Safety and Efficacy of a Single-Stage versus Two-Stage Intramedullary Nailing for Synchronous Impending or Pathologic Fractures of Bilateral Femur for Oncologic Indications: A Systematic Review

Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario.

Parker Solar Probe Observations of Solar Wind Energetic Proton Beams Produced by Magnetic Reconnection in the Near-Sun Heliospheric Current Sheet

We report observations of reconnection exhausts in the Heliospheric Current Sheet (HCS) during Parker Solar Probe Encounters 08 and 07, at 16 R _s and 20 R _s , respectively. Heliospheric current sheet (HCS) reconnection accelerated protons to almost twice the solar wind speed and increased the proton core energy by a factor of ∼3, due to the Alfvén speed being comparable to the solar wind flow speed at these near-Sun distances. Furthermore, protons were energized to super-thermal energies. During E08, energized protons were found to have leaked out of the exhaust along separatrix field lines, appearing as field-aligned energetic proton beams in a broad region outside the HCS. Concurrent dropouts of strahl electrons, indicating disconnection from the Sun, provide further evidence for the HCS being the source of the beams. Around the HCS in E07, there were also proton beams but without electron strahl dropouts, indicating that their origin was not the local HCS reconnection exhaust.

795 Adequacy of Surgical Excision Margins in Lentigo Maligna: An Audit

Aim

The optimal excision margin for Lentigo Maligna (LM) lesions has been a frequent topic of debate. An audit was carried out to compare the excision margins used for LM excisions with current NICE guidelines, and to assess the adequacy of these excision margins.

Method

A retrospective study was carried out to analyse all excisions of LM lesions in 2018. 33 patients were identified from the plastic surgery departmental database. Patient demographics, the site and distribution of LM lesions, and any history of previous skin cancer were analysed. Patient electronic records, operative notes, and histopathological reports were examined to determine the number of excisions done for each LM lesion along with the peripheral and deep surgical excision margins, and the histological clearance achieved. Complete histological clearance was determined by the Multidisciplinary team for each lesion.

Results

60 cases were identified. 60% of cases were located on the head and neck. The average peripheral surgical excision margin at first excision was 2.3mm. 55% of patients had a 2nd excision. The average peripheral surgical excision margin at 2nd excision was 5.4mm. 70.6% of cases achieved complete histological clearance at 2nd excision. 72.7% of lesions excised at 2nd excision with a 5mm or less surgical excision margin achieved complete histological clearance.

Conclusions

Taking >5mm surgical excision margins did not increase the rate of complete histological clearance for Lentigo Maligna lesions.

Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis

Background

Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality.

Methods

MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity.

Results

The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I² value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent.

Conclusion

Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.

The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis

Intra-operative hypotension is associated with acute postoperative kidney injury. It is unclear how much hypotension occurs before skin incision compared with after, or whether hypotension in these two periods is similarly associated with postoperative kidney injury. We analysed the association of mean arterial pressure < 65 mmHg with postoperative kidney injury in 42,825 patients who were anaesthetised for elective non-cardiac surgery. Intra-operative hypotension occurred in 30,423 (71%) patients: 22,569 (53%) patients before skin incision; and 24,102 (56%) patients after incision. Anaesthetised patients who were hypotensive had mean arterial pressures < 65 mmHg for a median (IQR [range]) of 5.5 (0.0-14.7 [0.0-60.0]) min.h^-1 before skin incision, compared with 1.7 [0.3-5.1 [0.0-57.5]) min.h^-1 after incision: a median (IQR [range]) of 36% (0%-84% [0%-100%]) of hypotensive readings were before incision. We diagnosed postoperative kidney injury in 2328 (5%) patients. The odds ratio (95%CI) for acute kidney injury was 1.05 (1.02-1.07) for each doubling of the duration of hypotension, p < 0.001. Postoperative kidney injury was associated with the product of hypotension duration and severity, that is, area under the curve, before skin incision and after, odds ratio (95%CI): 1.02 (1.01-1.04), p = 0.004; and 1.02 (1.00-1.04), p = 0.016, respectively. A substantial fraction of all hypotension happened before surgical incision and was thus completely due to anaesthetic management. We recommend that anaesthetists should avoid mean arterial pressure < 65 mmHg during surgery, especially after induction, assuming that its association with postoperative kidney injury is, at least in part, causal.

DNA methylation profiles of immune response-related genes in apical periodontitis

AIM

To investigate the DNA methylation profiles of immune response-related genes in apical periodontitis (AP) lesions.

METHODOLOGY

The methylation profiles on the cytosine-phosphate-guanine (CpG) regions of 22 gene promoters involved in inflammation and autoimmunity were assessed in 60 human AP lesions and 24 healthy periodontal ligaments (controls) using a pathway-specific real-time polymerase chain reaction array (EpiTect® Methyl Signature PCR Array Human Inflammatory Response). Differentially methylated genes were subsequently assessed for their mRNA expression. Data analyses (One-way anova, Tukey's multiple comparisons tests and Mann-Whitney tests) were performed using GraphPad Prism 6 software. P values ≤ 0.05 were considered statistically significant.

RESULTS

Significant DNA hypermethylation was observed for CXCL3 and FADD gene promoters in AP lesions when compared to control tissues (P < 0.001) and among other genes (P < 0.05). In contrast, IL12B and IL4R were associated with significant hypomethylation in comparison to other genes (P < 0.05). IL12B, IL4R, CXCL3 and FADD had differential mRNA expression in AP lesions and controls (P < 0.001).

CONCLUSIONS

Differential methylation profiles of immune response-related genes, such as FADD, CXCL3, IL12B and IL4R, may have an influence on individual AP susceptibility and patient treatment outcomes, through their potential contributions to altered expression of disease-relevant genes. Methylation and/or genetic variations in additional genes may also contribute to the dynamics of AP development and should be considered in future studies.

Pregnancy in a rudimentary uterine horn

A case of pregnancy reaching term in a rudimentary non-communicating horn of the uterus is presented. The pregnancy resulted in the delivery of a live child by cesarian section. The case is being reported for the rarity with which the foetus survives in this condition.