Successful percutaneous retrieval of embolized transcatheter left atrial appendage closure device (Watchman) using a modified vascular retrieval forceps

Transcatheter closure of the left atrial appendage (LAA) is increasingly considered as an alternative to oral anticoagulation in patients with previous major bleeding or at high-risk of bleeding. Device embolization with transcatheter LAA closure is a rare complication. Most cases are asymptomatic, but it can be life threatening. Depending on the location of embolization, percutaneous retrieval is feasible. Snares are usually used for retrieval, but other devices may be used. We report the case of a 63-year gentleman who underwent an uneventful LAA closure with Watchman device and routine testing next day showed embolization to the abdominal aorta. Retrieval was performed using a modified Cook vascular retrieval forceps.

Lay health educators within primary care practices to improve cancer screening uptake for South Asian patients: challenges in quality improvement

BACKGROUND

Cancer screening uptake is known to be low among South Asian residents of Ontario. The objective of this pilot study was to determine if lay health educators embedded within the practices of primary care providers could improve willingness to screen and cancer screening uptake for South Asian patients taking a quality improvement approach.

MATERIALS AND METHODS

Participating physicians selected quality improvement initiatives to use within their offices that they felt could increase willingness to screen and cancer screening uptake. They implemented initiatives, adapting as necessary, for six months.

RESULTS

Four primary care physicians participated in the study. All approximated that at least 60% of their patients were of South Asian ethnicity. All physicians chose to work with a preexisting lay health educator program geared toward South Asians. Health ambassadors spoke to patients in the office and telephoned patients. For all physicians, ~60% of South Asian patients who were overdue for cancer screening and who spoke directly to health ambassadors stated they were willing to be screened. One physician was able to track actual screening among contacted patients and found that screening uptake was relatively high: from 29.2% (colorectal cancer) to 44.6% (breast cancer) of patients came in for screening within six months of the first phone calls. Although physicians viewed the health ambassadors positively, they found the study to be time intensive and resource intensive, especially as this work was additional to usual clinical duties.

DISCUSSION

Using South Asian lay health educators embedded within primary care practices to telephone patients in their own languages showed promise in this study to increase awareness about willingness to screen and cancer screening uptake, but it was also time intensive and resource intensive with numerous challenges. Future quality improvement efforts should further develop the phone call invitation process, as well as explore how to provide infrastructure for lay health educator training and time.

Abstract OT1-01-07: A phase 2 study of eribulin followed by doxorubicin and cyclophosphamide as preoperative therapy for HER2-negative inflammatory breast cancer

Background: HER2 negative(neg) inflammatory breast cancer(IBC) exhibits relative resistance to chemotherapy evidenced by pCR(pathologic complete response rate) rates of 12-25% with preoperative taxane/anthracycline regimens. Eribulin(Eisai®) inhibits microtubular function via sequestration of tubulin into nonfunctional aggregates, thus being effective against taxane-resistant cancer. Preclinical data shows 2 mechanisms of action: reversion of EMT(epithelial to mesenchymal transition) and normalization of tumor vascularity. Treatment of triple negative breast cancer(TNBC) cell-lines with eribulin results in downregulation of mesenchymal markers with concomitant increase in expression of classical epithelial markers(Yoshida BJC 2014). In PDX models, eribulin improved blood perfusion in central region of tumors, increased vessel density, reduced vessel diameter, and reduced hypoxia. IBC is highly angiogenic, with increased microvessel density, higher fraction of proliferating endothelial cells and greater expression of pro-angiogenic genes compared with non-IBC(McCarthy CCR 2002). This preoperative study(EAC) exploits the angiogenic properties of IBC with the treatment scheme of eribulin(E) followed by doxorubicin/cyclosphosphamide(AC) in newly diagnosed HER2neg IBC.

Methods: Pts with HER2neg Stage III (cT4d,any N,M0) IBC are eligible if they have not received prior therapy for BC, have adequate organ function, cardiac ejection fraction > 50%, and willing to undergo 2 research biopsies (rbx) of the affected breast. Following baseline rbx, pts receive cycle 1, day(d)1 eribulin 1.4 mg/m2. A 2nd rbx occurs on d8, prior to dosing of E. Following 3 more cycles of E(1.4mg/m2 d1,d8,every 21d), pts receive 4 cycles of dose-dense AC(A-60 mg/m2,C-600mg/m2 every 14d). Pts with adequate disease response undergo mastectomy/axillary lymph node dissection followed by chest wall/regional lymph node radiation. Adjuvant endocrine therapy is used if hormone receptor positive. An imaging sub-study evaluates tumor perfusion via DCE-MRI pre and post 1st dose E.

Correlatives: To investigate whether E induces reversion of EMT in IBC, expression of 10 EMT-related genes are determined in each rbx, and normalization of tumor vessel phenotype are assessed by expression of 15 angiogenesis-related genes in rbx by RT-qPCR. Gene expression will be repeated on residual tumor at mastectomy. An imaging sub-study of DCE-MRI (10 pts) will assess vascular remodeling via changes in Ktrans , ve and vp determination of IBC region of interest, core and rim and changes in the iAUC computed pre and post 1st dose E.

Statistics: The primary endpoint is pCR. A Simon two-stage design is used. If the proportion of pts having pCR is < 0.10 then EAC is considered minimally effective, versus alternative hypothesis that EAC is worthy of further study if proportion pCR > 0.30. In the 1st stage, if < 2/16 pts have pCR, the study is stopped; if > 3 pts have pCR, the study proceeds. In the 2nd stage, EAC is rejected if < 4 of 25 pts have a pCR(α=0.10;β=0.10). Up to 25 pts will be enrolled. Secondary endpoints are residual cancer burden, disease-free survival, time to treatment failure and overall survival. Clinical trial information: NCT02623972.

Citation Format: Overmoyer B, Goel S, Regan M, Hirshfield-Bartek J, Schlosnagel E, Yeh E, Qin L, Bellon J, Nakhlis F, Jacene H, Winer E. A phase 2 study of eribulin followed by doxorubicin and cyclophosphamide as preoperative therapy for HER2-negative inflammatory breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-01-07.

Abstract OT2-02-03: Pilot study of zirconium-89 bevacizumab positron emission tomography for imaging angiogenesis in patients with inflammatory breast carcinoma receiving preoperative chemotherapy

Background: Inflammatory breast cancer (IBC) continues to have a poor prognosis despite standard tri-modality treatment with chemotherapy, mastectomy and radiation. Current methods of assessing primary tumor response (i.e., clinical exam and breast magnetic resonance imaging [MRI]) are limited for distinguishing residual tumor from responsive disease because of persistent morphologic changes in the breast. Therefore, the inability to accurately assess tumor response during treatment often results in the continuation of ineffective systemic chemotherapy until definitive pathologic evaluation at mastectomy. IBC has a highly angiogenic phenotype which is believed to play a role in this tumor's aggressiveness. The novel radiotracer Zirconium-89 (89Zr)-bevacizumab was developed for imaging tumor angiogenesis with PET. We hypothesize that, as an imaging biomarker of angiogenesis, 89Zr-bevacizumab-PET/CT is a more specific noninvasive functional imaging modality for detecting the presence of tumor angiogenesis compared to current diagnostic methods and will serve as a predictor of response to therapy in patients (pts) with IBC.

Methods: Pts with newly diagnosed HER2neg IBC who will receive preoperative chemotherapy are eligible for this pilot study. 89Zr-bevacizumab-PET/CT, breast MRI and FDG-PET/CT are performed before, after 2 cycles, and at the completion of preoperative therapy. Biopsies of primary IBC tumors are obtained prior to and after 2 cycles of preoperative therapy. At the completion of preoperative therapy, pts proceed to mastectomy or biopsy if ineligible to proceed to mastectomy based on current standards for assessing primary tumor response, i.e., clinical exam, breast MRI and lack of systemic progression. At the time of mastectomy, standard evaluation of the surgical specimen will determine pathologic response of IBC to preoperative chemotherapy. A research sample will be collected if residual cancer is present at the time of mastectomy for histologic evaluation of tumor angiogenesis.

Objectives/Correlatives: The primary objective is to determine feasibility of 89Zr-bevacizumab-PET/CT imaging in pts with IBC. The primary endpoint is assessment of radiolabeling of chelated bevacizumab and number of successfully acquired 89Zr-bevacizumab-PET/CT scans. Correlative studies will be performed on IBC tissue to assess extent of angiogenesis including microvessel density, vessel diameter, vascular pericyte coverage and tumor VEGF levels. Secondary objectives are: 1) To determine if 89Zr-bevacizumab accumulation in primary IBC tumors correlates with the extent of angiogenesis determined by correlative analysis on IBC tissue; 2) To assess the predictive value of 89Zr-bevacizumab-PET/CT after 2 cycles and at the end of preoperative therapy for determining pathologic response at mastectomy as given by residual cancer burden.

Statistics: This is an accrual, not statistical based, feasibility justification. Planned sample size is 10 in order to make a preliminary statement about feasibility and ability for 89Zr-bevacizumab-PET/CT to serve as a surrogate in vivo biomarker of tumor angiogenesis and response to preoperative chemotherapy.

Clinical Trial Information: NCT01894451.

Citation Format: Jacene HA, Overmoyer B, Schlosnagle EJ, Abbott A, Yeh E, Paolino J, Goel S, Culhane A, Bellon JR, Nakhlis F, Hirshfield-Bartek J, Van den Abbeele A. Pilot study of zirconium-89 bevacizumab positron emission tomography for imaging angiogenesis in patients with inflammatory breast carcinoma receiving preoperative chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-02-03.

The suppression of droplet-droplet coalescence in a sheared yield stress fluid

Efforts to stabilize emulsions against coalescence in flow have often focused on modifying properties of the interface between the continuous and dispersed phases, to create a repulsive barrier against coalescence. But prior to experiencing any interaction force, the liquid film between two colliding drops has to drain, and if this drainage process is arrested, coalescence will be suppressed. In this work, scaling analyses and thin-film lubrication simulations are used to study the hydrodynamic drainage properties of thin films of a Bingham fluid (a yield stress fluid, which flows only when a critical stress is exceeded) created between two drops colliding under the action of a constant force. Our study shows that the hydrodynamic drainage process can be arrested completely when the film reaches a critical thickness, before attractive forces result in the rupture of the film, provided that the film shape is in the dimpled configuration. This critical thickness is h_f=6τ₀²R³/γ², where τ₀ is the yield stress of the suspending medium, R is the drop radius and γ is the interfacial tension between the fluids. The yield stress can thus serve as an independent tuning parameter that sets an upper bound on the drop size beyond which coalescence is turned off in sheared emulsions.

Adductor accessorius - an unusual supernumerary adductor muscle of thigh

The knowledge of variant anatomy of medial compartment of thigh is extremely important in surgical procedures requiring obturator nerve block. The nerve block is also recommended for providing additional analgesia following major knee surgeries and for relieving painful adductor muscle spasm. The interfascial injection technique is commonly followed in ultrasound guided obturator nerve block. For this procedure it is imperative to identify the adductor muscles on sonography to inject the anesthetic solution in the intermuscular fascial planes. The presence of an additional muscle can prove useful in myocutaneous flap surgeries for reconstruction especially of perineum. We hereby report a case of such an anomalous supernumerary adductor muscle present between adductor brevis and proximal part of adductor magnus, in an adult Indian male cadaver, recorded during routine dissection in Department of Anatomy, Vardhman Mahavir Medical College and Safdarjung Hospital. The muscle was innervated by the posterior division of obturator nerve. The morphology, embryological basis and clinical aspects are also discussed.

Tuning the carrier concentration using Zintl chemistry in Mg3Sb2, and its implications for thermoelectric figure-of-merit

Zintl compounds are potential candidates for efficient thermoelectric materials, because typically they are small band gap semiconductors. In addition, such compounds allow fine tuning of the carrier concentration by chemical doping for the optimization of thermoelectric performance. Herein, such tunability is demonstrated in Mg3Sb2-based Zintl compounds via Zn(2+) doping at the Mg(2+) site of the anionic framework (Mg2Sb2)(2-), in the series Mg3-xZnxSb2 (0 ≤ x ≤ 0.1). The materials have been successfully synthesized using the spark plasma sintering (SPS) technique. X-ray diffraction (XRD) analysis confirms a single solid solution phase of Mg3-xZnxSb2 (0 ≤ x ≤ 0.1). The thermoelectric properties are characterized by the Seebeck coefficient, electrical conductivity, and thermal conductivity measurements from 323 K to 773 K. Isoelectronic Zn substitution at the Mg site presents the controlled variation in the carrier concentration for optimizing the high power factor and reduced thermal conductivity. These results lead to a substantial increase in ZT of 0.37 at 773 K for a composition with x = 0.10 which is ∼42% higher than undoped Mg3Sb2. The electronic transport data for the Mg3-xZnxSb2 (0 ≤ x ≤ 0.1) compound are analyzed using a single parabolic band model predicting that Mg2.9Zn0.1Sb2 exhibits a near-optimal carrier concentration for high ZT. The electronic structure of transport properties of these disordered Mg3-xZnxSb2 (0 ≤ x ≤ 0.1) is also studied using density functional theory and the results obtained are in good agreement with experimental results. The low cost, lightness and non-toxicity of the constituent elements make these materials ideal for mid-temperature thermoelectric applications.

Circulating T-helper 17 cells and associated cytokines in psoriasis

BACKGROUND

Recently, a new population of IL-17-producing CD4 T helper (Th) cells, named Th17, was identified and shown to be involved in various inflammatory and autoimmune diseases, including psoriasis.

AIM

To determine the frequency of Th17 cells and related cytokines in peripheral blood of patients with psoriasis, and to analyse their association with disease severity.

METHODS

This was a prospective study comprising 34 patients with psoriasis and 24 healthy controls. Clinicoepidemiological details of patients were recorded, and severity of psoriasis was assessed by means of the Psoriasis Area and Severity Index. Circulating Th1 and Th17 cells in untreated patients with psoriasis and healthy controls were quantified by flow cytometry. In sera collected from patients with psoriasis and healthy controls, concentrations of IL-17A and IL-23 were examined by ELISA.

RESULTS

Increased frequencies of CD4+ IL-17A+ T cells were seen in peripheral blood of patients with psoriasis vulgaris (P < 0.001). Although serum IL-17A and IL-23 concentrations were higher in patients with psoriasis than in controls, the results did not reach statistical significance. We could not find any correlation between the studied T cells or related cytokines and the disease severity.

CONCLUSION

Increased serum levels of circulating Th17 cells and related cytokines may contribute to the cutaneous pathology of psoriasis, as well as the inflammatory process that is a hallmark of psoriasis.

Yield of intensified tuberculosis case-finding activities using Xpert(®) MTB/RIF among risk groups in Nepal

SETTING

Twenty-two districts of Nepal, where intensified case-finding (ICF) activities for tuberculosis (TB) were implemented among risk groups under the TB REACH initiative in collaboration with the National TB Programme from July 2013 to November 2015.

OBJECTIVES

To assess the yield of TB screening using an algorithm with smear microscopy followed by Xpert(®) MTB/RIF.

DESIGN

A descriptive study using routinely collected data.

RESULTS

Of 145 679 individuals screened, 28 574 (19.6%) had presumptive TB; 1239 (4.3%) of these were diagnosed with TB and 1195 (96%) were initiated on anti-tuberculosis treatment. The yield of screening was highest among people living with the human immunodeficiency virus (PLHIV) (6.1%), followed by household contacts (3.5%) and urban slum dwellers (0.5%). Among other risk groups, such as prisoners, factory workers, refugees and individuals with diabetes, the yield was less than 0.5%. The number needed to screen to diagnose an active TB case was 17 for PLHIV, 29 for household contacts and 197 for urban slum dwellers. Of 11 525 patients from ICF and the routine programme, 112 (1%) were diagnosed with multidrug-resistant TB.

CONCLUSION

There was a substantial yield of TB cases among risk groups such as PLHIV and household contacts. Although the yield in urban slum dwellers was found to be moderate, some intervention should nonetheless be targeted because of the large population and poor access to care in this group.

Impact of modular training on tobacco control on the knowledge of health workers in two jurisdictions of northern India

BACKGROUND

National Tobacco Control Programme was launched in India in year 2007-08. It was realized that community health workers can play an important role of agents for positive change to bring down the tobacco morbidity and mortality in the country. Keeping this in view, a health worker guide was developed by the Government of India, Ministry of Health and Family Welfare (GOI) in collaboration with The Union South-East Asia (The Union) in the year 2010. The guide provides the information needed by the most basic level of health workers to effectively address the problem of tobacco use in the community. A modular training was conducted in two jurisdictions in India (namely, Chandigarh and Hamirpur (Himachal Pradesh)) to assess the usefulness of the guide as training material for community health workers in undertaking tobacco control activities at community and village levels.

MATERIALS AND METHODS

A total of 271 participants were trained, which included 133 from Chandigarh and 138 from Hamirpur. The pre and post-training assessment of knowledge of health worker was done.

RESULTS

There was marked increase in post-test scores as compared to the pretest scores. The health workers scoring more than 60% increased from 40% in the pretest to over 80% in the post-test. Only three workers had a post-test score of less than 30% against 54 workers in the pretest.

CONCLUSION

The understanding on tobacco control had increased significantly after the training in each group. It is strongly recommended that such training should be replicated to all community health workers across all the states in India.

Development of a multidisciplinary program for evaluation and treatment of pancreatic cancer in a community healthcare system

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Background: The incidence and mortality of pancreas cancer is rising in the United States. Only patients who are able to have complete (R0) resection have the potential of cure. Optimal surgical outcomes are influenced by local center volume and multidisciplinary support. We describe the development of a multidisciplinary approach to the evaluation and treatment of pancreas cancer in a community health care system. Methods: This project was initiated by the WellStar Cancer Program, encompassing 5 hospitals. An Institutional Guideline was developed, based upon NCCN, with refinements related to local capabilities and preferences. The Guideline emphasized the review of cases at a weekly tumor board for multidisciplinary coordination of care. Standards for staging evaluations, medical imaging, chemotherapy choices, radiation therapy, and surgical approach were included. A GI Nurse Navigator attended the conferences and assisted in the coordination of care. Specific outcomes were tracked by the Nurse Navigator and the Cancer Registry. Here we describe the program impact related to staging, treatment, nurse navigation, volume and outcomes during the 2011-2014 development phase of the program. Results: A total of 308 cases of pancreas cancer were captured by the registry in 2011-2014. 131 were diagnosed with stage IV disease and offered palliative therapy. 30 Stage I and 139 Stage II-III underwent staging evaluation and consideration of multidisciplinary care, summarized in the table below, and compared to a baseline registry cohort of the 4 preceding years. Conclusions: The development of a Multidisciplinary Team approach to pancreas cancer within a 5 hospital community system has led to improvement in treatment outcomes, including R0 resection rate. Full 2-year results to be updated at the meeting. [Table: see text]

Screening retreatment tuberculosis patients for drug resistance in mid-west Nepal: how well are we doing?

SETTING

Multidrug-resistant tuberculosis (MDR-TB, defined as resistance to isoniazid and rifampicin) is poorly detected in Nepal; one reason may be poor functioning of culture and drug susceptibility testing (CDST) services for retreatment tuberculosis (TB) patients.

OBJECTIVES

To determine, among retreatment TB patients in mid-west Nepal, 1) the number of patients registered for treatment between July 2011 and July 2012; 2) the number submitting sputum specimens for CDST to the Central Reference Laboratory (CRL), Kathmandu, along with the results; and 3) the length of time for submission and receipt of specimens.

DESIGN

Retrospective cohort study involving the review of treatment and laboratory registers from the Nepalgunj TB Referral Centre and the CRL.

RESULTS

Of 431 retreatment patients, 66 (15%) submitted sputum samples, of which 63 reached the CRL. Of these, 39 (62%) were culture-positive; 13 (33%) patients had MDR-TB. The CDST results of 19 patients were received back at the TB Referral Centre. The median turnaround time from sending specimens to receipt of results at the TB Referral Centre was 119 days.

CONCLUSION

Less than 10% of retreatment TB patients in mid-West Nepal had CDST results recorded, leading to the underdiagnosis of MDR-TB in the region. Urgent solutions are needed to rectify this problem.

Spinal metastasis of breast cancer presenting after 25 years: An extremely rare presentation

Breast cancer is the most frequently diagnosed cancer in females of the developed world and is gradually becoming the leading cause in the developing world as well. The innate biology of breast cancer is marked by varied presentations, characteristics, response, recurrence and metastatic phenomenon. Even an early stage breast cancer has the potential to recur and/or metastasize after extremely long duration and this possibility should be borne in the clinician's mind.

Rare atypical vascular pattern of subscapular artery: Anatomico-clinical insight

BACKGROUND AND OBJECTIVE

The use of muscles of scapular region in transposition and reparative surgery has made the anatomical knowledge of axillary artery and its branches imperative. The subscapular arterial tree is frequently used as a source of microvascular grafts to replace damaged or diseased portion of arteries especially in upper and lower limbs. This investigation is aimed to study the variation in branching pattern of the third part of axillary artery.

MATERIALS AND METHODS

Routine educational cadaveric dissection of a young adult Indian male cadaver.

RESULTS

The present article highlights a rare variation of the subscapular artery and its branches. The subscapular artery displayed a unique pattern of trifurcation. Its branches were seen supplying serratus anterior, subscapularis, latissimus dorsi and teres major muscles.

CONCLUSIONS

The study focuses on a new variation of the subscapular artery which could prove useful for interventional radiologists and surgeons in reconstructive surgeries.

Lithium overdose: early hemodialysis is the key!

A 65-year-old gentleman was referred to our hospital with encephalopathy and renal failure. His medications included lithium for the treatment of bipolar disorder. The clinical examination and the laboratory investigations that followed revealed findings classical of lithium overdose. The patient was successfully managed and discharged from the hospital on Day 9 of admission. Clinicians should be aware of this rather unusual and relatively rare differential cause of acute on chronic renal failure with encephalopathy.

Lithium overdose: early hemodialysis is the key!

A 65-year-old gentleman was referred to our hospital with encephalopathy and renal failure. His medications included lithium for the treatment of bipolar disorder. The clinical examination and the laboratory investigations that followed revealed findings classical of lithium overdose. The patient was successfully managed and discharged from the hospital on Day 9 of admission. Clinicians should be aware of this rather unusual and relatively rare differential cause of acute on chronic renal failure with encephalopathy.