COMPARISON OF ABDOMINAL EXERCISES AND NEUROMUSCULAR ELECTRICAL STIMULATION ON DIASTASIS RECTI ABDOMINIS MUSCLE IN POSTNATAL FEMALES WITH CAESAREAN SECTION

The separation of the two rectus abdominis muscles along the linea alba is termed diastasis of recti abdominis muscles (DRAM). DRAM is a common health problem in people that are both pregnant and postpartum. With a 100% frequency at gestational week 35, it is extremely frequent during pregnancy. Control and function of the trunk are greatly influenced by the musculature of the abdomen. The existence, extent, and duration of DRAM have been connected to low back and pelvic discomfort however the relationship is not conclusive. It has been proven to weaken abdominal muscles and impair their functioning in lumbo-pelvic stability. Additionally, DRAM has been linked to pelvic floor dysfunction. The mechanical control and function of the abdomen can be compromised by diastasis recti, which compromises the abdominal muscles. This study examined the impact of abdominal exercises and neuromuscular electrical stimulation on the DRAM in postnatal females who underwent Caesarean section. A total of 208 individuals, aged between 20 and 34, who had recti diastasis measuring more than 2.5 cm, underwent screening. They were split into two groups at random. Group B only received abdominal exercises, whereas Group A received NMES in addition to their activities. For a period of 12 weeks, the intervention was given to both groups three times a week. Changes have been recorded before and after the intervention. The pressure biofeedback unit, measuring tape, and vernier caliper were employed to evaluate the outcome measures of inter-recti distance, abdominal muscle strength, and waist-hip ratio, respectively. In every outcome, both groups had a highly significant (p<0.05) improvement. Furthermore, after 12 weeks, group A had improved in all measures with highly significant (p<0.05) intergroup comparisons. In comparison to MNES alone, NMES can have a more significant effect on reducing DRAM in postpartum women when paired with abdominal Exercise.

Characterization of outcomes of amino acid modifications using a combinatorial approach to reveal physical and structural perturbations: A case study using trastuzumab biosimilar

Biopharmaceuticals, such as monoclonal antibodies, are considered as life-saving drugs for autoimmune diseases, cancer and infectious diseases. However, biotherapeutics tend to undergo chemical degradation during various stages of manufacturing. The conditions of chemical degradation, along with the physical degradation pathways, have a direct influence on the overall stability, safety and efficacy of these therapeutics. While site-specific chemical changes have been well-explored and investigated using various analytical approaches, the resulting conformational and structural changes have not been much studied. Thus, we explored various biophysical techniques for assessing the influence of three representatives forced degradation conditions viz. oxidation, deamidation, and glycation, in a model therapeutic trastuzumab biosimilar. The site-specific modifications caused by these stress conditions were analysed using high resolution mass spectrometry. While their thermodynamic and conformational consequences were investigated by using differential scanning colorimetry (Nano-DSC), circular dichroism (CD) spectroscopy, analytical ultracentrifugation (AUC), and dynamic light scattering (DLS). The investigated stress conditions resulted in reduced thermodynamic stability of mAb, as confirmed using Nano-DSC. Secondary structure analysis performed with CD spectroscopy indicated detectable structural alterations in the beta sheets of stressed samples. DLS and SV-AUC studies demonstrated an enhanced level of aggregation and fragmentation in presence of all stress conditions. Thus, the biophysical analytical toolkits, when used simultaneously, could offer deeper insights into the subtle conformational changes that result from site-specific chemical modifications in mAbs. Hence, these analytical approaches may serve as significant additions to the battery of techniques used for forced degradation analysis of biopharmaceuticals.

1284 Comparison of British Association of Urological Surgeons (BAUS) 2008 and NICE 2015 Guidelines for Patients with Suspected Urinary Tract Cancer: An Audit of Haematuria Referrals

Introduction

BAUS guidelines for the investigation of haematuria were replaced by NICE guidelines in 2015. However, both criteria are currently used to refer patients to our Haematuria Clinic. We audit the haematuria referrals made to our unit and compare cancer yield.

Method

A retrospective review of all two-week wait haematuria referrals to a single UK teaching hospital between October 2019 and April 2020 was performed. Referrals were stratified into two groups: BAUS 2008 and NICE 2015 referral criteria. The outcomes of haematuria investigations were analyzed and the incidence of urinary tract cancer (UTC) compared between groups.

Results

316 referrals were analyzed. Of these, 123 (39%) and 193 (61%) referrals were made using BAUS and NICE criteria respectively. 233 (74%) patients were investigated for visible haematuria of which 68 (29%) were referred using BAUS criteria and 165 (71%) using NICE. UTC was identified in 20% of patients referred using NICE criteria and 4.4% using BAUS criteria. 83 (26%) patients were referred with non-visible haematuria. Of these, 55 (66%) were referred using BAUS criteria and 28 (34%) using NICE. UTC was identified in 2.5% of patients referred using BAUS criteria. No UTC was identified in referrals using NICE criteria.

Conclusions

Despite BAUS haematuria guidelines being superseded by NICE guidelines in 2015, these older guidelines still account for 40% of our two-week wait referrals. Furthermore, NICE guidelines have a higher cancer yield for visible haematuria compared to BAUS guidelines and should therefore take precedence to avoid subjecting patients to unnecessary and costly investigations.

909 Modern Integrated Surgical Teaching for Junior Doctors: Local Workshops and Online Webinars

Introduction

Reforms in the postgraduate and undergraduate curriculum have resulted in a lack of surgical teaching. By tailoring educational objectives to learning needs of junior doctors, we assessed the perceptions and knowledge transfer of our 2-phase surgical teaching programme.

Method

A perception questionnaire was distributed amongst junior doctors to establish confidence levels in surgical topics. Junior doctors were invited to attend (1) a local surgical techniques workshop and (2) an online national webinar. Perception questionnaire and knowledge tests were delivered before and after each session.

Result

87.5% (n = 14) participants were not confident assessing an unwell surgical patient when on-call. Mean confidence gain before and after the practical session was 4.18 (W = 91.0, p = 0.0002). 106 participants attended the online webinar. 61.3% (n = 65) were quite confident in assessing a sick surgical patient and 56.6% (n = 60) were quite confident managing a sick surgical patient. The majority (97.2%, n = 103) deemed the session to be useful to very useful. Mean knowledge gain before and after the session was 32.8% (t = 4.67, p = 0.009).

Conclusions

Improvement in confidence and knowledge in surgical topics amongst juniors can be feasible by implementing blended learning tools, such as online webinars.

Physician perceptions and practice patterns regarding fertility preservation in hematopoietic cell transplant recipients

Physician practice variation may be a barrier to informing hematopoietic cell transplant (HCT) recipients about fertility preservation (FP) options. We surveyed HCT physicians in the United States to evaluate FP knowledge, practices, perceptions and barriers. Of the 1035 physicians invited, 185 completed a 29-item web-survey. Most respondents demonstrated knowledge of FP issues and discussed and felt comfortable discussing FP. However, only 55% referred patients to an infertility specialist. Most did not provide educational materials to patients and only 35% felt that available materials were relevant for HCT. Notable barriers to discussing FP included perception that patients were too ill to delay transplant (63%), patients were already infertile from prior therapy (92%) and time constraints (41%). Pediatric HCT physicians and physicians with access to an infertility specialist were more likely to discuss FP and to discuss FP even when prognosis was poor. On analyses that considered physician demographics, knowledge and perceptions as predictors of referral for FP, access to an infertility specialist and belief that patients were interested in FP were observed to be significant. We highlight variation in HCT physician perceptions and practices regarding FP. Physicians are generally interested in discussing fertility issues with their patients but lack educational materials.

Outcome of hematopoietic stem cell transplant as salvage therapy for Hodgkin's lymphoma in adolescents and young adults at a single institution

For patients with relapsed Hodgkin's lymphoma (HL), high dose chemotherapy with stem cell rescue (HDCT-SCT) may improve survival over chemotherapy alone. We assessed the outcomes of HDCT-SCT in 37 consecutive adolescent and young adult patients with relapsed HL whose malignancy was categorized based on sensitivity to chemotherapy. We determined whether current outcomes supported the use of HDCT-SCT in all of our patients or just those patients with lower-risk characteristics such as chemosensitivity. With a median follow-up of 6.5 years, the 2-year overall survival (OS) was 89% (95% CI: 62-97%) for the chemosensitive patients (n = 21), whereas for patients with resistant disease (n = 16), OS was 53% (95% CI: 25-74%). Both autologous and allogeneic transplants were well tolerated, with 100-day treatment-related mortality under 10%. Our data show encouraging outcomes for patients with chemosensitive relapsed HL who receive hematopoietic stem cell transplant (HSCT) and support the value of the procedure even when the disease is chemoresistant.

Sigmoid sinus thrombosis presenting with posterior alexia in a patient with Behçet's disease and polycythaemia: a case report

Introduction

A 59-year-old Caucasian woman presented with an acute onset of alexia, noticed whilst driving. She described how while she could read car number plates, she had lost the ability to read and understand words on roadside advertisements and car window stickers.

Case presentation

Neurological examination was unremarkable apart from the inability to read full words or sentences. Imaging of the brain, initially computed tomography, followed by magnetic resonance venography, confirmed a diagnosis of sigmoid sinus thrombosis with associated venous infarction. The patient's past medical history revealed that she had suffered an ischemic stroke and following investigation for this, had undergone a nephrectomy for renal cell carcinoma. This was complicated by postoperative deep venous thrombosis. She had a persistent polycythaemia that was managed with venesection, and recently she had been diagnosed with Behçet's disease. Prior to this presentation, she had recently stopped her prophylactic antiplatelet medication as she was due to undergo a total knee replacement for osteoarthritis. She was managed with weight-adjusted, low molecular weight heparin followed by oral anticoagulation, and made a good recovery from her symptoms.

Conclusion

This case illustrates a classical neurological syndrome, highlights the importance of cerebral venous and sinus thrombosis as a cause of stroke, and the importance of remaining vigilant to a person's changing risk of venous thrombosis with evolving comorbidity.

Human herpesvirus-6 encephalitis following allogeneic hematopoietic stem cell transplantation

Immunosuppressive monoclonal antibodies directed to immune system cells may reduce rejection and graft versus host disease (GvHD) after allogeneic stem cell transplantation (SCT), but can increase the risks of viral infection. Here, we report human herpes virus-6 (HHV-6) encephalitis despite antiviral prophylaxis in 5 of 43 (11.6%) patients receiving alemtuzumab supported conditioning. Encephalitis occurred at 41-103 days (median 60 days) presenting with confusion in all patients, combined with amnesia (n=3) or seizures (n=2). MRI revealed non-specific white matter changes in two and a non-enhancing medial temporal lobe lesion in three patients. Cerebrospinal fluid (CSF) PCR amplification for HHV-6 was positive in all five patients, (600-2 25 000 (median 4700) copies/ml CSF), while analysis of peripheral blood revealed 100-22 500 (median 1200) viral copies/ml plasma. CSF protein was elevated in four patients, with minimal CSF pleocytosis. Intravenous foscarnet produced neurological improvement at 8-13 (median 11) days and negative plasma PCR at 30-66 (median 50) days. Four patients had complete neurological recovery, but one patient with persistent viral DNA in the CSF succumbed to progressive encephalopathy. Given this high incidence of HHV-6 and the possibility of successful outcome with prompt treatment, a high index of suspicion of this disorder is required in recipients of monoclonal antibody supported allografts.

Breast movement during normal and deep breathing, respiratory training and set up errors: implications for external beam partial breast irradiation

This study was designed to evaluate interfraction and intrafraction breast movement and to study the effect of respiratory training on respiratory indices. Five patients were immobilized in supine position in a vacuum bag and three-dimensional set up errors, respiratory movement of the breast during normal and deep breathing, tidal volume and breath hold time were recorded. All patients underwent respiratory training and all the respiratory indices were re-evaluated at the end of training. Cumulative maximum movement error (CMME) was calculated by adding directional maximum set up error and maximum post training movement during normal breathing. The mean set up deviation was 1.3 mm (SD +/- 0.5 mm), 1.3 mm (SD +/- 0.3 mm) and 4.4 mm (SD +/- 2.6 mm) in the mediolateral, superoinferior and anteroposterior dimensions. Pre-training mean of the maximum marker movement during normal breathing was 1.07 mm, 1.94 mm and 1.86 mm in the mediolateral, superoinferior and anteroposterior dimensions. During deep breathing these values were 2 mm, 5.5 mm and 4.8 mm. While respiratory training had negligible effect on breast movement during normal breathing, it resulted in a modest reduction during deep breathing (p = 0.2). The mean CMME recorded for these patients was 3.4 mm, 4.5 mm and 7.1 mm in the mediolateral, superoinferior and anteroposterior dimension. Respiratory training also resulted in an increase in breath hold time from a mean of 31 s to 44 s (p = 0.04) and tidal volume from a mean of 560 cm(3) to 1160 cm(3) (p = 0.04). With patients immobilized in the vacuum bag the CMMEs are relatively less. Individualized directional margins may aid in reduction of planning target volume (PTV).

Expression of the vascular endothelial growth factor receptors 1 and 2 in acute myeloid leukemia: incidence and feasibility of immunohistochemical staining

Vascular endothelial growth factor (VEGF) and its receptor tyrosine kinases, VEGFR-1 and VEGFR-2, are important therapeutic targets for various cancers including AML. Paraffin-embedded bone marrow samples (PE-BM) are, in most cases, the only tissue accessible to perform retrospective analyses of novel targets such as VEGF and/or its receptors. As a result, it limits our options to immunohistochemistry (IHS), or more expensive and less practical techniques such as enzyme-linked immunosorbent assay (ELISA) or fluorescence in situ hybridization (FISH). We analyzed the feasibility of IHS to measure VEGFR-1 and VEGFR-2 expression in 28 AML samples using monoclonal antibodies (moAbs) against Flt-1 (VEGFR-1) and KDR/Flk-1 (VEGFR-2). Medical records were reviewed for relevant clinical information. Expression of VEGFR-1 (+) and VEGFR-2 (+) were seen in 25% (7/28) and 43% (12/28) respectively. Forty-six percent (13/28) were dual-negatives for VEGFR-1 and VEGFR-2; 14% (4/28) were dual-positives for VEGFR-1 and VEGFR-2. An inferior survival was observed in patients whose myeloblasts express either VEGFR-1 (+) or VEGFR-2 (+), or both. Determination of expression of VEGF receptors (1 and 2) by IHS in PE-BM tissue is feasible. Prospective comparison of IHC to flow cytometry or other molecular techniques, and assessment of the prognostic significance of VEGF receptors in AML patients is warranted.

Malignant pleural effusion of multiple myeloma: prognostic factors and outcome

Malignant pleural effusion (MPE) in multiple myeloma (MM) is rare. Approximately 80 cases have been reported. To delineate optimal treatment and prognostic variables in these patients, we reviewed 11 MM patients with MPE. MPE developed at median of 12 months from diagnosis of MM. All the patients had high-risk disease based on complex karyotypic abnormalities including deletions of chromosome-13 (n=9), elevated beta-2 microglobulin (B2M) (n=9), high C-reactive protein (CRP) (n=8), high plasma cell labeling index (n=5) or high LDH (n=5). A significant increase in B2M, LDH, and CRP was observed at the onset of MPE. The initial diagnosis of MPE was based on positive cytology (n=9), pleural fluid cIg/DNA (n=9) or pleural fluid cytogenetics (n=4). Pleural tissue infiltration was found on pleural biopsy and autopsy in one patient each. Systemic chemotherapy comprising dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP) (n=7) and pleurodesis (n=7) were effective in resolving MPE but survival was short. High dose chemotherapy with peripheral blood stem cell support for MPE in six patients conferred no clear survival advantage. These patients died at median of four months from onset of MPE. Patients with bone marrow complex karyotypic abnormalities including deletion-13 (n=9) had a shorter (median--18 months) overall survival compared to patients with normal cytogenetics (median--38 months). MPE in patients with MM is often associated with high-risk disease including deletion 13 chromosomal abnormality and heralds a poor prognosis despite aggressive local and systemic treatment.

The foot and systemic disease. Differential diagnoses

The discipline of medicine is truly a combination of both science and art, and nowhere is this more true than in the practice of differential diagnosis. From the initial clinic visit, when the patient presents with a nonspecific symptom, until the final treatment is rendered, the clinician must constantly and critically evaluate his or her diagnosis. This process can be expedited by using a consistent and comprehensive methodology that reminds the clinician to entertain the full spectrum of causes. Two such methodologies have been presented in this article. It is important, however, to note that the systems presented here are by no means the sole, or even best, methods. The clinician should experiment and discover what works best for him or her. Any system is ideal if it allows the clinician to consistently derive the correct diagnosis in a short amount of time. After all, the most important part of any treatment is the proper diagnosis.

Granulocytic sarcoma of uterine cervix as presentation of acute myeloid leukemia: a case report and review of literature

Localized extramedullary collection of leukemic cells is termed as granulocytic sarcoma. Incidences of 2-8% in acute myeloid leukemia have been reported in various autopsy studies. In female it usually involves ovary. Since most of such tumors are asymptomatic, they are detected only at autopsy. We report here a case who manifested as abnormal vaginal bleeding, large cervical mass, renal failure, and aspergillous fungaemia. The patient died before she could be treated. From the present report it would appear that granulocytic sarcoma at times may precede other manifestations of leukemia.

Blood stem cell transplantation: current concepts

Mobilized peripheral blood haematopoietic progenitor cells are increasingly being used as against bone marrow (BM) transplants, following high dose chemotherapy and/or radiotherapy for the management of chemosensitive malignancies. Rapid haematopoietic reconstitution as evidenced by reduced duration of neutropaenia, fewer donor platelet infusions, shorter hospital stay and reduced cost of treatment are the advantages of this procedure. Reduced tumour cell contamination of mobilized blood compared to bone marrow however, has not been substantiated. Mobilization of lymphokine activated killer cells (LAK), use of blood stem cells (BSC) for allogeneic transplants and ex vivo expansion of the mobilized cells are emerging as the future areas for research. Addition of interleukin-3 (IL-3), stem cell factor (c-kit ligand) and PIXY-321 appear to open-up new vistas by enforcing trilineage and multilineage haematopoietic reconstitution.

Palliative treatment of malignant pericardial effusion: report of two cases and a review of the literature

Malignancy accounts for 40%-60% of pericardial effusions. Two individuals with malignant pericardial effusions secondary to lung, cancer, managed with the help of a percutaneous balloon pericardial window (PBPW), are discussed in this report. Clinical benefits in terms of reduction of breathlessness and improved diastolic function of the heart were documented in both. There were no procedure-related complications. The PBPW provides quick relief, appears diagnostically superior to an invasive technique and has a low rate of recurrence and complications.

Cutaneous metastases of lung cancer

The reported incidence of skin metastases from lung cancer varies from 2.8-7.5%. In the present study 8.7% of patients had skin metastases, with head and neck being the most common sites, nodular lesions the most common, and adenocarcinoma the most frequent histology. Although most patients develop these lesions during the course of a known progressive disease, they may be the presenting manifestation of a primary tumour in the lung. The occurrence of skin lesions in lung cancer announces an ominous prognosis. The response to chemotherapy is poor, possibly due to poor blood supply to the skin; monitoring response to chemotherapy, however, is easier when such lesions are present.

Spinal ganglioneuroblastoma--complete response to chemotherapy alone

Ganglioneuroblastoma in the spinal region is rare, the treatment of choice being surgical excision. We present a 21 year old male who was diagnosed to have this condition in the dorsolumbar spinal region. The tumour was extending intraspinally and was unresectable. Combination chemotherapy with Adriamycin (doxorubicin hydrochloride), vincristine, cyclophosphamide, etoposide, ifosfamide and cisplatin resulted in histologically proven complete remission. No radiotherapy or curative resection was done. The patient is alive without evidence of disease 24 months later. Never before has chemotherapy been successfully used as the sole modality of treatment in this condition. Our report raises important questions about the management of this rare condition, particularly in a situation of unresectability.