Primary giant hydatid cyst of the retroperitoneum: Diagnosis and therapeutic approaches

INTRODUCTION AND IMPORTANCE

Primary hydatid cyst of the retroperitoneum is an exceedingly rare manifestation of hydatid disease. Diagnosis proves challenging due to nonspecific symptoms, and the condition is typically not suspected when facing a retroperitoneal cystic mass, necessitating awareness among clinicians and surgeons, particularly in endemic regions.

CASE PRESENTATION

A 45-year-old male with a three-month history of progressive abdominal enlargement and pain. Living in a rural area, he exhibited a 30 cm, well-defined retroperitoneal cyst, with no guarding confirmed by CT-scan, with characteristic daughter cysts. The diagnosis of primary retroperitoneal hydatid cyst was supported by positive hydatid serology and eosinophilia. Surgical intervention was crucial, and a complete pericystectomy, with 4 cm of pericyst on the aorta due to safety concerns, was performed after three months of preoperative albendazole-based treatment. The postoperative course was uneventful, and a two-year follow-up revealed no recurrence.

CLINICAL DISCUSSION

The prevalence of hydatid disease in North Africa is high, yet retroperitoneal cases are rare. The difficulty to diagnosis retroperitoneal masses, underscores the importance of precise patient evaluation and detailed imaging analysis. Percutaneous puncture is contraindicated due to the risk of dissemination, highlighting even more the significance of accurate preoperative diagnosis. Surgery, coupled with Albendazole treatment, remains the gold-standard, associated with meticulous intraoperative precautions to prevent disease dissemination.

CONCLUSION

Primary retroperitoneal hydatid cyst is rare. Diagnosis is difficult. Precise determination of patient's background and detailed analysis of imaging findings are mandatory. Percutaneous puncture is forbidden as it leads to disease spreading or even anaphylactic shock. Surgical excision is the gold-standard.

Intrauterine device migration resulting in acute appendicitis: A case report

INTRODUCTION AND IMPORTANCE

The Intrauterine Contraceptive Device (IUD), a widely used contraceptive since 1965, has demonstrated efficacy but is associated with complications such as bleeding, pain, and rare occurrences of perforation. This case report details an IUD migration into the peritoneal cavity, leading to acute appendicitis.

CASE PRESENTATION

A 33-year-old woman, with a history of IUD insertion 16 months prior, presented with pelvic pain. Gynecological examination and computed tomography, revealed the IUD intraperitoneal migration. The patient underwent laparoscopic extraction of the IUD which was embedded in the appendix and appendectomy, with an uneventful recovery.

CLINICAL DISCUSSION

This case emphasizes the complexity of IUD migration and its rare association with acute appendicitis, underscoring the importance of vigilant monitoring and prompt intervention. We also explored factors contributing to IUD perforation risk, imaging modalities for detection, and emphasizes the necessity of surgical removal upon confirmation. We highlight the fact that despite the atypical presentation with minimal symptoms, we should always consider emergency situations. Surgical intervention, particularly laparoscopy, may be the standard approach for managing migrated IUDs.

CONCLUSION

We insist about the critical need for thorough assessment and vigilance in managing IUD-related complications, emphasizing timely intervention to ensure patient safety. This case contributes valuable insights into the complexities surrounding IUD migration, urging healthcare professionals to remain attentive to potential injuries in patients with a history of IUD insertion and abdominal pain.

Septic shock revealing boerhaave's syndrome a case report

INTRODUCTION AND IMPORTANCE

Boerhaave's syndrome, recognized as spontaneous esophageal rupture, is an uncommon and perilous medical condition marked by the spontaneous tearing of the esophagus. This paper highlights the importance of an early diagnosis and its correlation to better outcomes for a rare pathology with high mortality.

CLINICAL PRESENTATION

A 67-year-old female presenting with unexplored vomiting and hypertension, presented to the ER with a septic shock. The patient's clinical deterioration prompted emergency exploration, revealing a dilated esophagus with a 3-cm perforation. Despite surgical intervention, including suturing with a T-tube and esophageal exclusion, the patient succumbed to multiorgan failure.

CLINICAL DISCUSSION

Boerhaave's syndrome, triggered by forceful vomiting, presents diverse clinical manifestations, making accurate diagnosis challenging. The characteristic triad of vomiting, pain, and subcutaneous emphysema is observed in a minority of cases, often overshadowed by acute respiratory distress. Diagnostic modalities include chest X-rays, contrast esophagography, and computed tomography, aiding in visualizing contrast leakage and confirming the diagnosis. The choice of surgical technique, ranging from esophageal suturing to esophagectomy, depends on the duration between rupture and surgery initiation. In this case, a bipolar esophageal exclusion was performed due to the patient's critical condition.

CONCLUSION

Boerhaave's syndrome demands consideration in patients presenting with thoracic pain and vomiting, particularly in those with a pathological esophagus. Early diagnosis and surgical intervention remain pivotal in improving outcomes. Identification of hydro-pneumothorax in radiographic studies should prompt consideration of spontaneous esophageal rupture, highlighting the need for heightened clinical suspicion in nonspecific clinical scenarios.

Surgical management of a proximal splenic artery aneurysm: A case report

INTRODUCTION AND IMPORTANCE

Splenic artery aneurysms (SAA's) pose a rare yet clinically significant challenge, characterized by the weakening and ballooning of the splenic artery, potentially leading to severe complications such as rupture and hemorrhage.

CASE PRESENTATION

A 52-year-old female presenting with biliary colic. Diagnostic imaging revealed a saccular lesion closely associated with gallstones. A multidisciplinary approach guided the decision for surgery due to the size and location of the aneurysm. A bi sub costal laparotomy was performed, after the resection of the aneurysm, an arterial anastomosis with pds 5/0 suture was performed.

CLINICAL DISCUSSION

SAA's treatment modalities are tailored based on aneurysm localization and size. Imaging modalities such as Doppler ultrasound and CT angiography play a crucial role in accurate diagnosis, providing essential information for treatment planning. Treatment options include endovascular embolization, and surgical intervention. Traditionally open surgical techniques, including ligation of the splenic artery, aneurysmectomy, and splenectomy. Surgical treatment, especially for proximal aneurysms, is highlighted, with the presented alternative approach of resection with end-to-end anastomosis, showcasing an alternative surgical technique aimed at reducing the risk of spleen infarction.

CONCLUSION

SAA's are a rarity that emphasizes the need for early detection and intervention. We are urged to maintain a high index of suspicion, particularly in high-risk individuals. We report an alternative surgical technique that we hope will contributes to the expanding repertoire of approaches, calling for further research to optimize SAA management strategies in the quest for improved patient outcomes.

Pleural migration of biliary stent 10 years following treatment of hepatic hydatic echinococcosis: A case report

INTRODUCTION

Echinococcosis, caused by larval stages of taeniid cestodes, primarily affects the liver and is commonly treated surgically. However, a complication post-treatment is biliary fistula, necessitating interventions like biliary stents. While stent complications are recognized, proximal migration leading to pneumonia is exceptionally rare. This case report details an unusual occurrence of biliary stent migration years after hepatic hydatid echinococcosis treatment.

CASE PRESENTATION

A 42-year-old patient underwent 2014 surgery for a large hydatid cyst, resulting in a biliary fistula. Endoscopic sphincterotomy and biliary stent placement led to a successful outcome. Lost to follow-up, the patient reappeared in 2022 with basithoracic pain, fever, and a thoracic CT scan revealing transdiaphragmatic stent migration causing basal pneumonitis. Antibiotic therapy and endoscopic stent removal ensued with an uncomplicated recovery.

CLINICAL DISCUSSION

This report emphasizes a rare complication that is proximal migration of a biliary stent 10 years post-initial placement for biliary fistula management. Despite the absence of typical risk factors. We managed a successful endoscopic retrieval. This highlights the importance of vigilance and follow-up for potential complications associated with biliary stent. Unusual presentations, like pneumonitis, underscore the need for awareness and a cautious approach.

CONCLUSION

The primary complication following surgical intervention for hepatic hydatid cysts is the development of an external biliary fistula, necessitating the use of biliary stents for treatment. Given the rarity of complications observed in our case, the removal of stents post-treatment for biliary fistula becomes crucial, underscoring the significance of vigilant follow-up care.

Bouveret Syndrome: A rare form of gallstone ileus a case report

INTRODUCTION AND IMPORTANCE

Bouveret Syndrome, a rare form of gallstone ileus, involves the migration and impaction of a gallstone in the duodenum or stomach, causing gastric outlet obstruction. Early intervention and a comprehensive care plan are essential for favorable outcomes.

CASE PRESENTATION

This article presents a case of an 82-year-old female with a history of coronary artery disease and untreated gallstones. The patient experienced nausea, vomiting, and abdominal pain for two weeks. Diagnostic procedures revealed a cholecystoduodenal fistula with a 4 cm stone lodged at the duodenojejunal angle. For our patient the gallstone was moved to the jejunum, followed by enterotomy and a latero_lateral gastroenteroanastomosis.

CLINICAL DISCUSSION

The rarity of Bouveret Syndrome and its nonspecific symptoms make diagnosis challenging, necessitating differentiation from other gastrointestinal disorders. Esophagogastroduodenoscopy (EGD) and imaging, such as computed tomography (CT), play crucial roles in diagnosis. In this case, the EGD did not show gallstones up to the second part of the duodenum. Management involves a multidisciplinary approach, with supportive care for stabilization and the primary goal of removing the impacted stone. Treatment options include endoscopic, surgical, or lithotripsy techniques. Bouveret Syndrome poses challenges due to its rarity, leading to delayed diagnosis. Prognosis varies based on factors such as stone size, location, and overall patient condition.

CONCLUSION

Through this case we emphasizes the importance of awareness, timely diagnosis, and appropriate management, with EGD and CT scan playing key roles in diagnosis. Surgical intervention remains a viable treatment option when endoscopic approaches are unavailable. The article highlights the controversial nature of fistula repair in Bouveret Syndrome.

Palliative Radiotherapy for Haemostasis in Malignancy: a Systematic Review

AIMS

Palliative radiotherapy is commonly used to achieve haemostasis for malignancy-induced haemorrhages. Our study aimed to examine the efficacy of palliative radiotherapy in the control of haemorrhages caused by various types of malignancy.

MATERIALS AND METHODS

A systematic review of the literature was conducted to determine the level of evidence for the use of palliative radiotherapy in achieving haemostasis. Searches of the Medline, Embase and Cochrane databases were completed for studies published between January 1947 and May 2017. Studies that reported either a qualitative or a quantitative effect of radiotherapy were selected for inclusion during the review process.

RESULTS

In total, 836 abstracts were screened; 13 prospective and 45 retrospective studies met the criteria for inclusion in the review. Selected studies were sorted based on the underlying tumour type to provide readers the opportunity to compare dose and fractionation schedules. Significant variations in reporting of outcomes and low total patient numbers did not allow for a quantitative analysis to be carried out. A higher median dose and a hypofractionated schedule seem to provide numerically higher rates of control based on the available data.

CONCLUSIONS

Palliative radiotherapy is useful in the management of bleeding related to advanced and incurable malignancies. Brachytherapy seems to be effective in haemostasis of certain malignancies, especially that of gynaecological origin. Treatment should be tailored to individual patient situations given the palliative goals of any such therapy. Further prospective studies could help to delineate optimal dose and fractionation schedules.

Platelet transfusion in adults: An update

Many patients worldwide receive platelet components (PCs) through the transfusion of diverse types of blood components. PC transfusions are essential for the treatment of central thrombocytopenia of diverse causes, and such treatment is beneficial in patients at risk of severe bleeding. PC transfusions account for almost 10% of all the blood components supplied by blood services, but they are associated with about 3.25 times as many severe reactions (attributable to transfusion) than red blood cell transfusions after stringent in-process leukoreduction to less than 10⁶ residual cells per blood component. PCs are not homogeneous, due to the considerable differences between donors. Furthermore, the modes of PC collection and preparation, the safety precautions taken to limit either the most common (allergic-type reactions and febrile non-hemolytic reactions) or the most severe (bacterial contamination, pulmonary lesions) adverse reactions, and storage and conservation methods can all result in so-called PC "storage lesions". Some storage lesions affect PC quality, with implications for patient outcome. Good transfusion practices should result in higher levels of platelet recovery and efficacy, and lower complication rates. These practices include a matching of tissue ABH antigens whenever possible, and of platelet HLA (and, to a lesser extent, HPA) antigens in immunization situations. This review provides an overview of all the available information relating to platelet transfusion, from donor and donation to bedside transfusion, and considers the impact of the measures applied to increase transfusion efficacy while improving safety and preventing transfusion inefficacy and refractoriness. It also considers alternatives to platelet component (PC) transfusion.

OP0177 IMMUNOGENICITY INDUCED BY TWO AND THREE DOSES OF THE BNT162B2 mRNA VACCINE IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES AND IMMUNOCOMPETENT CONTROLS: A LONGITUDINAL MULTI-CENTER STUDY

Background

Data on the kinetics of the immune response to SARS-CoV-2 vaccination in patients with autoimmune inflammatory rheumatic diseases (AIIRD) are limited.

Objectives

To evaluate the kinetics of the immune response induced by two and three doses of the BNT162b2 mRNA vaccine in adult patients with AIIRD and immunocompetent controls.

Methods

A prospective multicenter study investigated the antibody response to the BNT162b2 vaccine by serial measurement of serum anti-SARS-CoV-2 S1/S2 IgG titers at the following time points: 2-6 weeks (AIIRD n=720, controls n=122) and six months (AIIRD n=628, controls=116) after the second vaccine dose, and 2-6 weeks after the third vaccine dose (AIIRD n=169, controls n=45). A seropositive response was defined as a detectable anti-S1/S2 IgG titer ≥ 15 BAU/ml. T-cell immune response was evaluated in a sample of patients (n=28) and controls (n=9) by intracellular staining of S-stimulated CD4+ T-cells for TNFα and IFNγ production.

Results

The two-dose vaccine regimen induced a higher humoral response in controls compared to patients, as reflected by the post-vaccination seropositivity rates of 100% vs 84.72%, p<0.0001, and 96.55% vs 74.26%, p<0.0001 at 2-to-6 weeks and at 6 months, respectively. The decline of S1/S2 IgG titers within six months was similar in controls and patients. Following the 3rd vaccine, the seropositivity rate increased to 80.47% and 100% in AIIRD and control groups, p=0.0028, with a significantly higher increase of S1/S2 IgG titers in controls compared with AIIRD patients, 284.09±76.58 vs 219.39±151.55 BAU/ml, p=0.0016. At all-time points, S1/S2 IgG titers were significantly lower in AIIRD patients compared with controls (Figure 1).

We further investigated the impact of therapies on the vaccine‘s immunogenicity (Figure 1). Glucocorticoids (GC) were associated with a significantly lower seropositivity rate and lower S1/S2 IgG titers compared to controls at all time points. Monotherapy with methotrexate (MTX) was associated with a comparable to controls humoral response at all time points. Anti-cytokine biologics (TNFi, IL6i, IL17i) were associated with an initial high seropositivity rate, similar to controls, followed by a steeper decline at 6 months, 79.82% vs 96.55%, p=0.0001, and restoration of seropositivity after the 3rd vaccine dose in all patients. JAKi were associated with a mildly decreased seropositivity rate after the 2nd vaccine dose and similar to controls response after the 3rd vaccine dose. Abatacept was associated with a reduced immunogenicity after the 2nd vaccine dose, but was restored to 100% seropositivity after the 3rd vaccine dose. Rituximab (RTX) significantly blunted the humoral response at all time points, with a seropositivity rate of 42% after the 2nd vaccine dose, 29% at 6 months, and with increase to 40% after the 3rd vaccine dose. A third of the RTX-treated patients who were seronegative after two vaccine doses, seroconverted after the 3rd dose. The multivariate model for predicting the seropositive response to vaccination found that higher S1/S2 IgG titers after the 2nd vaccine dose was associated with a higher seropositivity rate following the 3rd vaccine dose, OR 1.026 (1.008-1.045), p=0.0027, and that treatment with RTX was associated with a 14.3-fold risk for a negative humoral response, p≤0.0001. Cellular immune response, evaluated mainly in RTX treated patients, was preserved prior to and after the 3rd vaccine dose and was similar to controls.

Conclusion

Over a six-month period, the two dose BNTb262 vaccination was associated with a similar extent of waning of the humoral immune response in AIIRD patients and controls. The 3rd vaccine dose restored the response in all controls and in patients treated with MTX monotherapy, anti-cytokine biologics, abatacept, and JAKi. Treatment with GC and RTX was associated with an impaired humoral response at all time points.

Acknowledgements

We would like to thank the statistician Mr Yishai Friedlander and Mr Yoram Neufeld for their valuable assistance.

Disclosure of Interests

None declared

POS1244 THE EFFECT OF SECUKINUMAB ON THE HUMORAL RESPONSE FOLLOWING TWO AND THREE DOSES OF THE BNT162b2 mRNA VACCINE IN PATIENTS WITH SPONDYLOARTHRITIS

Background

Data on the effect of secukinumab on the humoral response to the BNT162b2 mRNA vaccine are limited.

Objectives

We aimed to assess prospectively the humoral response to the BNT162b2 mRNA vaccine in patients with spondyloarthritis (SpA) treated with secukinumab in comparison to immunocompetent controls.

Methods

Patients with psoriatic arthritis (PsA) or ankylosing spondylitis (AS) treated with secukinumab for at least 3 months and immunocompetent controls were vaccinated with two-dose regimen of the BNT162b2 mRNA vaccine. Clinical and laboratory assessments were performed at 2-8 weeks [SpA: 37 on secukinumab, (median age 53% female), 122 controls (median age 53, 51% female)], and 6 months [SpA: 27 on secukinumab, 116 controls] after the second vaccine dose. A subgroup of patients (22 SpA on secukinumab, 45 controls) were evaluated after the third vaccine dose. The seropositive response was defined as a detectable S1/S2 IgG ≥15 binding antibody units (BAU)/ml.

Results

The two-dose vaccine regimen induced a similar immunogenic response in patients and controls reflected by the seropositivity rates of 100% in both groups. After six months, the rate of seropositivity remained as high as 96% in both secukinumab-treated patients and immunocompetent controls. The decline of S1/S2 IgG titer within six months was similar in controls and secukinumab-treated patients, -66.4 (95% CI {-70.9, -39.9}) and -55 BAU/ml (95% CI {-95.42, -36.87)). Following the third vaccine, the seropositivity rate increased to 100 % in both groups. At all-time points, S1/S2 IgG titers were similar in secukinumab treated patients and immunocompetent controls (Figure 1).

Figure 1.

Kinetics of an immunogenic response (S1/S2 IgG titer) to two and three doses of the BNT162b2 mRNA vaccine in SpA patients treated with secukinumab and immunocompetent controls.

Conclusion

SpA patients treated with secukinumab consistently demonstrated an adequate humoral response to the BNT162b2 mRNA vaccination similar to immunocompetent controls, both short-term and within six months after two vaccine doses and after the third vaccine dose.

Acknowledgements

We would like to thank Mr Yishai Friedlander and Mr Yoram Neufeld for their assistance.

Disclosure of Interests

Ori Elkayam: None declared, Tali Eviatar: None declared, Hagit Peleg: None declared, Daphna Paran: None declared, David Levartovsky: None declared, Ilana Kaufman: None declared, Adi Broyde: None declared, Ofir Elalouf: None declared, Ari Polachek: None declared, Joy Feld: None declared, Amir Haddad: None declared, Tal Gazitt: None declared, Muna Elias: None declared, Nizar Hijaze: None declared, Maher Aassi Employee of: Novartis Pharma AG, Erhard Quebe-Fehling Employee of: Novartis Pharma AG, Ivette Alarcon Employee of: Novartis Pharma AG, Sara Pel: None declared, Devy Zisman: None declared, Victoria Furer: None declared

Analysis of light emission and Schlieren from short gap high voltage streamers representing lightning impulses

Light emissions and Schlieren structures were simultaneously observed from streamers produced by tens of kilovolts 1.2/50 μs impulses, representing the high voltage component of lightning, applied across a 4 cm air gap between a variety of electrode geometries and a ground plane in an unconfined environment. The results demonstrated that the light emissions and Schlieren structures coincide along the same streamer filaments but on different timescales; the light existing only during the microsecond timeframe impulse whereas the Schlieren continued to develop into the millisecond timeframe, moving towards the centre of the air gap whilst diffusing into the surrounding air within 100 ms. If an electrical breakdown did occur, the Schlieren structures outside the arc remained visible. Streamer formation theory for high voltage impulses is subsequently refined to include the observed Schlieren mechanism.

Tuberculous severe acute colitis. A case report

Introduction

and importance: Intestinal tuberculosis represents 2% of the ten million cases of tuberculosis reported in 2018. Herein, we report a case of tuberculous severe acute colitis. It is a rare and life-threatening condition. Our literature review found only five published cases. It occurs generally in immunocompromised patients. Extended colonic inflammation seems to be the main predictive factor of death. Moreover, an early diagnosis and rapid onset of antituberculous treatment are mandatory to save the patient's life.

Case presentation

Herein, we present a case of tuberculous severe acute colitis with a review of the reported cases. The patient presented with a severe and idiopathic acute colitis. He was put on broad-spectrum antibiotics and intravenous corticosteroids. At day two, he developed septic shock and colic perforation. Colectomy was performed. Microbiology investigation and pathology examination confirmed tuberculous colitis.

Clinical discussion

Tuberculous severe acute colitis occurs generally in immunocompromised patients. Extended colic inflammation seems to be the main predictive factor of death. Moreover, an early diagnosis and rapid onset of antituberculous treatment are mandatory to save the patient's life. However, diagnosis is difficult as symptoms aren't specific. Microbiology and pathology were compulsory to retain colic tuberculosis in all the reported cases.

Conclusion

Tuberculous severe acute colitis is a challenging and life-threatening condition. It usually occurs in immunocompromised patients. Abdominal CT-scan may evoke the diagnosis. Microbiology and pathology are mandatory to retain the diagnosis. Early diagnosis and onset of antituberculous treatment are compulsory to save the patient's life.

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Diagnosis of tuberculous severe acute colitis is difficult.

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It usually occurs in immunocompromised patients.

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Surgery is mandatory if perforation occurs.

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Early diagnosis and onset of antituberculous treatment are compulsory to save the patient's life.

Enterosalpingeal fistula complicating Crohn's disease: Report of two cases and review of the literature

Introduction and importance

Reports of enterosalpingeal fistulae complicating Crohn's disease are scarce. They involve the last ileal loop and lead to a progressive destruction of the salpinx. Usually, no genital symptoms are found. In all the cases reported in the literature, the fistula was diagnosed intra-operatively and resection of the right salpinx was performed without the patient's pre-operative consent.

Case presentation

We describe 2 cases of women presenting with an Enterosalpingeal fistulae complicating Crohn's disease. Radiological findings allowed a pre-operative diagnosis. Thus, the patients were warned of the right salpinx resection and consent was obtained.

Clinical discussion

Enterosalpingeal fistulae complicating Crohn's disease are exceptional. Indeed, to the best of our knowledge, only five cases have been reported till now. In all the reported cases, no genital signs were present. As for our patients who didn't experience such symptoms. Moreover, no radiological evidence of the enterosalpingeal fistula was found in the literature. Consequently, the fistula was always diagnosed intra-operatively. For our patients, radiological findings allowed a pre-operative diagnosis. This permitted to warn them of a possible resection of the fallopian tube. Intra-operative findings were unfortunately conflicting with its preservation.

Conclusion

Enterosalpingeal fistula is an exceptional complication of the Crohn's disease. No clinical findings are present. The diagnosis should be evoked when the CT-scan or the MRI show an abnormal apposition between the fallopian tube, the last loop and the cecum. Surgical resection of the involved salpinx with the diseased intestinal segment is unfortunately usually needed in a young patient population.

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Report of two cases of an unusual form of Crohn's disease.

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Unique preoperative imaging.

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Preoperative diagnosis of the fistulae. Thus, patients were warned of salpingectomy.

Intraperitoneal migrating mesh plug wrongfully taken for right colon cancer: A case report

BACKGROUND

The use of mesh has become nowadays a standard for hernia repairs. It allows a tension-free hernioplasty and has shown that it is an effective way to prevent recurrences. But complications have been described. Intraperitoneal migration of mesh plug is an uncommon complication.

CASE REPORT

In this paper we report a case of a 57 year old male who has been operated on 12 years ago, he had a mesh plug repair for a ventral incisional hernia. The mesh migrated into the abdominal cavity and it was wrongfully taken for a locally advanced right colon cancer. Colonoscopy was done and biopsies were taken, but the results were not conclusive. He was operated on. We found the mesh that had migrated and eroded the hepatic flexure. There was a granulation tissue that also included some of the small intestine. There was also an abscess in the abdominal wall. He had an en-bloc resection of a part of the abdominal wall, small intestine and right colon.

CONCLUSION

Mesh hernioplasty is a frequent, simple and effective procedure with a low recurrence rate but it can be associated to serious complications such as mesh migration.

OP0219 THE ASSOCIATION OF PSORIATIC ARTHRITIS WITH ALL-CAUSE MORTALITY AND LEADING CAUSES OF DEATH IN PSORIATIC ARTHRITIS

Background:

Data on the association between PsA and mortality remains conflicting as it has been hampered by small sample size with few events and the potential for confounders of selection and severity biases from clinic-based studies.

Objectives:

To examine the association between PsA and all-cause mortality in a cohort of PsA patients and matched controls, using data from a population-based large medical record database.

Methods:

Patients with newly diagnosis of PsA between January 1st, 2003 and December 31st, 2018 from the Clalit Health database were identified. 4 controls without PsA were selected and matched to cases of PsA by age (within 1 year), sex, ethnicity (Jewish vs. non-Jewish), and index date. The two groups were followed from the index date until the first occurrence of death from any cause or end of follow-up (June 30, 2019). Data on mortality and on the immediate cause of death was based on the Notification of Death form legally required by the Israeli Ministry of the Interior for every deceased person in the country. Demographic data including age, sex, ethnicity (Jewish or Arab), and socioeconomic status (SES) at inception were retrieved from the CHS database. Data regarding tobacco use (ever), obesity, body mass index, diabetes mellitus, hyperlipidemia, hypertension, ischemic heart disease, prior cerebrovascular accident, congestive heart failure, chronic renal failure, chronic obstructive pulmonary disease, cirrhosis, prior malignancy, psoriasis, and the concomitant use of glucocorticosteroids, conventional and biologic disease-modifying anti-rheumatic drugs (cDMARDs and bDMARDs, respectively) were extracted from the database.

We estimated the attributable fraction of the various causes of death in PsA patients and compared it to the proportionate mortality rate (PMR) of the leading causes of death in Israel during 2014-2016 based on a recently published report by the Central Bureau of Statistics. Cox proportional hazard regression models were used to estimate the crude and the multivariate adjusted hazard ratio (HR) for the association between PsA and all-cause mortality, as well as for factors associated with mortality within the PsA group.

Results:

A total of 5275 PsA patients were identified between 2003 and 2018 and where matched to 21,011 controls based on age, sex, and ethnicity. The mean age was 51.7 ± 15.4 years of whom 53% were females. More individuals in the PsA group were smokers, obese, with diabetes, hypertension, and dyslipidemia, as well as with a history of ischemic heart disease, cerebrovascular disease, congestive heart failure, chronic obstructive pulmonary disease, chronic renal failure and cirrhosis than patients in the control group, and 38.2% of PsA patients were on b-DMARDS. Overall 471 (8.9%) patients died in the PsA group compared to 1,668 (7.9%) in the control group during a mean follow-up of 7.2 ± 4.4 years. The crude HR for the association of PsA and all-cause mortality was 1.16 (95% CI, 1.042-1.29). However, the association was not significant on multivariate analysis with HR of 1.096 (95% CI, 0.977-1.229).

In PsA patients, malignancy was the leading cause of death, constituting 26% of all deaths, followed by ischemic heart disease 15.8%, diabetes 6.2%, cerebrovascular diseases 5.5% and septicemia 5.5%, in keeping with the order of the leading causes of death in the general population of Israel during 2014-2016 as recently reported by the Central Bureau of Statistics.

On multivariate model Cox regression analysis, male sex, increased body mass index, increased Charlson comorbidity index scores and history of hospitalization in a year prior to death were associated with higher mortality, whereas treatment bDMARDs and cDMARDs were associated with a lower relative risk of death.

Conclusion:

No clinically relevant increase in mortality rate was observed in PsA patients from the period 2003-2018. The most common causes of specific proportionate mortality rates in our cohort were similar to those in the general population.

Disclosure of Interests:

None declared

AB0551 TREATMENT WITH IXEKIZUMAB FOLLOWING SECUKINUMAB FAILURE IN PATIENTS WITH PSORIATIC ARTHRITIS: REAL-LIFE EXPERIENCE FROM A RESISTANT POPULATION

Background:

Anti-IL17 agents, such as Secukinumab (SEC) and Ixekizumab (IXE) have been shown to be efficacious for the treatment of psoriasis and PsA12. In the field of psoriasis, there is growing evidence of a successful switching between the two anti-IL-17 agents in case of an insufficient response to one of the treatments3 There is no information on the efficacy of switching between anti IL17 agents in PsA.

Objectives:

To assess the clinical response to IXE in patients with PsA following SEC failure.

Methods:

A retrospective observational study was conducted in two rheumatology centers in Israel, including PsA patients with a history of treatment with SEC, further treated with IXE for a minimum of 3 months. Lack of efficacy, loss of efficacy, and side effects over time were reported as a reason for switching to another anti-IL17 agent. The mean difference between the beginning of the follow up period and the different follow up points (6 and 12 months) was tested using a one-sample t-test. Time until treatment failure was estimated using Kaplan–Meier curves, and compared using the log-rank test. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were calculated using the Cox proportional-hazards model to test the association between each variable and the time to treatment failure.

Results:

The study included 23 PsA patients (11♀/12♂), mean age 58.7 years±13.4 SD. Most patients (n=20, 86%) received 2+ TNFi and 10 patients (43%) received both TNFi and ustekinumab. Median number of biologics prior to SEC was 3 (IQR 2-4). There was a significant improvement in TJC at 6 and 12 months (-2.16 [-4.0, -0.3]; p=0.025 and-1.69 [-3.09, -0.28]; p=0.022, respectively). SJC was significantly improved at 6 months but not at 12 months (-2.68 [-5.3, -0.04]; p= 0.046 and -1.50 [-4.25,1.25]; p=0.26, respectively). CDAI score was significantly improved at 6 months (-10.19, [-16.26, -4.1], p=0.002) and at 12 months (-9.29 [-14.8, -3.71], p=0.003) as was SDAI score (-10.13 [-16.4, -3.8], p=0.003 and -12.2 [-17.1, -7.2], p=0.0002). At six months, PASI50 was achieved by 81% (13 patients), PASI75 was achieved by 63% (10 patients), PASI90 was achieved by 50% (8 patients) and PASI100 by 31% (10 patients). At 12 months, PASI50 and PASI75 was achieved by 57% (8 patients), PASI90 was achieved by 43% (6 patients) and PASI100 by 21% (3 patients).

Over time, of the 23 patients treated with IXE, 15 patients (65%) had experienced treatment failure, with a median treatment period of 8 months (IQR 6.5-13.5), of which 4 (17%) had primary treatment failure and 11 patients (48%) secondary treatment failure. Reasons for treatment cessation were: worsening psoriasis (4 patients (27%)), worsening peripheral arthritis (4 patients (27%)), both (7 patients (47%)), worsening of axial disease (2 patients (13%)) and adverse events (1 patient, 6%).

Conclusion:

patients after failure of multiple biologic treatments experienced significant response of peripheral arthritis and dermatologic disease on IXE after they had previously failed SEC. . However, in this refractory cohort of PsA, the effect was limited on time with 65% failure after a median time of 8 months.Within class switch from SEC to IXE is a plausible therapeutic option in PsA patients following secukinumab failure.

References:

[1]Mease PJ, McInnes IB, Kirkham B, et al. N Engl J Med. 2015;373(14):1329-1339.

[2]Nash P, Kirkham B, Okada M, et al. Lancet Lond Engl. 2017;389(10086):2317-2327.

[3]Bokor-Billmann T, Schäkel K. J Dermatol Treat. 2019;30(3):216-220

Disclosure of Interests:

None declared.

POS0613 TOCILIZUMAB DECREASES ANGIOGENESIS IN RHEUMATOID ARTHRITIS THROUGH ITS REGULATORY EFFECT ON EMMPRIN/CD147

Background:

Angiogenesis is an important contributor to the development of Rheumatoid arthritis (RA). Tocilizumab (TCZ), an anti-IL-6 receptor antibody, is an immunosuppressant used in the treatment of RA patients, but its effects on angiogenesis and the molecular mechanisms regulating new blood vessel formation are not fully elucidated.

Objectives:

To evaluate the concentrations of pro- and anti-angiogenic factors in serum samples of RA patients, before and after the initiation of TCZ treatment and to explore in an in vitro co-culture system the mechanisms of TCZ action.

Methods:

We evaluated the concentrations of EMMPRIN, VEGF, MMP-9, IL-6, NGAL, endostatin and thrombospondin-1 (Tsp-1) using commercial ELISA kits from 40 RA patients, before and 4 months after the initiation of TCZ treatment. The levels of secreted EMMPRIN, VEGF MMP-9 and Tsp-1 were measured in an in vitro co-culture system of HT1080 fibroblasts and U937 monocytes with and without addition of anti-EMMPRIN blocking antibody. In the tube formation assay serum samples and supernatnats from the co-cultures were added to endothelial layer. Images were obtained after 6 hours of incubation and the number of closed lumens were counted in two separate fields. In the wound assay, supernatants from the co-cultures, with or without the addition of the anti-EMMPRIN antibody were added to the endothelial layer after scratching. The scratch site area was measured immediately and compared to the area after 24 hours of incubation to assess the distance of cell migration.

Results:

Study population included 40 RA patients, 33 (82.5%) females, mean age of 57.5±11.1 years, disease duration of 7.7±5.6 years, and 53.9% positive for rheumatoid factor initiating treatment with TCZ. In this patient cohort, 25/40 (62.5%) patients were classified as “responders” according to EULAR criteria.

Following 4 mounts of treatment, statistically significant reductions in the levels of EMMPRIN/CD147 (p=0.035), without significant changes in serum levels of MMP-9, VEGF, MMP-3 and MMP-7 and of the anti-angiogenetic factors Tsp-1 and endostatin were found. A statistically significant decrease in the ratio between the pro-angiogenic factor EMMPRIN and the anti-angiogenic factor Tsp-1 that was calculated for each patient 4 months after initiating TCZ was found(p=0.031). The decrease in angiogenesis was manifested by the reduced number of closed lumen tube-like structures formed by EaHy926 endothelial cell line after incubation with serum samples 4 months after initiation of TCZ, relative to the number of closed lumens formed prior to TCZ initiation (p=0.007). The ratio between EMMPRIN and Tsp-1 was significantly reduced in the responding patients versus non-responders (p=0.033), while the levels of VEGF, MMP-9, Tsp-1, and EMMPRIN were unchanged.

In vitro, the accumulation of the pro-angiogenic factors EMMRPIN, VEGF and MMP-9 in the supernatants was increased in the co-culture, while the accumulation of the anti-angiogenic factor Tsp-1 was decreased. When EMMPRIN was neutralized with a blocking antibody, supernatants derived from these co-cultures exhibited reduced migration, proliferation, and tube-like structure formation in functional assays.

Conclusion:

Our findings suggest an important role for EMMPRIN in mediating pro-angiogenic signals in RA patients, with EMMPRIN/Tsp-1 ratio serving as a marker of angiogenesis in RA. When administered to RA patients, TCZ in turn, exerts an anti-angiogenic effect through its regulation of EMMRPIN/CD147 levels.

Disclosure of Interests:

None declared

POS0147 ANALYSIS OF VENOUS THROMBOEMBOLIC RISK AMONG PSORIATIC ARTHRITIS PATIENTS

Background:

Psoriatic arthritis (PsA) is a chronic, immune-mediated, systemic inflammatory arthritis associated with comorbidities including metabolic syndrome, cardiovascular risk factors and cardiovascular disease (CVD).

Objectives:

To evaluate the prevalence of venous thromboembolism (VTE) in a PsA patient cohort using a large health care provider database.

Methods:

A large health care provider database serving 4.7 million healthcare subscribers was interrogated for an adult patient cohort who were newly diagnosed with PsA between January 2005 (start date) and 31 December 2018 with date of diagnosis considered the index date. A risk set was employed to randomly select 4 controls without PsA as a comparator group to the PsA cohort matched by age, sex, ethnic group, and index date. Both groups were followed from the index date until the first occurrence of VTE event, death, or end of follow-up 31 December 2019, whichever came first. Marginal model with robust covariant estimate counting for the matching was used to estimate the crude and adjusted hazard ratio (HR) for the association between PsA and VTE. Within the group of PSA patients, Cox proportional hazard regression models was used to calculate the risk of having VTE given demographic variables, SES, smoking, selected comorbidities, and conventional vs biologic disease modifying anti-rheumatic drugs (c/bDMARD). Continuous variables were summarized with mean ± standard deviation, and categorical variables were presented as numbers and proportions. All tests were 2-sided; p values of < = 0.05 were considered statistically significant. All data were analyzed using SPSS, 24 (IBM SPSS Statistics for Windows, version 24.0, 2016, Armonk, NY) and SAS, 9.4 (SAS institute Inc, Cary, NC).

Results:

The PsA cohort consisted of 5,275 patients, 53.2% females with mean age of 51.66 ±15.41. The control group consisted of 21,011 subjects matched for age and sex. In relation to the control group, the PsA cohort had a higher SES (25.1% vs 23.4%, p<0.0001), higher tobacco use (42.2% vs.39.6% p<0.0001) and obesity (33.5% vs 25.8%, p<0.0001). The study group had a statistically significant higher incidence of diabetes (33.8% vs 26.2%, p<0.0001), IHD (10.3% vs 8.6%, p<0.0001), CHF (2.2% vs 1.6%, p=0.004), hypertension (30.1% vs 26.2%, p<0.0001), CVA/TIA (4.6% vs 3.9%, p=0.024) and vascular disease (3.7% vs 3.0%, p=0.005). There were 62 patients (1.2%) diagnosed with VTE in the PsA group as opposed to 176 patients (0.8%) in the control group (p=0.023, HR=1.397, CI 1.05-1.87). The mean age of patients diagnosed with VTE was higher in the PsA group relative to controls (64.90± 13.20 vs 51.54 ± 15.41, respectively, p<0.0001), with higher age, BMI>30, cancer, IHD, vascular disease, and previous VTE found to be associated with VTE in the PsA group relative to controls in both univariate and multivariate analyses. The higher prevalence of VTE in PsA patients relative to controls did not remain statistically significant in multivariate analysis following adjustment for risk factors. Within the PsA group, patients with VTE were more often of older age and with past history of VTE. Both cDMARD and bDMARD were not associated with increased risk of VTE among PsA patients.

Conclusion:

The prevalence of VTE was higher in PsA group compared to the general population, but after adjustment for comorbidities and risk factors, it no longer remained statistically significant. Among PsA patients, age and previous history of VTE were associated with increased risk of VTE. Addressing VTE risk in the management of patients with PsA is recommended especially in the era of Janus kinase inhibitors.

Disclosure of Interests:

None declared

LB0003 IMMUNOGENICITY AND SAFETY OF THE BNT162b2 mRNA COVID-19 VACCINE IN ADULT PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES AND GENERAL POPULATION: A MULTICENTER STUDY

Background:

Vaccination represents a cornerstone in mastering the COVID-19 pandemic. Data on immunogenicity, efficacy, and safety of the novel BNT162b2 mRNA vaccine in patients with autoimmune inflammatory rheumatic diseases (AIIRD) are limited.

Objectives:

To investigate the immunogenicity, efficacy, and safety of the BNT162b2 mRNA vaccine in patients with AIIRD compared to the general population.

Methods:

A prospective multicenter study investigated immunogenicity, efficacy, and safety of the two-dose regimen BNT162b2 mRNA vaccine in adult patients with AIIRD including rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthropathy (axSpA), systemic lupus erythematosus (SLE), connective tissues diseases (CTD), systemic vasculitides, and idiopathic inflammatory myositis (IIM), compared to control subjects without rheumatic diseases or immunosuppressive therapies. Serum IgG antibody levels against SARS-CoV-2 spike S1/S2 proteins were measured 2 - 6 weeks after the second vaccine dose. Seropositivity was defined as IgG ≥15 binding antibody units (BAU)/ml. Post-vaccination efficacy defined as post-vaccination COVID-19 infection and safety were assessed. Pre- and post- vaccination disease activity indices were assessed as appropriate for each disease.

Results:

A total of 686 AIIRD patients and 121 controls participated into the study. AIIRD patients were significantly older than controls, mean age±SD 56.76±14.88 vs 50.76±14.68, respectively, p<0.0001. A total of 95.2% (n=653) AIIRD patients were treated with immunomodulatory medications.

The seropositivity rate was 86% (n=590) in patients with AIIRD compared to 100% in controls (p <0.0001) The level of the S1/S2 antibodies was significantly reduced in AIIRD patients compared to controls (mean± SD 132.9±91.7 vs 218.6±82.06, P<0.0001). In patients with PsA, AxSpA, SLE, and LVV, the seropositive rate was above 90%. In RA, the seropositive rate was 82.1% and the lowest seropositive rate (<40%) was observed in patients with AAV and IIM.

Anti-CD20 significantly impaired the vaccine’s immunogenicity, with the lowest seropositivity rate of 39%. The use of GC, mycophenolate mofetil (MMF), and abatacept was associated with a significantly lower rate of seropositivity (Figure 1). MTX significantly reduced the seropositivity in patients treated with MTX monotherapy and in combinations with other treatments (92% and 84%, respectively), although at a lesser magnitude than anti-CD20, MMF, and abatacept. More than 97% of patients treated with anti-cytokine therapies including TNFi, interleukin-17 and interleukin-6 inhibitors had an appropriate immunogenic response when used as monotherapy. The combination of TNFi with MTX significantly reduced the rate of seropositivity to 93%, p=0.04. Age over 65 years, a diagnosis of RA, IIM, ANCA-associated vascilitis, and treatment with GC, MMF, anti-CD20, and abatacept were associated with a reduced likelihood of seropositivity.

Figure 1.

Seropositivity rate by immunosuppressive treatment.

There were no post-vaccination symptomatic cases of COVID-19 among AIIRD patients and one mild case in the control group. Major adverse events in AIIRD patients included death (n=2) several weeks after the second vaccine dose, non-disseminated herpes zoster (n=6), uveitis (n=2), and pericarditis (n=1). Post-vaccination disease activity remained stable in the majority of patients.

Conclusion:

Vaccination with the BNTb262 vaccine resulted in an adequate immunogenic response with an acceptable safety profile in the majority of patients with AIIRD. Treatment with GC, rituximab, MMF, and abatacept may impair BNT162b2-induced immunogenicity. Postponing administration of rituximab, when clinically feasible, seems to be reasonable to improve vaccine-induced immunogenicity. Holding treatment with abatacept and MMF may be considered on an individual basis.

Disclosure of Interests:

None declared

AB0780 TREATMENT PERSISTENCE OF BIOLOGICS AMONG PATIENTS WITH PSORIATIC ARTHRITIS (PsA)

Background:

Persistence in biologic therapy in psoriatic arthritis is critical to optimize symptom remission, functional capacity and health care costs.

Objectives:

To estimate the persistence to biologic treatment prescribed to PsA patients in a real-life setting as well as factors associated with improved biologic drug survival in these patients.

Methods:

Patients with PsA from a large health care provider database with at least two consecutive dispensed prescriptions of a biologic agent indicated for PsA from January 1st, 2002 until December 31st, 2018 were identified and followed until medication stop date or the end of observation period. Patients were considered non-persistent whenever a new prescription was dispensed and a permissible gap of 6 months was exceeded prior to starting on this biologic agent from the prescription date. Treatment changes were based on physician decisions and patient preferences.

Demographic data including age, sex, BMI, ethnicity, smoking history and socioeconomic status as well as Charlson comorbidity index were retrieved. Data regarding use of steroids and non-biologic disease-modifying anti-rheumatic drugs were also extracted. Descriptive statistics, including means (standard deviations) for continuous variables and frequencies (%) for categorical variables, were used. Persistence estimates were derived using non-parametric survival analysis using Kaplan-Meier functions, with treatment discontinuations as failure events. Cox regression hazard ratio models were conducted to investigate factors associated with drug persistence.

Results:

2301 PsA patients with 2958 treatment periods were identified and included in the analyses. The mean age was 50.9±14 years of whom 54% were females, 70.4% of the study population had a BMI>25, and 36% were obese(BMI>30), 40% were current smokers, and 76% had a Charlson comorbidity index higher than 1. The most commonly prescribed drug was etanercept, followed by adalimumab, golimumab, secukinumab, ustekinumab and infliximab at 33%, 29%, 12%, 10%,8% and 8%, respectively. Only about 20% of patients remained on a particular biologic agent after 5 years, whereas about 40% persisted on therapy following 20 months of treatment. A Kaplan-Mayer survival analysis with pairwise comparisons of all treatment choices with respect to lines of therapy was conducted. When analyzing the data for all treatment periods and taking into account all lines of therapy, secukinumab had a higher persistency than adalimumab, infliximab and ustekinumab, with a Log Rank of 0.022, 0.047 and 0.001, respectively, as is shown in figure 1. Female sex and smoking were associated with lower drug persistence (HR=1.25, 95%CI 1.13-1.38 and HR=1.109, 95%CI 1.01-1.21, respectively). When analyzing the data regarding second-line biologic agents, secukinumab was found to be superior to adalimumab, etanercept, infliximab and ustekinumab but not to golimumab with a Log-Rank P value of 0.001, 0.004, 0.025 and 0.002, respectively (figure 2). On analyzing the data using only the first indicated biologic line, no superiority of any single anti-Tumor Necrosis Factor-alpha (anti-TNFα) agent was observed.

Conclusion:

In this large observational cohort, in the era of biologic therapy, a relatively low persistence was observed, with female sex and smoking having a negative impact on persistency. None of the anti-TNFα agents as first line therapy was found to be more persistent than others, while secukinumab was found to be superior to other biologics when indicated as second line of therapy.

References:

None

Figure 1.Figure 2.

Acknowledgments:

none

Disclosure of Interests:

None declared

Residents' knowledge in transfusion medicine and educational programs: A pilot study

BACKGROUND

Residents' knowledge in transfusion medicine significantly impacts the optimal use of blood and patient safety. Little is known regarding this topic in France in particular. The objectives were to evaluate their basic knowledge, to determine whether the objectives of the curricula were attained and subsequently to suggest ways for improvement.

METHODS

A cross-sectional study was conducted on 50 first year medical and surgical specialty residents rotating in a French university hospital.

RESULTS

Major gaps in the knowledge were noted among residents of various specialties, equally between those with low and sustained transfusion practice. The majority of these young doctors expressed difficulties in prescribing and handling transfusions, identifying and managing its complications and understanding their responsibilities. The roles of hemovigilance practitioners were further somehow unclear for participants.

CONCLUSION

Given these results, action plans appear needed to limit consequences. A special transfusion medicine educational program should be added to the currently available medical education curriculum in order to ensure physicians have adequate knowledge of transfusion basics; at least a practical assisted situation during residency would be of valuable interest.

Method for Recording Broadband High Resolution Emission Spectra of Laboratory Lightning Arcs

Lightning is one of the most common and destructive forces in nature and has long been studied using spectroscopic techniques, first with traditional camera film methods and then digital camera technology, from which several important characteristics have been derived. However, such work has always been limited due to the inherently random and non-repeatable nature of natural lightning events in the field. Recent developments in lightning test facilities now allow the reproducible generation of lightning arcs within controlled laboratory environments, providing a test bed for the development of new sensors and diagnostic techniques to understand lightning mechanisms better. One such technique is a spectroscopic system using digital camera technology capable of identifying the chemical elements with which the lightning arc interacts, with these data then being used to derive further characteristics. In this paper, the spectroscopic system is used to obtain the emission spectrum from a 100 kA peak, 100 µs duration lightning arc generated across a pair of hemispherical tungsten electrodes separated by a small air gap. To maintain a spectral resolution of less than 1 nm, several individual spectra were recorded across discrete wavelength ranges, averaged, stitched, and corrected to produce a final composite spectrum in the 450 nm (blue light) to 890 nm (near infrared light) range. Characteristic peaks within the data were then compared to an established publicly available database to identify the chemical element interactions. This method is readily applicable to a variety of other light emitting events, such as fast electrical discharges, partial discharges, and sparking in electrical equipment, apparatus, and systems.

Pneumatosis cystoides intestinalis revealed after a hand-to-hand aggression: A case report

INTRODUCTION

Pneumatosis cystoides intestinalis (PCI) is a condition defined by the presence of multiple gas-filled cysts within the intestinal wall. We demonstrated a case of PCI presenting as pneumoperitoneum following a hand-to-hand aggression. Consent was obtained from the patient for publication of this paper.

PRESENTATION OF THE CASE

This article describes a case of an 28 year-old man with medical history of gastroduodenal ulcer admitted in the emergency room with an acute abdominal pain secondary to a hand-to-hand aggression. Computed tomography (CT-scan) revealed signs of PCI, the presence of pneumoperitoneum and a small amount of fluid in the Douglas pouch. The patient underwent an urgent laparotomy in front of a high suspicion of a bowel perforation. Per operative findings revealed multiple small cysts of the terminal ileum and there were no bowel perforation.

DISCUSSION

Pneumatosis cystoides intestinalis may be related to a wide spectrum of gastrointestinal conditions. The diagnosis of PCI can be established by endoscopic ultrasound or CT-scan imaging. Management of PCI is conditioned by the clinical and radiological presentation which is essentially related to the primary cause. Conservative approach is allowed in a stable patient with no signs of complications. In the presence of predictive factors of pathologic PCI, namely transmural ischemia and bowel perforation, surgical operation is required.

CONCLUSION

The management of PCI may be challenging particularly in the presence of pneumoperitoneum. Complications must be excluded before considering a conservative therapy. Therefore, PCI should be interpreted with relevance to the entire clinical context.

Pancreatic mucinous cystadenoma doubly complicated by acute pancreatitis and retroperitoneal rupture

Mucinous cystadenomas are the most frequent cystic benign tumors of the pancreas. They are characterized by a malignant potential. Acute pancreatitis is their most common complication. This manuscript reports a unique complication of mucinous cystadenomas of the pancreas: retroperitoneal rupture associated to acute pancreatitis. After resuscitation, the patient underwent surgery. A cystic mass of the pancreas tail with retroperitoneal rupture was found. Splenopancreatectomy was performed. Outcomes were straightforward. After 3 years of follow-up, no signs of recurrence are highlighted.

A strangled hernia through the Winslow's hiatus: about a rare situation

Winslow's hiatus hernia is the rarest of the internal hernias. Its diagnosis is difficult and requires an urgent laparotomy to avoid necrosis of the incarcerated loop or even the death of the patient. We report the case of a patient operated urgently for acute intestinal obstruction caused by a strangled hernia through the Winslow's hiatus. A reduction by traction of the hernia was undertaken. Rapid management of this pathology is important using clinical and radiographical elements.

Transfusion-associated hazards: A revisit of their presentation

As a therapy or a support to other therapies, despite being largely beneficial to patients in general, transfusion it is not devoid of some risks. In a moderate number of cases, patients may manifest adverse reactions, otherwise referred to as transfusion-associated hazards (TAHs). The latest French 2016 haemovigilance report indicates that 93% of TAHs are minor (grade 1), 5.5% are moderate (grade 2) and 1.6% are severe (grade 3), with only five deaths (grade 4) being attributed to transfusion with relative certainty (imputability of level [or grade] 1 to 3). Health-care providers need to be well aware of the benefits and potential risks (to best evaluate and discuss the benefit-risk ratio), how to prevent TAHs, the overall costs and the availability of alternative therapeutic options. In high-income countries, most blood establishments (BEs) and hospital blood banks (HBBs) have developed tools for reporting and analysing at least severe transfusion reactions. With nearly two decades of haemovigilance, transfusion reaction databases should be quite informative, though there are four main caveats that prevent it from being fully efficient: (ai) reporting is mainly declarative and is thus barely exhaustive even in countries where it is mandatory by law; (aii) it is often difficult to differentiate between the different complications related to transfusion, diseases, comorbidities and other types of therapies in patients suffering from debilitating conditions; (aiii) there is a lack of consistency in the definitions used to describe and report some transfusion reactions, their severity and their likelihood of being related to transfusion; and (aiv) it is difficult to assess the imputability of a particular BC given to a patient who has previously received many BCs over a relatively short period of time. When compiling all available information published so far, it appears that TAHs can be analysed using different approaches: (bi) their pathophysiological nature; (bii) their severity; (biii) the onset scheme; (biv) a quality assessment (preventable or non-preventable); (bv) their impact on ongoing therapy. Moreover, TAHs can be reported either in a non-integrative or in an integrative way; in the latter case, presentation may also differ when issued by a blood establishment or a treating ward. At some point, a recapitulative document would be useful to gain a better understanding of TAHs in order to decrease their occurrence and severity and allow decision makers to determine action plans: this is what this review attempts to make. This review attempts to merge the different aspects, with a focus on the hospital side, i.e., how the most frequent TAHs can be avoided or mitigated.

Genetic variation in the progesterone receptor gene and susceptibility to recurrent pregnancy loss: a case-control study

OBJECTIVE

To investigate the association of progesterone receptor (PGR) gene variants with susceptibility to recurrent pregnancy loss (RPL).

DESIGN

Retrospective case-control study.

SETTING

Outpatient obstetrics and gynaecology clinics.

POPULATION

Women with RPL (396), defined as three or more consecutive miscarriages of unknown aetiology, and 361 women used as controls.

METHODS

PGR genotyping was performed by the allelic exclusion method (real-time polymerase chain reaction).

MAIN OUTCOME MEASURES

PGR single nucleotide polymorphisms (SNPs) and the distribution of their alleles, genotypes and haplotypes.

RESULTS

Higher minor allele frequencies (MAFs) for rs590688, rs10895068, and rs1942836 were seen in RPL cases than in controls, which remained significant after controlling for multiple comparisons. Significantly higher frequencies of heterozygous (1/2) rs608995, along with heterozygous (1/2) and homozygous (2/2) rs590688, rs10895068, and rs1942836 genotype carriers, were seen between RPL cases versus controls, respectively, which persisted after controlling for age, body mass index (BMI), and menarche. The increased risk of RPL associated with rs590688 and rs1942836 was dependent on the number of minor alleles, thus suggesting a 'dose-dependent' effect associated with both variants. Varied linkage disequilibrium (LD) was noted between rs590688, rs10895068, rs608995, and rs1942836 PGR variants associated with RPL. Haplotypes with an increased frequency of CGTC and reduced frequency of GGAT were noted in women with RPL, compared with controls, thereby indicating these haplotypes as RPL-susceptible and RPL-protective, respectively. This association persisted after controlling for multiple comparisons, and after adjusting for covariates.

CONCLUSIONS

We have confirmed a positive association of specific PGR variants (rs590688, rs10895068, and rs1942836) and PGR haplotypes (ATGCCGTC and ATTCGGTC) with an increased risk of RPL, thereby supporting a role for PGR as an RPL candidate locus.

TWEETABLE ABSTRACT

Genetic variants in progesterone receptor gene are associated with increased risk of recurrent pregnancy loss.

Round cell sarcoma of the colon with CIC rearrangement

Background

The CIC-rearranged sarcoma is a very rare highly aggressive malignant soft tissue group of tumors. It has recently been described as highly aggressive soft tissue tumors of children and young adults sharing similar morphological features with the Ewing sarcoma. The digestive localization is exceptional.

Case presentation

A 14-year-old male presented with a history of abdominal pain for 1 year, which increased in intensity over the last 2 months. Imaging findings showed a large heterogeneous mesenteric mass on the left flank of the abdomen. Exploratory laparotomy was performed and revealed a large cystic hypervascularized mass depending on the transverse colon and mesocolon. A wide excision of the lesion was performed with segmental colectomy. No postoperative complications were noted. The microscopic examination revealed a vaguely nodular growth of undifferentiated small round cells, arranged in solid sheets separated by thin fibrous septa with a scarce stroma. After an uncomplicated post-operative course, the patient was referred for chemotherapy. The patient died 2 months later with a peritoneal and pleural progression.

Conclusions

The CIC-rearranged sarcoma is an aggressive tumor. There is no standard therapy for this rare disease. Their treatment includes surgery and chemotherapy. Resistance to chemotherapy is common. Further publications and studies will help to determine a standard therapy for this rare disease.

[Not-for-profit: A report from the fourth annual symposium of ethics held by the National Institute for Blood Transfusion (France)]

The not-for-profit issue has been debated in November 2016 in Paris; this issue is one of the four canonical pillars of ethical blood donation. It is intimately bound to benevolence though it is distinct, as not-for-profit calls for institutions while benevolence calls for individuals. It is indeed intended that voluntary blood donors do not benefit from their donation and are thus non-remunerated. Not-for-profit is essential since it refers to the public character of blood as a putative public resource aimed at being shared as a tribute of solidarity. A central question however is linked to the capacity- or not -of public sectors to ensure that blood components are universally available, with special mention to plasma derived drugs, without the contribution of the for profit, private sector.

Abstract P5-16-22: Survival after adjuvant and neoadjuvant chemotherapy in elderly patients with triple negative breast cancer: A Cleveland Clinic experience

Background:

Triple negative breast cancer (TNBC) comprises of approximately 15% of the total breast cancers. There is limited data on treatment outcome of these patients in elderly population. We report our experience with elderly patients with TNBC treated at our tertiary care centers.

Objectives and rationale:

1. Percentage of TNBC patients who received neoadjuvant chemotherapy (NACT) vs. Adjuvant chemotherapy (ACT).

2. Chemotherapeutic agents used for NACT and ACT.

3. Progression free survival (PFS) and overall survival (OS) after neoadjuvant CT and adjuvant CT.

4. Outcomes between elderly patients 65-74 years vs. 75 years and above.

Methods:

With IRB approval, the Cleveland Clinic's database was used to identify TNBC patients treated between 2000 to 2013. OFS from the diagnosis of TNBC was the primary end point. Cox proportional hazard models with stepwise variable selections were used for data analysis.

Results:

A total of 223 patients, divided in to two groups, were prospectively followed. The age group from 65-74 years consisted of “Group A” (N=140, median 69) and 75 or older formed “Group B” (N= 83, median 80, maximum 92). Eighty eight percent had ductal carcinoma. Clinically majority had stage I (50%) and stage II (33%) disease; 17% had stage III disease and most tumors were poorly differentiated (74%, grade 3). Slightly more than half the patients had lumpectomies (55%); and in only 13% of cases (25/190) were margins positive. Patients who received neoadjuvant (NACT), aduvant chemotherapy (ACT) and radiation therapy (RT) were 65%, 53% and 38% respectively. For NACT primarily doxorubicin, cyclophosphamide and paclitaxel were used whereas for ACT it was docetaxel with cyclophosphamide. Group B had somewhat poorer performance status than younger patients (p=.05), received chemotherapy especially neoadjuvant therapy much less frequently (p&lt;.0001). OS and PFS were significantly lower in Group B (p=0.001 and 0.007 respectively). This holds true even if one adjusts for performance status and use of chemotherapy (p=0.04 and 0.03 respectively).

Conclusion:

Among elderly patients with triple negative breast cancer, those above 75 years and older have poorer outcomes compared to those with age 65-74 years. However, this is a retrospective study and has limitations; prospective randomized studies are needed to confirm these findings.

Citation Format: Mohapatra S, Seepana J, Haddad A, Spiro T, Daw H. Survival after adjuvant and neoadjuvant chemotherapy in elderly patients with triple negative breast cancer: A Cleveland Clinic experience [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 P5-16-22.

A European survey on donor deferral for allergy: Rationale and initial results of a survey in 35 countries

Allergy accounts to near 0.5% of all reported transfusion adverse events. The responsibility of blood components themselves and - therefore - of blood donors is still questioned. The European Community undertook a large international survey to address the consistency and homogeneity of medical selection of blood donors with regard to the risk of allergy, and especially of transferring allergy to recipients. This short report presents the salient points of the survey, stressing that there is inconsistency in addressing the allergy question within countries or systems, with paths of improvement.

Transfusion as an Inflammation Hit: Knowns and Unknowns

Transfusion of blood cell components is frequent in the therapeutic arsenal; it is globally safe or even very safe. At present, residual clinical manifestations are principally inflammatory in nature. If some rare clinical hazards manifest as acute inflammation symptoms of various origin, most of them linked with conflicting and undesirable biological material accompanying the therapeutic component (infectious pathogen, pathogenic antibody, unwanted antigen, or allergen), the general feature is subtler and less visible, and essentially consists of alloimmunization or febrile non-hemolytic transfusion reaction. The present essay aims to present updates in hematology and immunology that help understand how, when, and why subclinical inflammation underlies alloimmunization and circumstances characteristic of red blood cells and – even more frequently – platelets that contribute inflammatory mediators. Modern transfusion medicine makes sustained efforts to limit such inflammatory hazards; efforts can be successful only if one has a clear view of each element’s role.