[Coagulopathies, thrombotic risk and anticoagulation in COVID-19]

Clinical observations indicate that COVID-19 often provokes coagulopathies, which have been associated with high morbidity and mortality rates. These coagulopathies likely result from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection-elicited systemic inflammation and endothelial damage. Patients with severe COVID-19 are at high risk of venous and arterial thromboembolic diseases; they can also develop disseminated intravascular coagulation in the most advanced stages of the disease. Medical Organisations on Thrombosis and Hemostasis, among which the Belgian Society on Thrombosis and Haemostasis (BSTH), have formulated recommendations for the prophylaxis and treatment of COVID-19-related venous thromboembolism in ambulatory and hospitalised patients, as well as for the anticoagulation of COVID-19 patients in need of long-term anticoagulation for unrelated cause.These recommendations provide every hospital and primary care physicians with an easy-to-use clinical guidance; they mainly rely on limited level of evidence and are likely to evolve with knowledge of COVID-19 pathophysiology and availability of data from ongoing clinical trials.

[Haemophilic ankle arthropathy : case reports and review of the literature]

Haemophilic arthropathy affects about half of the patients who suffer from haemophilia. Despite the fact that it's one of the main morbidity factors of haemophilia and that the pathophysiology of its mechanism is slowly better understood, its management is still under discussion. The cases of two men (53 and 54 years old) who suffer from ankle haemophilic arthropathy since several years are reported. For both cases, different aspects of the management are investigated, including a medicated and a physiotherapy approach, and an adequate orthotic. Other treatments are available and sometimes used, such as radio- or arthroscopic synovectomy, corticosteroids or platelet-rich plasma in?ltration or visco-supplementation.

Abstract P5-09-01: Simulation in continuing professional development in oncologic care: Advancing evidence-based decisions in the management of HER2-positive metastatic breast cancer

Background: Breast cancer is the second leading cause of cancer death among women. The growth factor receptor HER2 is overexpressed in 20% to 30% of invasive breast cancers, and use of HER2-targeted therapies have improved responses and survival in patients with metastatic breast cancer (MBC). However, the choice of the most appropriate agents and their sequencing is crucial to maximizing beneficial patient outcomes. A study was conducted to determine if simulation-based educational interventions to address underlying clinical practice gaps could improve competence and performance of oncologists in the management of HER2-positive breast cancer.

Methods: A cohort of US-practicing oncologists who participated in online simulation-based education was evaluated. The interventions consisted of two cases presented in a platform that allowed physician learners to assess the patient and choose from an extensive database of diagnostic possibilities matching the scope and depth of actual practice. Clinical decisions made by participants were analyzed using a sophisticated decision engine, and instantaneous clinical guidance was provided at each decision point employing current evidence-based and expert faculty recommendations. Participant decisions were collected after clinical guidance and compared with each user's baseline data using a 2-tailed paired T-test to provide P values for assessing the impact of simulation-based education on the clinical decisions made by participants as of 12/4/2014.

Results: The assessment sample consisted of 123 oncologists who made clinical decisions within the simulation and proceeded to the concluding debrief section. As a result of clinical guidance provided through simulation, significant improvements were observed in several areas of management of patients with HER2-positive MBC, specifically:

•35% improvement (P<.001) in the selection of the preferred treatment regimen (trastuzumab, pertuzumab, with a taxel) in the first-line setting

•21% improvement (P=.003) in evidence-based treatment selection for individuals whose disease progressed on first-line therapy

•A 35% decrease was seen in the number of participants who selected trastuzumab for individuals whose disease progressed on first-line therapy, which demonstrated an improvement in oncologists ability to select the most appropriate selection based on the current evidence-base

•39% (P<.001) improvement in the number of oncologists who ordered adverse event counseling for the patient

•Similarly, 33% more participants (P<.001) referred a patient for psychosocial counseling after clinical guidance

The data gathered during simulation also provided insights into the remaining gaps, including the choice of the most appropriate, evidence-based first line HER2-targeted regimen in patients with MBC.

Conclusion: This study showed improvements in evidence-based practice patterns of oncologists who were selecting therapeutic protocols for patients with HER2-positive MBC, thus demonstrating that simulation-based instruction can result in an increase in evidence-based clinical decisions and, therefore, may play a role in improving the quality of care and patient outcomes.

Citation Format: Herrmann TL, Blevins D, Warters M, Peters P. Simulation in continuing professional development in oncologic care: Advancing evidence-based decisions in the management of HER2-positive metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-09-01.

[Perioperative management of direct oral anticoagulants: not much evidence but several different approaches]

New oral anticoagulants (NOACs) are a major step forward in the field of anticoagulation. As a consequence, the number of patients treated with NOACs that have to undergo surgery constantly increases. The optimal management of such patients is not clearly determined so far as scientifically established data are lacking. A first proposal is to mimic the perioperative management of patients on vitamin-K antagonists. When the risk of perioperative bleeding is low, NOAC intake is stopped 24 hours before surgery. If the risk of postoperative hemorrhage is moderate or high, NOAC treatment is interrupted 5 days before surgery with a low molecular weight heparin bridging whenever necessary. A second option is based on pharmacokinetic data. When the risk of perioperative bleeding is low, NOAC intake is stopped the day before surgery. If the risk of perioperative bleeding is higher, NOAC intake is suspended for 5 half lives before surgery, 48-72 hours or more. This interruption should be for a longer period in the presence of renal failure. When an unforeseen surgery is needed, the procedure must be delayed as late as possible. In case of emergency, non specific pro-hemostatic agents such as prothrombin complexes or recombinant factor VIIa have not strongly proven useful and must only be used in last ditch effort.

Multiple squamous cell carcinomas following introduction of nilotinib

BACKGROUND

Nilotinib is a second generation tyrosine kinase inhibitor, used in the treatment of chronic myelogenous leukaemia (CML).

METHODS

We assessed a 72-year-old woman who was treated with nilotinib for CML.

RESULTS

During the year following commencement of nilotinib, the patient developed eight squamous cell carcinomas (SCCs) on her legs.

CONCLUSIONS

Development of SCC is a previously unreported adverse reaction to nilotinib.

[Clinical case of the month. Extended portal vein thrombosis in patient on vitamin K antagonists]

There is a long-recognized association between cancer and venous thromboembolism. Venous thrombosis is the most common paraneoplastic complication. We describe a case of rupture of esophageal varices in a patient with a paraneoplastic portal thrombosis. We highlight the links between venous thromboembolism and cancer and also discuss treatment and prognostic factors.

Learning Chronobiology by Improving Wikipedia

Although chronobiology is of growing interest to scientists, physicians, and the general public, access to recent discoveries and historical perspectives is limited. Wikipedia is an online, user-written encyclopedia that could enhance public access to current understanding in chronobiology. However, Wikipedia is lacking important information and is not universally trusted. Here, 46 students in a university course edited Wikipedia to enhance public access to important discoveries in chronobiology. Students worked for an average of 9 h each to evaluate the primary literature and available Wikipedia information, nominated sites for editing, and, after voting, edited the 15 Wikipedia pages they determined to be highest priorities. This assignment ( http://www.nslc.wustl.edu/courses/Bio4030/wikipedia_project.html ) was easy to implement, required relatively short time commitments from the professor and students, and had measurable impacts on Wikipedia and the students. Students created 3 new Wikipedia sites, edited 12 additional sites, and cited 347 peer-reviewed articles. The targeted sites all became top hits in online search engines. Because their writing was and will be read by a worldwide audience, students found the experience rewarding. Students reported significantly increased comfort with reading, critiquing, and summarizing primary literature and benefited from seeing their work edited by other scientists and editors of Wikipedia. We conclude that, in a short project, students can assist in making chronobiology widely accessible and learn from the editorial process.

Expression of fat mobilizing genes in human epicardial adipose tissue

BACKGROUND

Epicardial adipose tissue (EAT) mass correlates with metabolic syndrome and coronary artery disease (CAD). However, little is known about the expression of genes involved in triglyceride (TG) storage and mobilization in EAT. We therefore analyzed the expression of genes involved in fat mobilization in EAT in comparison to subcutaneous abdominal adipose tissue (AAT) in CAD patients and in controls.

METHODS

EAT and AAT were obtained during coronary artery bypass graft (CABG) surgery from 16 CAD patients and from 14 non-CAD patients presenting for valve surgery. The state of atherosclerosis was assessed by angiography. RNA from tissues were extracted, reversibly transcribed and quantified by real time polymerase chain reaction (RT-PCR). The following genes were analyzed: perilipin-1 and -5 (PLIN1, PLIN5), lipoprotein lipase (LPL), hormone sensitive lipase (HSL), adipose triglyceride lipase (ATGL), comparative gene identification-58 (CIG-58), angiopoietin like protein 4 (ANGPTL4), in addition to interleukine-6 (IL-6), leptin (LEP) and adiponectin (ADPN).

RESULTS

A significant expression of all listed genes could be observed in EAT. The relative expression pattern of the 10 genes in EAT was comparable to the expression in AAT, yet there was a significantly higher overall expression in AAT. The expression of the listed genes was not different between CAD patients and controls.

CONCLUSION

It is suggested that the postulated difference in EAT volume between CAD patients and non-CAD patients is not caused by a differential mRNA expression of fat mobilizing genes. Further work on protein levels and enzyme activities will be necessary to get a complete picture.

Rapid growth of cervical cancer metastasis in the brain

Cervical cancer rarely metastasises to the brain, with occurrences of approximately 0.77%. Our patient was referred for treatment of a brain lesion on the background of known metastatic cervical cancer to the lungs and new onset seizure activity. The lesion grew in size from 18 mm to 29 mm in a period of 14 days. The lesion was debulked and the patient returned to the care of her oncology team. The brain is an increasingly common site for metastases of cervical cancer and must be considered when staging these patients.

Inhibition of human immunodeficiency virus-1 (HIV-1) by beta-chemokine analogues in mononuclear cells from HIV-1-infected patients with active tuberculosis

Tuberculosis (TB) enhances human immunodeficiency virus-1 (HIV-1) activity in patients with dual HIV-1/TB infection. Therapies that control augmentations of HIV-1 activity at sites of Mycobacterium tuberculosis (MTB) infection may be useful in inhibition of viral expansion. Regulated upon activation, normal T-cell expressed and secreted (RANTES) analogues (AOP and NNY) are potent in inhibiting the entry of primary HIV-1 isolates into host mononuclear cells. These analogues were used to inhibit MTB-induced HIV-1 entry in blood monunuclear cells (PBMC) from patients with pulmonary TB, and pleural fluid mononuclear cells (PFMC) from patients with pleural TB. PBMC or PFMC were cultured with and without MTB in presence and absence of RANTES analogues. HIV-1 strong stop DNA was assessed by real-time polymerase chain reaction (PCR) as a measure of infection. CCR5 mRNA was assessed by real-time reverse transcription (RT)-PCR and by immunostaining and FACS analysis. HIV-1 infection was induced by MTB in vitro in PBMC from the majority (14 of 20) of HIV-1/TB subjects, and new infection was inhibited by AOP- or NNY-RANTES. HIV-1 infection was also inhibited by these reagents in MTB-induced PFMC from three of three patients with pleural TB. Expression of CCR5 mRNA was significantly induced by MTB in PBMC from patients with pulmonary TB. Further, expression of CCR5 was higher in PFMC compared to PBMC from patients with pleural TB. Also, CCR5 was fourfold higher on CD14(+) pleural mononuclear cells than on CD4(+) lymphocytes. Blocking new HIV-1 infection of mononuclear cells may be useful in control of HIV-1 during dual HIV-1/TB infection.

Verapamil (VP) improves the outcome after renal transplantation (CRT)

Calcium antagonists (CATs) have a role in the management of certain types of renal insufficiency. These include prophylaxis against post-transplant-associated acute renal failure and cyclosporine A (CsA)-induced renal dysfunction. For the transplanted kidney, CATs may be beneficial in several settings. First, a CAT during organ procurement protects the kidney during ischemic periods. Second, CATs given perioperatively protect the kidney during reperfusion and early after transplantation. Third, CATs also offer protection against CsA nephrotoxicity.

Mountain medicine education in Europe

All educational programs in mountain medicine in Europe are presented with their history, evolution, and current status. A comparison and a summary of those programs, as well as an estimate of the number of doctors trained in mountain medicine, are offered. Special focus is put on new developments and subspecialty programs. All programs listed in the Union Internationale des Associations Alpinistes (UIAA) information papers and all programs known through different publications were contacted and asked to forward information about recent courses, materials from former courses, and program syllabi. This information was reviewed and different specific topics were developed in depth. There are 13 different programs in Europe offering medical education in mountain medicine: 3 in France; 2 each in Italy, Spain, and the United Kingdom; and 1 each in Switzerland, Austria, Germany, and The Netherlands. The duration of these courses varies from a long weekend to a full 3-week course with theoretical and practical instruction. At this moment, most programs still have different contents and structures, which are being standardized by the UIAA and the International Commission for Alpine Rescue Medical Commission (ICAR MEDCOM). At least 2600 doctors have had a first-contact course in high-altitude medicine, and at least 2000 have participated in a full course of 1 week of more. A large number of doctors in Europe have become acquainted with mountain medicine by participating in different medical education programs. These programs should be optimized and further specialized in the different areas of mountain medicine, including expedition, alpine, and rescue medicine.

Computer assisted screw insertion into real 3D rapid prototyping pelvis models

OBJECTIVE

Show the use of computer navigation in exact screw positioning in the different pelvic bones.

BACKGROUND

Computer assisted pedicle screw insertion in the spine is an established procedure. Screw fixation is also used in highly difficult pelvic and hip surgery (arthroplasty revision surgery and tumor surgery).

DESIGN

Insert as long screws as possible with computer navigation into the different bones of the pelvis and compare these results with a non-computer controlled method.

METHODS

The computer navigation was done with the system of Medivision (Oberdorf, Switzerland), the software was SurgiGATE 2.1. Optically controlled spine instruments and a special calibrated drill were used. The screw insertion with and without computer navigation took place in seven real rapid prototyping pelvis models matched by pairs. Three screws were inserted into the Os ileum, one into the Os pubis and one into the Os ischium. The length of the inserted screws were measured and compared using routine statistic methods.

RESULTS

The mean screw length with vs. without computer navigation was 8.9 vs. 5.7 cm in the Os ileum (P=0.0001), 6.0 vs. 4.2 cm in the Os pubis (P=0.01) and 4.3 vs. 3.9 cm in the Os ischium (not significant).

CONCLUSIONS

The use of computer navigation allows for the insertion of longer screws into the bones of the pelvis (more exact positioning), which requires a more precise original point of entry and direction of the drill (vector).

RELEVANCE

The insertion of fixation screws in highly difficult pelvic and hip surgery (revision arthroplasty, tumor surgery) are another field for the use of computer navigation.

Nerve compression syndromes in sport climbers

The aim of this study was to determine and evaluate nerve compression syndromes of the upper and lower extremity in sport climbing. Although considerable research has been conducted on orthopedic problems associated with sport climbing, there has been little comprehensive evaluation of the associated neurological problems. The retrospective study performed on 83 active sport climbers presenting with complaints of the upper or lower extremity showed that 21 climbers (25.3%) were diagnosed with a nerve compression syndrome, 14 climbers of the upper extremity, 7 climbers of the lower extremity. Most nerve compression syndromes could be treated by combined conservative modalities (nonsteroidal anti-inflammatory drugs, ice, splinting, physical therapy, rest or decreased training with a rehabilitation training program) and changes in climbing patterns (scientific training planning with warming up and cooling down as well as stretching exercises, longer rest periods, different hand positions, appropriate climbing shoes). Surgical decompression was rarely necessary. Nerve compression syndromes must be included in the general spectrum of medical problems associated with sport climbing.

Increased replication of HIV-1 at sites of Mycobacterium tuberculosis infection: potential mechanisms of viral activation

Tuberculosis (TB) enhances HIV-1 replication and the progression to AIDS in dually infected patients. We employed pleural TB as a model to understand the interaction of the host with HIV-1 during active TB, at sites of Mycobacterium tuberculosis (MTB) infection. HIV-1 replication was enhanced both in the cellular (pleural compared with blood mononuclear cells) and acellular (pleural fluid compared with plasma) compartments of the pleural space. Several potential mechanisms for expansion of HIV-1 in situ were found, including augmentation in expression of tumor necrosis factor (TNF)-alpha and the HIV-1 noninhibitory beta-chemokine (MCP-1), low presence of HIV-1 inhibitory beta-chemokines (MIP-1 alpha, MIP-1 beta, and RANTES [regulated on activation, normal T expressed and secreted]), and upregulation in expression of the HIV-1 coreceptor, CCR5, by pleural fluid mononuclear cells. Thus, at sites of MTB infection, conditions are propitious both for transcriptional activation of HIV-1 in latently infected mononuclear cells, and facilitation of viral infection of newly recruited cells. These mechanisms may contribute to enhanced viral burden and dissemination during TB infection.

Orthopedic problems in sport climbing

Sport climbing is associated with unique upper- and lower-limb injuries involving predominantly the hand, elbow, and shoulder, and to a lesser extent the foot. Many pathologic conditions are limited to sport climbing. Physicians treating sport climbers should be aware of these unique injuries and overuse syndromes. This article presents an overview of orthopedic problems (injuries, overuse syndromes, and fractures) resulting from sport climbing. Sport climbing is defined in the context of existing mountain sports, and its characteristics and technical terms are presented. The etiology, diagnosis, and specific treatment for orthopedic problems associated with sport climbing are described.

Orthopedic problems in sport climbing

Sport climbing is associated with unique upper- and lower-limb injuries involving predominantly the hand, elbow, and shoulder, and to a lesser extent the foot. Many pathologic conditions are limited to sport climbing. Physicians treating sport climbers should be aware of these unique injuries and overuse syndromes. This article presents an overview of orthopedic problems (injuries, overuse syndromes, and fractures) resulting from sport climbing. Sport climbing is defined in the context of existing mountain sports, and its characteristics and technical terms are presented. The etiology, diagnosis, and specific treatment for orthopedic problems associated with sport climbing are described.

Activation of β‐Chemokines and CCR5 in Persons Infected with Human Immunodeficiency Virus Type 1 and Tuberculosis

Tuberculosis (TB) in human immunodeficiency virus type 1 (HIV-1)-infected persons is associated with progression of HIV-1 disease. The expression of macrophage inflammatory protein (MIP)-1alpha and CCR5 was assessed in HIV-1-infected patients with pulmonary TB (HIV-1/PTB) and without PTB (HIV-1/C), PTB patients not infected with HIV-1 (PTB), and control subjects. Mycobacterium tuberculosis (MTB)-induced MIP-1alpha production was lower in peripheral blood mononuclear cells (PBMC) of HIV-1/PTB patients than in those of PTB patients (P< .05) and was lower in PBMC of HIV-1/C patients than in those of control subjects (P< .005). However, MIP-1alpha production was higher in PBMC of HIV/PTB patients than in those of HIV-1/C patients (P< .01). The pattern of MTB-induced RANTES production was similar to that of MIP-1alpha. However, MTB induced greater expression of mRNA for CCR5 in PBMC of HIV-1/PTB patients than in those of HIV-1/C patients (P< .04). Furthermore, the MTB-induced HIV p24 antigen level in PBMC of HIV-1/PTB patients with a CD4 cell count <500 cells/microL was higher (P< .05) than that in HIV-1/C patients. Thus, perturbations in chemokine pathways in HIV-1/PTB patients may accelerate HIV-1 disease.

Macrophage‐Activating Cytokines in Human Immununodeficiency Virus Type 1–Infected and –Uninfected Patients with Pulmonary Tuberculosis

Tuberculosis (TB) is the most common opportunistic infection in human immunodeficiency virus type 1 (HIV-1)-infected patients globally and occurs throughout the course of HIV-1 disease. Here the production of interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha by peripheral blood mononuclear cells (PBMC) of HIV-1-infected versus -uninfected patients with newly diagnosed pulmonary TB (PTB) was compared. Findings were correlated with cytokine profiles, clinical presentation, and expression of inducible nitric oxide (iNOS). Most HIV-1/PTB patients with a CD4 cell count of 200-500 cells/microL had high IFN-gamma production and radiographic evidence of atypical PTB. Low IFN-gamma production and radiographic evidence of reactivated PTB characterized both HIV-1/PTB patients with a CD4 cell count >or=500 cells/microL and HIV-1-uninfected patients. TNF-alpha levels were similar in all HIV-1/PTB patients, regardless of CD4 cell count. Induction of iNOS in PBMC was low and was associated with low IFN-gamma production. These data underscore the potential pathogenic role of macrophage-activating cytokines in TB in HIV-1-infected patients.

[Electronic plantar pressure measurements in different types of moutaineering boots]

Specific footwear has been developed for different, partly newly developed mountain sports. This footwear has very different basic characteristics. This experimental study is dealing with the dynamic parameters of electronic plantar pressure measurements in normal walking using different mountain sport shoes designed for a special purpose in mountaineering. These mountain shoes included a hiking shoe, a trekking shoe and a high-alpine shoe which can take crampons. The electronic plantar pressure measurements were done with the Parotec system of the company Paromed with insoles with hydrocell-sensors. The data obtained during the study were proceeded through a variant analysis. There were no significant differences for impulse and contact time, nevertheless concerning maximal pressure there were significant differences between walking barefoot and walking with the hiking and high-alpine shoe. Even when walking in different mountain shoes the feet conserve their own characteristics and their walking style. The different mountain shoes did not alter most of the measured plantar parameters significantly comparing barefoot walking to walking with the different mountain shoes or comparing walking in the different mountain shoes.

Practical aspects in mountain medicine education

Mountain medicine education is provided through many different courses. The newest developments include an international Union Internationale des Associations Alpinistes--Internationale Kommission für Alpines Rettungswesen--International Society of Mountain Medicine (UIAA-IKAR-ISMM) label for mountain medicine courses that comply with certain minimal requirements in theoretical and practical educational aspects. Participants in the courses that fulfill these specific conditions are eligible to obtain the International Diploma of Mountain Medicine, which is recognized by the above-mentioned international bodies governing mountain sports and mountain medicine. The Swiss course cycle, and especially the structure and content of the Swiss summer course 1999, which was organized by the Swiss Alpine Club and the Swiss Society for Mountain Medicine, are described in this article and some annotations are given. Theoretical and practical requirements for obtaining the International Diploma of Mountain Medicine in Switzerland are also presented.