A Radiation Therapy Contouring Atlas for Delineation of the Level I-II Axilla in the Prone Position

PURPOSE/OBJECTIVE(S)

When patients are treated prone for whole breast irradiation (WBI), the axilla typically receives less dose than when patients are treated with WBI in the supine position. There are situations, however, where the axilla is a target as in a situation where the physician intends to treat with "high tangents" to provide good coverage of both the breast and level I-II axilla. In these scenarios, ideal target delineation when the patient is in the prone position is not well-defined. While different consensus guidelines exist for delineation of the nodal areas in the supine position, to our knowledge there are no contouring guidelines for the regional nodes in the prone position based on bone, skin, vascular and muscle landmarks.

MATERIALS/METHODS

Forty-three patients treated with high tangents in the prone position from 2012-2018 were identified as representative cases. The level I and II regional nodal contours from the Radiation Therapy Oncology Group (RTOG) breast cancer atlas were adapted for prone position by a radiation oncologist and a breast radiologist based on anatomic considerations and changes observed from supine to prone positioning on diagnostic imaging. The revised nodal contours were reviewed by an expanded expert multidisciplinary panel including additional breast radiation oncologists and surgical oncologists to delineate the level I and II axilla on noncontrast computed tomography (CT) scans.

RESULTS

We adapted the RTOG breast cancer atlas, supported by detailed figures, in order to create a CT based atlas of the level I and II axillary lymph node stations in the prone position. For the level I axilla, the cranial and caudal anatomic boundaries remain unchanged. With transition to the prone position from supine, tenting of the pectoralis major occurs displacing the muscle from the chest wall and shifting the axillary space anteromedial to the lateral border of the pectoralis major. Therefore, the anterior boundary is now defined by the plane of the anterior extent of the pectoralis major to skin. The medial boundary is defined by the plane of the lateral border of the pectoralis major and pectoralis minor including to ribs and intercostal muscles. The lateral boundary is defined by the skin, cropped by 5mm. The posterior boundary is defined by the plane of the anterior surface of the latissimus dorsi and subscapularis muscle to skin. For the level II axilla, the cranial, posterior, medial and lateral boundaries remain unchanged. With transition from supine to prone, the axilla exhibits an anterolateral shift, now laterally abutting the lateral border of the pectoralis minor. The anterior boundary is now defined as the posterior aspect of the pectoralis major muscle. The caudal boundary is where the pectoralis minor inserts into ribs.

CONCLUSION

The adaptations to the RTOG breast cancer atlas for prone positioning will enable radiation oncologists to more accurately target the level I and II axilla when treating patients prone in whom the axilla is a target in addition to the breast.

Kommerell's diverticulum: an unusual cause of unilateral vocal cord palsy?

Kommerell's diverticulum is a rare congenital anomaly of the aortic arch system in which there is a left- or right-sided aortic arch with an aberrant subclavian artery on the contralateral side. Patients with this anomaly can be asymptomatic or have features of tracheal or oesophageal compression. However, there is a rising suspicion that it may be a rare cause of unilateral vocal cord palsy through its compression of the recurrent laryngeal nerve. We describe a patient who had a long history of hoarse voice and left vocal cord palsy with no other obvious cause, who was found to have a Kommerell's diverticulum on a contrast-enhanced computed tomography scan.

Utility of frozen section in pediatric and adolescent malignant ovarian nonseminomatous germ cell tumors: A report from the children's oncology group

PURPOSE

In adult women, most malignant ovarian tumors are epithelial in origin. The use of intra-operative frozen section to distinguish between benign and malignant histology is reliable in guiding operative decision-making to determine the extent of surgical staging required. Pediatric and adolescent patients with ovarian masses have a much different spectrum of pathology with most tumors arising from germ cell precursors. This review was undertaken to assess the concordance between the intra-operative frozen section and the final diagnosis as an aid to guide extent of surgical staging in a group of pediatric and adolescent patients with malignant ovarian germ cell tumors.

METHODS

Records of patients aged 0 to 20 years with malignant ovarian germ cell tumors enrolled on Children's Oncology Group study AGCT0132 were reviewed. Pathology reports from patients who had both intra-operative frozen section diagnosis and final paraffin section diagnosis were compared using descriptive statistics. By inclusion criteria for the study, all patients had a final diagnosis of malignancy with required yolk sac tumor, choriocarcinoma or embryonal carcinoma histology. Available central review of pathology final paraffin section slides were compared with final institution pathology reports.

RESULTS

Of 131 eligible patients with ovarian germ cell tumors, 60 (45.8%) had both intra-operative frozen section and final paraffin section diagnoses available. Intra-operative frozen section diagnoses were classified as: incorrect diagnosis of benign tumor (13.3%), confirmation of malignancy (61.7%), immature teratoma (16.7%), germ cell tumor not otherwise specified (5%) and no diagnosis provided (3.3%). Intra-operative frozen section was incorrect in 23 of 60 (38.3%) patients evaluated. Central pathology review was concordant with the final institution pathology diagnosis in 76.3% of patients. Central pathology review identified additional germ cell tumor components in 23.7% of patients.

CONCLUSIONS

In pediatric and adolescent patients with a confirmed final diagnosis of ovarian germ cell malignancy, intra-operative frozen section diagnosis is not reliable to inform the extent of surgical staging required. Central review by an expert germ cell tumor pathologist provides important additional information to guide therapy.

412 Knowledge and Practices for the Prevention of the Diabetic Foot in North Wales

Aim

Diabetes mellitus can result in a wide range of foot complications such as ulceration, infection, and amputation. The National Institute for Health and Care Excellence (NICE) recommend that all diabetic patients should receive verbal and written information relating to their foot care. Here we assess our compliance with the national guidelines and the levels of patient knowledge amongst the diabetic population in the North West of Wales.

Method

A questionnaire was provided to all adult diabetic patients attending the outpatient podiatry service over the course of three weeks at Ysbyty Gwynedd, North Wales. The survey included compliance and knowledge-based questions regarding foot care.

Results

A total of 65 patients were recruited and completed questionnaires. The majority of the patients were males (male:female ratio 2:1) and over 70 years and had type II diabetes.

98% of patients admitted to receiving verbal diabetic advice while only 57% received written information. Compliance with daily foot checks was 82%. Regarding patient knowledge, over 90% of patients selected the correct answer to 11 out of the 15 knowledge-based questions. Despite 95% recognising that poor footwear can contribute to diabetic foot complications, only 86% recognised that walking barefoot carries similar risks.

Conclusions

Diabetic foot knowledge is high within our studied population. Use of patient information leaflets can be further improved to help educate patients in avoiding barefoot walking and to prevent diabetic foot complications and limb loss.

A novel case of lupus nephritis and mixed connective tissue disorder in a COVID-19 patient

Introduction

Mixed connective tissue disease (MCTD) is a rare autoimmune condition characterized by Scleroderma, Polymyositis, and Systemic Lupus Erythematous (SLE). Though a possible relationship between COVID-19 and autoimmune diseases has been recently reported, its pathophysiological mechanism behind flares in Lupus Nephritis (LN), a complication of SLE, remains unknown.

Case presentation

A 22-year-old COVID-19 positive female presented with anemia, bilateral pitting edema, periorbital swelling, and posterior cervical lymphadenitis. Further inspection revealed lower abdominal striae, hepatosplenomegaly, and hyperpigmented skin nodules. Complete blood counts showed elevated inflammatory markers and excessively high protein creatinine ratio. Antinuclear antibody titers were elevated (anti-smith and U1 small nuclear ribonucleoprotein) and Rheumatoid Factor was positive. She was diagnosed with MCTD associated with a flare of LN. To control her lupus flare, a lower dose of steroids was initially administered, in addition to oral hydroxychloroquine and intravenous cyclophosphamide. Her condition steadily improved and was discharged on oral steroid maintenance medication.

Discussion

We present a rare phenomenon of newly diagnosed LN, a complication of SLE, with MCTD in a PCR-confirmed COVID-19 patient. The diagnostic conundrum and treatment hurdles should be carefully addressed when patients present with lupus and COVID-19 pneumonia, with further exploration of the immuno-pathophysiology of COVID-19 infection in multi-systemic organ dysfunction in autoimmune disorders.

Conclusion

In COVID-19 patients with LN and acute renal injury, it is critical to promptly and cautiously treat symptomatic flares associated with autoimmune disorders such as SLE and MCTD that may have gone unnoticed to prevent morbidity from an additional respiratory infection.

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SLE disease has been associated with COVID-19. However, there is a lack of data on LN in conjunction with MCTD in COVID-19 positive patients.

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A possible relationship between Coronavirus disease 2019 (COVID-19) and autoimmune disease has been documented in many case reports.

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Because of the overlapping clinical manifestations and laboratory findings between lupus and COVID-19 pneumonia, the diagnostic problems and treatment hurdles should be carefully addressed.

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In COVID-19 patients with LN flare and acute renal injury, it is critical to resolve any reversible causes of the kidney injury and manage the COVID-19 before treating the LN.

Candida glabrata infection of a pancreatic pseudocyst in a COVID-19 patient: A case report and review of the literature

Introduction

Pancreatic pseudocysts remain a feared complication of acute or chronic pancreatitis and are often characterized by collections of fluids due to underlying damage to the pancreatic ducts, culminating in a walled-off region bereft of an epithelial layer but surrounded by granulation tissue. While fungal infections of pancreatic pseudocysts are rarely encountered, candida albicans remains the most frequently implicated organism.

Case presentation

A 55-year-old male presented with pain in the left-hypochondriac region, accompanied by non-bilious emesis and nausea. Interestingly, the patient also tested positive for a COVID-19 infection. Investigative workup divulged enhancing pancreatic walls with a radiologic impression consistent with a pancreatic pseudocyst. An ultrasound-guided external drainage was performed; the drainage was conducted unremarkably, with the resultant fluid collection revealing the presence of Candida Glabrata. The patient was commenced on antifungal therapy and continues to do well to date.

Discussion

Infectious ailments of pancreatic pseudocysts remain a widely known complication of acute pancreatitis. While it is rare, fungal infection is a crucial consideration for patients with pancreatic pseudocysts, especially in the context of a lack of an adequate response to antibiotics, deterioration, comorbidities, and immunocompromised states.

Conclusion

Rapid identification of the microbe responsible for pancreatic pseudocyst infection is vital for time-sensitive treatment and a more rapid recovery, curbing associated morbidity and mortality.

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Fungal infections of pancreatic pseudocysts remain a rare but well-characterized complication, culminating in significant morbidity and mortality.

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Telltale signs include unresponsiveness to antibiotics and worsening clinical symptoms.

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Rapid identification of the responsible microbe is vital for time-sensitive treatment and a more rapid recovery.

The role of family factors in the association between early adulthood BMI and risk of cardiovascular disease. An intergenerational study of BMI in early adulthood and cardiovascular mortality in parents, aunts and uncles

Background

High body mass index (BMI) in childhood and adolescence is related to cardiovascular disease (CVD). Causality is not established because common genetic or early life socioeconomic factors (family factors) may explain this relationship. We aimed to study the role of family factors in the association between BMI and CVD by investigating if early adulthood BMI in conscripts and CVD mortality in their parents/aunts/uncles are related.

Methods

Data from the Armed Forces Personnel Database (including height and weight among conscripts) were linked with data from the Norwegian Population Registry, generational data from the Norwegian Family Based Life Course Study, the National Educational Registry and the Cause of Death Registry using unique personal identification numbers. The study sample (N=369 464) was Norwegian males born 1967-1993, who could be linked to both parents and at least one maternal and one paternal aunt or uncle. Subsamples were identified as conscripts whose parents/aunts/uncles had data on cardiovascular risk factors available from Norwegian health surveys. Cox proportional hazards regression models were used to estimate hazard ratios (HR) of CVD mortality in the parental generation according to BMI categories of conscripts.

Results

Parents of conscripts with obesity or overweight had a higher hazard of CVD death (fathers HR obese: 1.99 (1.79,2.21), overweight: 1.33 (1.24,1.42) mothers HR obese: 1.65 (1.32,2.07), overweight: 1.23 (1.07,1.42)) than parents of normal- or underweight conscripts. Aunts and uncles of conscripts with obesity and overweight had an elevated hazard of CVD death, but less so than parents. Adjustment for CVD risk factors attenuated the results in parents, aunts and uncles.

Conclusions

Family factors may impact the relationship between early adulthood overweight and CVD in parents. These can be genes with impact on BMI over generations and genes with a pleiotropic effect on both obesity and CVD, as well as shared environment over generations.

Effectiveness of direct oral anticoagulants in obese adults with atrial fibrillation: an overview examining the evidence from international systematic reviews and meta-analyses

Background

Obesity may influence the pharmacology of direct oral anticoagulants (DOAC) that are recommended by all international guidelines for stroke prevention in adults with atrial fibrillation (AF).

Purpose

To evaluate the safety and efficacy of DOACs in obese adults with AF.

Methods

Medline, CINAHL, Scopus, Web of Science, Cochrane Database, Johanna Briggs Institute, Embase, Psych Info and ProQuest were searched till April 2020. Only systematic reviews with meta-analyses, that were published after 2005 and were in the English language were included. Articles were screened by title and abstract, followed by full text assessment using the Covidence systematic review software. Data was extracted using a standardised extraction tool. AMSTAR-2® and ROBIS® tools were used for quality and risk of bias assessment. The entire process was undertaken by two investigators at each stage of the study selection, appraisal, and data extraction. Disagreements were resolved through consensus discussion with a third arbitrary investigator. Statistical analyses were performed using the DerSimonian and Laird method for random effects. Meta-analysis was performed using only randomised controlled trials from eligible systematic reviews at both 12 months and across the entire trial. Primary outcomes assessed was stroke (ischemic or haemorrhagic) or systemic or pulmonary embolism. Secondary outcomes assessed included all-cause mortality, transient ischemic attack, myocardial infarction, major bleed, all cause-hospitalisation, and cardiovascular mortality.

Results

Of the 8162 articles screened, a total of five systematic reviews were included in this overview. There was disagreement within the published reviews on the effect of DOAC in obesity. Four of the five reviews were of either “low” or “critically low” quality, with inconsistencies in data extraction and appropriateness of the included studies and statistical methods used in analysis. Data from only the RE-LY, AVERROES and ENGAGE AF-TIMI 48 trials, were available for the meta-analysis, which did not find any significant difference between all BMI groups for all outcomes, at both time points. However, analysis of the different weight groups versus normal weight, highlighted non-significant differences between the different DOACs.

Conclusion

There was no difference between the BMI classes in any of the outcomes assessed. However, the non-significant trends that were seen, suggests individual superiority of DOACs may exist within the obese adult populations. There is a need for prospective trials to evaluate which DOACs are safe and efficacious in the obese class III adults and at which dose.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Australian Government Research Training Program (RTP) Heart Foundation of AustraliaNational Health and Medical Research Council (NHMRC)

1476 North Wales Vascular Surgery Zoom Webinar Teaching Programme for Medical Students and Junior Doctors

Aim

Surgical Education is now more widely delivered on virtual platforms due to the COVID-19 pandemic. Due to centralisation of Vascular Surgery services in North Wales to Glan Clwyd Hospital (Central), Medical Students, Junior Doctors and General Surgical Registrars have reduced exposure to the speciality and the management of common cases in neighbouring hospitals (East and West). Subsequently, we developed a regional virtual teaching programme to help bridge gaps in knowledge and to instil confidence when providing a service.

Method

We developed a 4-part didactic webinar educational programme which covered parts of the medical undergraduate and MRCS curricula pertaining to Vascular Surgery. Under/Postgraduate educational leads from Central, East and West were contacted to promote our programme. Webinars were delivered on ZOOM video conferencing once weekly throughout December 2020. Feedback forms were collected on Google Forms™ and used 5-point Linkert scales to grade responses and analysis of data was carried out on Microsoft Excel®.

Results

186 feedback forms were collected and respondents reported significant improvements in knowledge in each of the subjects covered: [1] Abdominal Aortic Aneurysms - (2.59±1.07/5 to 4.23±0.65/5, p = <0.0001, n = 60), [2] Acute Limb Ischaemia – (2.55±1.11/5 to 4.21±0.72/5, p = <0.0001, n = 42); [3] Chronic Limb Ischaemia (2.57±1.03/5 to 4.23±0.77/5, p = <0.0001, n = 35); [4] Vascular Emergencies (2.94±1.28/5 to 4.37±0.63/5, p = <0.0001, n = 49). Overall topic interest, presentational skills and clinical usefulness was also rated highly.

Conclusions

Through this virtually delivered regional teaching programme, we successfully enhanced Vascular Surgery knowledge and addressed the educational needs of Medical Students and Junior Doctors across North Wales.

Difficult Central Venous Cannulation under Laryngeal Mask Airway Anesthesia in Adolescent

We report a case of difficult central venous cannulation under general anesthesia with laryngeal mask airway in a young female child. Our case demonstrated a difficulty in surgically finding the right internal jugular vein due to neck veins displacements by laryngeal mask airway, which caused morbidity such as prolonged surgical duration and excessive blood loss. Once the laryngeal mask airway was replaced with endotracheal tube, the internal jugular vein appeared on surface and procedure was successfully completed in a few minutes. Such difficulties warrant an alternate approach in airway management in order to prevent major adverse effects.

Quality of life, continence and frequency of pouchitis following laparoscopic versus open colectomy and ileal pouch-anal anastomosis: an Irish perspective

BACKGROUND

This study aims to assess quality of life outcomes, continence, rates of pouchitis and predictors of pouchitis for patients undergoing laparoscopic versus open three-stage ileal pouch-anal anastomosis (IPAA) surgery in our institution.

METHODS

Forty-two patients having had three-stage (IPAA) surgery were identified. One was excluded as they had undergone pouchectomy. A postal questionnaire followed by telephone contact was undertaken. The questionnaire was based on The Gastrointestinal Quality of Life Index (GIQLI) and Wexner/Cleveland Clinic Faecal Incontinence Symptom Severity Scoring Systems.

AIMS

Our aim was to assess morbidity, quality of life, incidence of pouchitis and continence following restorative panproctocolectomy and IPAA.

RESULTS

Thirty-five patients completed the response. The median age at colectomy of our patient population was 32 years. 57 % were male and 43 % were female. 54.3 % of cases were carried out laparoscopically. 8/19 patients who had laparoscopic surgery had pouchitis (42.1 %) versus 9/16 patients who had open surgery (56.3 %). The median Wexner score was 0. Nine patients (25.7 %) had a GIQLI score that was within or above the range reported for healthy controls. The rate of complications was 31.7 % for emergency cases and 25.7 % for elective cases. The rate of pouchitis in this group was 48.5 %. Overall pelvic sepsis rate was 12.8 %.

CONCLUSIONS

Ileal pouch-anal anastomosis is a successful and well-tolerated procedure with 94 % of patients opting to have the surgery again. Preliminary results do not show any significant difference in the incidence of pouchitis following laparoscopic surgery.

Detection of precytopathic effect of enteroviruses in clinical specimens by centrifugation-enhanced antigen detection

Rapid enterovirus detection is important for decisions about antibiotic administration and length of hospital stay. The efficacy of rapid antigen detection-cell culture amplification (Ag-CCA) was evaluated with monoclonal antibodies (MAbs) 5-D8/1 (DAKO) and Pan-Enterovirus clone 2E11 (Chemicon) with 10 poliovirus, echovirus, and coxsackievirus type A and B stock isolates and College of American Pathologists check samples. By using Ag-CCA technology, MAb 2E11 was more sensitive than 5-D8/1 at detecting a greater number of stock isolates at or past tube (cytopathic effect [CPE]) culture (TC) end points. The efficacy of Ag-CCA in the clinical setting was subsequently confirmed with 273 consecutively freshly collected nasopharyngeal aspirate or swab specimens, rectal swab, and cerebrospinal fluid specimens during the 1999 enterovirus season. All specimens were tested by Ag-CCA in parallel with rhesus monkey kidney (RhMk), MRC-5, and A549 conventional TCs. Approximately 60% of field specimens were additionally tested with Hep-2 and HNK conventional TCs. Sixty-two percent of the clinical specimens tested were Ag-CCA positive after 48 h. Among 51 isolates, the mean time to CPE or culture confirmation was 5.5 days (range, 2 to 18 days). After 48 h, Ag-CCA achieved sensitivity, specificity, and positive and negative predictive values of 62, 100, 100, and 93%, respectively. During the same period, TC-CPE displayed test parameters of 12, 100, 100, and 85%, respectively. After 5 days, the sensitivity and specificity of Ag-CCA increased to 92 and 98%, respectively. Within the same period, isolation attained sensitivity and specificity of 52 and 100%, respectively. Although Ag-CCA displayed slightly reduced sensitivity and reduced specificity compared with conventional cell culture after 14 days, the markedly superior 48-h enterovirus Ag-CCA detection rate supports incorporation of this assay into the routine clinical setting.

Effects on pubertal growth and reproduction in rats exposed to lead perinatally or continuously throughout development

The reproductive, endocrine, and growth effects of developmental lead exposure were assessed using a rat model in which 0.6% lead acetate (w/v) was administered in the drinking water ad libitum during different developmental periods to determine if lead actions were a result of direct effects of continuous exposure to the metal ion or secondary to disrupted neonatal "endocrine imprinting." Sprague Dawley rats were exposed to lead: (1) from gestational d 5 through birth; (2) during pregnancy and lactation; (3) during lactation only; (4) from birth through adulthood; or (5) from gestational d 5 through adulthood. Lead effects were measured on the development of aspects of the reproductive system, adult sex steroid levels, and growth rates in both male and female animals. The relative weights of male secondary sex organs in adult offspring were not significantly affected in any of the lead-treated groups. In contrast, female pups exposed to lead from birth through adulthood or from gestational day 5 through adulthood were observed to have significantly delayed vaginal opening and disrupted estrus cycling. These effects on female reproductive physiology were not observed in animals where lead exposure was confined only to pregnancy or lactation. Significant suppression of adult mean serum testosterone levels was only observed in male pups exposed to lead continuously from gestational age 5 d throughout life. Lead decreased birth weight in all animals exposed in utero and mean body weights were significantly decreased in all lead-treated groups up to weaning. Analysis of growth curves revealed that all lead-treated groups had significantly reduced growth rates during lactation. However, in addition, in male pups exposed to lead during pregnancy and lactation, from birth or from gestational age 5 d, growth rates were also significantly reduced during puberty. Postpubertal growth rates were unaffected in any lead-treated group. Thus, delayed female reproductive development and suppression of adult male serum testosterone concentration required continuous exposure to the heavy metal. Little evidence was observed for an alteration of "endocrine imprinting" by lead on either reproductive or growth parameters. Exposure during early development (pregnancy and lactation) resulted in no permanent effects in this model other than small (10%) decreases in the body weight of pups postpuberty.

Reproductive toxicity and growth effects in rats exposed to lead at different periods during development

The reproductive toxicity and growth effects of developmental lead exposure were assessed using a rat model in which 0.6% (w/v) lead acetate was administered in the drinking water ad libitum. Three series of experiments were conducted in which lead exposure was initiated beginning in utero, prepubertally, or postpubertally. Lead effects were measured on reproductive physiology and endocrinology, sexually dimorphic hepatic testosterone hydroxylation, and growth rates in both male and female animals. In male animals secondary sex organ weights were significantly decreased only in animals exposed prepubertally. In addition, serum testosterone levels were significantly suppressed, most severely in animals exposed from in utero (in the in utero group). Little effect was observed in adult female rats. However, in female animals exposed prepubertally, delayed vaginal opening and disrupted estrus cycling was observed. More severe reproductive disruption was accompanied by suppression of circulating estradiol in the in utero group. Effects on circulating sex steroids were accompanied by variable effects on circulating luteinizing hormone (LH) levels, pituitary LH, and pituitary LH beta mRNA, suggesting a dual site of lead action: (a) at the level of the hypothalamic pituitary unit, and (b) directly at the level of gonadal steroid biosynthesis. Prepubertal growth in both sexes was suppressed 25% in the in utero group. However, pubertal growth rates were significantly suppressed only in male animals and postpubertal growth was not significantly different from controls in any of the experiments, despite continued exposure to high lead levels in the drinking water. In addition, at age 85 days, male-specific hepatic hydroxylation of testosterone at positions 2 alpha and 16 alpha, which is catalyzed by a cytochrome P450 isozyme CYP 2C11, itself regulated by sexually dimorphic growth hormone secretion, was unaffected. This suggests that the growth effects of lead are possibly due to a delay in the development of sex-specific pituitary growth hormone secretion patterns rather than a persistent developmental defect. Thus, the reproductive and growth effects of lead are complex and sex-dependent, and appear to involve multiple sites on the hypothalamic-pituitary-gonadal axis.