement of the percentage brain volume change on 3D-T1WI remains the criterion standard and should be encouraged in future prospective studies, T2-FLAIR-derived percentage lateral ventricle volume change may be a more feasible surrogate when historical or other practical constraints limit the availability of percentage brain volume change on 3D-T1WI.

Ethnobotanical and ecological study of Punica granatum in Dir district, Khyber Pakhtunkhwa, Pakistan

Punica granatum L. (wild) belongs to family Punicaceae, a woody plant, predominantly found on calcareous and alkaline soils. The species is extensively utilized as food and firewood and for the extraction of various chemicals due to its therapeutic properties. To understand the ethno-botanical and ecological status of the species on a regional scale, a questionnaire survey was conducted in the Dir (L) area using close and open-ended questionnaires. Data collected from 124 respondents were analysed quantitatively using statistical analysis to calculate indices like Relative Frequency of Citation (RFC), Use value (UV) and multivariate analysis. GPS data used for the presence data of the plants were used to develop GIS thematic maps. Geo-referenced data on P. granatum was collected from the study area, using GPS. Results suggest that the plant is mostly used as a remedy for dry cough, as an astringent, people used powder form of fruit peelings. It was documented in the present investigation that P. granatum is mainly eradicated due to its extensive use as firewood. The study also evaluated on the major aspect of how the P. granatum can be conserved naturally. It was found out that the plant is conserved in areas inaccessible to humans. The status of the vegetation community around this plant was also explored, it is found out that specific shrub and tree communities were major flora growing in proximity to P. granatum. The finding of this survey has concluded that wild P. granatum is an endangered species due to its extensive and uncontrollable use for firewood, curing diseases and its economic potential. These findings could be exploited to take necessary steps for the conservation of this species.