RET Fusion Testing in Patients With NSCLC: The RETING Study

Introduction

RET inhibitors with impressive overall response rates are now available for patients with NSCLC, yet the identification of RET fusions remains a difficult challenge. Most guidelines encourage the upfront use of next-generation sequencing (NGS), or alternatively, fluorescence in situ hybridization (FISH) or reverse transcriptase-polymerase chain reaction (RT-PCR) when NGS is not possible or available. Taken together, the suboptimal performance of single-analyte assays to detect RET fusions, although consistent with the notion of encouraging universal NGS, is currently widening some of the clinical practice gaps in the implementation of predictive biomarkers in patients with advanced NSCLC.

Methods

This situation prompted us to evaluate several RET assays in a large multicenter cohort of RET fusion-positive NSCLC (n = 38) to obtain real-world data. In addition to RNA-based NGS (the criterion standard method), all positive specimens underwent break-apart RET FISH with two different assays and were also tested by an RT-PCR assay.

Results

The most common RET partners were KIF5B (78.9%), followed by CCDC6 (15.8%). The two RET NGS-positive but FISH-negative samples contained a KIF5B(15)-RET(12) fusion. The three RET fusions not identified with RT-PCR were AKAP13(35)-RET(12), KIF5B(24)-RET(9) and KIF5B(24)-RET(11). All three false-negative RT-PCR cases were FISH-positive, exhibited a typical break-apart pattern, and contained a very high number of positive tumor cells with both FISH assays. Signet ring cells, psammoma bodies, and pleomorphic features were frequently observed (in 34.2%, 39.5%, and 39.5% of tumors, respectively).

Conclusions

In-depth knowledge of the advantages and disadvantages of the different RET testing methodologies could help clinical and molecular tumor boards implement and maintain sensible algorithms for the rapid and effective detection of RET fusions in patients with NSCLC. The likelihood of RET false-negative results with both FISH and RT-PCR reinforces the need for upfront NGS in patients with NSCLC.

Efficient Identification of Patients With NTRK Fusions Using a Supervised Tumor-Agnostic Approach

CONTEXT.—

The neurotrophic tropomyosin receptor kinase (NTRK) family gene rearrangements have been recently incorporated as predictive biomarkers in a "tumor-agnostic" manner. However, the identification of these patients is extremely challenging because the overall frequency of NTRK fusions is below 1%. Academic groups and professional organizations have released recommendations on the algorithms to detect NTRK fusions. The European Society for Medical Oncology proposal encourages the use of next-generation sequencing (NGS) if available, or alternatively immunohistochemistry (IHC) could be used for screening with NGS confirmation of all positive IHC results. Other academic groups have included histologic and genomic information in the testing algorithm.

OBJECTIVE.—

To apply some of these triaging strategies for a more efficient identification of NTRK fusions within a single institution, so pathologists can gain practical insight on how to start looking for NTRK fusions.

DESIGN.—

A multiparametric strategy combining histologic (secretory carcinomas of the breast and salivary gland; papillary thyroid carcinomas; infantile fibrosarcoma) and genomic (driver-negative non-small cell lung carcinomas, microsatellite instability-high colorectal adenocarcinomas, and wild-type gastrointestinal stromal tumors) triaging was put forward.

RESULTS.—

Samples from 323 tumors were stained with the VENTANA pan-TRK EPR17341 Assay as a screening method. All positive IHC cases were simultaneously studied by 2 NGS tests, Oncomine Comprehensive Assay v3 and FoundationOne CDx. With this approach, the detection rate of NTRK fusions was 20 times higher (5.57%) by only screening 323 patients than the largest cohort in the literature (0.30%) comprising several hundred thousand patients.

CONCLUSIONS.—

Based on our findings, we propose a multiparametric strategy (ie, "supervised tumor-agnostic approach") when pathologists start searching for NTRK fusions.

Clinical and histological features and treatment outcomes of patients with Morbihan disease: a systematic review

Morbihan disease (MD) is considered a rare complication of rosacea, which is difficult to diagnose and challenging to treat. Here, we performed a systematic review of available case reports and case series to summarize key clinical and pathologic features of and successful treatment regimens for MD. We conducted a search of the PubMed/MEDLINE, EMBASE, and Cochrane electronic databases from their inception to the date of search on March 6, 2023. We found that MD affects patients in the fifth decade of life on average, more commonly reported in male than female (69% vs 31%). Clinically, MD affects the eyelids, cheeks, and forehead most commonly, presenting as non-pitting, erythematous edema or an edematous plaque. On biopsy, the pathologic features, such as dermal edema, sebaceous hyperplasia, perivascular and periadnexal inflammatory infiltrate, and granulomatous reaction, are frequently reported. Out of 55 patients who were able to achieve complete response without recurrence, 35% of patients were treated with isotretinoin and 22% were treated with tetracycline antibiotics with a daily dosage range of 20-80 mg and 40-200 mg, respectively. Out of those 55 patients, 22% and 7% were treated successfully with surgical intervention and intralesional injection of steroids, respectively. Additionally, lymphatic drainage has been shown to be an effective adjunctive therapeutic tool. More studies are necessary to understand the disease mechanism to improve the diagnosis of and develop evidence-based therapies for MD.

Slugging: TikTokTM as a source of a viral "harmless" beauty trend

"Slugging" is a viral beauty trend on TikTok^TM that entails slathering a petrolatum-based ointment on the skin as a last step in your evening skincare routine. Due to its occlusive nature, slugging has a potential risk for harm. Here, we screened top 50 TikTok videos on slugging and analyzed upload source, content, and quality of each video. Overall, 18 (36.7%) videos were deemed educational, discussing risks and/or benefits. By upload source, health care providers (HCPs) created more educational videos (87.5%, P = .009), while online influencers created more patient experience videos (43.3%). This difference was evident when comparing the upload source. DISCERN scores (a validated measure of video's quality as a source of information) differed significantly among HCP, influencers, and others (3, 2, 2, respectively, P = .01). Together, our study demonstrates that compared to influencers and others, HCPs created videos of more high-quality, educational content on slugging.

Conradi-Hünermann-Happle syndrome: Clinical and trichoscopic findings

Conradi-Hünermann-Happle syndrome (CHHS) is a rare genodermatosis resulting from mutations in the EBP (emopamil binding protein) gene. Dermatologic manifestations may include cicatricial alopecia, ichthyosis, follicular atrophoderma, pigmentary abnormalities, and nail dystrophy. In addition to genetic testing and clinical findings, trichoscopic findings may aid in the diagnosis. In this case report, we discuss the trichoscopic findings in a 3-year-old girl with CHHS and how these findings help us understand the pathophysiology of this disease.

Online Cognitive Behavioral Therapy (CBT) Life Skills Program for Depression: Pilot Randomized Controlled Trial

BACKGROUND

Depression is a common mental health problem with significant personal and social consequences. Studies have suggested that cognitive behavioral therapy (CBT) is an effective treatment for depression and anxiety when delivered one-to-one by an expert practitioner, but access to this talking therapy is often limited, and waiting lists can be long. However, a range of low-intensity interventions that can increase access to services are available including guided CBT self-help materials delivered via books, classes, and online packages.

OBJECTIVE

This project aimed to pilot a randomized controlled trial (RCT) of an online CBT-based life skills course with community-based individuals experiencing depression.

METHODS

Individuals with symptoms of depression were recruited directly from the community via newspaper advertisements. Participants were remotely randomized to receive either immediate access (IA) or delayed access (DA) to a research version of the Living Life to the Full online CBT-based life skills package (3rd edition) with telephone support provided by nonspecialist, charity-based workers while they used the online intervention. The primary end point was at 3 months postrandomization, at which point, the DA group were offered the intervention. Levels of depression, anxiety, social functioning, and satisfaction were assessed.

RESULTS

There were effective recruitment, randomization, and uptake, with 19 IA and 17 DA control participants entering the pilot study via newspaper advertisements and 13 of the 19 participants taking up the intervention. Overall, 72% (26/36) were not currently under the care of their general practitioner. The online package was acceptable to participants; the mean satisfaction score on the Client Satisfaction Questionnaire was 21 out of 32 (SD 8.89). At 3 months, data collection was achieved from 78% (28/36) of the participants. The efficacy and retention data were used for a power calculation indicating that 72 participants in total will be required for a future substantive RCT.

CONCLUSIONS

The research design successfully tested the recruitment, data collection, and intervention delivery. The pilot study has provided data for the required sample size for the full RCT.

TRIAL REGISTRATION

ISRCTN registry ISRCTN12890709; https://doi.org/10.1186/ISRCTN12890709.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-016-1336-y.

Authentic Self and Last Resort: International Perceptions of Psychiatric Neurosurgery

Psychiatric neurosurgery has resurfaced over the past two decades for the treatment of severe mental health disorders, with improved precision and safety over older interventions alongside the development of novel ones. Little is known, however, about current public opinions, expectations, hopes, and concerns over this evolution in neurotechnology, particularly given the controversial history of psychosurgery. To fill this knowledge gap, we conducted a study with eight focus groups in Vancouver and Montreal (Canada; n = 14), Berlin (Germany; n = 22), and Madrid (Spain; n = 12). Focus group texts were transcribed and analyzed using qualitative content analysis in the language local to each city, guided by the theoretical framework of pragmatic neuroethics. Findings indicate that participants across all cities hold concerns about the last resort nature of psychiatric neurosurgery and the potential impact on the authentic self of patients who undergo these procedures. The views captured serve to advance discussion on the appropriate timing for psychiatric neurosurgery, promote sound health policy for the allocation of this resource, and foster scientific literacy about advances for mental health internationally.

Rapid response to COVID-19, escalation and de-escalation strategies to match surge capacity of Intensive Care beds to a large scale epidemic

Introducción

Uno de los principales retos en el manejo de la COVID-19 es el aumento súbito de la demanda de camas de cuidados intensivos. En este artículo se describen las estrategias de gestión hospitalaria durante la escalada y desescalada de la respuesta a la epidemia de COVID-19 en un hospital terciario de Madrid.

Materiales y métodos

Los datos derivan del sistema informático del hospital y del plan de contingencia del mismo.

Resultados

La epidemia de COVID-19 produjo un rápido aumento de los pacientes con necesidad de cuidados intensivos, lo que saturó las camas de UVI disponibles en pocos días. El hospital tuvo que aumentar su capacidad abriendo cuatro UVI adicionales para proporcionar los cuidados necesarios a todos los pacientes. Los retos principales fueron relativos a la infraestructura hospitalaria, los materiales y el personal. Gracias a las estrategias de gestión utilizadas, el hospital fue capaz de aumentar su capacidad de camas de UVI en un 340%, proporcionar cuidados a todos los pacientes con necesidad y mantener una mínima actividad quirúrgica programada.

Conclusiones

La capacidad de un hospital de aumentar su capacidad para enfrentarse a eventos excepcionales es difícil de cuantificar y se enfrenta a limitaciones físicas (materiales, personal, espacios). Con una gestión flexible y adaptable durante eventos excepcionales se pueden alargar significativamente estos límites.

Pan-TRK Immunohistochemistry: An Example-Based Practical Approach to Efficiently Identify Patients With NTRK Fusion Cancer

CONTEXT.—

Food and Drug Administration-approved TRK inhibitors with impressive overall response rates are now available for patients with multiple cancer types that harbor NTRK rearrangements, yet the identification of NTRK fusions remains a difficult challenge. These alterations are highly recurrent in extremely rare malignancies or can be detected in exceedingly small subsets of common tumor types. A 2-step approach has been proposed, involving a screening by immunohistochemistry (IHC) followed by a confirmatory method (fluorescence in situ hybridization, reverse transcriptase-polymerase chain reaction, or next-generation sequencing) in cases expressing the protein. However, there is no interpretation guide for any of the available IHC clones.

OBJECTIVE.—

To provide a pragmatic update on the use of pan-TRK IHC. Selected examples of the different IHC staining patterns across multiple histologies are shown.

DATA SOURCES.—

Primary literature review with PubMed, combined with personal diagnostic and research experience.

CONCLUSIONS.—

In-depth knowledge of pan-TRK IHC will help pathologists implement a rational approach to the detection of NTRK fusions in human malignancies.

Personality dimensions and drug of choice: A descriptive study using Cloninger's temperament and character inventory revised

Personality dimensions related with drug use are novelty seeking, impulsivity and harm avoidance. Studies predicting drug of choice over personality variables are controversial.

Objective

To describe personality profile of drug users in relation to substance of choice.

Aims

To know personality dimension differences according to drug used.

Methods

Cloninger's TCI-R was administered to 218 patients in a dual diagnosis unit.

SPSS was applied.

Results

Of the patients, 33.94% had personality disorder. Principal substances used were alcohol, cocaine and cannabis.

Most of drug users had normal scores in each dimension. No high scores were found in reward dependence, self-directedness and cooperativeness with any drug.

High scores were observed for novelty seeking in 42.9% of timulants users; for arm avoidance in a quarter of cocaine, alcohol and methadone users and for persistence in 18.2% of hypnotics users.

Low scores were observed for reward dependence in 45% of heroine and hypnotics users; for persistence in 50% of methadone and 32% of cocaine users; for self-directedness in most of types of drug users and for cooperativeness in up to 50% in heroine, hypnotics, stimulants and cocaine users.

Statistical significant differences were observed for cocaine use and high novelty seeking and low cooperation; for non cannabis use and high harm avoidance; for non anfetamine use and low scores in reward dependence; for opiate use and low self-directedness.

Conclusions

Most of patients had normal scores in the different dimensions.

Presence of comorbid personality disorder led us to consider the results with caution.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Scar wars

BACKGROUND

Burn scars are common in the paediatric population. When involving the face, it diminishes quality of life. Ablative fractional laser (AFL) therapy is becoming the preferred choice for established scars due to its greater potential depth for thermal injury (4 mm), which leads to photothermolysis with subsequent neocollagenesis and collagen fibre realignment and remodelling. Combined with small z-plasties and topical steroids, it has been proven to: flatten and decrease the volume of scars, increase pliability and decrease pruritus and erythema. The purpose of the case series was to determine the clinical significance of a single session of AFL therapy, combined with small z-plasties and topical steroids on facial scars post burn injury.

METHOD

Four cases of paediatric facial scarring post burns were selected to undergo a single treatment of AFL therapy, accompanied by small z-plasties and topical steroids. Modified Vancouver Scar Scores (MVSS) pre- and postoperatively at 3 and 6 months were evaluated.

RESULTS

Improvement of all components of the MVSS was achieved after 6 months, with major improvement in scar pliability and symptomatology. The mean MVSS improved from 14 (range 12-16) preoperatively to 5 and 5.5 respectively at 3 and 6 months postoperatively. Non-parametric analysis with Friedman Two-Way ANOVA by Rank showed a statistical significance between the pre- and postoperative MVSS (p = 0.024).

CONCLUSION

AFL should form an integral part of the burn scar armamentarium.

5132Effect of PCSK9 inhibitors treatment on acute coronary syndrome and stroke incidence: a metanalysis of currently available clinical trials

Background

Proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitors have demonstrated to induce large reductions in low-density lipoprotein cholesterol (LDLc) and major cardiovascular events but none of the studies was statistically powered to demonstrate reductions in specific endpoints rather than a combined end-point of major cardiovascular events.

Methods

We performed an intention-to-treat meta-analysis in line with recommendations from the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement using currently available studies involving PCSK9 inhibitors. The endpoint assessed were acute coronary syndrome (ACS) and stroke.

Results

We included 81,544 patients, 41,147 treated with a PSCK9 inhibitors: 17,179 with evolocumab; 13,718 with bococizumab and 10,250 with alirocumab (table 1). A total of 1,316 ACS were registered in the treatment group vs. 1,608 in controls, resulting in 18.0% reduction associated with PCSK9 treatment (figure 1). This result was reproduced exactly in the EBCT althougt a non-significant heterogeneity was detected (p=0.052). Metaregression analyses did not demonstrate the implication of the study (p=0.45), study drugs (p=0.26), age (p=0.89), hypertension (p=0.81) or diabetes (p=0.81) on such result.

Results on stroke incidence are presented in figure 2. PCSK9 inhibitors treatment resulted in a 24% reduction of stroke when all studies were analyzed together; heterogeneity was statistically significant (p=0.021) but it was not observed in the EBCT analysis where PCSK9 inhibitors were associated with 24% stroke incidence reduction.

Conclusions

The meta-analysis of currently available studies demonstrates that PCSK9 inhibitors treatment reduces the incidence of ACS by 18% and stroke by 24%.

Production of Hydronium Ion (H3O)+ and Protonated Water Clusters (H2O)nH+ after Energetic Ion Bombardment of Water Ice in Astrophysical Environments

Water ice exists on many objects in space. The most abundant icy species, among them water, are present in the icy satellites of the outer Solar System giant planets. The nuclei of comets, which are mainly composed of water ice, give another example of its abundance. In the interstellar medium (ISM), ice mantles, formed by molecular species sticking on dust grains, consist mainly of water ice. All these objects are exposed to ionizing radiation like ions, UV photons, and electrons. Sputtering of atoms, molecules, ions, and radicals from icy surfaces may populate and maintain exospheres of icy objects in the Solar System. In other respects, ionized hydrides such as OH⁺, H₂O⁺, and H₃O⁺ have been detected in the gas phase in star-forming regions. Interactions with cosmic rays could be an additional explanation to the current models for the formation of those species. In fact, laboratory simulations showed that the main components of the sputtered ionic species from water ice are oxygen hydrides. In this work, water ice targets were irradiated at several temperatures (10-200 K) by 90 keV O⁶⁺ ions, yielding an electronic stopping power of about 12 eV/Å, when the nuclear stopping power is comparable to the electronic stopping power. Sputtering of secondary ions after bombardment of the ice target was analyzed by time-of-flight mass spectrometry (TOF-SIMS). Besides hydrogen ions (H⁺, H₂⁺, H₃⁺), also O⁺, O²⁺, OH⁺, (H₂O)⁺, and clusters of (H₂O)_nH⁺ with n = 1-8 are emitted. Our results show a progressive yield decrease with increasing temperature of all of the detected species. This is related to the structure of the ice: the ionic sputtering yield for crystalline ice is much lower than for an amorphous ice. For instance, amorphous ice at 10 K exhibits a yield of the order of 2 × 10^-6 secondary (H₂O)_nH⁺ hydride ions/projectile (with n = 1-8). As the temperature is increasing toward the phase transition to crystalline ice, the yields decrease by about one order of magnitude.

Infant burns: A single institution retrospective review

Thermal injuries amongst infants are common and a cause of significant mortality and morbidity in South Africa. This has been attributed to the lack of an enabling environment (poverty-related lack of safe living conditions) and the cognitive and physical developmental immaturity of infants, who depend on their surroundings and adults to keep them safe. This is a retrospective observational study of 548 infant admissions over 48 months. Infant was defined as children below 13 months of age. The 548 infants constituted 23% of all paediatric burn admissions of ages 0-12 years. Three hundred and fourteen were males (57%) and 234 (42.7%) females. The infants were divided in a pre-ambulatory group of 143 (26%) infants of 0-6 months and an ambulatory group of 7 months to 12 months consisting of 457 (83.3%). The total body surface area (TBSA) ranged from 2-65%. Seventy-six percent (417 infants) occurred in the home environment. Scalds accounted for 86% (471 infants) and 6% (33 infants) were as a result of flame burns. Non-accidental injuries accounted for 1.2%. The anatomical distributions varied between the pre-ambulatory and ambulatory groups. Conservative management was done in 397 (72.4%) and 101(18.4%) infants underwent surgery. Infection was suspected in 76 (13.5%) infants with positive blood cultures in 15(20%) of the 76. ICU care was received in 46 (8.3%) infants and 15 (32.6%) of these had inhalation injuries. Of the inhalation injuries 11(23.9%) infants underwent mechanical ventilation of an average of 4.4 days. Ventilator associated pneumonia was diagnosed in 8(17%) of the ventilated children. The mortality rate was 0.36%. The surgically treated patients acquired more complications than the conservatively treated group. Special treatment considerations should be considered in this paediatric sub-group.

Sublay repair results in superior mesh incorporation and histological fibrogenesis in comparison to onlay and primary suture in an experimental rat model

PURPOSE

To compare adhesion scores, repair strength and histological findings among sublay, onlay and primary repair incisional hernioplasty techniques. Surgical repairs were employed directly on healthy animals, without previous hernia induction, to avoid confounding factors related to hernia development.

METHODS

Forty Wistar rats were divided into four groups, control, simulation, onlay and sublay. After 42 days, adhesion intensity, tensile strength of the abdominal wall and anatomopathological histological substrate were compared.

RESULTS

SL group presented greater adhesion scores (p < 0.0001), higher tensiometric (p < 0.0001), and was characterized by more histiocytes, mononuclear cells, macrovacuolar granulomas and type I collagen on histological analysis. Pearson correlation between adhesions and tensiometry, and between tensiometry and neocollagenization showed a strong positive association (r = 0.8905 and 0.6757, respectively in SL group, p < 0.05).

CONCLUSION

Mesh positioning in sublay compartment was followed by increased adhesion development and provides a stronger mesh-tissue attachment, in addition, resulted in a different histological profile of the inflammation/repair substrate. The intensity of these findings was directly correlated, suggesting they could be the result of a common biological phenomenon. Our findings indicate that mesh placement following the retromuscular technique generates a superior repair response, and give clues to a better understanding of the superiority of sublay repair in achieving lower recurrence rates. Characterization of the cellular and molecular elements responsible for the superiority of this technique is in our view an essential prerequisite aiming for improvements in the therapeutic options for the treatment of this disease.

Below the surface: Twenty-five years of seafloor litter monitoring in coastal seas of North West Europe (1992-2017)

Marine litter presents a global problem, with increasing quantities documented in recent decades. The distribution and abundance of marine litter on the seafloor off the United Kingdom's (UK) coasts were quantified during 39 independent scientific surveys conducted between 1992 and 2017. Widespread distribution of litter items, especially plastics, were found on the seabed of the North Sea, English Channel, Celtic Sea and Irish Sea. High variation in abundance of litter items, ranging from 0 to 1835 pieces km^-2 of seafloor, was observed. Plastic tems such as bags, bottles and fishing related debris were commonly observed across all areas. Over the entire 25-year period (1992-2017), 63% of the 2461 trawls contained at least one plastic litter item. There was no significant temporal trend in the percentage of trawls containing any or total plastic litter items across the long-term datasets. Statistically significant trends, however, were observed in specific plastic litter categories only. These trends were all positive except for a negative trend in plastic bags in the Greater North Sea - suggesting that behavioural and legislative changes could reduce the problem of marine litter within decades.

The value of WhatsApp communication in paediatric burn care

BACKGROUND

Telemedicine is increasingly applied in developed settings to facilitate transfer of information to and from burn surgeons across vast geographic areas. WhatsApp is a widely available and extremely user-friendly encrypted smartphone application that does not require the expensive physical and personnel infrastructure that characterizes many of these telemedicine systems. The aim of this study was to review the use of WhatsApp to facilitate paediatric burn injury consultations to a regional burn centre in a developing country, where burn care continues to be thwarted by administrative apathy, poor resource allocation and lack of attention to medical and nursing education at all levels.

METHODS

A retrospective review was undertaken of all consultations using WhatsApp over an 18-month period, received by the burn centre's two senior medical practitioners. The specific origin and nature of the telemedicine requests for advice, transfer or follow-up were collected, as were data relating to the demographics of the patients, the aetiology, mechanism and extent of the burn injury. The impact of the system of communication in terms of reductions in admissions and clinic visits was assessed, and a cost analysis was undertaken. Feedback was also obtained from those health practitioners regularly using the service.

RESULTS

838 communications occurred during the study period, which included 1562 distinct clinical queries. 486 interactions (58%) originated from within the hospital, the majority of which were initiated by surgeons in training or burn nurse practitioners. 352 (42%) consultations were from outside the hospital. Queries related to the full spectrum of burn care, including emergency management and stabilization, triage and transfer, the need for escharotomy, fluid resuscitation, wound care, the timing and nature of surgical intervention, as well as follow-up and rehabilitation. While no significant changes in the number of surgical interventions or admissions were observed when compared to the five years prior to the intervention, outpatient visits reduced significantly during the study period. It was estimated that over 150 unnecessary admissions were also avoided as a result of the triage made possible by WhatsApp, which translated into considerable cost saving for the institution.

DISCUSSION

Incorporating WhatsApp technology into the daily processes of burn care has significantly improved the quality of paediatric burn care referrals to specialist burn services. Specifically, WhatsApp has contributed to reductions in unnecessary referrals and outpatient visits, facilitated opportunities for continuing medical education, improved the care of major burn injuries through more effective prehospital communication, and enabled greater allocation of scarce specialist resources at the burn centre. This study motivates for the wider application of WhatsApp for burn care referrals, especially in developing countries.

Mass problem in the Standard Model

We propose a new SU(3)C ⊗ SU(2)L ⊗ U(1)Y ⊗ U(1)X gauge model which is non universal respect to the three fermion families of the Standard Model. We introduce additional one top-like quark, two bottom-like quarks and three right handed neutrinos in order to have an anomaly free theory. We also consider additional three right handed neutrinos which are singlets respect to the gauge symmetry of the model to implement see saw mechanism and give masses to the light neutrinos according to the neutrino oscillation phenomenology. In the context of this horizontal gauge symmetry we find mass ansatz for leptons and quarks. In particular, from the analysis of solar, atmospheric, reactor and accelerator neutrino oscillation experiments, we get the allow region for the Yukawa couplings for the charge and neutral lepton sectors according with the mass squared differences and mixing angles for the two neutrino hierarchy schemes, normal and inverted.

[Unsuccessful pain treatment over 6 years of a thoracic radiculopathy caused by an unrecognized Tarlov cyst]

This article presents a case of unsuccessful pharmaceutical and invasive pain treatment for 6 years without any adequate diagnostics in a female suffering from unilateral thoracic radiculopathy (Th8, right) leading to severe disability and unemployment. The origin was an undetected Tarlov cyst. After resection of the cyst the pain and other complaints disappeared (follow up: 8 months) without need for further pain medication. This case underlines the necessity of adequate diagnostics ahead of long-term pain treatment. Thoracic Tarlov cysts are very uncommon but should be included in the differential diagnosis because curative treatment may be possible.

Prognostic value of antigen expression in multiple myeloma: a PETHEMA/GEM study on 1265 patients enrolled in four consecutive clinical trials

Persistence of minimal residual disease (MRD) after treatment for myeloma predicts inferior outcomes, but within MRD-positive patients there is great heterogeneity with both early and very late relapses. Among different MRD techniques, flow cytometry provides additional information about antigen expression on tumor cells, which could potentially contribute to stratify MRD-positive patients. We investigated the prognostic value of those antigens required to monitor MRD in 1265 newly diagnosed patients enrolled in the GEM2000, GEM2005MENOS65, GEM2005MAS65 and GEM2010MAS65 protocols. Overall, CD19^pos, CD27^neg, CD38^lo, CD45^pos, CD81^pos, CD117^neg and CD138^lo expression predicted inferior outcomes. Through principal component analysis, we found that simultaneous CD38^lowCD81^posCD117^neg expression emerged as the most powerful combination with independent prognostic value for progression-free survival (HR:1.69; P=0.002). This unique phenotypic profile retained prognostic value among MRD-positive patients. We then used next-generation flow to determine antigen stability throughout the course of the disease, and found that the expression of antigens required to monitor MRD is mostly stable from diagnosis to MRD stages, except for CD81 whose expression progressively increased from baseline to chemoresistant tumor cells (14 vs 28%). Altogether, we showed that the phenotypic profile of tumor cells provides additional prognostic information, and could be used to further predict risk of relapse among MRD-positive patients.

A real-time stress classification system based on arousal analysis of the nervous system by an F-state machine

BACKGROUND AND OBJECTIVE

Detection and labelling of an increment in the human stress level is a contribution focused principally on improving the quality of life of people. This work is aimed to develop a biophysical real-time stress identification and classification system, analysing two noninvasive signals, the galvanic skin response and the heart rate variability.

METHODS

An experimental procedure was designed and configured in order to elicit a stressful situation that is similar to those found in real cases. A total of 166 subjects participated in this experimental stage. The set of registered signals of each subject was considered as one experiment. A preliminary qualitative analysis of the signals collected was made, based on previous counselling received from neurophysiologists and psychologists. This study revealed a relationship between changes in the temporal signals and the induced stress states in each subject. To identify and classify such states, a subsequent quantitative analysis was performed in order to determine specific numerical information related to the above mentioned relationship. This second analysis gives the particular details to design the finally proposed classification algorithm, based on a Finite State Machine.

RESULTS

The proposed system is able to classify the detected stress stages at three levels: low, medium, and high. Furthermore, the system identifies persistent stress situations or momentary alerts, depending on the subject's arousal. The system reaches an F₁ score of 0.984 in the case of high level, an F₁ score of 0.970 for medium level, and an F₁ score of 0.943 for low level.

CONCLUSION

The resulting system is able to detect and classify different stress stages only based on two non invasive signals. These signals can be collected in people during their monitoring and be processed in a real-time sense, as the system can be previously preconfigured. Therefore, it could easily be implemented in a wearable prototype that could be worn by end users without feeling to be monitored. Besides, due to its low computational, the computation of the signals slopes is easy to do and its deployment in real-time applications is feasible.

Recombinant 60-kDa heat shock protein from Paracoccidioides brasiliensis: is it a good antigen for serological diagnosis of paracoccidioidomycosis?

Paracoccidioides brasiliensis and P. lutzii are fungi that cause paracoccidioidomycosis (PCM), the most prevalent systemic mycosis in South America. For serological diagnosis, although 43-kDa glycoprotein (gp43) is regarded as highly specific for PCM, the occurrence of false negative reactions in sera from patients infected with P. lutzii suggests that preparation with only one antigen is not recommended. Heat shock proteins are feasible alternatives as a second antigen because they are often highly immunogenic. In this study, we evaluated the usefulness of recombinant 60-kDa heat shock protein from P. brasiliensis (rPbHsp60) for the serological diagnosis of PCM. Using western blotting assay, we observed that 77.3% of the sera from PCM patients were positive to rPbHsp60, with 90.9% positivity to recombinant gp43 (rgp43). More importantly, sera from healthy subjects had 27% positivity to rPbHsp60 and none to rgp43. When rPbHsp60 was used in ELISA, we did not observe significant differences between the reactions with sera from PCM patients and healthy subjects, while the difference was clearly evident when the antigen was rgp43. Furthermore, rPbHsp60 was recognized by sera from patients with histoplasmosis, aspergillosis, sporotrichosis or tuberculosis in an ELISA test. These results show that rPbHsp60 is not a good antigen for PCM diagnosis.

Experience and outcomes of micrografting for major paediatric burns

BACKGROUND

The deficit of donor sites in major burns over 50% of the total body surface area has necessitated the application of methods besides traditional meshed autografting to achieve definitive skin cover. The Meek micrografting technique was introduced at this hospital in 2011, especially in the absence of a reliable source of deceased donor allograft skin. The purpose of this study was to evaluate this strategy with reference to its technical execution, efficacy and indications in the context of major paediatric burn surgery.

METHODS

A cohort study was performed of all paediatric patients with major burn who underwent Meek micrografting at a dedicated paediatric burn centre in a developing country over a five year period. Demographics, details of their burns, operative management and clinical course and outcomes were collected from patient records and operative notes and analysed.

RESULTS

Thirty-five patients were managed using the micrografting technique during the study period. The mean patient age was 4.1 years (range 3 months-11 years) and their mean total body surface area (TBSA) burn was 49.7% (range 15-86%). Eleven patients sustained inhalation injuries and five developed a re-feeding syndrome on account of delayed referral. The mean abbreviated burn severity index (ABSI) was 8.5 (range 2-13). The hospital length of stay in the 27 survivors was a mean of 75.5 days, equating to 1.4 days per percentage burn. Eight patients died during the course of treatment, with a mean TBSA burn of 67.75% (range 38-86%). Graft take one month after surgery was documented to be more than 90% in 24 patients, of whom 3 subsequently died. Eleven patients had less than 90% graft take at this time, of whom 5 died.

CONCLUSION

There is a considerable 'learning curve' associated with this technique. In order to achieve success one must ensure a completely viable, non-infected bed, obtained by tangential or fascial excision, followed by allografting as temporary coverage and to 'test the wound bed' for definitive coverage. Infection resulted in the majority of autograft loss in this series, and in addition to risk factors like burn size and inhalation injury, accounted for many of the deaths in this series. Meek micrografting offers high expansion ratios, thereby facilitating durable wound cover in the presence of limited donor sites. It is unlikely that a lethal dose, 50% (LD₅₀) of almost 70% TBSA would have been possible in this context without the regular application of this technique. This study advocates for the widespread availability of Meek micrografting and deceased donor allograft skin in developing countries.

Identification of SNPs in growth-related genes in Colombian creole cattle

Colombian creole cattle have important adaptation traits related to heat tolerance and reproductive and productive efficiency. Romosinuano (ROMO) and Blanco Orejinegro (BON) are the most common breeds used by Colombian cattle breeders. Growth traits are of prime importance in these animals, which are mainly raised for beef production. Genes encoding growth hormone, growth hormone receptor, homeobox protein, insulin growth factor binding protein 3, leptin, and myostatin have been associated with physiological growth pathways in cattle and other species. We therefore aimed to identify single nucleotide polymorphisms (SNPs) within these genes in ROMO, BON, and Zebu cattle. DNA regions of these genes were sequenced in 386 animals; 47 new SNPs were found, of which 14 were located in the exonic regions, thereby changing the protein sequence. An association of SNPs with weaning weight (WW), daily weight gain at weaning (DWG), and weight at 16 months (W16M) traits was deduced. The genetic analysis revealed several SNPs related to these traits. The SNP GhRE06.2 had a significant association with WW and the SNP Lep03.4 was highly associated with DWG and W16M. Other polymorphisms were significantly associated with WW and DWG, although they did not surpass the Bonferroni significance threshold. The new mutations identified may indicate important points of genetic control in the DNA that could be responsible for changes in the expression of the analyzed traits. These SNPs might be used in future breeding programs to improve the productive performance of cattle in beef farms.