287 Retrospective Review of a Single Surgeon 5-Year Experience of Paediatric Breast Reconstruction - Challenges, Experience, and the Increasing Role of Lipofilling

Aim

This case series reviews the presentation, clinical and surgical management of paediatric breast cases undertaken by a single surgeon. The series demonstrates the powerful role of lipomodelling when used with breast reshaping techniques to achieve good outcomes and avoid the need to commit young patients to breast implants.

Method

Retrospective analysis of paediatric breast referrals to a single surgeon at a regional plastic surgery breast reconstruction unit over a 5-year period.

Results

In a 5-year period, 15 cases which presented in childhood to a tertiary paediatric centre were referred on to our regional plastic surgery breast reconstruction unit. Two patients underwent correction of breast hypoplasia secondary to Poland's syndrome. Nine patients presented for breast asymmetry with associated tuberous deformity. One patient had maldevelopment of a breast secondary to a burn's contracture. Two patients presented with gigantomastia and one patient with juvenile fibroadenomas.

Conclusions

Paediatric breast abnormalities represent a small but important caseload for a breast reconstructive surgeon. This case series demonstrates the need for careful assessment and an individualised surgical plan for each patient. The surgical plan must achieve a satisfactory outcome whilst minimising the need for further procedures as the patient grows. It is the senior surgeon's preference to avoid breast implant-based reconstruction where possible. In all but one case lipomodelling combined with reshaping of the native tissue was used to good effect.

Hesperidin-loaded nanoemulsions improve cytotoxicity, induce apoptosis, and downregulate miR-21 and miR-155 expression in MCF-7

Hesperidin, a ubiquitous plant-based flavanone, was encapsulated into nanoemulsions (HP-NEM) using a spontaneous emulsification method to improve its solubility and enhance bioavailability and efficacy in breast cancer treatment using MCF-7 cell lines. The cytotoxic and apoptotic effects of HP-NEM against MCF-7 and its impact on oncomiRs, microRNA-21, and microRNA-155 expression were also assessed. The optimised HP-NEM displayed a spherical shape with 305 ± 40.8 nm, 0.308 ± 0.04, and -11.6 ± 3.30 mV and 93 ± 0.45% for particle size, polydispersity index (PDI), zeta-potential (ζ), and encapsulation efficiency, respectively. Cytotoxicity studies using MTT assay showed selective toxicity of the HP-NEM against MCF-7 without affecting normal cells (HEK 293). Treatment with the HP-NEM induced cell death through apoptosis, cell cycle arrest in the G2/M phase, and downregulated miR-21 and miR-155 expression in MCF-7. This study supports the use of HP-NEM as a potential therapeutic agent in breast cancer treatment.

Formulation of pH responsive multilamellar vesicles for targeted delivery of hydrophilic antibiotics

Fight against antimicrobial resistance calls for innovative strategies that can target infection sites and enhance activity of antibiotics. Herein is a pH responsive multilamellar vesicles (MLVs) for targeting bacterial infection sites. The vancomycin (VCM) loaded MLVs had 62.25 ± 8.7 nm, 0.15 ± 0.01 and -5.55 ± 2.76 mV size, PDI and zeta potential, respectively at pH 7.4. The MLVs had a negative ZP at pH 7.4 that switched to a positive charge and faster release of the drug at acidic pH. The encapsulation efficiency was found to be 46.34 ± 3.88 %. In silico studies of the lipids, interaction suggested an energetically stable system. Studies to determine the minimum inhibitory concentration studies (MIC) showed the MLVs had 2-times and 8-times MIC against Staphylococcus aureus (SA) and Methicillin resistance SA respectively at physiological pH. While at pH 6.0 there was 8 times reduction in MICs for the formulation against SA and MRSA in comparison to the bare drug. Fluorescence-activated Cell Sorting (FACS) studies demonstrated that even with 8-times lower MIC, MLVs had a similar elimination ability of MRSA cells when compared to the bare drug. Fluorescence microscopy showed MLVs had the ability to clear biofilms while the bare drug could not. Mice skin infection models studies showed that the colony finding units (CFUs) of MRSA recovered from groups treated with MLVs was 4,050 and 525-fold lower than the untreated and bare VCM treated groups, respectively. This study demonstrated pH-responsive multilamellar vesicles as effective system for targeting and enhancing antibacterial agents.

88 Improving Clinical Effectiveness At Identifying Patients Requiring Advanced Care Plans

Our project was conducted in a district general hospital across five acute geriatric wards. Our team included consultants, registrars, and ward matrons. The project focused on improvement of care for geriatric inpatients, with moderate to severe frailty. Advanced care planning (ACP) columns are displayed on white boards. They indicate whether ACPs are required/initiated for each patient. When previously utilised, ACPs were initiated for 78% of appropriate patients [1]. Following a change in staff and reduction in awareness/education, the ACP column use reduced with fewer ACPs established.

Our goals were to ensure completion of the ACP column, encourage junior doctor/nurse involvement and trigger a greater number of appropriate ACPs initiated Improvement in ACP practice was addressed by daily board round review of appropriate patients for ACP, increasing awareness of ACP triggers and education around discussion content. Interventions consisted of: 1, a flow-chart adjacent to white boards prompting “Do not attempt resuscitation (DNAR)” and ACP processes. This signposted staff to information on ACP triggers and “how to start a conversation”. 2 Involving registrar “champions” on each ward. We explained our intervention to all team members to encourage engagement.

Data from the ACP columns were audited prior to intervention, 2 weeks and 6 weeks after intervention. There was a 54% increase in ACP documentation after 6 weeks across the wards.

The improvement in the use of the ACP column correlated with a greater number of ACPs initiated. This facilitated an increase in consideration of patient wishes towards the end of life. Increasing use of a daily ACP prompts on board rounds triggers an increase in ACP implementation for appropriate patients. Sustainability was achieved by recruitment of ward “ACP champions”. Junior doctors/matrons were more empowered to discuss ACPs. Results were presented at departmental teaching to reinforce the positive impact of the intervention.

Formulation of pH-Responsive Quatsomes from Quaternary Bicephalic Surfactants and Cholesterol for Enhanced Delivery of Vancomycin against Methicillin Resistant Staphylococcus aureus

Globally, human beings continue to be at high risk of infectious diseases caused by methicillin-resistant Staphylococcus aureus (MRSA); and current treatments are being depleted due to antimicrobial resistance. Therefore, the synthesis and formulation of novel materials is essential for combating antimicrobial resistance. The study aimed to synthesize a quaternary bicephalic surfactant (StBAclm) and thereof to formulate pH-responsive vancomycin (VCM)-loaded quatsomes to enhance the activity of the antibiotic against MRSA. The surfactant structure was confirmed using 1H, 13C nuclear magnetic resonance (NMR), Fourier-transform infrared spectroscopy (FT-IR), and high-resolution mass spectrometry (HRMS). The quatsomes were prepared using a sonication/dispersion method and were characterized using various in vitro, in vivo, and in silico techniques. The in vitro cell biocompatibility studies of the surfactant and pH-responsive vancomycin-loaded quatsomes (VCM-StBAclm-Qt1) revealed that they are biosafe. The prepared quatsomes had a mean hydrodynamic diameter (MHD), polydispersity index (PDI), and drug encapsulation efficiency (DEE) of 122.9 ± 3.78 nm, 0.169 ± 0.02 mV, and 52.22 ± 8.4%, respectively, with surface charge switching from negative to positive at pH 7.4 and pH 6.0, respectively. High-resolution transmission electron microscopy (HR-TEM) characterization of the quatsomes showed spherical vesicles with MHD similar to the one obtained from the zeta-sizer. The in vitro drug release of VCM from the quatsomes was faster at pH 6.0 compared to pH 7.4. The minimum inhibitory concentration (MIC) of the drug loaded quatsomes against MRSA was 32-fold and 8-fold lower at pH 6.0 and pH 7.4, respectively, compared to bare VCM, demonstrating the pH-responsiveness of the quatsomes and the enhanced activity of VCM at acidic pH. The drug-loaded quatsomes demonstrated higher electrical conductivity and a decrease in protein and deoxyribonucleic acid (DNA) concentrations as compared to the bare drug. This confirmed greater MRSA membrane damage, compared to treatment with bare VCM. The flow cytometry study showed that the drug-loaded quatsomes had a similar bactericidal killing effect on MRSA despite a lower (8-fold) VCM concentration when compared to the bare VCM. Fluorescence microscopy revealed the ability of the drug-loaded quatsomes to eradicate MRSA biofilms. The in vivo studies in a skin infection mice model showed that groups treated with VCM-loaded quatsomes had a 13-fold decrease in MRSA CFUs when compared to the bare VCM treated groups. This study confirmed the potential of pH-responsive VCM-StBAclm quatsomes as an effective delivery system for targeted delivery and for enhancing the activity of antibiotics.

Novel chitosan-based pH-responsive lipid-polymer hybrid nanovesicles (OLA-LPHVs) for delivery of vancomycin against methicillin-resistant Staphylococcus aureus infections

The development of novel materials is necessary for adequate delivery of drugs to combat the Methicillin-resistant Staphylococcus aureus (MRSA) burden due to the limitations of conventional methods and challenges associated with antimicrobial resistance. Hence, this study aimed to synthesise a novel oleylamine based zwitterionic lipid (OLA) and explore its potential to formulate chitosan-based pH-responsive lipid-polymer hybrid nanovesicles (VM-OLA-LPHVs1) to deliver VM against MRSA. The OLA was synthesised, and the structure characterised by ¹H NMR, ¹³C NMR, FT-IR and HR-MS. The preliminary biocompatibility of OLA and VM-OLA-LPHVs1 was evaluated on HEK-293, A-549, MCF-7 and HepG-2 cell lines using in vitro cytotoxicity assay. The VM-OLA-LPHVs1 were formulated by ionic gelation method and characterised in order to determine the hydrodynamic diameter (D_H), morphology in vitro and in vivo antibacterial efficacy. The result of the in vitro cytotoxicity study revealed cell viability of above 75% in all cell lines when exposed to OLA and VM-OLA-LPHVs1, thus indicating their biosafety. The VM-OLA-LPHVs1 had a D_H, polydispersity index (PDI), and EE% of 198.0 ± 14.04 nm, 0.137 ± 0.02, and 45.61 ± 0.54% respectively at physiological pH, with surface-charge (ζ) switching from negative at pH 7.4 to positive at pH 6.0. The VM release from the VM-OLA-LPHVs1 was faster at pH 6.0 compared to physiological pH, with 97% release after 72-h. The VM-OLA-LPHVs1 had a lower minimum inhibitory concentration (MIC) value of 0.59 μg/mL at pH 6.0 compared to 2.39 μg/mL at pH 7.4, against MRSA with 52.9-fold antibacterial enhancement. The flow cytometry study revealed that VM-OLA-LPHVs1 had similar bactericidal efficacy on MRSA compared to bare VM, despite an 8-fold lower VM concentration in the nanovesicles. Additionally, fluorescence microscopy study showed the ability of the VM-OLA-LPHVs1 to eliminate biofilms. The electrical conductivity, and protein/DNA concentration, increased and decreased respectively, as compared to bare VM which indicated greater MRSA membrane damage. The in vivo studies in a BALB/c mouse-infected skin model treated with VM-OLA-LPHVs1 revealed 95-fold lower MRSA burden compared to the group treated with bare VM. These findings suggest that OLA can be used as an effective novel material for complexation with biodegradable polymer chitosan (CHs) to form pH-responsive VM-OLA-LPHVs1 nanovesicles which show greater potential for enhancement and improvement of treatment of bacterial infections.

Immune checkpoint inhibitors: a promising anticancer therapy

Immune checkpoint inhibitors (ICIs) are revolutionizing the treatment of many cancers and have demonstrated their potential as 'cancer terminators'. However, ICI treatment also has constraints, such as its immune-related adverse events (irAEs) and therapeutic resistance. These drawbacks are gradually being overcome through better knowledge of the immune system, history of disease, duration of treatment, combinational drug regimes, adequate biomarkers, and effective patient response monitoring. In this review, we discuss the present ICI therapy landscape and its therapeutic outcomes for various diseases. We also highlight biomarkers related to the ICI response.

Delivery of novel vancomycin nanoplexes for combating methicillin resistant Staphylococcus aureus (MRSA) infections

The development of novel antibiotic systems is needed to address the methicillin-resistant Staphylococcus aureus (MRSA) infections. The aim of the study was to explore the novel nanoplex delivery method for vancomycin (VCM) against MRSA using dextran sulfate sodium salt (DXT) as a polyelectrolyte complexing agent. Nanoplexes were formulated by the self-assembling amphiphile polyelectrolyte complexation method and characterized. The size, polydispersity index (PDI), and zeta potential (ZP) of the optimized VCM nanoplexes were 84.6 ± 4.248 nm, 0.449 ± 0.024 and -33.0 ± 4.87 mV respectively, with 90.4 ± 0.77% complexation efficiency (CE %) and 62.3 ± 0.23% drug loading. The in vitro (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide)tetrazolium (MTT) studies of the nanoplexes were found to be non-toxic against different mammalian cell lines tested and may confirm its biosafety. While the in vitro drug release studies demonstrated sustained slower release. The in silico study confirmed the spontaneous interaction of VCM with DXT in the presence of sodium chloride. A 6.24-fold enhancement was observed for VCM nanoplexes via in vitro antibacterial studies. Flow-cytometric analysis showed effective cell killing of 67% from VCM nanoplexes compared to 32.98% from the bare vancomycin at the minimum inhibitory concentration (MIC) of 1.25 μg/mL. The in vivo studies using BALB/c mouse skin infection model revealed that nanoplexes reduced MRSA burden by 2.3-folds compared to bare VCM. The novel nanoplexes have potential to be a promising delivery system to combat MRSA infections for improved treatment of bacterial infections.

Do diabetic patients receiving conventional dialysis solutions benefit from peritoneal dialysis?

AIM

The study aimed to evaluate the impact of glucose-based peritoneal dialysis solutions (GBPDS) on diabetic patients on maintenance peritoneal dialysis.

METHODS

In this cross-sectional study we compared the influence of long term use of GBPDS on sixteen parameters related to the peritoneal glucose load, hydration status, inflammation, blood pressure, lipid profile and left ventricular mass in 45 stable PD patients (20 diabetic and 25 non-diabetic) receiving GBPDS.

RESULTS

At 24 months HbA1c, peritoneal glucose load index (PGLI), fluid overload (FO), plasma BNP, hsCRP and IL-6 levels, WBC count, blood pressure, triglycerides, LDL-C and left ventricular mass index (LVMI) were higher in diabetic patients compared to non-diabetic subjects (P ≤ 0.04). Of 16 tested variables, 14 had deteriorated at 24 months in diabetic patients. PGLI values > 3 g/kg/day or FO > 1.0 L were associated with abnormal values of HbA1c, plasma BNP, CRP and plasma IL-6 levels. 60% of diabetic patients had PGLI > 3g/kg/day compared to 32% of non-diabetic patients (P < 0.001). Seventy per cent of diabetic patients had FO > 1.0 L compared to 28% of non-diabetic patients (P < 0.001). Only 12% of diabetic patients had nocturnal blood pressure dipping compared to 45% of non-diabetics (P = 0.03). 57.8% of the studied patients had increased LVMI. Diabetic patients had higher LVMI values compared to non-diabetics (P < 0.001). The presence of DM was found to be the most powerful predictor for the development of LVH (P < 0.001).

CONCLUSION

Utilization of GBPDS in diabetic PD patients may be associated with substantial adverse consequences affecting glycemic control, hydration status, lipid profile, inflammation, blood pressure control and LVM.

Promoting social inclusion through Unified Sports for youth with intellectual disabilities: a five-nation study

BACKGROUND

Although the promotion of social inclusion through sports has received increased attention with other disadvantaged groups, this is not the case for children and adults with intellectual disability who experience marked social isolation. The study evaluated the outcomes from one sports programme with particular reference to the processes that were perceived to enhance social inclusion.

METHOD

The Youth Unified Sports programme of Special Olympics combines players with intellectual disabilities (called athletes) and those without intellectual disabilities (called partners) of similar skill level in the same sports teams for training and competition. Alongside the development of sporting skills, the programme offers athletes a platform to socialise with peers and to take part in the life of their community. Unified football and basketball teams from five countries--Germany, Hungary, Poland, Serbia and Ukraine--participated. Individual and group interviews were held with athletes, partners, coaches, parents and community leaders: totalling around 40 informants per country.

RESULTS

Qualitative data analysis identified four thematic processes that were perceived by informants across all countries and the two sports to facilitate social inclusion of athletes. These were: (1) the personal development of athletes and partners; (2) the creation of inclusive and equal bonds; (3) the promotion of positive perceptions of athletes; and (4) building alliances within local communities.

CONCLUSIONS

Unified Sports does provide a vehicle for promoting the social inclusion of people with intellectual disabilities that is theoretically credible in terms of social capital scholarship and which contains lessons for advancing social inclusion in other contexts. Nonetheless, certain limitations are identified that require further consideration to enhance athletes' social inclusion in the wider community.

Chronic allograft nephropathy score before sirolimus rescue predicts allograft function in renal transplant patients

Chronic allograft nephropathy (CAN) is a major indication for initiation of sirolimus (SRL) in renal transplantation (TX) to prevent deterioration of renal function. We evaluated whether the CAN score at time of sirolimus rescue (SRL-R) predicts renal allograft function. CAN score is the sum of the following 4 categories: glomerulopathy (cg, 0-3), interstitial fibrosis (ci, 0-3), tubular atrophy (ct, 0-3), and vasculopathy (cv, 0-3). This is a retrospective cohort study of renal transplant recipients from July 2001 to March 2004. Immunosuppression consisted of preconditioning with rabbit anti-thymocyte globulin or alemtuzumab and maintenance with tacrolimus (TAC) monotherapy with spaced weaning, if applicable, SRL-R was achieved by conversion from TAC, or by addition to reduced doses of TAC. Ninety patients received SRL. Thirty-three of these patients met the inclusion criteria of the following: (1) receipt of SRL for >6 months, and (2) follow-up of > or =6 months. There were 16 patients in the low-CAN (0-4) group and 17 patients in the high-CAN (>4) group. Cockcroft-Gault (C-G) glomerular filtration rate (GFR) was calculated at SRL-R and at 1, 3, 6, and 12 months. The DeltaGFR was significantly better in the low-CAN group at 1, 3, and 6 months. A trend toward an improved DeltaGFR was present at 12 months in the low-CAN group (P = .16). CAN scoring at the time of SRL-R predicts recovery of renal allograft function (as measured using DeltaGFR), and should be used in preference to biochemical markers (Cr and C-G GFR), which may not be reliable predictors.

Studies on Johne's Disease in Egyptian Cattle

Johne's disease (JD) or paratuberculosis is a serious problem of cattle industry worldwide. For a long period of time, Egypt was considered to be free of JD. In the present study, 2150 Egyptian cattle were examined clinically for JD. Among these, samples from 160 cows were investigated for the presence of Mycobacterium avium ssp. paratuberculosis using various laboratory methods including direct microscopic examination, faecal culture and polymerase chain reaction (PCR). According to the data obtained by the culture method, positive results could be observed for 75 cows from three of five investigated districts in Egypt. Comparably investigated samples from 40 cows of one known positive flock from Hesse, Germany yielded positive reactions for 20 cows. The present study is the first description of JD in Egypt.

An alternative technique for revision arthrodesis of the rheumatoid wrist: a case report

Few studies address the problem of failed rheumatoid wrist arthrodesis. We report a case of this difficult complication that was treated with a new technique of arthrodesis, which includes both the ulnocarpal and radiocarpal sites with 2 intramedullary nails and an ulnar ostectomy.

Infected internal iliac artery aneurysm: a case report

Isolated internal iliac aneurysms are rare, and although most are of atherosclerotic origin the cause may also be congenital, traumatic, associated with pregnancy or infectious. A 56-year-old man presented with a swollen, painful left lower limb. Within a few days, weakness of the limb developed with fever and an acute abdomen with free air on x-ray. At emergency laparotomy a small perforation was found in the ascending colon. Examination of the left iliac fossa revealed a ruptured left internal iliac artery aneurysm. Extra-anatomic cross-femoral bypass grafting was done to revascularize the left lower extremity. The patient recovered without complication. At discharge the weakness had improved but knee flexion and extension were weak. Culture of the aneurysm contents grew Staphylococcus aureus and Pseudomonas aeruginosa. The authors discuss the presentation and management of infected internal iliac artery aneurysms.

Une synthèse hautement stéréosélective de diènes conjugués (E)

A general method for the preparation of (E) terminal conjugated dienes was developed by the flash thermolysis of 2-substituted 2,5-dihydrothiophene-1,1-dioxides generated by a retro Diels–Alder reaction. This process allows the obtention of conjugated dienes, bearing or not a functionality (alcohols, esters), with an excellent stereoisomeric purity (in general higher than 98%). An application to the synthesis of (E)-9,11-dodecadien-1-yl acetate, the major component of the sex pheromone of Diparopsiscastanea, shows the generality and the efficacy of this method.