Machine learning accurately quantifies epicardial adipose tissue from non-contrast CT images in coronary artery disease

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Industry Alignment Fund – Pre-positioning Programme

Background

Epicardial adipose tissue (EAT) is the visceral fat deposit within the pericardium that surrounds the heart and the coronary arteries. EAT volume measured from non-contrast CT (NCCT) has been demonstrated to be significantly associated with adverse cardiovascular risk,1 particularly in patients with coronary artery disease.2 However, routine measurement of EAT volume is still challenging in clinical practice, as it is a tedious manual process and prone to human error.

Purpose

We aimed to develop a fully automated AI toolkit (i.e., AI EAT) for the quantification of EAT from routine NCCT scans and assess its performance in reference to clinical ground truth.

Methods

This is a multicenter study which performs CT scans in 5000 Asian Admixture patients (APOLLO study NCT05509010). In the current stage of this study, NCCT data analysis were conducted in 551 patients with 26,037 images. AI EAT was developed via a novel deep learning framework using an ensemble region-based UNet. The region-based UNet uses 2 component UNet models to perform segmentation of pericardium at the apex region and non-apex region (middle and basal). EAT volume was obtained by automated thresholding of the voxels (-190 to -30 Hounsfield Unit) within the pericardium (Figure 1). The network was trained in 501 patients with 23,712 NCCT images and tested in 50 patients with 2,325 NCCT images. The performance of AI EAT was evaluated with respect to clinical ground truth using Dice similarity coefficient (DSC), Pearson correlation, and Bland-Altman analysis.

Results

The AI EAT quantification process took less than 10 seconds per subject, compared with 20-30 minutes for expert readers. Compared to clinical ground truth, our AI EAT achieved a DSC of 0.96±0.01 and 0.91±0.02 for pericardium and EAT segmentations, respectively. There was strong agreement between the AI EAT and clinical ground truth in deriving the EAT volume (r=0.99, P<0.001) with minimal error of 7±5%.

Conclusion

End-to-end deep learning system accurately quantifies epicardial adipose tissue in standard NCCT images without manual segmentation.

The Impact of Body Mass Index Upon the Efficacy of Adalimumab in Hidradenitis Suppurativa

Elevated BMI in Hidradenitis Suppurativa is associated with decreased response to Adalimumab therapy. BMI is proposed to segregate distinct disease subtypes. It remains unresolved whether a threshold BMI exists above which increased dosages may provide clinical benefit. Individual patient data from 578 PIONEER Phase 3 participants were analyzed. Descriptive, multivariable regression analysis and receiver operating characteristic (ROC) curves were calculated to assess the relationship between BMI and clinical outcome measures using R v3.5.3. Participants in the overweight and obese BMI category had reduced odds (58 and 67%, respectively) of achieving HiSCR [OR = 0.42 (95%CI −0.19, 0.91) p = 0.03], [OR = 0.33 (95%CI 0.16, 0.67) p = 0.002] compared to participants with BMI < 25. Reduction in AN count and IHS4 score was not significantly associated. ROC analysis did not reveal any cut off value predictive of treatment outcome. No correlation between BMI and baseline disease activity or covariate interactions were identified. These findings suggest BMI is a significant covariate in the setting of lower baseline disease activity, supporting the concept of disease heterogeneity and differential therapeutic response to Adalimumab.

Dermal tunnels influence time to clinical response and family history influences time to loss of clinical response in patients with hidradenitis suppurativa treated with adalimumab

BACKGROUND

Clinical response in hidradenitis suppurativa (HS) is most commonly assessed using the Hidradenitis Suppurativa Clinical Response (HiSCR) measure. Dermal tunnels, increased body mass index, smoking and antibiotic use significantly decrease the odds of achieving HiSCR. However, there are few data exploring if clinical features are also associated with length of time to achieve clinical response and/or time to lose clinical response.

AIM

To explore whether variables associated with achievement of HiSCR are associated with time to achieve HiSCR and time to loss of HiSCR in patients with HS treated with adalimumab 40 mg weekly in the PIONEER open-label extension study.

METHODS

Time-to-event analyses were performed to estimate time to achieve HiSCR and time to loss of HiSCR. The log rank test was used to compare cumulative incidence curves for a priori patient- and disease-associated factors. Cox regression analysis was performed to compare time-to-event outcomes in the presence of a priori variables. All statistical analyses were completed with R software (V3.5.3).

RESULTS

Presence of dermal tunnels significantly increased the time to achieve HiSCR (median 32.6 vs. 14.3 weeks, P = 0.02) and the hazard ratio (HR) was significant after controlling for patient and disease factors (HR = 0.70, 95% CI 0.51-0.96, P = 0.03). A positive family history of HS significantly decreased the time to loss of HiSCR (median 11.4 vs. 18 weeks, P < 0.001) and remained significant in Cox regression analysis (HR = 2.01, 95% CI 1.40-2.88, P < 0.001).

CONCLUSION

The presence of dermal tunnels significantly influences the odds of achieving HiSCR and the time to achieve HiSCR, while family history influences time to loss of HiSCR.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Towards OPM-MEG in a virtual reality environment

Virtual reality (VR) provides an immersive environment in which a participant can experience a feeling of presence in a virtual world. Such environments generate strong emotional and physical responses and have been used for wide-ranging applications. The ability to collect functional neuroimaging data whilst a participant is immersed in VR would represent a step change for experimental paradigms; unfortunately, traditional brain imaging requires participants to remain still, limiting the scope of naturalistic interaction within VR. Recently however, a new type of magnetoencephalography (MEG) device has been developed, that employs scalp-mounted optically-pumped magnetometers (OPMs) to measure brain electrophysiology. Lightweight OPMs, coupled with precise control of the background magnetic field, enables participant movement during data acquisition. Here, we exploit this technology to acquire MEG data whilst a participant uses a virtual reality head-mounted display (VRHMD). We show that, despite increased magnetic interference from the VRHMD, we were able to measure modulation of alpha-band oscillations, and the visual evoked field. Moreover, in a VR experiment in which a participant had to move their head to look around a virtual wall and view a visual stimulus, we showed that the measured MEG signals map spatially in accordance with the known organisation of primary visual cortex. This technique could transform the type of neuroscientific experiment that can be undertaken using functional neuroimaging.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Sporadic pemphigus foliaceus and class II human leucocyte antigen allele associations in the white British and Indo-Asian populations in the UK

BACKGROUND

Pemphigus foliaceus (PF) has both genetic and environmental susceptibility factors. Current data on human leucocyte antigen (HLA) in patients with sporadic PF are limited.

AIM

To better define the distribution of HLA alleles in patients with PF in the UK.

METHODS

We recruited 36 patients [26 of white British (WB) descent, 10 of Indo-Asian (IA) descent] with PF who were living in the UK and 159 ethnically matched normal controls, and analysed their class II HLA DRB1 and DQB1 allele distribution.

RESULTS

There was an increased frequency of DRB1*1404 in association with DQB1*0503 in IA patients with PF. The DRB1*04 allele group as a whole had an increased frequency (P < 0.001) in the WB patient group compared with controls. The alleles contributing to this significance were DRB1*0401 (P = 0.03) and DRB1*0404 (P < 0.01).

CONCLUSION

This is the largest HLA association study in sporadic PF from the UK to date. There appears to be a difference in PF susceptibility alleles between WB and IA patients, highlighting the importance of racial variation in genetic susceptibility to disease development.

Pleasures and Risks Associated with Bingo Playing in an Australian Aboriginal Community: Lessons for Policy and Intervention

Bingo playing in Australian Indigenous communities has received little academic attention. We report here on an exploratory study designed to understand the complex benefits and harms associated with bingo playing for Aboriginal people in Sunraysia, a regional community in Victoria, Australia. The research was strongly participatory, and conducted in collaboration with staff of an Aboriginal community-controlled organisation. Twenty-six members of the Sunraysia Aboriginal community were interviewed, with interviews primarily conducted by workers from the Aboriginal organisation. Echoing research from other countries, but with a unique focus on the experience of bingo for Aboriginal people in Australia, this study demonstrates compelling reasons why Aboriginal people in Sunraysia play bingo, and how bingo playing both exposes players to risk and mitigates against a wide range of harms. We found that, for many people in the study, bingo was variously a site that reinforces social connectedness, a source of fun and excitement and a strategy to find solace or respite in the face of personal pain and structural injustice. In contrast with other forms of gambling, bingo presents risks that can generally be managed, largely because of the smaller financial spend involved. However, people also described harms including exhausting the family budget, family conflict and encouragement to commence other forms of gambling. We argue for enhanced regulation of commercial bingo and suggest that not-for-profit bingo be implemented as a harm reduction strategy to enable people to experience some of the pleasures associated with gambling, with reduced risk of financial and social harms.

Feasibility of Cryopreserved Conduits for Complex Vascular Reconstruction in the Pediatric Population: The Case of a 3-Year-Old With Femoral Vessels Transections

This report presents an unusual case of traumatic iliofemoral vessel transection in a 3-year-old patient successfully reconstructed using a cryopreserved greater saphenous conduit. Five years after injury, the patient continues to do well with normal ambulation. An arterial duplex demonstrated graft patency free of aneurysmal dilatation. These encouraging results suggest that the natural history of cryopreserved conduits may differ in the pediatric population and cryopreserved conduits could be used for complex vascular reconstructions.

Pediatric Secondary Overtriage in a Statewide Trauma System

Secondary overtriage is a term that describes patients who are discharged home shortly after being transferred, an indication that transfer and hospitalization were unnecessary. The study goal was to identify factors associated with secondary triage. A statewide trauma registry was used to identify trauma patients aged less than 18 years during a 6-year period (2007-2012) who were discharged within 48 hours from arrival and did not undergo a surgical procedure. We compared those that were treated at initial facility and those transferred to a second facility using clinical indices including patterns of injury pattern using multivariate logistic regression. Of the 4441 patients who fit our inclusion criteria, 801 (18%) were transferred. Younger age groups were more likely to be transferred. Factors associated with being transferred included head, spinal, and facial injuries, and patient arrival during the nighttime work shifts. In conclusion, young patients who have signs of possible neurological or spinal injuries and those who arrive during nondaytime shifts during the workday are more likely to be transferred to another trauma center. These may reflect the comfort level and resources of the local facility.

Pediatric Secondary Overtriage in a Statewide Trauma System

Secondary overtriage is a term that describes patients who are discharged home shortly after being transferred, an indication that transfer and hospitalization were unnecessary. The study goal was to identify factors associated with secondary triage. A statewide trauma registry was used to identify trauma patients aged less than 18 years during a 6-year period (2007–2012) who were discharged within 48 hours from arrival and did not undergo a surgical procedure. We compared those that were treated at initial facility and those transferred to a second facility using clinical indices including patterns of injury pattern using multivariate logistic regression. Of the 4441 patients who fit our inclusion criteria, 801 (18%) were transferred. Younger age groups were more likely to be transferred. Factors associated with being transferred included head, spinal, and facial injuries, and patient arrival during the nighttime work shifts. In conclusion, young patients who have signs of possible neurological or spinal injuries and those who arrive during nondaytime shifts during the workday are more likely to be transferred to another trauma center. These may reflect the comfort level and resources of the local facility.

Femoral hernias in the pediatric patient: a case report and review of the literature

We report a case of a femoral hernia in a 9-year-old male. Femoral hernias in children are rare and a diagnostic challenge. Definitive treatment is with surgical repair.

The clinical spectrum of de novo donor-specific antibodies in pediatric renal transplant recipients

The development of donor-specific HLA antibodies (DSA) is associated with worse renal allograft survival in adult patients. This study assessed the natural history of de novo DSA, and its impact on renal function in pediatric renal transplant recipients (RTR). HLA antibodies were measured prospectively using single-antigen-bead assays at 1, 3, 6 and 12 months posttransplant followed by 12-monthly intervals and during episodes of allograft dysfunction. Of 215 patients with HLA antibody monitoring, 75 (35%) developed DSA at median of 0.25 years posttransplant with a high prevalence of Class II (70%) and HLA-DQ (45%) DSA. DSA resolved in 35 (47%) patients and was associated with earlier detection (median, inter-quartile range 0.14, 0.09-0.33 vs. 0.84, 0.15-2.37 years) and lower mean fluorescence intensity (MFI) (2658, 1573-3819 vs. 7820, 5166-11 990). Overall, DSA positive patients had more rapid GFR decline with a 50% reduction in GFR at mean 5.3 (CI: 4.7-5.8) years versus 6.1 (5.7-6.4) years in DSA negative patients (p = 0.02). GFR decreased by a magnitude of 1 mL/min/1.73 m(2) per log10 increase in Class II DSA MFI (p < 0.01). Using Cox regression, independent factors predicting poorer renal allograft outcome were older age at transplant (hazard ratio 1.1, CI: 1.0-1.2 per year), tubulitis (1.5, 1.3-1.8) and microvasculature injury (2.9, 1.4-5.7). In conclusion, pediatric RTR with de novo DSA and microvasculature injury were at risk of allograft failure.

A new approach to HLA typing designed for solid organ transplantation: epityping and its application to the HLA-A locus

HLA-specific antibodies bind discrete clusters of amino acids called epitopes, but serological assignment of antibody specificities makes no reference to this. As HLA typing for solid organ transplantation is provided at only medium (serologically equivalent) resolution, this means that recipient HLA antibodies to donor HLA epitopes may not be identified. We have designed a novel and rapid HLA-A epitope typing method (epityping) using a two-stage PCR-SSP-based method to detect the HLA-A locus epitopes described by El Awar et al. 2007, Transplantation, 84, 532. The initial PCR step utilizes HLA-A locus-specific primers; the product is cleaned using the QIAquick Spin Purification procedure. The purified product is tested using our in-house epitope-specific primer panel, the results being visualized using gel electrophoresis. Twenty two UCLA DNA Exchange samples were epityped, blinded to the HLA type. Of the 75 primer pairs, the mean correlation coefficient was 0.95 with each sample giving 67 or more correct primer results. In all cases, it was possible to derive the first field classic HLA type from the epityping results. These results indicate that a method for identification of HLA epitopes which is comparable in time, cost and technical expertise to current HLA typing methods is achievable. Redesigning HLA typing to correlate with what the antibody binds should minimize inappropriate organ allocation. We suggest that epityping provides a more effective method than standard HLA typing for solid organ transplantation.

A proposed classification for the spectrum of vanishing gastroschisis

Infants born with gastroschisis in association with intestinal atresia are well described. We are the proposing the classification of vanishing gastroschisis. In this series of six cases, at one end of the spectrum is an infant having gastroschisis with a much narrower defect on the right side of umbilicus. The ischemic bowel loops were connected to bowel inside the abdomen by a fibrous band compressing the exposed bowel mesentery. On the other end of spectrum, an infant having extensive bowel atresia and complete closure of abdominal wall defect (gastroschisis) detected on antenatal ultrasound. These cases should raise awareness of this devastating complication in prenatal management of gastroschisis.

Hemangioma of the scrotal septum: a rare entity in infants with review of the literature

Hemagiomas are most common tumors in infancy; however, scrotal septum hemangiomas are very rare with only 45 cases reported in the literature. We report a case of a 6-month-old child who presented with a scrotal mass at birth which had increased in size with age. A scrotal ultrasound with color doppler analysis, revealed a soft tissue mass with diffusely increased blood flow. Scrotal mass excision was performed and the pathology confirmed a capillary hemangioma.

Effects of fatigue on surgeon performance and surgical outcomes: a systematic review

BACKGROUND

Sleep deprivation and disturbances in circadian rhythms generally lead to poor performance, but is there a link in surgery? This review aimed to determine whether fatigue has an impact on surgeon performance or surgical outcomes.

METHODS

Studies were identified by searching EMBASE, CINAHL, PubMed, The Cochrane Library, Current Contents and clinical trials databases. Inclusion of relevant studies was by application of a predetermined protocol and independent assessment by two reviewers. Each included study was critically appraised for its study quality according to the methods used for Cochrane Reviews. Data from included studies were extracted by one researcher using standardized data extraction tables developed a priori and checked by a second researcher.

RESULTS

From 823 potentially relevant studies, a total of 16 studies were included in this review: two randomized controlled trials, five non-randomized comparative studies and nine case series. Of five studies that directly measure clinical performance, three studies reported no significant difference as a result of sleep deprivation, while two studies found increases in complications or errors. Eleven studies assessed psychomotor skill performance using a variety of simulation-based methods when a participant was rested and/or fatigued. Two randomized controlled trials reported no significant differences, while the nine remaining studies reported mixed results. Surgical residents with less surgical training/experience appeared to be more affected than more senior residents.

CONCLUSION

There is little evidence, as yet, to inform the issue of the effect of fatigue on surgical performance.

Immunogenic and tolerogenic signatures in human immunodeficiency virus (HIV)-infected controllers compared with progressors and a conversion strategy of virus control

Epidemiological studies have identified a small cohort of controllers of human immunodeficiency virus (HIV)-1 infection, who without treatment have no detectable virus, and others who progress at a variable rate. The objective of this study was to distinguish immune signatures in HIV controllers and progressors, by evaluating tolerogenic and immunogenic factors in untreated HIV-1 infected individuals. The recruited population was divided into putative elite controllers (PEC), long-term non-progressors (LTNP), normal progressors (NP) and fast progressors (FP). The proportion of regulatory T cells [T(regs) , CD4+ CD25+ forkhead box P3 (FoxP3+)], programmed death (PD)-1 and cytotoxic T lymphocyte antigen (CTLA)-inhibitory molecules and CD40L, CD69 and Ki67 activation markers were evaluated in peripheral blood mononuclear cells (PBMC) by flow cytometry. Significant differences were found between HIV controllers and HIV progressors, with up-regulation of T(regs) , PD-1 and CTLA-4 and decrease of CD40L expression in progressors compared with controllers. Expression of CD40L and concentrations of interleukin (IL)-6, CCL-3, and CCL-4 were significantly higher in PEC and LTNP than in NP and FP. In an attempt to convert immune signatures of progressors to those of controllers, seven agents were used to stimulate PBMC from the four cohorts. Treatment with CD40L and IL-4 or PD-1 antibodies in vitro were most effective in converting the immune signatures of progressors to those observed in controllers by down-regulating T(regs) and up-regulating CD40L expression in CD4+ T cells. The conversion concept merits translation to in vivo immune control of HIV infection.

Idiopathic non-hypertrophic pyloric stenosis in an infant successfully treated via endoscopic approach

Non-peptic, non-hypertrophic pyloric stenosis has rarely been reported in pediatric literature. Endoscopic pyloric balloon dilation has been shown to be a safe procedure in treating gastric outlet obstruction in older children and adults. Partial gastric outlet obstruction (GOO) was diagnosed in an infant by history and confirmed by an upper gastrointestinal series (UGI). Abdominal ultrasonography and computed tomography scan excluded idiopathic hypertrophic pyloric stenosis, abdominal tumors, gastrointestinal and hepato-biliary-pancreatic anomalies. Endoscopic findings showed a pinhole-sized pylorus and did not indicate peptic ulcer disease, Helicobacter pylori infection, antral web, or evidence of allergic and inflammatory bowel diseases. Three sessions of a step-wise endoscopic pyloric balloon dilation were conducted under general anesthesia and a fluoroscopy at two week intervals using catheter balloons (Boston Scientific Microvasive^®, MA, USA) of increasing diameters. Repeat UGI after the first session revealed normal gastrointestinal transit and no intestinal obstruction. The patient tolerated solid food without any gastrointestinal symptoms since the first session. The endoscope was able to be passed through the pylorus after the last session. Although the etiology of GOO in this infant is unclear (proposed mechanisms are herein discussed), endoscopic pyloric balloon dilation was a safe procedure for treating this young infant with non-peptic, non-hypertrophic pyloric stenosis and should be considered as an initial approach before pyloroplasty in such presentations.

Bouveret syndrome: a case report

Bouveret syndrome is characterized by the migration of a gallstone through a cholecystenteric fistula into the proximal duodenum resulting in gastric outlet obstruction. Bouveret syndrome is a rare phenomenon that most commonly occurs in females and the elderly. A 79-year-old female presented with symptoms of gastric outlet obstruction and was diagnosed with Bouveret syndrome. This report describes the symptoms, diagnosis, and management of Bouveret syndrome, as well as its prevalence and differentiation from gallstone ileus. Patients with Bouveret syndrome present with varied, non-specific symptoms that may include emesis, abdominal pain, anorexia, and abdominal distention. Computed tomography remains the diagnostic modality of choice. Although different techniques are reported, surgical intervention is almost always required in the treatment of Bouveret syndrome.

Gallstone pancreatitis in pediatric patients--a common disease in an uncommon population

Pancreatitis remains an uncommon entity in the pediatric population. Pediatric pancreatitis generally follows an inciting traumatic event or anatomic abnormality. Unlike the adult population, cholelithiasis and alcohol are rare causes. During a five-month period in 2006, we encountered four cases of gallstone pancreatitis in pediatric patients, all of whom presented with recurrent abdominal pain and emesis. Laboratory testing revealed an elevated lipase. Imaging studies including ultrasound and computerized tomography (CT) showed cholelithiasis. Each patient underwent a normal intraoperative cholangiogram and subsequent laparoscopic cholecystectomy for cholelithiasis.

Pediatric femoral hernias: a case report and review of the literature

Femoral hernias are rarely seen in children. We are presenting a case report of a femoral hernia with a review of the literature. It is always challenging to diagnose femoral hernias in children, particularly when the child has already undergone an operation for same side inguinal hernia.

Oropharyngeal tumor in the newborn: a case report

BACKGROUND

An oropharyngeal tumor presenting as a protruding mass from the mouth of the newborn infant is very rare. This mass has the potential to obstruct the airway and requires urgent medical management, diagnosis and appropriate surgical management.

OBJECTIVES

To report a case of a newborn with an oropharyngeal mass presenting at birth and focus on key clinical issues for the physician faced with the care of such an infant.

METHODS AND RESULTS

We describe a newborn infant who was born with a large mass protruding from the oral cavity at birth, without respiratory distress. The mass was surgically removed with no complications. The histology of the mass revealed it to be a pharyngeal dermoid polyp, also called 'hairy polyp'. The infant did well after tumor removal and was discharged home within a couple of days.

CONCLUSIONS

We report a case of a newborn with a pharyngeal dermoid polyp presenting as an oropharyngeal mass.

Foreign body ingestion causing gastric and diaphragmatic perforation in a child

Foreign body ingestion is a common problem in children. Most ingested foreign bodies pass through the gastrointestinal tract without difficulty once they reach the stomach. Perforation of the gastrointestinal tract very rarely occurs. This case report discusses the clinical presentation and management of a very unusual case of an eyeliner pencil ingested by a child that perforated the stomach and diaphragm, causing empyema.

A prospective audit evaluating the role of video-assisted cervical mediastinoscopy (VAM) as a training tool☆

OBJECTIVE

Cervical mediastinoscopy is an important diagnostic and staging technique. Limited operative field and visibility have traditionally made it a difficult procedure to learn and supervise. Video-assisted techniques can aid training in the procedure. We designed a prospective study to assess the usefulness of video-assisted mediastinoscopy (VAM) as a training tool.

METHODS

43 patients were operated upon by two trainees during their initial formation in general thoracic surgery (25 patients in 15 months, and 18 patients in 9 months, respectively).

INDICATIONS

staging (n = 23), diagnosis of enlarged mediastinal nodes (n = 14) and diagnosis/staging (n = 6). End-points of the study: operative time, need of consultant assistance during procedures, and ability of the trainee to identify all nodal stations independently.

RESULTS

There were no complications. The mean operative time was 29 (range 18-51) min. Valid histological samples were obtained in all cases. There were no false negative results in the 13 patients who underwent subsequent lung resection (sensitivity 100%). Operative time (R2 = 0.83 and 0.77), need for consultant assistance (R2 = 0.98 and 0.94), and failure to independently reach all nodal stations (R2 = 0.95 and 0.94) significantly decreased with experience in both trainees' cases (cubic curve fit; P < 0.001 throughout).

DISCUSSION

VAM permits a rapid learning and adequate supervision of the technique without compromising safety, operative time or completeness of the procedure. The main advantages are: increased visual field, image magnification, adequate light source and the ability to use two instruments simultaneously. VAM should be the technique of choice in thoracic surgical teaching units.

Allo-immunization elicits CCR5 antibodies, SDF-1 chemokines, and CD8-suppressor factors that inhibit transmission of R5 and X4 HIV-1 in women

Studies in humans suggest that allo-immunization induces CC-chemokines, CD8-suppressor factors (SF) and anti-HIV immunity. Here we report that allo-immunization with unmatched leucocytes from partners of women with recurrent spontaneous abortion elicits specific antibodies to the CCR5 receptor. Such antibodies inhibit replication of M-tropic HIV-1 (R5) and MIP-1beta-mediated chemotaxis. These CCR5 antibodies were also found in the sera of multiparous women that were naturally immunized by semi-allogeneic fetal antigens. The specificity of these antibodies was demonstrated by adsorption with CCR5 transfected HEK-293 cells, a baculovirus CCR5 preparation and a peptide of the 2nd extra-cellular loop of CCR5. Allo-immunization also stimulated increased concentrations of the CXC chemokine, SDF-1alpha and CD8-SF that inhibit T-tropic HIV-1 (X4) replication. We suggest that allo- immunization may elicit (a) CC chemokines, CCR5 antibodies and CD8-SF that inhibit M-tropic HIV-1 infection and (b) the CXC chemokine SDF-1alpha and CD8-SF that inhibit T-tropic HIV-1 infection.

MHC class I chain-like gene A (MICA) and its associations with inflammatory bowel disease and peripheral arthropathy

MHC class I chain gene A (MICA) is a non-classical Class I gene which is expressed on the surface of epithelia without beta 2-microglobulin. The gene is found in the major histocompatibility complex (MHC) in tight linkage disequilibrium with human leucocyte antigen-B (HLA-B). Its precise function is unknown, but it interacts with gamma delta T cells of the intestinal immune system. This region of the MHC has been implicated in inflammatory bowel disease (IBD) pathogenesis by recent association mapping studies and this study was performed to examine the prevalence of MICA gene polymorphisms in IBD, in particular in type 2 peripheral arthropathy (PeA), which also has a strong HLA-B association. An assessment of the prevalence of MICA polymorphisms in IBD was made. Blood from 50 ulcerative colitis (UC) and 50 Crohn's disease controls was taken and MICA status determined using allele-specific PCR for 16 known alleles of MICA. A further 91 UC patients were recruited to confirm the results of this stage, and then the polymorphisms were studied in 52 type 1 and 45 type 2 PeA patients. The MICA status of these groups was compared with 118 blood and organ donor controls with appropriate correction for multiple comparisons. UC overall was associated with possession of MICA*007 in 32% compared to 11% of controls (P(c) = 0.017). This association was confirmed in a second cohort of 91 patients (23% versus 11%, P = 0.02). These were independent of HLA class I status. Type 2 IBD PeA was associated with MICA*008 in 98% compared to 73% of controls (P = 0.0001). MICA*007 is associated with susceptibility to UC in our population and MICA*008 with type 2 IBD PeA. Further work is now required to assess the distribution and expression of MICA throughout the gut in health and disease.

Corneodesmosin expression in psoriasis vulgaris differs from normal skin and other inflammatory skin disorders

SUMMARY

Corneodesmosin (Cdsn) is a late differentiation epidermal glycoprotein putatively involved in keratinocyte adhesion. The Cdsn gene lies within the susceptibility region on chromosome 6p21.3 (PSORS1) for psoriasis, a common chronic disfiguring skin disease. A particular allelic variant of Cdsn has a strong association with psoriasis. Therefore, genetically and biologically, Cdsn is a possible candidate gene for psoriasis susceptibility. To investigate a potential role for Cdsn in psoriasis pathogenesis, protein expression studies were performed by quantitative immunohistochemistry on normal skin, psoriatic skin (lesional and nonlesional), and other skin disorders using monoclonal antibodies (G36-19 and F28-27). In normal and nonlesional skin, Cdsn was expressed in stratum corneum and one or two layers of superficial stratum granulosum. In lesional psoriasis, there was a significant increase in Cdsn expression, which was observed in multiple layers of stratum spinosum and in stratum corneum. The expression pattern varied from granular, cytoplasmic immunoreactivity to cell surface labeling with weakly immunoreactive cytoplasm. In chronic atopic dermatitis, lichen planus, mycosis fungoides, and pityriasis rubra pilaris, Cdsn immunoreactivity was confined to stratum corneum and upper stratum granulosum with no stratum spinosum immunoreactivity. Immunoelectron microscopy of normal and lesional psoriatic skin demonstrated Cdsn release concomitant with involucrin incorporation into cell envelopes and completed before mature envelope formation. Extracellular release of Cdsn occurred at a lower level of the epidermis in psoriasis than normal skin. These protein expression studies provide evidence of altered Cdsn expression in psoriasis consistent with a role of Cdsn in disease pathogenesis. Further functional and genetic studies of Cdsn are justified to determine its role as a potential psoriasis-susceptibility factor.

Mapping MHC-encoded susceptibility and resistance in primary sclerosing cholangitis: the role of MICA polymorphism

BACKGROUND & AIMS

Recent studies suggest that major histocompatibility complex-encoded susceptibility to primary sclerosing cholangitis (PSC) maps to the HLA B-TNFA region on chromosome 6p21.3.

METHODS

The present study uses a standard polymerase chain reaction protocol to investigate the 16 common alleles of the MICA locus as candidates in 2 patient populations (King's College Hospital, London, and John Radcliffe Hospital, Oxford).

RESULTS

The MICA*002 allele was found in 4 of 62 (6.4%) patients and none of 50 patients vs. 41 of 118 (35%) controls (pc = 0.00018, odds ratio [OR] = 0.12, and P = 0.0000016, OR = 0.0, respectively). Overall, the MICA*008 allele was more common in PSC (gene frequency 66% vs. 48% of controls, P = 0.0023, OR = 2.11). However, unlike MICA*002 in which the difference was a result of the absence of MICA*002 heterozygotes, the MICA*008 association may be caused by an increased frequency of MICA*008 homozygosity in patients (58% vs. 22%, pc = 0.000015, OR = 5.01 and 58% vs. 22%, P = 0.0000056, OR = 4.51, respectively). Though MICA*008 is found on the ancestral 8.1 haplotype, stratification analysis indicates that this association is independent of B8 and other HLA haplotypes associated with PSC.

CONCLUSIONS

The MICA*002 allele has a strong dominant effect in reducing the risk of PSC, whereas the increased risk of disease associated with MICA*008 may be a recessive effect requiring 2 copies of the MICA*008 allele.

Correlation between parental perception and actual childhood patterns of bicycle helmet use and riding practices: implications for designing injury prevention strategies

BACKGROUND/PURPOSE

Bicycle injuries account for 10% of all pediatric traumatic deaths. Bicycle helmets have proven to decrease morbidity and mortality, yet trauma data show low helmet use among injured children. However, owning a bicycle helmet does not universally result in a child wearing a helmet. Furthermore, we hypothesize that parental perception of their children's use of the bicycle helmet may not reflect accurately true utilization by their child. To investigate this hypothesis the authors examined both parents' and their children's reports of bicycle ownership, supervision, riding patterns, and helmet use.

METHODS

A random sample of grade 5 and 6 students (ages 8 to 12) and their parents were surveyed about bicycle ownership, riding patterns, supervision, and helmet use. The children and their guardians responded independently to the questionnaire. Statistical analysis was performed using the chi(2) test when indicated.

RESULTS

Eighty-eight of 102 children (86%) responded. This represented 56% girls and 44% boys aged 8 to 12 years. Sixty-nine of 90 (77%) of the parents returned the survey. Ninety-six percent of the children owned a bicycle. A total of 87.5% of children owned a bicycle helmet. Eighty percent of the time children ride their bicycles on the road or sidewalk, with less then 20% on marked trails or parks. Parents reported that their children wear a helmet 90% of the time. In contrast, children report no helmet use in up to 61% of riding instances (P <.05). Parents themselves do not wear a helmet in greater then 60% when riding, which is correlated by their children. Seventy-one percent of the children report that they ride unsupervised the majority of the time.

CONCLUSIONS

Bicycle and bicycle helmet ownership is high among this study group. There is a significant possibility that children will ride unsupervised, in at-risk situations, without wearing a helmet. Parental perceptions about bicycle helmet use by their children may not accurately reflect true utilization. In this study group parents appear as poor role models for their children. Injury prevention strategies need to focus on children and adults to improve effectiveness.

Posterior flank approach to the peritoneum for ventriculoperitoneal shunting

We report a technique for insertion of a distal shunt catheter into the peritoneal cavity through a posterior incision. This has been helpful in patients with impaired access anteriorly. It may also be useful in elective situations. We have performed this procedure on 3 infants where the traditional anterior approaches would have been difficult due to subcutaneous scar tissue, ostomy sites and anterior intra-abdominal adhesions. This technique was safe and provided easy access to the peritoneal cavity. Complications would be similar to those for the standard ventriculoperitoneal shunts including bowel perforation, damage to the kidney or liver, infection and occasionally posterior cervical webbing that may cause pain locally or pull the head into an extended position.

Assessing the subjective experience of being a participant in psychiatric research

OBJECTIVE

To address both clinical and ethical concerns in psychiatric research, the study assessed the subjective experience of being a participant in a feasibility study of outcome in long-term psychodynamic psychotherapy and psychoanalysis.

METHOD

A questionnaire assessing positive and negative reactions to three typical research methodologies (self-report questionnaires, structured diagnostic interviews, and tape-recording of sessions) was administered to 23 patient-therapist pairs.

RESULTS

Patients reported that questionnaires and interviews were slightly to moderately helpful in promoting self-realization and facilitating therapy, and not at all to slightly intrusive and disruptive. Adjustment to audiotaping of sessions was rapid (within two sessions). Therapists significantly overestimated the negative effects and underestimated the positive benefit patients reported from participating in research.

CONCLUSIONS

Traditional objections to research in dynamic psychotherapy on the grounds that patients experience research procedures as significantly intrusive and disruptive appear to be unfounded.