Langerhans cell histiocytosis of the shoulder girdle, pelvis and extremities: a review of radiographic and MRI features in 85 cases

OBJECTIVES

To describe the radiographic and MRI features of histologically proven Langerhans cell histiocytosis (LCH) of the bone.

MATERIALS AND METHODS

A retrospective review of the radiographic and MRI features of 85 histologically proven cases of skeletal LCH over a 12-year period. Clinical data recorded included age, gender and location. Radiographic features evaluated included Lodwick grading, cortical/periosteal response and matrix mineralisation. MRI features assessed included lesion size and T1-weighted signal intensity (T1W SI), nature of margin, hypointense rim, enhancement pattern, bone marrow and soft tissue oedema, soft tissue mass, fluid-fluid levels, the penumbra sign and the budding and bulging signs.

RESULTS

The study included 85 patients, 54 males and 31 females with mean age of 13 years (range 1-76 years). The femur was the commonest bone involved (38.8%), followed by the scapula (9.4%), clavicle (8.2%), ilium (8.2%) and ischium (8.2%). The mean maximal lesion size was 40 mm (range 16-85 mm). The commonest radiographic appearance was of a lytic lesion with no appreciable sclerotic rim, an intact expanded cortex and either absent or laminated periosteal response. MRI demonstrated a hypointense rim (41.5%), the budding (31.7%) and bulging (36.6%) signs, eccentric extra-osseous mass (42.7%), prominent bone marrow (95.3%) and soft tissue oedema (84.1%). Rarer features included haemorrhage (2.4%), the penumbra sign (3.5%) and fluid-fluid levels (2.4%). Thirteen of 25 post-contrast studies showed peripheral/rim enhancement with central necrosis.

CONCLUSIONS

LCH classically presents as a moderately aggressive lytic bone lesion on radiography, with prominent reactive bone and soft tissue oedema being a characteristic feature on MRI.

Real-world experience of eltrombopag in immune thrombocytopenia

Immune thrombocytopenia (ITP) is characterized by decreased platelet count in the peripheral circulation. The first-line therapy is corticosteroids with 53-80% overall response rate. Eltrombopag has been used as second-line therapy in ITP for over a decade now. The long-term efficacy and safety profile have been widely reported in the western world. However, the data from the resource-constraint settings of the developing world is scarce. We aim to present the real-life experience of efficacy and safety of eltrombopag from the resource-constraint settings. This was a retrospective, single-center study conducted at a tertiary care hospital in Northern India from 2012-2019. On audit of medical records, patients of ITP receiving eltrombopag were screened for inclusion. Patients whose treatment outcomes were not available were excluded. Finally, 53 patients were analyzed using statistical packages of Python v3.7. The patients' median age was 35 years (range 17-78), with 23 (43.4%) being female. The median time to response was 35 days (range 28-50 days) and the cumulative overall response rates (ORR) at day 30, day 60 and day 90 were 41.5%, 69.8%, and 81.1% respectively. A total of 10 patients on eltrombopag relapsed during follow up. The cumulative rate of relapse at one year, three years, and five years were 6.6%, 25.3%, and 47.7%, respectively. There was no significant difference in outcome (response rate or relapse) in any subgroups depending on age, sex, duration of disease, number of prior lines of treatment, splenectomy, or baseline platelet count. Six patients stopped eltrombopag after having a median sustained response for 796 days (range 658-1185), and after a median follow up of 624 days (range 92-1339), they continued to be in remission. Seventeen patients (17/53, 32%) reported one or more adverse events while on eltrombopag therapy. A total of 49 adverse events (n=4, grade ≥3 CTCAEv4) were noted. Anemia was the most frequent adverse event followed by hepatobiliary dysfunction as reflected by deranged AST/ALT or raised bilirubin. The use of eltrombopag among adult ITP patients in resource-constraint settings was well-tolerated and yielded excellent overall response. The benefit was found to be sustained on long-term follow up. However, events like anemia, hepatobiliary, and thrombotic complications merit closer follow up.

Gastrointestinal stress as innate defence against microbial attack

The human gastrointestinal (GI) tract has been bestowed with the most difficult task of protecting the underlying biological compartments from the resident commensal flora and the potential pathogens in transit through the GI tract. It has a unique environment in which several defence tactics are at play while maintaining homeostasis and health. The GI tract shows myriad number of environmental extremes, which includes pH variations, anaerobic conditions, nutrient limitations, elevated osmolarity etc., which puts a check to colonization and growth of nonfriendly microbial strains. The GI tract acts as a highly selective barrier/platform for ingested food and is the primary playground for balance between the resident and uninvited organisms. This review focuses on antimicrobial defense mechanisms of different sections of human GI tract. In addition, the protective mechanisms used by microbes to combat the human GI defence systems are also discussed. The ability to survive this innate defence mechanism determines the capability of probiotic or pathogen strains to confer health benefits or induce clinical events respectively.

Safety and Tolerability of Clofazimine in a Cohort of Children With Odontogenic Mycobacterium abscessus Infection

Mycobacterium abscessus infections can be challenging to treat. Clofazimine has excellent in vitro activity against M abscessus, but reports of its use, particularly in children, have been limited. In this study, clofazimine was given to 27 children during an outbreak of odontogenic mycobacterial infections and seemed to be well tolerated as part of a multidrug regimen.

First Measurement of Λ_{c} Baryon Production in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the first measurement of the charmed baryon Λ_{c}^{±} production at midrapidity (|y|<1) in Au+Au collisions at sqrt[s_{NN}]=200  GeV collected by the STAR experiment at the Relativistic Heavy Ion Collider. The Λ_{c}/D^{0} [denoting (Λ_{c}^{+}+Λ_{c}^{-})/(D^{0}+D[over ¯]^{0})] yield ratio is measured to be 1.08±0.16  (stat)±0.26  (sys) in the 0%-20% most central Au+Au collisions for the transverse momentum (p_{T}) range 3<p_{T}<6  GeV/c. This is significantly larger than the pythia model calculations for p+p collisions. The measured Λ_{c}/D^{0} ratio, as a function of p_{T} and collision centrality, is comparable to the baryon-to-meson ratios for light and strange hadrons in Au+Au collisions. Model calculations including coalescence hadronization for charmed baryon and meson formation reproduce the features of our measured Λ_{c}/D^{0} ratio.

Protocol for the development and validation procedure of the managing the link and strengthening transition from child to adult mental health care (MILESTONE) suite of measures

Background

Mental health disorders in the child and adolescent population are a pressing public health concern. Despite the high prevalence of psychopathology in this vulnerable population, the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) has many obstacles such as deficiencies in planning, organisational readiness and policy gaps. All these factors contribute to an inadequate and suboptimal transition process. A suite of measures is required that would allow young people to be assessed in a structured and standardised way to determine the on-going need for care and to improve communication across clinicians at CAMHS and AMHS. This will have the potential to reduce the overall health economic burden and could also improve the quality of life for patients travelling across the transition boundary. The MILESTONE (Managing the Link and Strengthening Transition from Child to Adult Mental Health Care) project aims to address the significant socioeconomic and societal challenge related to the transition process. This protocol paper describes the development of two MILESTONE transition-related measures: The Transition Readiness and Appropriateness Measure (TRAM), designed to be a decision-making aide for clinicians, and the Transition Related Outcome Measure (TROM), for examining the outcome of transition.

Methods

The TRAM and TROM have been developed and were validated following the US FDA Guidance for Patient-reported Outcome Measures which follows an incremental stepwise framework. The study gathers information from service users, parents, families and mental health care professionals who have experience working with young people undergoing the transition process from eight European countries.

Discussion

There is an urgent need for comprehensive measures that can assess transition across the CAMHS/AMHS boundary. This study protocol describes the process of development of two new transition measures: the TRAM and TROM. The TRAM has the potential to nurture better transitions as the findings can be summarised and provided to clinicians as a clinician-decision making support tool for identifying cases who need to transition and the TROM can be used to examine the outcomes of the transition process.

Trial registration

MILESTONE study registration: ISRCTN83240263 Registered 23-July-2015 - ClinicalTrials.gov NCT03013595 Registered 6 January 2017.

Surgical management of atypical mycobacterial cervical lymphadenitis in an outbreak of odontological infection

INTRODUCTION

We report on our experience with surgical management of nosocomial Mycobacterium abscessus cervical lymphadenitis in the setting of an epidemic linked to a dental practice in the community.

METHODS

This is an observational case series of children who required surgical treatment of cervical lymphadenitis as part of multidisciplinary management of nosocomial M. abscessus infections. We describe the criteria for surgical management of cervical lymphadenitis as well as patient characteristics and outcomes.

RESULTS

Over 1000 children undergoing pulpectomies and pulpotomies at a local dental practice with a contaminated water source were identified as potentially susceptible to atypical mycobacteria infection, identified as M. abscessus. Between August 2016 and May 2017 108 children underwent inpatient evaluation at our institution by general pediatricians and pediatric infectious disease specialists. 90 children required at least 1 surgical intervention by pediatric otolaryngology and/or oral and maxillofacial surgery (OMFS). Children were evaluated by the Pediatric Otolaryngology service if computer tomography (CT) scan of the neck demonstrated lymph nodes of at least 1.5 cm in shortest dimension or lymph nodes with central hypolucencies suspicious for infection with central necrosis. Pediatric Otolaryngology intervened on 11 patients all of whom required selective cervical lymphadenectomy with or without curettage. These patients ranged in age from 3 to 8 years; 8 were male, 6 had concurrent pulmonary nodules. Two patients underwent curettage in addition to lymphadenectomy. Five patients required at least 2 surgical interventions by Pediatric Otolaryngology.

CONCLUSION

We found M. abscessus to be an aggressive infection requiring early cervical lymphadenectomy in select patients.

Acute myocardial infarction associated with severe Plasmodium vivax malaria

Malaria is still a major public health problem, even after many preventive strategies. Plasmodium vivax is also a major health concern now due to the addition of new unusual manifestations day by day in its clinical profile. Herewith, we report a case of a 15-yr-old male of severe P. vivax malaria (complicated with thrombocytopenia, hepatitis, acute lung injury, and shock), who developed chest pain. Later, he was confirmed to have acute myocardial infarction based on electrocardiography, cardiac enzymes, and echocardiography. PubMed and Google-based literature search found that it was the first confirmed case of this type. Fortunately, timely diagnosis and appropriate management saved his life.

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Introduction:

Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment.

Material and Methods:

Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes.

Results:

Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor.

Conclusion:

“Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

175 Use of equine chorionic gonadotrophin in a minimum-handling protocol for oocyte collection in bison

Wood bison (Bison bison athabascae) and plains bison (Bison bison bison) are threatened subspecies native to North America. The creation of a germplasm biobank will connect valuable and inaccessible genetics from geographically distant herds in a biosecure manner. Protocols that are feasible in field conditions are required for cumulus-oocyte complex (COC) collection for the purpose of invitro embryo production (IVP). The efficacy of a single dose of equine chorionic gonadotrophin (ECG) was tested in an effort to develop a minimum-handling ovarian superstimulation protocol for bison. The experimental design enabled comparison between ECG-treated and non-superstimulated bison. Transvaginal ultrasound-guided follicle ablation was performed in mature wood bison (n=24) during May (anovulatory season) to induce follicular wave emergence the following day. Immediately after ablation, the bison were assigned to one of three groups (n=8 per group) and treated intramuscularly with 5000IU of ECG (Folligon, Merck), 2500IU of ECG, or saline (control). Transvaginal COC collection was performed 5 days later. Follicular and COC data were recorded, and only grade 1 and 2 COC were used for IVP. The COC were matured invitro for 25-28h at 38.8°C, fertilised (2×106 spermmL−1), and co-incubated at 38.8°C in 5% O2, 5% CO2, and 90% N2 for 18h. Presumptive zygotes were denuded and cultured at 38.8°C in 5% O2, 5% CO2, and 90% N2. Nominal data were compared among groups using analysis of variance, and proportional data were compared using GLIMMIX. The total number of follicles ≥3mm on the day of COC collection was greater in the 5000-IU ECG group than in the 2500-IU ECG and control groups (37.5±6.9, 17.5±2.0, and 16.9±2.0, respectively; P&lt;0.005). The number of follicles 5-8mm was also greater in the 5000-IU ECG group than in the 2500-IU ECG and control groups (12.5±2.1, 7.6±1.0, and 5.8±0.9, respectively; P&lt;0.01), as was the number of follicles &gt;8mm (21.1±5.4, 3.3±1.2, and 0.9±0.2, respectively; P&lt;0.0005). The proportion of grade 1 and 2 COC/total COC recovered was greater in the 5000-IU ECG group than in the 2500-IU ECG and control groups (84/124 (68%), 39/76 (51%), and 37/75 (49%), respectively; P&lt;0.05). The proportion of cleaved zygotes/number of COC matured, assessed at 56h after fertilisation, was similar among the 5000-IU ECG, 2500-IU ECG, and control groups (42/84 (50%), 27/39 (69%), and 21/37 (57%), respectively; P=0.20). The proportion of embryos of IETS grades 1-3/number of COC matured was also similar among the 5000-IU ECG, 2500-IU ECG, and control groups (15/84 (17.9%), 8/39 (20.5%), and 7/37 (18.9%), respectively; P=0.94), but the bison in the 5000-IU ECG group produced twice as many embryos than those in the other groups. In summary, a single dose of 5000IU of ECG increased the number and size of follicles available for COC collection, more than doubled the number of COC collected for IVP, and resulted in the production of more embryos than the other groups. A single dose of 5000IU of ECG is effective in a minimum-handling protocol for ovarian superstimulation and IVP in bison. This research was supported by NSERC.

156 Oestrus response, corpus luteum function, and pregnancy rates following aromatase inhibitor treatment in beef heifers

In a previous study involving the use of the aromatase inhibitor letrozole to synchronise ovulation, incomplete luteolysis appeared to confound the synchronising effect in letrozole-treated heifers. Experiments were done to determine whether letrozole treatment interferes with luteolysis and affects the timing of oestrus (Experiment 1) and whether pregnancy rate is affected by the stage of the oestrous cycle during which letrozole treatment is initiated (Experiment 2). In Experiment 1, Hereford heifers were fitted with a HeatWatch sensor and given prostaglandin F2α (PGF2α). Ovulation (Day 0) was determined by daily ultrasonography, and on Day 3 heifers were given an intravaginal letrozole-releasing device or a sham device for 4 days (n=16 per group). Half of the heifers in each group were given PGF2α on Day 7 (PGF 1×) or on Day 7 and 7.5 (PGF 2×). Ultrasonography and blood sampling were done daily from device insertion to removal, every 12h for 72h following PGF2α and daily for 14 days following ovulation. In Experiment 2, heifers were randomly assigned to three groups (n=10-11 per group) in which a 4-day letrozole-releasing device treatment was initiated during metoestrus (Days 0-2), diestrus (Days 7-9), or pro-oestrus (Days 15-17). Prostaglandin F2α was given at device removal and again 12h later. Heifers were inseminated with frozen-thawed semen and given gonadotrophin-releasing hormone 66h after device removal. Ultrasonography and blood sampling were done twice daily from device removal until ovulation. End points examined included dominant follicle and corpus luteum (CL) diameters, onset of oestrus, and plasma concentrations of oestradiol determined by radioimmunoassay. Nominal data were compared using GENMOD, analysis of variance, or mixed model for repeated-measures and were expressed as means±s.e.m. Proportional data were analysed using chi-square. In Experiment 1, no main effects or interactions were detected between device or PGF treatment for onset of oestrus following PGF2α (overall 60.0±2.5h) or CL diameter profiles during luteolysis. Residual variation was reduced in the timing of the first PGF to ovulation in the PGF 2× group versus the PGF 1× group (5.6±2.2h vs. 15.2±3.2 h; P&lt;0.01). The CL diameter following ovulation was greater in the PGF 2× group compared with the PGF 1× group (P=0.03). Circulating plasma oestradiol during treatment was greater (P=0.04) in both the PGF 1× and sham groups. In Experiment 2, a greater proportion of heifers in the pro-oestrus group ovulated ≤24h after device withdrawal compared with the metoestrus and diestrus groups combined (6/11 vs. 0/22, respectively; P&lt;0.05). Pregnancy rate tended to be greater in the metoestrus group than in the diestrus group (10/11 vs. 6/10; P=0.08), and pregnancy rate in both groups was greater than that in the pro-oestrus group (0/11; P&lt;0.05). In conclusion, letrozole treatment did not interfere with luteolysis, and PGF2α given 2× at a 12-h interval on Day 7 after ovulation decreased variance in the timing to ovulation. Treatment initiated during metoestrus and diestrus yielded greater pregnancy rates than that started during pro-oestrus and warrants efficacy testing in a large fixed-time AI field trial. This research was supported by Alberta Agriculture and Forestry and by Dechra.

The NeST (neoadjuvant systemic therapy in breast cancer) study - Protocol for a prospective multi-centre cohort study to assess the current utilization and short-term outcomes of neoadjuvant systemic therapies in breast cancer

INTRODUCTION

Neoadjuvant systemic therapy (NST) has several potential advantages in the treatment of breast cancer. However, there is currently considerable variation in NST use across the UK. The NeST study is a national, prospective, multicentre cohort study that will investigate current patterns of care with respect to NST in the UK.

METHODS AND ANALYSIS

Phase 1 - a national practice questionnaire (NPQ) to survey current practice.Phase 2 - a multi-centre prospective cohort study of breast cancer patients, undergoing NST.Women undergoing NST as their MDT recommended primary breast cancer treatment between December 2017 and May 2018 will be included. The breast surgery and oncological professional associations and the trainee research collaborative networks will encourage participation by all breast cancer centres.Patient demographics, radiological, oncological, surgical and pathological data will be collected, including complications and the need for further intervention/treatment. Data will be collated to establish current practice in the UK, regarding NST usage and variability of access and provision of these therapies. Prospective data on 600 patients from ~50 centres are anticipated.Trial registration: ISRCTN11160072.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this study, as per the online Health Research Authority decision tool. The information obtained will provide valuable insights to help patients make informed decisions about their treatment. These data should establish current practice in the UK concerning NST, inform future service delivery as well as identifying further research questions.This protocol will be disseminated through the Mammary Fold Academic Research Collaborative (MFAC), the Reconstructive Surgery Trials Network and the Association of Breast Surgery. Participating units will have access to their own data and collective results will be presented at relevant conferences and published in appropriate peer-reviewed journals, as well as being made accessible to relevant patient groups.

Oral Antibiotics for Treating Children With Community-Acquired Pneumonia Complicated by Empyema

No consensus exists on management of children with community-acquired pneumonia complicated by empyema (CAP-Em). We evaluated outpatient oral (O-Abx) compared with parenteral antibiotics (OPAT) in children with CAP-Em. We also evaluated inflammatory markers to guide length of treatment. We conducted a retrospective cohort study of patients discharged (2006-2016) with CAP-Em. Primary outcome measured was treatment success (no change in antibiotics or readmission to hospital for treatment of CAP-Em). White blood cell (WBC) count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) serial measurements were identified. Success was achieved in 133/144 (92.4%) O-Abx and 7/12 (58%) OPAT patients (P = .0031). WBC and CRP decreased early; and ESR increased initially (admit and switch to O-Abx) and decreased by end of treatment. O-Abx is the modality of choice for treatment of CAP-Em after hospital discharge. WBC and CRP are useful to monitor success of O-Abx switch; and ESR provides guidance for length of treatment.

2634. Human Metapneumovirus in a Children’s Hospital: It Should Get More Attention

Background

Viral respiratory infections are a major cause of hospitalization and intensive care unit (ICU) admission to children’s hospitals. Rates of respiratory syncytial virus (RSV) and influenza are closely tracked due to their known morbidity. We had previously observed over one season that human metapneumovirus (hMPV)-infected children have high rates of hospitalizations and ICU admissions, particularly those with chronic lung disease (CLD). We expanded our data to include an additional 5 seasons to compare rates of hospitalizations and hospital-acquired infections (HAIs) due to hMPV, RSV and influenza.

Methods

During the 2014–2019 winter viral seasons, hMPV, RSV and influenza infections were tracked through both PCR testing (Biofire Respiratory Panel) and DFA testing (D3 Ultra DFA Respiratory Virus Screening & ID Kit; Diagnostic Hybrids). For hMPV admissions, rates of hospitalizations, ICU admissions, HAIs and mortalities were assessed and compared with RSV and influenza admissions. Retrospective data were used to study patients infected with hMPV.

Results

During the winter seasons of 2014–2019, the rates of hospitalization due to hMPV were significantly higher than both RSV and influenza (Figure 1). ICU admissions and HAIs for hMPV were similar to RSV and influenza (Figures 2 and 3). There were 9 deaths over this time period; 5 due to RSV, 3 due to influenza and 1 due to hMPV. The proportion of deaths due to hMPV compared with RSV and influenza was similar (P = 0.54, 0.89, respectively). Of the 315 total admissions with hMPV, 43 (13.7%) had CLD and 13 (4.1%) were tracheostomy dependent. Among 67 hMPV ICU admissions from 2014–2019, 56 (84%) had an underlying medical diagnosis, 25 (37%) had CLD, 13 (19%) had tracheostomies, and 17 (25%) required mechanical ventilation. The average age of hMPV infected children in our ICU is 4 years 1 month.

Conclusion

Our large descriptive study of hMPV-infected children over 6 seasons showed higher rates of hospitalization compared with RSV and influenza, similar ICU and HAI rates, and similar rates of mortality. ICU admitted children often had associated co-morbidities, including CLD. Further studies for focused disease surveillance and potential vaccine development for high-risk children are needed.

Disclosures

All authors: No reported disclosures.