Pentraxin-3 - a potential biomarker in ANCA-associated vasculitis

OBJECTIVE

The aim of this study was to investigate pentraxin-3 (PTX3) as a potential biomarker of inflammatory activity in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) at baseline and 6 month follow-up in a longitudinal cohort.

METHOD

Plasma PTX3 levels were measured in 79 newly diagnosed or relapsing AAV patients at baseline and 6 month follow-up, and in 23 healthy controls. Urinary PTX3 levels were measured in 34 of the patients. C-reactive protein (CRP), creatinine, and albuminuria were measured and the cumulative glucocorticoid dose at inclusion was calculated. The Birmingham Vasculitis Activity Score (BVAS) was assessed at baseline and follow-up.

RESULTS

Plasma PTX3 levels were significantly higher at baseline than at 6 months (2.85 vs 1.23 ng/mL, p < 0.001). Plasma and urinary PTX3 levels correlated with BVAS at baseline (ρ = 0.45, p < 0.001, and ρ = 0.49, p = 0.008, respectively). A significant correlation between both plasma and urinary PTX3 levels and estimated glomerular filtration rate and albuminuria was found. However, there was no correlation between plasma and urinary PTX3 levels. At baseline, plasma and urinary PTX3 levels were significantly higher in patients with kidney involvement. PTX3 levels did not correlate with CRP, nor was there a correlation between CRP levels and BVAS at baseline.

CONCLUSION

Plasma and urinary PTX3 seem to reflect disease activity in AAV better than the commonly used CRP. PTX3 may have a potential role as a biomarker in monitoring disease activity in AAV patients, particularly in patients with kidney involvement.

Treatment response of colorectal cancer liver metastases to neoadjuvant or conversion therapy: a prospective multicentre follow-up study using MRI, diffusion-weighted imaging and 1H-MR spectroscopy compared with histology (subgroup in the RAXO trial)

BACKGROUND

Colorectal cancer liver metastases respond to chemotherapy and targeted agents not only by shrinking, but also by morphologic and metabolic changes. The aim of this study was to evaluate the value of advanced magnetic resonance imaging (MRI) methods in predicting treatment response and survival.

PATIENTS AND METHODS

We investigated contrast-enhanced MRI, apparent diffusion coefficient (ADC) in diffusion-weighted imaging and 1H-magnetic resonance spectroscopy (1H-MRS) in detecting early morphologic and metabolic changes in borderline or resectable liver metastases, as a response to first-line neoadjuvant or conversion therapy in a prospective substudy of the RAXO trial (NCT01531621, EudraCT2011-003158-24). MRI findings were compared with histology of resected liver metastases and Kaplan-Meier estimates of overall survival (OS).

RESULTS

In 2012-2018, 52 patients at four Finnish university hospitals were recruited. Forty-seven patients received neoadjuvant or conversion chemotherapy and 40 liver resections were carried out. Low ADC values (below median) of the representative liver metastases, at baseline and after systemic therapy, were associated with partial response according to RECIST criteria, but not with morphologic MRI changes or histology. Decreasing ADC values following systemic therapy were associated with improved OS compared to unchanged or increasing ADC, both in the liver resected subgroup (5-year OS rate 100% and 34%, respectively, P = 0.022) and systemic therapy subgroup (5-year OS rate 62% and 23%, P = 0.049). 1H-MRS revealed steatohepatosis induced by systemic therapy.

CONCLUSIONS

Low ADC values at baseline or during systemic therapy were associated with treatment response by RECIST but not with histology, morphologic or detectable metabolic changes. A decreasing ADC during systemic therapy is associated with improved OS both in all patients receiving systemic therapy and in the resected subgroup.

Validity and reliability of the Swedish version of the Self-Efficacy for Managing Chronic Disease scale for individuals with systemic sclerosis

ObjectiveTo investigate aspects of validity and reliability of the Swedish version of the Self-Efficacy for Managing Chronic Disease (SEMCD-Swe) scale in systemic sclerosis (SSc).Method: A forward-backward translation procedure was used. Content validity was assessed through interviews with 11 people with SSc and 10 healthcare professionals. Construct validity, internal consistency, test-retest reliability, and floor and ceiling effects were evaluated in 104 SSc patients.Results: The content validity of the SEMCD-Swe was interpreted as satisfactory, but some adjustments were made to increase the understanding. Confirmatory factor analysis supported a single-factor structure. Moderate to strong correlations between the SEMCD-Swe and Scleroderma Health Assessment Questionnaire; Multidimensional Assessment of Fatigue; Patient Health Questionnaire-8 (r_s = -0.4 to -0.7), and RAND-36 subscales (r_s = 0.5 to 0.7) were found. Weak correlations were found between SEMCD-Swe and modified Rodnan skin score; and disease severity of peripheral vascular and lung (r_s = -0.1 to -0.2) and kidney (r_s = 0.1) systems (Medsger severity scale). Cronbach's alpha was sufficient (0.85) and corrected item-to-total correlations were good (≥ 0.50). The intraclass correlation coefficient for the total score was sufficient (0.82). No floor or ceiling effects were found.Conclusion: Support for construct validity was indicated, as the SEMCD-Swe in SSc show a single-factor structure and is more strongly associated with pain, fatigue, depressive symptoms, interferences with daily activities, disability, and quality of life than with disease severity. Our results also indicate support for content validity and reliability. However, the responsiveness of the SEMCD-Swe needs to be tested.

Assessing the microbial risk of faecal sludge use in Ugandan agriculture by comparing field and theoretical model output

Reuse of faecal sludge in agriculture has many potential benefits, but also poses risks to human health. To better understand the potential risks, Quantitative Microbial Risk Assessment (QMRA) was performed for three population groups in Kampala, Uganda: wastewater and faecal sludge treatment plant workers; farmers using faecal sludge; and consumers of faecal sludge-fertilised vegetables. Two models were applied for farmers and consumers, one based on pathogen concentrations from field sampling of sludge, soils and vegetables, and one based on theoretical pathogen contribution from the last sludge application, including decay and soil to crop transfer of pathogens. The risk was evaluated for two pathogens (enterohaemorrhagic E. coli (EHEC) and Ascaris lumbricoides). The field data on sludge, soil and vegetables indicated that the last application of faecal sludge was not the sole pathogen source. Correspondingly, the model using field data resulted in higher risks for farmers and consumers than the theoretical model assuming risk from sludge only, except when negligible for both. For farmers, the yearly risk of illness, based on measured concentrations, was 26% from EHEC and 70% from Ascaris, compared with 1.2% and 1.4%, respectively, considering the theoretically assumed contribution from the sludge. For consumers, the risk of illness based on field samples was higher from consumption of leafy vegetables (100% from EHEC, 99% from Ascaris) than from consumption of cabbages (negligible for EHEC, 26% from Ascaris). With the theoretical model, the risk of illness from EHEC was negligible for both crops, whereas the risk of illness from Ascaris was 64% and 16% for leafy vegetables and cabbage, respectively. For treatment plant workers, yearly risk of illness was 100% from EHEC and 99.4% from Ascaris. Mitigation practices evaluated could reduce the relative risk by 30-70%. These results can help guide treatment and use of faecal sludge in Kampala, to protect plant workers, farmers and consumers.

Centralized repeated resectability assessment of patients with colorectal liver metastases during first-line treatment: prospective study

BACKGROUND

Metastasectomy is probably underused in metastatic colorectal cancer. The aim of this study was to investigate the effect of centralized repeated assessment on resectability rate of liver metastases.

METHODS

The prospective RAXO study was a nationwide study in Finland. Patients with treatable metastatic colorectal cancer at any site were eligible. This planned substudy included patients with baseline liver metastases between 2012 and 2018. Resectability was reassessed by the multidisciplinary team at Helsinki tertiary referral centre upfront and twice during first-line systemic therapy. Outcomes were resectability rates, management changes, and survival.

RESULTS

Of 812 patients included, 301 (37.1 per cent) had liver-only metastases. Of these, tumours were categorized as upfront resectable in 161 (53.5 per cent), and became amenable to surgery during systemic treatment in 63 (20.9 per cent). Some 207 patients (68.7 per cent) eventually underwent liver resection or ablation. At baseline, a discrepancy in resectability between central and local judgement was noted for 102 patients (33.9 per cent). Median disease-free survival (DFS) after first resection was 20 months and overall survival (OS) 79 months. Median OS after diagnosis of metastatic colorectal cancer was 80, 32, and 21 months in R0-1 resection, R2/ablation, and non-resected groups, and 5-year OS rates were 68, 37, and 9 per cent, respectively. Liver and extrahepatic metastases were present in 511 patients. Of these, tumours in 72 patients (14.1 per cent) were categorized as upfront resectable, and 53 patients (10.4 per cent) became eligible for surgery. Eventually 110 patients (21.5 per cent) underwent liver resection or ablation. At baseline, a discrepancy between local and central resectability was noted for 116 patients (22.7 per cent). Median DFS from first resection was 7 months and median OS 55 months. Median OS after diagnosis of metastatic colorectal cancer was 79, 42, and 17 months in R0-1 resection, R2/ablation, and non-resected groups, with 5-year OS rates of 65, 39, and 2 per cent, respectively.

CONCLUSION

Repeated centralized resectability assessment in patients with colorectal liver metastases improved resection and survival rates.

Perceptions of nurses on inter-shift handover: A descriptive study in Hospital Kuala Lumpur, Malaysia

INTRODUCTION

The quality of information and efficiency in the practice and care environments are important aspects of nursing care. The use of a reliable and valid scale can monitor the quality of handover and provide information for continuous improvement of practice. This study aims to describe the perception of nurses, on the domains of quality of information, efficiency, interaction and support and patient involvement.

METHOD

A cross-sectional descriptive study was conducted among 450 nurses from 37 wards in Hospital Kuala Lumpur. Nurses on shift duty were recruited by convenience sampling from the Medical, Surgery, Obstetrics & Gynaecology, Orthopaedic and Paediatric wards. Using a validated questionnaire (Handover Evaluation Scale), nurses self-rated their perceptions using a 7-point scale and provided open-ended responses to the strengths and challenges that they faced. Descriptive and inferential analyses were done while open-ended questions were summarised based on key themes.

RESULTS

A total of 414 nurses completed the survey (92.0% response rate). Nurses had an overall mean (SD) perception score of 5.01 (SD 0.56). They perceived good interaction and support during handover and on the quality of information that they received, with mean scores of 5.54 (SD 0.79) and 5.19 (SD 0.69), respectively. There was an association between the departments where the nurses worked and their overall perceptions on nursing handover (p<0.001). Interruptions being the most common theme emerged from the open-ended section.

CONCLUSION

Despite having substantial interaction and support amongst nurses, opportunities for improvements were noted. Improvements in the quality of handover information and reducing interruptions should be the main emphases as these were perceived to be essential in the current handover practices by nurses.

OP0101-HPR QUALITY OF LIFE IN PEOPLE WITH SYSTEMIC SCLEROSIS WITH DIFFERENT DEGREES OF LUNG DISEASE - A CROSS-SECTIONAL STUDY

Background:

There are few studies evaluating different aspects of quality of life including depressive symptoms and physical capacity and physical activity in patients with systemic sclerosis (SSc) with different degrees of lung disease.

Objectives:

The aim of this study was to evaluate differences in self-reported disability, physical capacity and activity, depressive symptoms and quality of life, between patients with SSc with no-mild lung disease and those with moderate-endstage lung disease.

Methods:

In this cross-sectional study, 279 patients with SSc fulfilling the 2013 ACR/EULAR criteria for SSc (84% limited and 16% diffuse SSc) were included. Medsger disease severity scale was used to subgroup the patients into no-mild (n=156) or moderate- endstage lung disease (n=115). Disability was measured with Health Assessment Questionnaire-Disability Index (HAQ-DI); physical capacity (ability to walk, jog/run); and physical activity (different intensities) was measured with three single questions; depressive symptoms with Hospital Anxiety and Depression-scale (HADs); and quality of life was measured with TheShort Form(36) Health Survey (SF-36).

Results:

Patients with moderate-endstage lung disease reported higher scores on HAQ-DI (p<0.001) and lower scores on SF-36 physical component (p<0.0001) than patients with no-mild lung disease. Patients with moderate-endstage lung disease reported lower physical capacity (p<0.0001), less physical activity on low to moderate intensity the past 6 months (p<0.016) and less exercise on moderate to high intensity the past year (p=0.022) compared to those with no-mild lung disease. There was no difference between the two subgroups when it comes to the mental component in SF-36 (p=0.2), however patients with moderate-endstage lung disease had lower scores on the subscales vitality ((p=0.003), social function (p=0.002) and emotional role function (p=0.005) as well as higher scores on the HADs depressive symptoms scale (p=0.024), than the patients with no-mild lung disease.

Conclusion:

Patients with SSc with moderate-endstage lung disease report more disability, lower physical capacity and activity, are more depressed and the physical aspects of quality of life is lower, as well as vitality, social function and emotional role function, compared to patients with no-mild lung disease. Studies evaluating whether increased physical activity and exercise may improve depressive symptoms and aspects of quality of life in patients with moderate-endstage lung disease are needed.

References:

[1]Liem SIE, Meessen JMTA, Wolterbeek R, Ajmone Marsan N, Ninaber MK, Vliet Vlieland TPM, de Vries-Bouwstra JK. Physical activity in patients with systemic sclerosis. Rheumatol Int. 2018;38:443-453

[2]March C, Huscher D, Preis E, Makowka A, Hoeppner J, Buttgereit F, Riemekasten G, Norman K, Siegert E. Prevalence, Risk Factors and Assessment of Depressive Symptoms in Patients With Systemic Sclerosis. Arch Rheumatol. 2019;28;34:253-261

Acknowledgments:

Thanks to the patients involved in the study, patient research partner Monica Holmnér and the staff at the rheumatological clinic, Karolinska University Hospital

Disclosure of Interests:

None declared

Geographic variation in the use of lymphadenectomy and external-beam radiotherapy for endometrial cancer: a cross-sectional analysis of population-based data

OBJECTIVE

To quantify geographic variation in the use of lymphadenectomy and/or external-beam radiotherapy (EBRT) for endometrial cancer in England.

DESIGN

Cross-sectional analysis of population-based data.

SETTING

English cancer registry data, linked to chemotherapy, radiotherapy and hospital episodes statistics data.

POPULATION

Twenty-two thousand four hundred and eighty-three women with endometrial cancer presenting without clinical or radiological evidence of distant metastatic spread, diagnosed in England from 2013 to 2016.

METHODS

Proportions of patients receiving lymphadenectomy and/or EBRT were compared across 19 Cancer Alliances, to identify variations in clinical practice. Two separate logistic regression models assessed the impact on variation of adjustment for tumour and patient characteristics.

MAIN OUTCOME MEASURES

Receipt of lymphadenectomy, receipt of EBRT.

RESULTS

There was substantial variation by Cancer Alliance in the adjusted proportion of women with endometrial cancer receiving lymphadenectomy (range 5% [95% CI 4-6%] to 48% [95% CI 45-52%]) and EBRT (range 10% [95% CI 7-12%] to 31% [95% CI 28-33%]), after adjusting for variation in pathological grade, age, comorbidities, deprivation, ethnic group and (EBRT only) FIGO stage. Different approaches to clinical practice were identified; (i) one Cancer Alliance had significantly higher than average lymphadenectomy and significantly lower than average EBRT use, (ii) three had high use of both lymphadenectomy and EBRT, (iii) one had low lymphadenectomy use and high EBRT use, and (iv) three had low use of both lymphadenectomy and EBRT.

CONCLUSIONS

Lymphadenectomy is probably used to triage for EBRT when lymphadenectomy use is high and EBRT use is low. This is probably a result of variation in local endometrial cancer management guidelines, suggesting that UK recommendations should be clarified.

TWEETABLE ABSTRACT

There is geographic variation in England in the use of lymphadenectomy and radiotherapy to treat endometrial cancer.

Differences in Prognostic Factors and Recurrence Patterns After Curative-Intent Resection of Perihilar and Distal Cholangiocarcinomas

BACKGROUND

Perihilar cholangiocarcinoma and distal cholangiocarcinoma arise from the same tissue but require different surgical treatment methods. It remains unclear whether these cholangiocarcinoma types have different outcomes, prognostic factors, and/or recurrence patterns.

METHODS

This retrospective study evaluated patients who underwent curative-intent resection for perihilar cholangiocarcinoma or distal cholangiocarcinoma at a tertiary academic hospital during 2000-2015. Survival and prognostic factors were identified using Kaplan-Meier and Cox regression analyses.

RESULTS

The 90-day mortality rates were 0% for perihilar cholangiocarcinoma (36 patients) and 4% for distal cholangiocarcinoma (47 patients). There were no significant differences between perihilar cholangiocarcinoma or distal cholangiocarcinoma in median overall survival (30.9 vs 40.4 months) or median disease-free survival (14.2 vs 21.4 months). Among perihilar cholangiocarcinoma patients, age > 65 years was an independent predictor of poorer overall survival (hazard ratio: 2.45, 95% confidence interval: 1.07-5.64), while requiring bile duct re-resection was an independent predictor of disease-free survival (hazard ratio: 2.76, 95% confidence interval: 1.01-7.51). Among distal cholangiocarcinoma patients, a pN1 category independently predicted poorer overall survival (hazard ratio: 3.40, 95% confidence interval: 1.14-10.11), while preoperative CA19-9 levels >30 U/mL (hazard ratio: 2.51, 95% confidence interval: 1.09-5.79) and pN1 category (hazard ratio: 2.51, 95% confidence interval: 1.09-5.79) predicted a shorter disease-free survival. Local recurrence was more common with perihilar cholangiocarcinoma (50% of recurrences), while multiple synchronous sites were more common for distal cholangiocarcinoma (41% of recurrences).

CONCLUSION

Perihilar cholangiocarcinoma and distal cholangiocarcinoma patients have similar survival outcomes. However, local control appears to be more prognostic for perihilar cholangiocarcinoma patients, while positive lymph nodes are critical prognostic factor for distal cholangiocarcinoma patients.

Increased prevalence of pancreaticobiliary maljunction in biliary malignancies

AIM

The incidence of pancreaticobiliary maljunction is thought to approximate 1:100,000 within Western populations. We aimed to study the significance of pancreaticobiliary maljunction in biliary tract malignancies.

METHODS

Medical records and magnetic resonance cholangiopancreatography images of 252 consecutive patients treated for biliary malignancies during 2005-2016 were reviewed. Patients with other known risk factors for biliary cancers (n = 27) were excluded. A common pancreaticobiliary channel measuring ⩾10 mm outside the duodenal wall was defined as pancreaticobiliary maljunction.

MAIN RESULTS

Of the 225 patients, a reliably interpretable preoperative magnetic resonance cholangiopancreatography was available for 73 (32%). Sex (47% vs 57% females) and age at diagnosis (67 vs 66 years) were similar among patients with or without an magnetic resonance cholangiopancreatography (p = ns for both). In magnetic resonance cholangiopancreatography, a pancreaticobiliary maljunction with a median length of 20 mm (range 10-23 mm) was identified in four patients (5.5%, 95% confidence interval 1.6-14), while none had evident accompanying biliary tree dilatation. Pancreaticobiliary maljunction patients were significantly more often females (100% vs 43%, p = 0.043), less likely to have intrahepatic bile duct cancer (0% vs 65%, p = 0.019) while more likely to have gallbladder cancer (75% vs 22%, p = 0.044) compared to the others. Age at diagnosis (66 vs 67 years, p = 0.898), extrahepatic bile duct cancer incidence (25% vs 13%, p = 0.453), and survival status at last follow-up (50% vs 42% alive, p = 1.000) were comparable between the subgroups.

CONCLUSION

The prevalence of pancreaticobiliary maljunction is substantially higher in adults with biliary malignancies than one would expect based on its incidence, reinforcing the etiologic role of pancreaticobiliary maljunction especially in females with gallbladder cancer.

Histologically Verified Biliary Invasion was Associated with Impaired Liver Recurrence-Free Survival in Resected Colorectal Cancer Liver Metastases

Background and Aims:

The impact of biliary invasion on recurrence and survival, after resection of colorectal cancer liver metastases, is not well known as publications are limited to small patient series. The aim was to investigate if biliary invasion in liver resected patients associated with liver relapses and recurrence-free survival. Secondary endpoints included association with other prognostic factors, disease-free survival and overall survival.

Materials and Methods:

All patients with histologically verified biliary invasion (n = 31, 9%) were identified among 344 patients with liver resection between January 2009 and March 2015. Controls (n = 78) were selected from the same time period and matched for, among others, size and number of colorectal cancer liver metastasis.

Results:

Median liver recurrence-free survival was significantly shorter in patients with biliary invasion than in controls (15.3 months versus not reached; p = 0.031) and more relapses were noted in the liver (61.3% versus 33.3%; p = 0.010), respectively. In univariate analyses for liver recurrence-free survival, biliary invasion was the only significant prognostic factor; p = 0.034. There were no statistical differences in disease-free and overall survival between the groups.

Conclusion:

Biliary invasion was associated with higher liver recurrence rates and shorter liver recurrence-free survival in patients with resected colorectal cancer liver metastasis.

A rare case of non-contact salter harris type 2 fracture of distal femur during a football match

Distal femoral physeal fractures in adolescents are often due to high velocity injuries. We present an unusual case of a non-contact distal femoral physeal fracture that occurred during a football match. A torsional force had been directed at the fracture site occurring at the growth plate causing a transverse fracture rather than a spiral fracture. It is important to be aware that such fractures can occur despite little or no evidence of contact. These type of injuries should also be treated as an emergency to reduce the risk of further complications.

Decreasing incidence of cancer after liver transplantation-A Nordic population-based study over 3 decades

Cancer remains one of the most serious long-term complications after liver transplantation (LT). Data for all adult LT patients between 1982 and 2013 were extracted from the Nordic Liver Transplant Registry. Through linkage with respective national cancer-registry data, we calculated standardized incidence ratios (SIRs) based on country, sex, calendar time, and age-specific incidence rates. Altogether 461 cancers were observed in 424 individuals of the 4246 LT patients during a mean 6.6-year follow-up. The overall SIR was 2.22 (95% confidence interval [CI], 2.02-2.43). SIRs were especially increased for colorectal cancer in recipients with primary sclerosing cholangitis (4.04) and for lung cancer in recipients with alcoholic liver disease (4.96). A decrease in the SIR for cancers occurring within 10 years post-LT was observed from the 1980s: 4.53 (95%CI, 2.47-7.60), the 1990s: 3.17 (95%CI, 2.70-3.71), to the 2000s: 1.76 (95%CI, 1.51-2.05). This was observed across age- and indication-groups. The sequential decrease for the SIR of non-Hodgkin lymphoma was 25.0-12.9-7.53, and for nonmelanoma skin cancer 80.0-29.7-10.4. Cancer risk after LT was found to be decreasing over time, especially for those cancers that are strongly associated with immunosuppression. Whether immunosuppression minimization contributed to this decrease merits further study.

Decentralised black water treatment by combined auto-thermal aerobic digestion and ammonia - A pilot study optimising treatment capacity

Partial heating of black water by auto-thermal aerobic digestion was combined with the addition of 1% w/w urea and monitoring of pathogens and indicator organisms over a 21-day period. After initial mixing, the 160 m³ black water (60 m³ heated and 100 m³ non-heated) was left undisturbed. The urea was confirmed to be fully degraded into ammonia (5.1 g N L^-1) first after 14 days, while the pH stabilised at around 9.2 after one week. The initial temperature of 17 °C fell by 6 °C during the study. E. coli and Salmonella spp., which are sensitive to ammonia, were inactivated during the first few days of the study, despite the urea only being partly hydrolysed. At day 14, f-RNA bacteriophages could also no longer be detected. The more persistent somatic coliphages, Enterococcus spp. and Ascaris eggs, showed significant but slow inactivation. The treatment proved to be efficient with regards to salmonella, which is a target pathogen in the Swedish context, but for parasite egg inactivation a higher temperature was required. The treatment would benefit from more frequent stirring to speed up the hydrolysis of urea and thus improve treatment efficiency. The alternative treatment scheme could increase capacity by 2.4 times, albeit with a 40% higher cost per volume due to the increased use of urea.

Distribution of Intraportally Implanted Microspheres and Fluorescent Islets in Mice

The aim of the study was to evaluate the distribution of intraportally transplanted islets in mice. We initially administered 2000 polystyrene microspheres with a diameter of 50 μm intraportally into normoglycemic C57BL/6 mice. In separate experiments other mice were injected similarly with 300 microspheres each with a diameter of 100 or 200 μm. One week later the animals were killed, and the lungs and livers were removed and divided into lobes. The number of microspheres in each individual liver lobe and in the lungs was counted using a stereomicroscope. In other experiments, athymic C57BL/6 mice were similarly implanted with 250 islets isolated from transgenic mice expressing the enhanced yellow fluorescent protein in the islet cells. The distribution of microspheres and islets was independent of size, and fairly homogenous within the liver, with the exception of the caudate lobe, which contained fewer microspheres and islets, respectively. Approximately one third of all microspheres and islets were present as aggregates. Eighty-five to 90% of the implanted microspheres were identified in the liver sections, whereas 60–65% of the implanted islets were recovered. Aggregates or single fluorescent cells were observed in the liver of islet-implanted mice. We conclude that islets and microspheres implanted into the liver distribute fairly homogenously and quite a few of them exist as aggregates or, with respect to islets, as fragments.

Increased Serum Levels of the IL-33 Neutralizing sST2 in Limited Cutaneous Systemic Sclerosis

The pathophysiology of both limited cutaneous systemic sclerosis (lcSSc) and diffuse cutaneous SSc (dcSSc), representing two subtypes of an autoimmune disease of the connective tissue, is still enigmatic. Life-limiting, progressive fibrotic changes as a consequence of vasculopathy and autoimmunity are characteristic in varying extent for lcSSc and dcSSc. Previously, an increased IL-33 serum concentration in early phase SSc patients and an elevated tissue expression of its receptor, ST2L, on endothelial cells (EC) were described. While suggested as a biomarker for fibrotic diseases, for example liver fibrosis, the role of soluble ST2 (sST2) in the pathological processes and its contribution to vascular fibrosis in SSc has not been investigated. Here, we showed that sST2 is elevated in late phase limited cutaneous SSc (lcSSc) as compared to patients with shorter disease duration or with the diffuse subtype of SSc. We demonstrated that sST2, not IL-33, is significantly increased in serum of lcSSc patients with disease duration over 9 years. Soluble ST2 was not elevated in healthy controls or in SSc patients with early skin involvement or disease duration shorter than 9 years. Furthermore, we observed that sST2 serum levels were lowered by iloprost (prostacyclin) treatment. After 5 days of iloprost infusion, sST2 serum levels fell in 6 of 7 patients. Therefore, we not only like to propose sST2 as a biomarker for progressive vascular fibrosis, but moreover, suggest that the involvement of sST2 in the pathogenesis of lcSSc may be exploited therapeutically.

Modeling the inactivation of ascaris eggs as a function of ammonia concentration and temperature

Ammonia sanitization is a promising technology for sanitizing human excreta intended for use as a fertilizer in agriculture. Ascaris eggs are the most persistent pathogens regarding ammonia inactivation and are commonly present in fecal sludge in low- and middle-income countries. In this study, a model for predicting ammonia inactivation of ascaris eggs was developed. Data from four previous studies were compiled and analyzed statistically, and a mathematical model for the treatment time required for inactivation was created. The inactivation rate increased with NH3 activity to the power of 0.7. The required treatment time was found to decrease 10-fold for each 16 °C temperature increase. Dry matter (DM) content and pH had no direct effect on inactivation, but had an indirect effect due to their impact on NH3 activity, which was estimated using the Pitzer approach. An additional model giving an approximation of Pitzer NH3 activity but based on the Emerson approach, DM content and total ammonia (NHTot) was also developed. The treatment time required for different log10 reductions of ascaris egg viability can thus easily be estimated by the model as a function of NH3 activity and temperature. The impact on treatment time by different treatment options can then be theoretically evaluated, promoting improvements of the treatment e.g. by adding urea or alkaline agents, or increasing the temperature by solar heating.

Enhanced recovery protocol after liver resection

BACKGROUND

Enhanced recovery protocols (ERPs) accelerate patient recovery and shorten hospital stay by optimization of perioperative care. However, experience with ERPs is still limited in liver surgery.

METHODS

The implementation of a multimodal ERP was studied in patients who underwent open and laparoscopic liver surgery. An opioid-sparing pain treatment was chosen together with early mobilization and oral feeding, as well as restricted use of abdominal drains and catheters. Date to discharge, postoperative complications and patient satisfaction were assessed. A historical cohort of patients who underwent liver resection served as a control group.

RESULTS

Some 134 liver resections (126 open, 8 laparoscopic) were performed between April 2013 and March 2014. Operations were carried out mostly for malignant liver tumours. One hundred and six (79.1 per cent) of the 134 patients were discharged by the fifth postoperative day. The median (range) postoperative hospital stay was 4 (2-11) days, compared with 6 (4-16) days for the control group (P < 0.001). Only four patients in the ERP group were readmitted and the 30-day mortality rate was zero.

CONCLUSION

An ERP for perioperative care after liver surgery was introduced safely and effectively. Discharge within 4 days is achievable with no increase in adverse events and good patient satisfaction.

Giant Chondrosarcoma of Proximal Humerus in an Adult Female Patient: A Case Report

Chondrosarcoma is the third most common primary tumour of the bone, after myeloma and osteosarcoma. Most of the chondrosarcoma grow slowly and rarely metastasize, and they have an excellent prognosis after adequate surgery. However most of them are chemo or radio-resistant. We report a case of primary chondrosarcoma of proximal humerus in a 36-year-old female who presented with a six years history of left shoulder swelling and restricted range of motion. Trucut biopsy showed a well-differentiated chondrosarcoma. The patient underwent forequarter amputation of left upper limb and was started on chemotherapy following operation.

Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications)

BACKGROUND

There are limited data on surgical outcomes in gynaecological oncology. We report on predictors of complications in a multicentre prospective study.

METHODS

Data on surgical procedures and resulting complications were contemporaneously recorded on consented patients in 10 participating UK gynaecological cancer centres. Patients were sent follow-up letters to capture any further complications. Post-operative (Post-op) complications were graded (I-V) in increasing severity using the Clavien-Dindo system. Grade I complications were excluded from the analysis. Univariable and multivariable regression was used to identify predictors of complications using all surgery for intra-operative (Intra-op) and only those with both hospital and patient-reported data for Post-op complications.

RESULTS

Prospective data were available on 2948 major operations undertaken between April 2010 and February 2012. Median age was 62 years, with 35% obese and 20.4% ASA grade ⩾3. Consultant gynaecological oncologists performed 74.3% of operations. Intra-op complications were reported in 139 of 2948 and Grade II-V Post-op complications in 379 of 1462 surgeries. The predictors of risk were different for Intra-op and Post-op complications. For Intra-op complications, previous abdominal surgery, metabolic/endocrine disorders (excluding diabetes), surgical complexity and final diagnosis were significant in univariable and multivariable regression (P<0.05), with diabetes only in multivariable regression (P=0.006). For Post-op complications, age, comorbidity status, diabetes, surgical approach, duration of surgery, and final diagnosis were significant in both univariable and multivariable regression (P<0.05).

CONCLUSIONS

This multicentre prospective audit benchmarks the considerable morbidity associated with gynaecological oncology surgery. There are significant patient and surgical factors that influence this risk.

Traumatic floating clavicle: a case report

ABSTRACT

Shoulder girdle injuries after high energy traumatic impacts to the shoulder have been well documented. Based on the series of 1603 injuries of the shoulder girdle reported by Cave and colleagues, 85% of the dislocations were glenohumeral, 12% acromioclavicular and 3% sternoclavicular (1). Less frequently described are injuries involving both the sternoclavicular and acromioclavicular joints simultaneously in one extremity. The present report discusses a case of traumatic floating clavicle associated with ipsilateral forearm and wrist injury which was treated surgically.

KEY WORDS

Floating clavicle, bipolar dislocation, sternoclavicular.

Argininosuccinate lyase in enterocytes protects from development of necrotizing enterocolitis

Necrotizing enterocolitis (NEC), the most common neonatal gastrointestinal emergency, results in significant mortality and morbidity, yet its pathogenesis remains unclear. Argininosuccinate lyase (ASL) is the only enzyme in mammals that is capable of synthesizing arginine. Arginine has several homeostatic roles in the gut and its deficiency has been associated with NEC. Because enterocytes are the primary sites of arginine synthesis in neonatal mammals, we evaluated the consequences of disruption of arginine synthesis in the enterocytes on the pathogenesis of NEC. We devised a novel approach to study the role of enterocyte-derived ASL in NEC by generating and characterizing a mouse model with enterocyte-specific deletion of Asl (Asl(flox/flox); VillinCre(tg/+), or CKO). We hypothesized that the presence of ASL in a cell-specific manner in the enterocytes is protective in the pathogenesis of NEC. Loss of ASL in enterocytes resulted in an increased incidence of NEC that was associated with a proinflammatory state and increased enterocyte apoptosis. Knockdown of ASL in intestinal epithelial cell lines resulted in decreased migration in response to lipopolysaccharide. Our results show that enterocyte-derived ASL has a protective role in NEC.

Does an enhanced recovery integrated care pathway (ICP) encourage adherence to prescribing guidelines, accelerate postoperative recovery and reduce the length of stay for gynaecological oncology patients?

A new integrated care pathway (ICP) proforma for gynaecological oncology patients was developed and introduced in early 2010. The ICP is a goal-defined and time-specified documentation by gynaecological oncology doctors and nurses, guided by certain parameters to be achieved in pre and postoperative days. All patients were admitted to the same unit and underwent a major abdominal/pelvic procedure for confirmed or suspected gynaecological malignancy, including hysterectomy and oophorectomy. The control group included 58 randomly selected patients from May 2008 to March 2009 and the intervention group comprised 52 patients, after the introduction of the ICP. The effectiveness was assessed with a variety of measurements: the duration of intraperitoneal drains, urethral catheters and intravenous fluids postoperatively; time taken for the patient to eat and drink; time taken to mobilisation; and the total length of stay in hospital. We also assessed whether the implementation of the care pathway was associated with an increase in adherence to prescribing guidelines for thromboprophylaxis and postoperative antibiotics and sodium docusate. The new ICP encouraged clearer documentation and regular review of fluids, drains and catheters. There was a modest reduction in the length of stay and an increase in prescribed thromboprophylaxis and sodium docusate ( Cheung et al. 2011 ).

Electrocardiography in 110 patients with systemic sclerosis: a cross-sectional comparison with population-based controls

OBJECTIVES

Patchy fibrosis of the myocardium is thought to cause conduction abnormalities in patients with systemic sclerosis (SSc). We compared the prevalence and type of rhythm/conduction disturbances in 74% of the SSc patients in Stockholm County and controls.

METHOD

A total of 110 SSc patients (age 62 ± 12 years) fulfilling the American College of Rheumatology (ACR) criteria for SSc and 105 gender- and age-matched controls participated in this study. A 12-lead resting electrocardiogram (ECG) was performed in all participants. The first 49 patients and 42 controls also underwent a 22-24-h Holter ECG recording. Associations with disease subsets, autoantibodies, cardiovascular risk factors, and left ventricular ejection fraction (LVEF), as estimated by echocardiography, were investigated.

RESULTS

Abnormal ECGs were found in 28% of patients and 17% of controls (p = 0.05). Atrioventricular (AV) and/or intraventricular (IV) conduction abnormalities were found in 15% of patients and 5% of controls (p < 0.01). Four patients, but no controls, had low anteroseptal R-wave/septal Q-wave patterns with narrow QRS complexes, simulating a septal wall infarction pattern. Patients had more abnormal Holter ECG recordings than controls (38% vs. 17%, p = 0.05). All participants with a normal resting ECG had an LVEF ≥ 50%.

CONCLUSIONS

Although ECGs are inexpensive, commonly available screening tools, to detect arrhythmias, such as frequent ventricular extrasystoles (VES), Holter tracings should be performed. The frequencies of AV and/or IV conduction abnormalities and septal Q waves/low R waves have not changed since 1985. The unmet need of anti-fibrotic treatment in SSc is underscored by these findings.

Vulval cancer incidence, mortality and survival in England: age-related trends

OBJECTIVE

To explore the trends and age characteristics of vulval cancer incidence, mortality, survival and stage of disease.

DESIGN

Retrospective population-based observational study based on cancer registry and Office for National Statistics data.

SETTING

England.

POPULATION

All women diagnosed with vulval cancer, defined by the site of the tumour (ICD-10 code C51).

METHODS

Including all C51 cases, Poisson regression was used to test for trends in incidence and mortality rates, and generalised linear modelling was used to test for trends in relative survival. Excluding women with melanomas, basal cell carcinomas and Paget disease, stage was investigated as a percentage of staged data by age.

MAIN OUTCOME MEASURES

Age-standardised incidence and mortality rates, relative survival rates and stage of disease at diagnosis.

RESULTS

From 1990, there was a statistically significant increase in overall incidence (P = 0.018) and decrease in mortality (P < 0.001). In addition, there were statistically significant increases in overall survival (1-year, P < 0.001; 5-year, P < 0.001). However, from 1990, incidence increased in women aged 20-39 years (P = 0.002), 40-49 and 50-59 years (both P < 0.001) and 60-69 years (P = 0.030) and decreased in women aged 80 years and above (P < 0.001). There were statistically significant decreases in mortality in women aged ≥60 years (P < 0.001), and statistically significant increases in 1-year survival in women aged ≥40 years (P ≤ 0.047) and in 5-year survival in women aged 40-49 and ≥60 years (P ≤ 0.011). Stage patterns by age highlight diagnosis at an earlier stage in younger women and more advanced stage diagnosis in older women.

CONCLUSION

Survival from vulval cancer has improved and mortality has decreased since 1990. The overall incidence of disease has increased as a result of more new diagnoses in the under 70-year age group.

Patient-reporting improves estimates of postoperative complication rates: a prospective cohort study in gynaecological oncology

Background:

Most studies use hospital data to calculate postoperative complication rates (PCRs). We report on improving PCR estimates through use of patient-reporting.

Methods:

A prospective cohort study of major surgery performed at 10 UK gynaecological cancer centres was undertaken. Hospitals entered the data contemporaneously into an online database. Patients were sent follow-up letters to capture postoperative complications. Grade II–V (Clavien–Dindo classification) patient-reported postoperative complications were verified from hospital records. Postoperative complication rate was defined as the proportion of surgeries with a Grade II–V postoperative complication.

Results:

Patient replies were received for 1462 (68%) of 2152 surgeries undertaken between April 2010 and February 2012. Overall, 452 Grade II–V (402 II, 50 III–V) complications were reported in 379 of the 1462 surgeries. This included 172 surgeries with 200 hospital-reported complications and 231 with 280 patient-reported complications. All (100% concordance) 36 Grade III–V and 158 of 280 (56.4% concordance) Grade II patient-reported complications were verified on hospital case-note review. The PCR using hospital-reported data was 11.8% (172 out of 1462; 95% CI 11–14), patient-reported was 15.8% (231 out of 1462; 95% CI 14–17.8), hospital and verified patient-reported was 19.4% (283 out of 1462; 95% CI 17.4–21.4) and all data were 25.9% (379 out of 1462; 95% CI 24–28). After excluding Grade II complications, the hospital and patient verified Grade III–V PCR was 3.3% (48 out of 1462; 95% CI 2.5–4.3).

Conclusion:

This is the first prospective study of postoperative complications we are aware of in gynaecological oncology to include the patient-reported data. Patient-reporting is invaluable for obtaining complete information on postoperative complications. Primary care case-note review is likely to improve verification rates of patient-reported Grade II complications.

Complement activation during liver transplantation-special emphasis on patients with atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy often caused by mutations in complement factor H (CFH), the main regulator of alternative complement pathway. Because CFH is produced mainly by the liver, combined liver-kidney transplantation is a reasonable option in treatment of patients with severe aHUS. We studied complement activation by monitoring activation markers during liver transplantation in two aHUS patients treated extensively with plasma exchange and nine other liver transplantation patients. After the reperfusion, a clear increase in all the activation markers except C4d was observed indicating that the activation occurs mainly through the alternative pathway. Concentration of SC5b-9 was higher in the hepatic than the portal vein indicating complement activation in the graft. Preoperatively and early during the operation, the aHUS patients showed highest C3d concentrations but otherwise their activation markers were similar to the other patients. In the other patients, correlation was found between perioperative SC5b-9 concentration and postoperative alanine aminotransferase and histological changes. This study explains why supply of normal CFH by extensive plasma exchange is beneficial before combined liver-kidney transplantation of aHUS patients. Also the results suggest that perioperative inhibition of the terminal complement cascade might be beneficial if enhanced complement activation is expected.

Laparoscopic liver surgery: new frontiers

Laparoscopic liver resection (LHR) has shown classical advantages of minimally invasive surgery over open counterpart. In spite of introduction in early 1990's only few centres worldwide adapted LHR to routine practice. It was due to considerable technical challenges and uncertainty about oncologic outcomes. Surgical instrumentation and accumulation of surgical experience has largely enabled to solve many technical considerations. Intraoperative navigation options have also been improved. Consequently indications have been drastically expanded nearly reaching criteria equal to open liver resection in expert centres. Recent studies have verified oncologic integrity of LHR. However, mastering of LHR is still a quite demanding task limiting expansion of this patient friendly technique. This emphasizes the necessity of systematic training for laparoscopic liver surgery. This article reviews the state of the art of laparoscopic liver surgery lightening burning issues of research and clinical practice.

Treatment of Biliary Complications after Laparoscopic Cholecystectomy

The incidence of iatrogenic bile duct injury remains high despite increased awareness of the problem. This major complication following laparoscopic cholecystectomy (LC) has a significant impact on patient's well-being and even survival despite seemingly adequate therapy. The management of bile duct injury (BDI) includes education to avoid the insult, proper and early diagnosis and preferably early treatment. It is of utmost importance to involve experienced hepatobiliary surgeon early enough to perform corrective reconstruction or to plan other therapies with a multidisciplinary team including interventional radiologist and advanced endoscopist. The selection of correct therapy at the earliest possible phase has significant effect on patient outcome. The treatment options are surgery and endoscopy, either immediately or delayed.

By constant and continuous analysis of the problem and information to the surgical community it should be possible to decrease the prevalence of iatrogenic BDI and even to avoid it.