Clinical and operative risk factors for complications after Apert hand syndactyly reconstruction

This study evaluated how Apert hand syndactyly presentations and reconstructive techniques influence reconstruction outcomes. All cases at a major paediatric hospital between 2007 and 2022 were analysed, including 98 web space reconstructions in 17 patients. Overall, 62% of hands developed complications and 15% required revision surgery. Upton hand type was significantly associated with postoperative complication incidence, specifically including range-of-motion deficits, flexion contracture, web creep and revision surgery. More severe syndactylies may benefit from additional measures to reduce complications. Rectangular commissural flaps showed 1.9 times greater complication risk than interdigitating triangular flaps, including 11.2 times greater risk of web creep. Zigzag volar finger flaps showed 1.8 times greater complication risk than straight-line incisions, including 3.8 times greater risk of web creep. Our study showed that interdigitating triangular commissural flaps and straight-line volar finger incisions are preferable to rectangular commissural and zigzag finger flaps in most cases of Apert hand syndactyly to minimize complications.

LEVEL OF EVIDENCE

III.

[Colorectal adenocarcinoma with enteroblastic differentiation: a clinicopathological analysis of eight cases]

Objective: To investigate the clinicopathological features of colorectal adenocarcinoma with enteroblastic differentiation (CAED). Methods: Eight cases of CAED diagnosed at the Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China from January 2017 to August 2023 were collected. The histopathological, immunohistochemical, molecular and prognostic features of 8 CAED cases were analyzed. The relevant studies were also reviewed. Results: Among the eight patients, there were six males and two females, with an average age of 58 years (range: 29-77 years, median age: 61.5 years). Preoperative serum alpha-fetoprotein levels were elevated in five patients (14.0-286.6 μg/L). Four tumors were located in the colon, and four tumors in the rectum. Two patients were clinically staged as advanced stage (stage Ⅳ), and distant metastasis occurred at the initial diagnosis (one case had liver metastasis, and the other had lung, bone and multiple lymph nodes metastases). Six patients were clinically staged as locally-advanced stage (Stage Ⅱ-Ⅲ). Three of them developed distant metastases after surgery (one case had liver metastasis, one case had lung metastasis, and one case had peritoneal metastasis). Additionally, two patients died at 9 months and 24 months after surgery, respectively. The tumors were composed of various proportions of adenocarcinoma components with enteroblastic differentiation (30%-100%) and classical tubular adenocarcinoma components. The component with enteroblastic differentiation exhibited morphology similar to embryonic intestinal epithelium: cuboidal or columnar tumor cells arranged in tubular, papillary, cribriform, or solid nest patterns, with clear cytoplasm. Immunohistochemical studies showed that tumor cells expressed at least one oncofetal protein (SALL4, Glypican-3, and AFP). In addition, focal squamous differentiation was observed in 3 cases (3/8). Compared to the primary tumor, both CAED and squamous differentiation components were increased in the metastatic tumors. Based on the sequencing results of KRAS, NRAS and BRAF of the primary and/or metastatic tumors, 5 cases were wild-type, while KRAS exon 2 (G13D) mutations were identified in 2 cases. Conclusions: CAED is a rare colorectal malignancy with a dismal prognosis. Accurate pathological diagnosis is prognostically valuable. The histological features of enteroblastic differentiation, elevated serum AFP levels, and the expression of oncofetal proteins play an important role in the tumor diagnosis.

The impact of low-mode symmetry on inertial fusion energy output in the burning plasma state

Indirect Drive Inertial Confinement Fusion Experiments on the National Ignition Facility (NIF) have achieved a burning plasma state with neutron yields exceeding 170 kJ, roughly 3 times the prior record and a necessary stage for igniting plasmas. The results are achieved despite multiple sources of degradations that lead to high variability in performance. Results shown here, for the first time, include an empirical correction factor for mode-2 asymmetry in the burning plasma regime in addition to previously determined corrections for radiative mix and mode-1. Analysis shows that including these three corrections alone accounts for the measured fusion performance variability in the two highest performing experimental campaigns on the NIF to within error. Here we quantify the performance sensitivity to mode-2 symmetry in the burning plasma regime and apply the results, in the form of an empirical correction to a 1D performance model. Furthermore, we find the sensitivity to mode-2 determined through a series of integrated 2D radiation hydrodynamic simulations to be consistent with the experimentally determined sensitivity only when including alpha-heating.

Novel and recurrent variants in PAX6 in four patients with ocular phenotypes from Southeast Asia

Aniridia is an autosomal dominant condition characterized by the complete or partial absence of the iris, often with additional presentations such as foveal hypoplasia, nystagmus, cataract, glaucoma and other ocular abnormalities. Most cases are caused by heterozygous mutations in the paired box 6 gene (PAX6), which codes for a transcription factor that regulates eye development. Four patients from our hospital who presented with ocular phenotypes were recruited for research sequencing with informed consent. Sanger sequencing of PAX6 coding exons or exome sequencing was performed on genomic DNA from venous blood samples. Variants in PAX6 were identified in the four patients. Two variants are recurrent single-nucleotide substitutions - one is a substitution found in a patient with bilateral aniridia, whereas the other is a splice variant in a patient with nystagmus and neuroblastoma. The other two variants are novel and found in two patients with isolated aniridia. Both are small duplications that are predicted to lead to premature termination. For the recurrent variants, the comparison of phenotypes for patients with identical variants would shed light on the mechanisms of pathogenesis, and the discovery of two novel variants expands the spectrum of PAX6 mutations.

Clinical and Histopathological Investigation of Pediatric Melanonychia: A Single-Center Retrospective Case Series

HYPOTHESIS

The natural history of pediatric melanonychia and the necessity of biopsy for ruling out melanoma are debated in the literature. We hypothesize that there is a low rate of malignant nail pathology among pediatric patients undergoing nail bed biopsy for melanonychia.

METHODS

We performed a retrospective chart review of 54 pediatric patients (age <18 years) at a single institution who presented with melanonychia and underwent nail bed biopsy from 2007 to 2022. Data points collected included patient demographics, medical history, physical exam findings, pathology reports, and clinical photos. Univariate and multivariate analyses were performed to assess for risk factors associated with high-risk pathology findings.

RESULTS

The average age of melanonychia onset was 5.5 years (SD 4.4). The average age of first biopsy was 7.8 years (SD 4.3). On physical exam, 27 patients had at least four features concerning for melanoma (asymmetry, border irregularity, color heterogeneity, diameter > 1/3 of nail, evolving color, evolving diameter, Hutchinson's sign). The most common pathology diagnoses were melanocytic nevus (35%), atypical intraepidermal melanocytic proliferation (AIMP) with benign features (24%), subungual lentigo (22%), and AIMP with concerning features (17%). There were no cases of melanoma in situ or invasive malignant melanoma. On multivariate regression, the only significant risk factor associated with more concerning pathology (AIMP with concerning features) was the calendar year in which biopsy was performed (coefficient = -0.34, P = 0.016). There was no association between physical exam features and high-risk pathology. Twelve patients had surgical re-excision of the lesion, 6 of which were due to incomplete excision of AIMP with concerning features and 6 of which were due to recurrence.

CONCLUSIONS

Our case series did not find any cases of melanoma in situ or malignant melanoma arising from pediatric melanonychia. Atypical intraepidermal melanocytic proliferation with concerning features was associated only with the year in which the biopsy was performed, which may reflect the improved understanding of pediatric melanonychia as often benign despite concerning features on pathology. The decision to perform a nail matrix biopsy in pediatric melanonychia should be based on a collaborative discussion between the patient's parents, dermatologist, and plastic surgeon.

Charting Outcomes in the Hand Surgery Fellowship Match

PURPOSE

The hand surgery fellowship match attracts applicants from general, plastic, and orthopedic surgery residency training. The purpose of this study was to understand recent trends in applications and match rates in the hand surgery fellowship match.

METHODS

The National Resident Matching Program provided program and applicant data from the hand surgery fellowship match (2012-2020). The primary outcomes of interest were match rates and number of unfilled fellowship positions by specialty. Trends over time and comparisons of the percentage of unfilled spots by specialty were observed.

RESULTS

The total number of applicants decreased from 199 to 188 (5.5% decrease), while the number of available positions increased from 150 to 177 (18.0% increase) during the study period. The increase in available positions was driven primarily by orthopedic fellowships, which increased from 124 to 149 (20.2% increase). The percentage of applicants that did not match to a hand surgery fellowship decreased from 24.6% in 2012 to 5.9% in 2020. United States graduates had higher match rates than non-United States graduates during each year, but this disparity narrowed over time. Most applicants matched at one of their top 3 choices (first choice, 33.3%; second choice, 12.9%; third choice, 7.9%). Applicants matching at their first choice increased from 28.1% in 2012 to 39.4% in 2020. Plastic surgery hand surgery fellowships had a higher rate of unmatched positions relative to orthopedic surgery fellowships (6.1% vs 2.2%).

CONCLUSIONS

Match rates in the hand surgery fellowship match have increased because of an overall increase in training positions and decrease in applicants. More research is needed to understand disparities in match rates by specialty.

CLINICAL RELEVANCE

The diverse training experiences of hand surgeons historically have been viewed as a strength for the specialty. Understanding recent trends in the hand surgery fellowship match by specialty can help future applicants and faculty anticipate likely match outcomes.

Physeal Fractures of the Distal Ulna: Incidence and Risk Factors for Premature Growth Arrest

BACKGROUND

The aim of this study is to assess the rate of distal ulnar growth arrest following physeal fracture and to identify specific risk factors for premature physeal closure.

METHODS

A retrospective review of patients with a distal ulnar physeal fracture was performed at a single United States children's hospital. Patients without 6-month follow-up were excluded. Patient demographics, injury characteristics, treatment, and outcomes were abstracted. Fractures were classified by the Salter-Harris (SH) system. All follow-up radiographs were reviewed for changes in ulnar variance or signs of premature physeal arrest.

RESULTS

Fifty-six children with distal ulnar physeal fracture at a mean age of 10.7±3.3 years were included with a mean follow-up of 1.9 years. The most common fracture pattern was a SH II (52.7%), versus SH I (29.1%), SH III (9.1%), and SH IV (9.1%). Of displaced fractures (41.1%), the mean translation was 40.2±38.3% the and mean angulation was 24.8±20.9 degrees. Eleven fractures (19.6%) demonstrated radiographic signs of growth disturbance, including 3 patients (5.4%) with growth disturbance but continued longitudinal growth and 8 patients (14.3%) with complete growth arrest. The average ulnar variance was -3.4 mm. Three patients underwent subsequent surgical reconstruction including ulnar lengthening with an external fixator, distal ulna completion epiphysiodesis with distal radius epiphysiodesis, and ulnar corrective osteotomy. Patients with displaced fractures and SH III/IV fractures were more likely to develop a growth disturbance (34.8% vs. 3.2%, P =0.003; 50.0% vs. 11.1%, P =0.012, respectively). Children with less than 2 years of skeletal growth remaining at the time of injury had a higher risk of growth disturbance (46.2% vs. 9.5%, P =0.007).

CONCLUSIONS

SH III and IV fractures are more common injury patterns in the distal ulna compared with the distal radius. Growth disturbance or growth arrest occurs in ~20% of distal ulnar physeal fractures. Displaced fractures, intra-articular fractures, fractures requiring open reduction, and older children are at increased risk of distal ulnar growth arrest and should be followed more closely.

LEVEL OF EVIDENCE

Level IV--case series.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

The influence of directional preference on lateral patellar dislocation: a case report

BACKGROUND

There is little consensus on the conservative management of lateral patellar dislocations (LPD). Mechanical diagnosis and therapy (MDT) is an established classification system in the spinal and extremity population. This case report describes the use of MDT in the management and classification of a patient with LPD.

CASE DESCRIPTION

The patient was a 20-year-old female with a 3-month history of left knee pain precipitated by a lateral patellar dislocation. The patient described pain and a feeling of instability with standing and walking and limitations in work and recreational activities which involve lifting, squatting, and running. Based on the patient's response to repeated end range knee movements, the patient was found to have a directional preference (DP) for knee extension and instruction in performance of knee extension DP exercises was provided.

OUTCOMES

The patient's knee examination and subsequent intervention included her responses to repeated end range knee movements. Her knee pain was abolished, and strength, function, and motion were fully restored in five visits. A minimal clinically important difference (MCID) was achieved on the Lower Extremity Functional Scale (LEFS). At discharge, the patient was able to independently manage symptoms and perform all work and recreational activities at a pre-injury level and these improvements were maintained at a 9-month follow-up.

DISCUSSION

There are various management strategies for lateral patellar dislocation. This case demonstrated the use of classifying, subgrouping, and treating a patient with lateral patellar dislocation using the principle of DP.

CONCLUSION

The patient's outcomes suggest that MDT may be used in the nonoperative management of people with LPD who present with a DP.

Does Irreducibility Always Mean a Complex Dislocation? An Analysis of 33 Pediatric Metacarpophalangeal Joint Dislocations

BACKGROUND

Previous failed reduction and certain radiographic indicators historically have been used to differentiate simple and complex metacarpophalangeal joint (MPJ) dislocations in children, the latter of which warrants open reduction. This investigation aimed to determine the necessity for open reduction with these indicators and establish a new treatment algorithm and educational focus for these rare injuries.

METHODS

A 12-year retrospective study was conducted on all children with MPJ dislocations at a single pediatric hospital. The rates of successful closed reduction, number of reduction attempts, and radiographic findings were detailed. Operative details and postoperative outcomes were also gathered.

RESULTS

Thirty-three patients with a mean age of 11.1 years were included. Most were male [ n = 27 (82%)] and had undergone two or more previous reduction attempts at an outside facility. Stable closed reduction was then achieved outside of the operating room in five patients and in the operating room under general anesthesia in another 14, for a total of 19 of 33 patients (57.6%). The thumb was injured most often [ n = 19 (57.6%)] and more likely to undergo successful closed reduction ( P = 0.04). There was no relationship between number of previous reduction attempts and ability to achieve closed reduction ( P = 0.72). Neither joint-space widening nor proximal phalanx bayonetting was correlated radiographically with failure of closed reduction ( P = 0.22 and P = 1, respectively).

CONCLUSIONS

This study supports closed reduction of pediatric MPJ dislocations in the operating room under general anesthesia before conversion to open reduction, regardless of injury characteristics or previous reduction attempts. This strategy is likely to limit unnecessary open surgery and related risks.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Natural History of Pediatric Hand and Wrist Ganglion Cysts: Longitudinal Follow-Up of a Prospective, Dual-Center Cohort

PURPOSE

This investigation describes the outcomes of pediatric ganglion cysts in a prospective cohort that elected not to undergo cyst aspiration or surgical treatment. Our primary aim was to investigate the rate of spontaneous resolution over time among the subset of patients who did not undergo specific treatments.

METHODS

Children (aged ≤18 years) who presented to the clinic with ganglion cysts of the hand or wrist were enrolled in a prospective two-center registry between 2017 and 2021. Enrolled subjects who never elected to undergo cyst aspiration or surgical treatment were analyzed. The data collected included age, sex, cyst location and laterality, hand dominance, Wong-Baker pain scale scores, and Patient-Reported Outcome Measurement Information System upper-extremity scores. Follow-up surveys were completed for up to 5 years.

RESULTS

A total of 157 cysts in 154 children, with an average age of 9.4 years and a female-to-male ratio of 1.4:1, were eligible. The most common ganglion location was dorsal wrist (67/157, 42.7%), followed by volar wrist (49/157, 31.2%), the flexor tendon sheath (29/157, 18.5%), and the extensor tendon synovial lining (8/157, 5.1%). The average follow-up duration was 2.5 years after initial presentation to the clinic, and 63.1% (99/157) of the patients responded to follow-up surveys. Among them, 62.6% (62/99) of cysts spontaneously resolved; the resolution rates ranged from 51.9% of volar wrist ganglions to 81% of flexor tendon sheath cysts, with an average time to resolution of 14.1 months after cyst presentation. Cysts were more likely to resolve in the hand than in the wrist (84.0% vs 55.4%, respectively). Cysts present for >12 months at initial evaluation were less likely to resolve spontaneously (41.2% vs 67.1%).

CONCLUSIONS

Of children who elected not to undergo aspiration or surgical treatment, approximately two-thirds of families reported that their child's ganglion cyst resolved spontaneously. Cysts that resolve spontaneously usually do so within 2 years of presentation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pediatric hand fractures detection on radiographs: do localization cues improve diagnostic performance?

OBJECTIVE

To compare the diagnostic accuracy and interpretation time for detection of pediatric fractures on hand radiographs with and without localization cues.

MATERIALS AND METHODS

Consecutive children, who underwent radiographic examinations after injury, over 2 years (2019-2021) and with > 2 weeks of follow-up to confirm the presence or absence of a fracture, were included. Four readers, blinded to history and diagnosis, retrospectively reviewed all images twice, without and with cue, at least 1 week apart and after randomization, to determine the presence or absence of a fracture, and if present, anatomic location and diagnostic confidence were recorded. Interpretation time for each study was also recorded and averaged across readers. Inter-reader agreement was calculated using Fleiss' kappa. Diagnostic accuracy and interpretation time were compared between examinations using sensitivity, specificity, and Mann-Whitney U correlation.

RESULTS

Study group included 92 children (61 boys, 31 girls; 10.8 ± 3.4 years) with and 40 (31 boys, 9 girls; 10.9 ± 3.7 years) without fractures. Cue improved inter-reader agreement (κ = 0.47 to 0.62). While the specificity decreased (63 to 62%), sensitivity (75 to 78%), diagnostic accuracy (71 to 73%), and confidence improved (78 to 87%, p < 0.01), and interpretation time (median: 40 to 22 s, p < 0.001) reduced with examinations with localization cue. Specifically, examinations with fracture and cue had the shortest interpretation time (median: 16 s), whereas examinations without fracture and without cue had the longest interpretation time (median: 48 s).

CONCLUSION

Localization cues increased inter-reader agreement and diagnostic confidence, reduced interpretation time in the detection of fractures on pediatric hand radiographs, while maintaining diagnostic accuracy.

Differences in Academic Qualifications for Leadership at Hand Surgery Fellowships in the United States

Objective In the United States, orthopaedic, general, and plastic surgery hand fellowship programs train hand surgeons. Currently, differences in the academic qualifications of hand surgery fellowship directors (HSFDs) are unknown. This study compares the academic qualifications of HSFDs by specialty.

Methods American Medical Association's Residency and Fellowship Database was queried for hand surgery fellowship training programs. Scholarly activity, academic characteristics, and training pedigrees were collected for each HSFD.

Results Ninety-two HSFDs (73 orthopaedic surgeons, 17 plastic surgeons, 2 general surgeons) were identified. Most were male (87%) and Caucasian (82%). Mean age was 55 ± 11 years and most were trained in orthopaedic surgery (80%). Ten percent of orthopaedic hand surgery fellowship programs were run by a plastic surgeon HSFD, which was greater than 0% of plastic surgery hand fellowship programs run by an orthopaedic surgeon HSFD (p < 0.05). Mean H-index was 15 ± 9 from an average of 57 ± 47 publications. Orthopaedic and plastic surgeon HSFDs had similar levels of scholarly activity (p > 0.05). Age correlated with higher H-index values (r = 0.38, p < 0.001). More plastic surgeon HSFDs were trained by their top five fellowship programs than orthopaedic surgeon HSFDs (65 vs. 27%, p < 0.05).

Conclusion Ultimately, HSFDs have strong research backgrounds and similar characteristics despite disparate training pathways. Women and racial minority groups are largely underrepresented among leadership positions at hand surgery fellowships. These benchmarks can help inform future diversity initiatives.

Evaluating the effectiveness of physical exercise in improving standardized testing performances through attention indices

INTRODUCTION

In the United States, standardized tests have risen in prevalence, extending their importance from education placement to employment. Attention is crucial to improving testing performance. Past studies have established that acute, coordinative, aerobic exercise improves attention, which is measured by the D2 Attention Test, emotional analysis, reading time, and eye movement tracking. No studies have drawn connections between physical exercise's quantifiable improvement in attention to improvements in standardized tests; therefore, this study would attempt to do so.

METHODS

This study defines attention to be positively related to reading speed and negatively related to the number of eye drifts. High school students were selected to read and answer two reading passages from an SAT (Scholastic Assessment Test) exam, before and after a short 80% intensity run. Their reading times, facial video, and test scores were recorded. Dlib plots the facial landmark and OpenCV tracks movement of the pupil.

RESULTS

Through paired-samples t-tests, this study found out that after exercise, subjects displayed increased reading speed and fewer eye drifts, coupled with increased mean scores.

CONCLUSION

Thus, this study demonstrated that running, as an acute, coordinative, aerobic exercise, helps increase the testing performance of the SAT reading section by measuring attention. Future research could focus on including head movement as an attention index, replicate the experiment on different standardized tests or exercises, and conduct natural experiments to better simulate real-life conditions to increase applicability.

ODP079 BCG-Osis, a Rare Cause of 1,25 Hydroxy Vitamin D Mediated Hypercalcemia

Background

Non-parathyroid hormone (PTH) mediated hypercalcemia is mostly related to malignancy and less commonly caused by granulomatous diseases. We report a rare case of severe hypercalcemia caused by systemic granulomatous disease after intravesical Bacillus Calmette-Guerin (BCG) treatment for bladder cancer (BCGosis).

Clinical Case

74-year-old male with history of bladder cancer treated with intravesical BCG a year ago, was hospitalized with confusion, weakness, recurrent falls and polyuria for a few days. He had night sweats and 50 lb weight loss over 6 months. Lab evaluation showed hypercalcemia with calcium 10.9 mg/dL, albumin 3.6 g/dL, corrected calcium 11.2 mg/dL, PTH 12 pg/ml, and 25 OH vitamin D 44ng/ml. He had normal thyroid hormone levels, serum electrophoresis and PTHrP <2 pmol/L. CT chest/abdomen/pelvis without contrast revealed sub-cm pulmonary nodules and non-obstructive renal calculi and bone scan showed no evidence of osseous metastases. He was treated with intravenous (IV) hydration and pamidronate 60 mg infusion, and his corrected calcium improved to 9.7 mg/dL. He was admitted again 3 weeks later with hypercalcemia, calcium 11.9 mg/DL, albumin 3.2 g/dL, corrected calcium 12.5 mg/dL, 25 OH vitamin D 24 ng/ml, PTH 14.6 pg/ml, and PTHrP <2 pmol/L. He received IV hydration and zoledronic acid 4 mg infusion. 3 weeks later he was hospitalized for the third time for recurrent hypercalcemia and worsening renal failure, calcium 13.2, albumin 2.6 g/dL, corrected calcium 14.2 mg/dL, PTH 19.2 pg/ml. 1,25 OH vitamin D checked this time was elevated at 113 pg/mL. He received another infusion of zoledronic acid 4 mg infusion and 10 days later required denosumab 120 mg for resistant hypercalcemia. PET CT scan showed multiple hypermetabolic foci in right neck, right anterior 4th rib, scrotum, and around left kidney and aorta. He underwent biopsy of the right rib lesion which demonstrated + AFB on smear and histiocytic inflammation, which led to diagnosis of BCGosis, with subsequent cultures positive for Mycobacterium bovis. He was started on multi drug regimen with rifampin, isoniazid and ethambutol. Follow up labs at 4 weeks showed normalization of calcium 8.9 mg/dL, albumin 3.2 g/dL, corrected calcium 9.78 mg/dL, PTH 54 pg/ml and low 1,25 OH vitamin D 17 pg/mL. Calcium and 1,25 OH vitamin D levels were stable at 4 months follow up.

Conclusion

Intravesical BCG treatment can be associated with systemic reactions in 1- 5% of patients. Granulomas associated with disseminated BCG infection can lead to hypercalcemia due to increased 1-alpha-hydroxylase activity in macrophages, causing elevated 1,25 OH vitamin D levels. Therefore, evaluation of 1,25 OH vitamin D levels is critical to determine the etiology of hypercalcemia. Treatment of underlying BCGosis with anti-tuberculosis treatment is key in management of hypercalcemia along with supportive treatments that may include IV hydration, bisphosphonates and/or glucocorticoids.

Presentation: No date and time listed

Factors Influencing Why Children and Their Families Choose Surgery for Ganglion Cysts

PURPOSE

Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients.

METHODS

This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up.

RESULTS

A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients.

CONCLUSIONS

Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children

PURPOSE

Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort.

METHODS

A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores.

RESULTS

A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores.

CONCLUSIONS

Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Transition to Independent Research Funding Among National Institutes of Health K Grant Awardees at Departments of Orthopaedic Surgery

BACKGROUND

The National Institutes of Health (NIH) supports mentored research career development awards (K awards) to increase the pipeline of independently funded scientists. This study analyzed the portfolio of K grants that were awarded to orthopaedic surgery departments and characterized the factors that were associated with successful transition to independent NIH research funding, including R01 grants.

METHODS

This was a retrospective cohort study of K-award recipients in orthopaedic surgery departments in the United States from 1996 to 2018. A query was performed on the NIH Research Portfolio Online Reporting Tools (RePORT) database for NIH grants that were awarded to departments of orthopaedic surgery, general surgery, otolaryngology, obstetrics and gynecology, ophthalmology, and urology. Rates of transition to independent research funding were compared by specialty for K grants that were awarded from 1996 to 2011. The percentage of faculty with mentored research career development awards and the return on investment (ROI) were calculated. An internet and Scopus (Elsevier) database search determined the investigator characteristics. The factors that were associated with successful transition to independent funding were determined via chi-square and unpaired t tests.

RESULTS

Sixty K-award recipients were identified in orthopaedic surgery departments. Most were men (77%) and research scientists (53%). Fifty percent of the K-award recipients transitioned to independent research funding. Research scientists had the highest rate of transition to independent research funding (71%, p = 0.016) relative to clinicians (0%) and orthopaedic surgeons (40%). Higher levels of publication productivity were associated with successful transition to independent research funding. Similar rates of transition to independent research funding existed among surgical specialties (p = 0.107). Orthopaedic surgery had the lowest percentage of faculty with a K award (1.4%) but had the highest ROI (198%) of these awards.

CONCLUSIONS

Orthopaedic surgery had similar rates of transition to independent research funding when compared with other surgical specialties but had a lower prevalence of K awards among faculty. Orthopaedic surgeon-scientists have lower rates of transition to independent research funding when compared with their research-scientist colleagues. These findings highlight a need for greater support to foster the pipeline of future NIH-funded orthopaedic investigators.

CLINICAL RELEVANCE

As the largest support of biomedical research in the U.S., the NIH is an important stakeholder in orthopaedic innovations and discoveries. This study highlights barriers in the procurement of NIH funding across surgical specialties and affirms the need for greater resources toward supporting NIH funding in orthopaedic surgery.

High urinary excretion rate of glucose attenuates serum uric acid level in type 2 diabetes with normal renal function

AIMS/INTRODUCTION

The relationship between urinary excretion rate of glucose (UEGL) and uric acid (UA) metabolism in adults with type 2 diabetes (T2D) remains unclear to date. This study aimed to investigate the relationships of UEGL with serum UA (SUA), urinary excretion rate of uric acid (UEUA), and renal clearance of uric acid (CLUA) in adults with T2D. We hypothesised that high UEGL increases UA excretion, which in turn leads to lower SUA.

MATERIALS AND METHODS

This was a cross-sectional study of 635 inpatients with T2D recruited between 2018 and 2019. The relationships of UEGL with UEUA, CLUA, and hyperuricaemia were assessed using analysis of covariance and multivariate regression analysis.

RESULTS

Patients in the higher quartile of UEGL tended to have lower SUA levels than those in the lower quartile. In contrast, patients in the higher quartile of UEGL tended to have higher CLUA (p for trend < 0.0001), and a similar trend was observed for UEUA. In adjusted multivariable linear regression model, UEGL was negatively correlated with SUA (β = - 0.023, 95% CI - 0.034 to - 0.013, p < 0.0001). However, positive correlations of UEGL with UEUA (β = 0.046, 95% CI 0.018-0.074, p = 0.001) and CLUA (β = 0.063, 95% CI 0.042-0.085, p < 0.0001) were found. Furthermore, consistent significant inverse associations were observed between quartiles of UEGL and hyperuricaemia in the adjusted multivariate logistic regression model.

CONCLUSIONS

A high UEGL level was positively correlated with UEUA and CLUA. Moreover, it was inversely associated with SUA level, and a consistently increased UEGL level reduced the risk of hyperuricaemia in patients with T2D.

Dental Pulp Stem Cell Polarization: Effects of Biophysical Factors

Dental pulp stem cells (DPSCs) have the potential to polarize, differentiate, and form tubular dentin under certain conditions. However, the factors that initiate and regulate DPSC polarization and its underlying mechanism remain unclear. Identification of the factors that control DPSC polarization is a prerequisite for tubular dentin regeneration. We recently developed a unique bioinspired 3-dimensional platform that is capable of deciphering the factors that initiate and modulate cell polarization. The bioinspired platform has a simple background and confines a single cell on each microisland of the platform; therefore, it is an effective tool to study DPSC polarization at the single-cell level. In this work, we explored the effects of biophysical factors (surface topography, microisland area, geometry, tubular size, and gravity) on single DPSC polarization. Our results demonstrated that nanofibrous architecture, microisland area, tubular size, and gravity participated in regulating DPSC polarization by influencing the formation of the DPSC process and relocation of the Golgi apparatus. Among these factors, nanofibrous architecture, tubular size, and appropriate microisland area were indispensable for initiating DPSC polarization, whereas gravity served as an auxiliary factor to the process of DPSC polarization. Meanwhile, microisland geometry had a limited effect on DPSC polarization. Collectively, this work provides information on DPSC polarization and paves the way for the development of new biomaterials for tubular dentin regeneration.

Pediatric Hand and Upper Extremity Injuries Presenting to Emergency Departments in the United States: Epidemiology and Health Care-Associated Costs

Background: Upper extremity injuries represent one of the most common pediatric conditions presenting to emergency departments (EDs) in the United States. We aim to describe the epidemiology, trends, and costs of pediatric patients who present to US EDs with upper extremity injuries. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients aged <18 years associated with a primary diagnosis involving the upper extremity from 2008 to 2012. Patients were divided into 4 groups by age (≤5 years, 6-9 years, 10-13 years, and 14-17 years) and a trauma subgroup. Primary outcomes were prevalence, etiology, and associated charges. Results: In total, 11.7 million ED encounters were identified, and 89.8% had a primary diagnosis involving the upper extremity. Fracture was the most common injury type (28.2%). Dislocations were common in the youngest group (17.7%) but rare in the other 3 (range = 0.8%-1.6%). There were 73.2% of trauma-related visits, most commonly due to falls (29.9%); 96.9% of trauma patients were discharged home from the ED. There were bimodal peaks of incidence in the spring and fall and a nadir in the winter. Emergency department charges of $21.2 billion were generated during the 4 years studied. While volume of visits decreased during the study, associated charges rose by 1.21%. Conclusions: Pediatric upper extremity injuries place burden on the economy of the US health care system. Types of injuries and anticipated payers vary among age groups, and while total yearly visits have decreased over the study period, the average cost of visits has risen.

[Gastric SWI/SNF-complex deficient undifferentiated/rhabdoid carcinoma: a clinicopathological study]

Objective: To investigate the clinicopathological features, immunohistochemical characteristics, differential diagnosis and prognosis of gastric SWI/SNF-complex deficient undifferentiated/rhabdoid carcinomas. Methods: Two cases of gastric SWI/SNF-complex deficient undifferentiated/rhabdoid carcinoma were collected at Fudan University Shanghai Cancer Center, Shanghai, China from 2017 to 2018. The clinicopathological characteristics were analyzed. Hematoxylin and eosin, and immunohistochemical stains were performed, and the relevant literatures were reviewed. Results: The two patients were both male, aged 60 and 74 years, respectively. Their symptoms were both abdominal pain. The tumor arose in the esophagogastric junction in case 1, and the cardia to the fundus and the posterior wall of the upper part of gastric body in case 2. Both tumors were present as an ulcerative mass. The patients died of tumor 11 months and 8 months after surgery, respectively. Histologically, the tumor cells arranged in sheets, nests, cords or trabecular patterns, and pseudoavleolar structure. The tumor cells were epithelioid with uniform morphology, while the tumors showed scant stroma and massive necrosis. Variable rhabdoid cells and multinucleated giant cells were seen in both cases. SMARCA4 encoding protein BRG1 was undetectable in both tumors, while SMARCB1 encoding protein INI1 was detected. The tumor cells were diffusely positive for vimentin and negative for epithelial marker (CKpan), gastrointestinal stromal tumor markers (CD117 and DOG1), myogenic markers (desmin and myogenin), melanoma markers (S-100 protein, SOX10 and HMB45), and lymphohematopoietic markers (LCA and CD20). Conclusions: Gastric SWI/SNF-complex deficient undifferentiated/rhabdoid carcinoma is a rare and highly aggressive tumor with poor prognosis. The detection of subunits protein expression of SWI/SNF complex is important for diagnosis of the tumor.

Recalcitrant Pseudomonas Aeruginosa Keratitis with Hyphaema

Purpose

To report a case of recalcitrant pseudomonas keratitis with a rare presentation of hyphaema.

Observation

A 45-year-old female was noted to have contact lens-related pseudomonas keratitis with hyphaema. The organism was refractory to multiple antibiotics and only responded to Tazocin eye drops.

Conclusion and Importance

Hyphaema is a rare presentation in bacterial keratitis and could represent infection with an especially virulent organism. Use of Aspirin could precipitate hyphaema in infective keratitis. Alternative antibiotic choices such as Tazocin, colistin, meropenem, and imipenem can be considered when standard therapy is ineffective for multidrug-resistant Pseudomonas keratitis.

Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function

Introduction Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma.

Materials and Methods A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure.

Results Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/–17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1–95 months). The average defect size was 5.79 +/–4.54 cm2. Reconstruction was performed 0–4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61).

Conclusion Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

[Ovarian Sertoli-Leydig cell tumors: DICER1 hotspot mutations and associated clinicopathological features]

Objective: To investigate DICER1 hotspot mutations in ovarian Sertoli-Leydig cell tumor (SLCT) and its associated clinicopathological features. Methods: Forty-three SLCTs and 40 other sex cord-stromal tumors (SCSTs) diagnosed between 2010 and 2017 at Fudan University Shanghai Cancer Center were examined for somatic DICER1 hotspot mutations by Sanger sequencing. The associations between mutation status and clinicopathological features, including patient age, tumor differentiation and recurrence, were analyzed. Results: Somatic DICER1 mutations were found in 51% (22/43) of SLCTs, while none in the other 40 SCSTs. The most common mutation of DICER1 was p.D1709N in exon 24 (41%, 9/22) and the second most common mutation of DICER1 was p.E1813K in exon 25 (14%, 3/22). A novel frameshift mutation (c.5464delG, p.M1837fs*16) was identified in one SLCT with microcystic pattern. Mutations were more likely to occur in patients under forty years of age (P=0.046), whereas no significant associations were found between DICER1 mutations and clinical symptoms, morphology or tumor recurrence. Conclusions: Somatic DCIER1 hotspot mutations are specifically found in SLCT and may serve as an ancillary marker in differential diagnosis of SLCT from other SCST. The mutations occur more often in young patients (<40 years old). Additional studies are warranted to examine the associations between DICER1 mutations and clinicopathological features and prognosis of SLCT.

Oral Mucositis: An Update on Innate Immunity and New Interventional Targets

Oral mucositis (OM), a common debilitating toxicity associated with chemo- and radiation therapies, is a significant unmet clinical need for head and neck cancer patients. The biological complexities of chemoradiotherapy-induced OM involve interactions among disrupted tissue structures, inflammatory infiltrations, and oral microbiome, whereby several master inflammatory pathways constitute the complicated regulatory networks. Oral mucosal damages triggered by chemoradiotherapy-induced cell apoptosis were further exacerbated by the amplified inflammatory cascades dominantly governed by the innate immune responses. The coexistence of microbiome and innate immune components in oral mucosal barriers indicates that a signaling hub coordinates the interaction between environmental cues and host cells during tissue and immune homeostasis. Dysbiotic shifts in oral microbiota caused by cytotoxic cancer therapies may also contribute to the progression and severity of chemoradiotherapy-induced OM. In this review, we have updated the mechanisms involving innate immunity-governed inflammatory cascades in the pathobiology of chemoradiotherapy-induced OM and the development of new interventional targets for the management of this severe morbidity in head and neck cancer patients.

Scattering Studies with Low-Energy Kaon-Proton Femtoscopy in Proton-Proton Collisions at the LHC

The study of the strength and behavior of the antikaon-nucleon (K[over ¯]N) interaction constitutes one of the key focuses of the strangeness sector in low-energy quantum chromodynamics (QCD). In this Letter a unique high-precision measurement of the strong interaction between kaons and protons, close and above the kinematic threshold, is presented. The femtoscopic measurements of the correlation function at low pair-frame relative momentum of (K^{+}p⊕K^{-}p[over ¯]) and (K^{-}p⊕K^{+}p[over ¯]) pairs measured in pp collisions at sqrt[s]=5, 7, and 13 TeV are reported. A structure observed around a relative momentum of 58  MeV/c in the measured correlation function of (K^{-}p⊕K^{+}p[over ¯]) with a significance of 4.4σ constitutes the first experimental evidence for the opening of the (K[over ¯]^{0}n⊕K^{0}n[over ¯]) isospin breaking channel due to the mass difference between charged and neutral kaons. The measured correlation functions have been compared to Jülich and Kyoto models in addition to the Coulomb potential. The high-precision data at low relative momenta presented in this work prove femtoscopy to be a powerful complementary tool to scattering experiments and provide new constraints above the K[over ¯]N threshold for low-energy QCD chiral models.

Assessment of Apparent Internal Carotid Tandem Occlusion on High-Resolution Vessel Wall Imaging: Comparison with Digital Subtraction Angiography

BACKGROUND AND PURPOSE

Not all tandem occlusions diagnosed on traditional vascular imaging modalities, such as MRA, represent actual complete ICA occlusion. This study aimed to explore the utility of high-resolution vessel wall imaging in identifying true ICA tandem occlusions and screening patients for their suitability for endovascular recanalization.

MATERIALS AND METHODS

Patients with no signal in the ICA on MRA were retrospectively reviewed. Two neuroradiologists independently reviewed their high-resolution vessel wall images to assess whether there were true tandem occlusions and categorized all cases into intracranial ICA occlusion, extracranial ICA occlusion, tandem occlusion, or near-occlusion. DSA classified patient images into the same 4 categories, which were used as the comparison with high-resolution vessel wall imaging. The suitability for recanalization of occluded vessels was evaluated on high-resolution vessel wall imaging compared with DSA.

RESULTS

Forty-five patients with no ICA signal on MRA who had available high-resolution vessel wall imaging and DSA images were included. Among the 34 patients (34/45, 75.6%) with tandem occlusions on DSA, 18 cases also showed tandem occlusions on high-resolution vessel wall imaging. The remaining 16 patients, intracranial ICA, extracranial ICA occlusions and near-occlusions were found in 2, 6, and 8 patients, respectively, on the basis of high-resolution vessel wall imaging. A total of 20 cases (20/45, 44.4%) were considered suitable for recanalization on the basis of both DSA and high-resolution vessel wall imaging. Among the 25 patients deemed unsuitable for recanalization by DSA, 11 were deemed suitable for recanalization by high-resolution vessel wall imaging.

CONCLUSIONS

High-resolution vessel wall imaging could allow identification of true ICA tandem occlusion in patients with an absence of signal on MRA. Findings on high-resolution vessel wall imaging can be used to screen more suitable candidates for recanalization therapy.

The Impact of Training Pathway on Breast Surgery Cases Performed during Plastic Surgery Residency

BACKGROUND

Operative volume is a critical component of surgical resident education. This study compares reported breast surgery case volume between resident training pathways in plastic surgery.

METHODS

This retrospective cohort study reviewed case logs of plastic surgery residents in the independent/combined and integrated training pathways. Breast surgery case volume was compared via t tests across two major categories: reconstructive and aesthetic. Differences in intra-pathway variability were compared with F tests. Five consecutive cohorts of plastic surgery residents (n = 818): independent/combined (n = 526, 64%) and integrated (n = 292, 36%) at Accreditation Council for Graduate Medical Education (ACGME) accredited residency programs, were included (2011-2015).

RESULTS

Independent/combined residents reported significantly more aesthetic cases than integrated residents, but similar reconstructive cases. Independent/combined residents reported more breast augmentations, mastopexy, cosmetic breast fat grafting, and other cosmetic breast cases. Within the reconstructive category, independent residents reported more breast reconstruction fat grafting cases while integrated residents reported more breast reconstruction with pedicle flap, other breast reconstruction, and breast reduction cases. Independent residents had greater intra-pathway variability in five case subcategories, while integrated residents had greater variability in one case subcategory.

CONCLUSIONS

Disparities in breast surgery case volume exist by plastic surgery residency training pathway. Given the importance of case volume to residents and faculty, these disparities may warrant greater attention.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Measurement of ϒ(1S) Elliptic Flow at Forward Rapidity in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The first measurement of the ϒ(1S) elliptic flow coefficient (v_{2}) is performed at forward rapidity (2.5<y<4) in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The results are obtained with the scalar product method and are reported as a function of transverse momentum (p_{T}) up to 15  GeV/c in the 5%-60% centrality interval. The measured ϒ(1S)v_{2} is consistent with 0 and with the small positive values predicted by transport models within uncertainties. The v_{2} coefficient in 2<p_{T}<15  GeV/c is lower than that of inclusive J/ψ mesons in the same p_{T} interval by 2.6 standard deviations. These results, combined with earlier suppression measurements, are in agreement with a scenario in which the ϒ(1S) production in Pb-Pb collisions at LHC energies is dominated by dissociation limited to the early stage of the collision, whereas in the J/ψ case there is substantial experimental evidence of an additional regeneration component.

655. Detection of Antibiotic Resistance Genes in Clinical Samples using T2 Magnetic Resonance

Background

Antibiotic-resistant bacteria are spread through selective pressure from the use of broad-spectrum empirical therapies, mobile genetic elements that pass resistance genes between species, and the inability to rapidly and appropriately respond to their presence. Resistance gene identification is often performed with post culture molecular diagnostic tests. The T2Resistance Panel, which detects methicillin resistance genes mecA/C; vancomycin resistance genes vanA/B; carbapenemases bla_KPC, bla_OXA-48,bla_NDM, bla_VIM, and bla_IMP; AmpC β-lactamases bla_CMY and bla_DHA; and extended-spectrum β-lactamases bla_CTX-M directly from patient blood samples, is based on T2 magnetic resonance (T2MR), an FDA-cleared technology with demonstrated high sensitivity and specificity for culture-independent bacterial and fungal species identification. Here we report the clinical performance of T2MR detection of resistance genes directly from patient blood samples.

Methods

Patients with a clinical diagnosis of sepsis and an order for blood culture (BC) were enrolled in the study at two sites. BCs were managed using standard procedures and MALDI-TOF for species identification. Resistance testing with the T2MR assay was performed on a direct patient draw and compared with diagnostic test results from concurrent BC specimen and BC specimen taken at other points in time. The potential impact on therapy was evaluated through patient chart review.

Results

T2MR detected the same resistance genes as detected by post culture diagnostics in 100% of samples from concurrent blood draws. Discordant results occurred when T2MR was taken ≥48 hours after BC for patients on antimicrobial therapy. The average time to positive result was 5.9 hours with T2MR vs. 30.6 hours with post-culture molecular testing.

Conclusion

The T2Resistance Panel detected antibiotic resistance genes in clinical samples and displayed agreement with post culture genetic testing. T2MR results were achieved faster than culture-dependent diagnostic testing results and may allow for an earlier change from empiric to directed therapy. The use of culture-independent diagnostics like T2MR could enable a quicker response to antibiotic-resistant organisms for individual patients and developing outbreaks.

Disclosures

All authors: No reported disclosures.

Investigations of Anisotropic Flow Using Multiparticle Azimuthal Correlations in pp, p-Pb, Xe-Xe, and Pb-Pb Collisions at the LHC

Measurements of anisotropic flow coefficients (v_{n}) and their cross-correlations using two- and multiparticle cumulant methods are reported in collisions of pp at sqrt[s]=13  TeV, p-Pb at a center-of-mass energy per nucleon pair sqrt[s_{NN}]=5.02  TeV, Xe-Xe at sqrt[s_{NN}]=5.44  TeV, and Pb-Pb at sqrt[s_{NN}]=5.02  TeV recorded with the ALICE detector. The multiplicity dependence of v_{n} is studied in a very wide range from 20 to 3000 particles produced in the midrapidity region |η|<0.8 for the transverse momentum range 0.2<p_{T}<3.0  GeV/c. An ordering of the coefficients v_{2}>v_{3}>v_{4} is found in pp and p-Pb collisions, similar to that seen in large collision systems, while a weak v_{2} multiplicity dependence is observed relative to nucleus-nucleus collisions in the same multiplicity range. Using a novel subevent method, v_{2} measured with four-particle cumulants is found to be compatible with that from six-particle cumulants in pp and p-Pb collisions. The magnitude of the correlation between v_{n}^{2} and v_{m}^{2}, evaluated with the symmetric cumulants SC(m,n) is observed to be positive at all multiplicities for v_{2} and v_{4}, while for v_{2} and v_{3} it is negative and changes sign for multiplicities below 100, which may indicate a different v_{n} fluctuation pattern in this multiplicity range. The observed long-range multiparticle azimuthal correlations in high multiplicity pp and p-Pb collisions can neither be described by pythia 8 nor by impact-parameter-Glasma, music, and ultrarelativistic quantum molecular dynamics model calculations, and hence, provide new insights into the understanding of collective effects in small collision systems.

Effects of endovascular first strategy on spliced vein bypass outcomes

OBJECTIVE

Aggressive endovascular interventions for patients without adequate full-length venous conduit have gained popularity. The purpose of this study is to evaluate the outcomes of spliced vein bypass (SVB) as primary treatment versus treatment after failed endovascular intervention (endovascular SVB [ESVB]) for infrainguinal revascularization.

METHODS

A retrospective analysis of a single vascular group's database of all SVBs was queried for demographics, indications, intraoperative details, and outcomes. Exclusion criteria included acute ischemia, aneurysm, dual outflow, bypass revisions, and patients lost to immediate follow-up. SPSS software was used for statistical analysis.

RESULTS

Two hundred thirty-five infrainguinal SVBs were performed between January 2011 and March 2017. There were 182 SVB (77%) and 53 ESVB (23%) with a mean follow-up of 488 days (range, 1-2140). Demographics between the SVB and ESVB groups were similar in all categories recorded: diabetes, hypertension, coronary artery disease, current smoker, chronic obstructive pulmonary disease, hyperlipidemia, and renal disease (P = .29). Indications for bypass were not statistically significant between SVB and ESVB (P = .48). The study included Rutherford class 3 (14 vs 2), class 4 (51 vs 20), class 5 (67 vs 18), and class 6 (50 vs 13). Inflow was grouped into iliac (2.6%), femoral (88%), and popliteal (9.8%). Outflow arteries were grouped into below knee popliteal (14.9%) and infrapopliteal (85.1%). Inflow and outflow arteries, as well as number of spliced pieces per bypass were not different between groups. Major amputation rates were not different between SVB and ESVB for the entire study period. There was no statistical difference with patency outcomes based on Kaplan-Meier survival analysis (P = .84).

CONCLUSIONS

An aggressive endovascular first strategy for treatment of patients without adequate autogenous conduit seems to offer benefit without negatively affecting future bypass options. SVB patency and major amputation rates in this series were not affected by a prior endovascular treatment.

First Observation of an Attractive Interaction between a Proton and a Cascade Baryon

This Letter presents the first experimental observation of the attractive strong interaction between a proton and a multistrange baryon (hyperon) Ξ^{-}. The result is extracted from two-particle correlations of combined p-Ξ^{-}⊕p[over ¯]-Ξ[over ¯]^{+} pairs measured in p-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC with ALICE. The measured correlation function is compared with the prediction obtained assuming only an attractive Coulomb interaction and a standard deviation in the range [3.6, 5.3] is found. Since the measured p-Ξ^{-}⊕p[over ¯]-Ξ[over ¯]^{+} correlation is significantly enhanced with respect to the Coulomb prediction, the presence of an additional, strong, attractive interaction is evident. The data are compatible with recent lattice calculations by the HAL-QCD Collaboration, with a standard deviation in the range [1.8, 3.7]. The lattice potential predicts a shallow repulsive Ξ^{-} interaction within pure neutron matter and this implies stiffer equations of state for neutron-rich matter including hyperons. Implications of the strong interaction for the modeling of neutron stars are discussed.

[Expression of SMARCA4(BRG1) and SMARCB1(INI1) in dedifferentiated and undifferentiated endometrial carcinomas and their correlations with clinicopathological features]

Objective: To investigate the expression of SMARCA4 (BRG1) and SMARCB1 (INI-1) protein in endometrial dedifferentiated carcinoma (DDC) and undifferentiated carcinoma (UDC), and their correlation with clinicopathologic features. Methods: Clinicopathological information was gathered for 26 cases of DDC and UDC and consulting hospitals from January, 2006 to December, 2018 in Fudan University Shanghai Cancer Center, including 10 cases of DDC and 16 cases of UDC. Morphologic features and diagnosis were reviewed by two pathologists. Immunohistochemistry for expression of BRG1 and INI1 protein was performed. The correlations with clinicopathologic features were analyzed. Results: BRG1 and INI1 loss were present in 14 of 26 cases of DDC/UDC, including 12 BRG1-deficient cases and 2 INI1-deficient cases, respectively. Six cases demonstrated variable amounts of rhabdoid cells in 14 BRG1/INI1-deficient cases, and only 1 case showed rhabdoid cells in the 12 intact expression cases. However, there was no significantly statistical difference (P=0.060). Age, invasive depth, lymph node status and FIGO stage were not associated with the expression of the BRG1 and INI1 (P=0.437, P=0.672, P=0.242, P=0.348). Remarkably, the BGR1/INI1-deficient patients had worse survival than those with intact expression (4.7 vs. 22.9, P=0.033). Conclusion: BRG1/INI1-deficient is observed in approximately half of DDC and UDC. Identification of these tumors is clinically relevant due to their more aggressive behavior and poor prognosis. Hence, BRG1 and INI1 immunohistochemical stains should be performed for DDC and UDC in order to help the pathologists to distinguish these tumors from other carcinomas, and to predict the clinical prognosis.

[Clinicopathological study of BCOR rearrangement in high grade endometrial stromal sarcoma]

Objective: To investigate clinicopathological, cytogenetic features and differential diagnoses of high grade endometrial stromal sarcoma (HGESS) with BCOR gene rearrangement. Methods: Five cases of HGESS with BCOR rearrangement were collected from consultant files (2016-2018) at Fudan University Shanghai Cancer Center. Interphase FISH was performed using a dual color break-apart probe. The clinical data, histologic features and immunohistochemical findings were reviewed. Results: All 5 cases occurred in adult women with a median age of 48 (range, 45-55) years. Abdominal pain and abnormal vaginal bleeding were the most common symptoms. Microscopically, the tumors showed mainly tongue-like and/or intersecting myometrial invasion. Stromal myxoid matrix and/or collagen plaques were prominent in all the cases. Most tumors consisted of uniform, haphazard fascicles of short spindle cells with mild to moderate nuclear atypia. Mitotic figures and necrosis were easily identified. Significant nuclear pleomorphism was not seen. Most tumors were rich in thick-walled small vessels. Prominent perivascular tumor cell whorling seen in conventional low-grade endometrial stromal sarcoma was not seen. All tumors expressed CD10 with only focal or absent desmin, SMA and/or h-caldesmon staining. ER or PR expression was seen in 4 tumors and 1 tumor showed both marker expression. Diffuse cyclin D1 was present in 2 tumors. BCOR immunoreactivity was present with strong staining in 3 cases and moderate staining in 1 case respectively. Ki-67 index ranged from 10% to 30%. Fluorescence in situ hybridization confirmed chromosomal aberration of BCOR gene in all tumors, that were previously diagnosed as myxoid leiomyosarcoma (2 cases), spindle cell uterine sarcoma (2 cases) and low-grade endometrial stromal sarcoma (1 case). Limited follow-up information revealed that 3/5 patients developed tumor recurrence, metastasis or death within one year. Conclusion: BCOR rearranged HGESS has distinct morphological features and aggressive clinical behavior. In the presence of significant overlapping morphologic features between BCOR rearranged HGESS and other myxoid uterine mesenchymal tumors, especially myxoid leiomyosarcoma, molecular analysis is essential for accurate diagnoses.